WPR09LA046

NTSB accident investigation · Piper PA-28-180 · Monterey, CA · November 26, 2008

Accident · Serious injuriesLimited investigationFinal report
Date
November 25, 2008, 17:45 local (Nov 26, 2008, 01:45 UTC)
Place
Monterey, CA
Injuries
1 serious, 1 minor
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N2383RPiper PA-28-180
Defining event
Approach-VFR pattern downwind: Fuel starvation
Weather
Visual (VMC) · Night
Status
Completed · report March 23, 2009
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration
FAA report
20081125853899A
Case key
69501

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The pilot's inadequate fuel system management and inflight planning that led to a loss of engine power due to fuel exhaustion. Contributing to the accident was the pilot's failure to use the landing checklist.

Findings · 4

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Fluids: fuelAircraft › Fluids/misc hardware · Fluid managementPiper PA-28-180: 32 casesAll aircraft: 1,695 casesProbable cause
Use of equip/info: use of checklistPersonnel issues › Task performance · PilotPiper PA-28-180: 3 casesAll aircraft: 336 casesProbable cause
Fuel systemAircraft › Aircraft systems · Incorrect use/operationPiper PA-28-180: 2 casesAll aircraft: 181 casesProbable cause
Planning/preparation: fuel planningPersonnel issues › Task performance · PilotPiper PA-28-180: 17 casesAll aircraft: 719 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Fuel starvationApproach-VFR pattern downwindPiper PA-28-180: 17 casesAll aircraft: 733 casesDefining event

Analysis

The pilot reported that after an uneventful flight he entered the traffic pattern for the active runway. As he turned from downwind to base leg, the engine lost power. The pilot stated that he realized that he "had forgotten to switch the fuel tanks and had run the right fuel tank dry." He immediately switched to the left fuel tank and noted that he already had the fuel boost pump on in anticipation for landing. Despite his efforts, the engine did not restart and the airplane descended into trees and subsequently impacted the ground. The pilot stated that, "if I had used my landing checklist, I would have not run the right tank dry because I would have turned to the fullest tank for landing." Examination of the airplane revealed that it came to rest in a vertical position within a parking lot. The right wing was partially separated from the fuselage and exhibited structural damage. The horizontal stabilator was also structurally damaged. During removal of the airplane, recovery crews reported that they drained 24 ounces of fuel from the left wing fuel tank and 8 ounces of fuel from the right wing fuel tank.

Factual narrative

On November 25, 2008, about 1745 Pacific standard time, a Piper PA-28-180 airplane, N2383R, was substantially damaged when it impacted trees and subsequently terrain following a loss of engine power while on final approach to the Monterey Peninsula Airport (MRY), Monterey, California. The airplane was registered to private individuals and operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91. The private pilot sustained minor injuries and his passenger sustained serious injuries. Visual meteorological conditions prevailed and no flight plan was filed for the personal flight. The cross-country flight originated from Calexico International Airport (CXL), Calexico, California, about 1430 with an intended destination of MRY. The pilot reported that after an uneventful flight, he entered the traffic pattern for runway 10 left. As he turned from downwind to base at an altitude of about 800 feet above ground level (agl), the engine lost power. The pilot stated that he realized he "had forgotten to switch the fuel tanks and had run the right fuel tank dry." He immediately switched to the left fuel tank and noted that he already had the fuel boost pump on in anticipation for landing. Despite his efforts, the engine did not restart and the airplane descended into trees and subsequently impacted the ground. The pilot further reported that prior to departure from CXL; he had topped off the airplane with fuel in Mexicali, Mexico. He then flew 15 minutes to CXL where he underwent an inspection by the US Customs and Border Protection for re-entry into the United States. The pilot added in the Operator/Owner Safety Recommendation section of the Pilot/Operator Aircraft Accident Report Form, "if I had used my landing checklist, I would have not run the right tank dry because I would have turned to the fullest tank for landing." Examination of the airplane by a Federal Aviation Administration (FAA) inspector revealed that the airplane came to rest in a vertical position within a parking lot. The right wing was partially separated from the fuselage and exhibited structural damage. The horizontal stabilator was also structurally damaged. During removal of the airplane, recovery crews reported that they drained 24 ounces of fuel from the left wing fuel tank and 8 ounces of fuel from the right wing fuel tank.

Aircraft

Registration
N2383R
Reported as
Piper PA-28-180
Category
Airplane
Serial number
28-5749
Airframe hours
4,600
Engine
Lycoming O-360 SER, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · May 1, 2008 · 40 hours before
Departed
CXL · Calexico, CA
Destination
MRY · Monterey, CA
Flight plan
Unknown
Airport
MRY · Monterey Peninsula Airport

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
60
Injuries
Minor
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Without waivers/limitations
Last flight review
May 10, 2007
Seat
Left
Flight hours
2,477 total · 1,680 in this make and model · 2,477 as pilot in command · 18 in the last 90 days · 18 in the last 30 days · 7 in the last 24 hours

Weather

Conditions
Visual (VMC) · Night
Wind
220° at 3 knots
Visibility
10 statute miles
Lowest ceiling
2,500 ft overcast
Temperature
57 °F, dew point 54 °F
Observed at
MRY, 1 nm away

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.