# NTSB WPR09LA046: Piper PA-28-180, N2383R, Monterey, CA, November 26, 2008 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: November 25, 2008, 17:45 local (Nov 26, 2008, 01:45 UTC) - Place: Monterey, CA - Coordinates: 36.586944, -121.842781 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=36.5869&lon=-121.8428&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-VFR pattern downwind: Fuel starvation](https://openairdocs.org/ntsb-events/191) - Highest injury: Serious injuries - Injuries: 1 serious, 1 minor - Status: Completed, report March 23, 2009 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 69501 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR09LA046 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/69501/pdf - Page: https://openairdocs.org/ntsb/WPR09LA046 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid management (probable cause); cases with it: [Piper PA-28-180, 32 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=7102808), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Use of equip/info: use of checklist](https://openairdocs.org/ntsb-findings/02063030): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-28-180, 3 cases](https://openairdocs.org/ntsb-findings/02063030/cases.md?model=7102808), [All aircraft, 336 cases](https://openairdocs.org/ntsb-findings/02063030/cases.md) - [Fuel system](https://openairdocs.org/ntsb-findings/01022800): Aircraft › Aircraft systems · Incorrect use/operation (probable cause); cases with it: [Piper PA-28-180, 2 cases](https://openairdocs.org/ntsb-findings/01022800/cases.md?model=7102808), [All aircraft, 181 cases](https://openairdocs.org/ntsb-findings/01022800/cases.md) - [Planning/preparation: fuel planning](https://openairdocs.org/ntsb-findings/02061030): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-28-180, 17 cases](https://openairdocs.org/ntsb-findings/02061030/cases.md?model=7102808), [All aircraft, 719 cases](https://openairdocs.org/ntsb-findings/02061030/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach-VFR pattern downwind: Fuel starvation](https://openairdocs.org/ntsb-events/191) (defining event); cases with it: [Piper PA-28-180, 17 cases](https://openairdocs.org/ntsb-events/191/sequence.md?model=7102808), [All aircraft, 733 cases](https://openairdocs.org/ntsb-events/191/sequence.md) ## 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](https://openairdocs.org/deregistered/N2383R-2013-09-19), registration cancelled 2013-09-19, S/N 28-5749, built 1969 (OpenAirDocs) - Reported make and model: PIPER PA-28-180 - Registry model: [Piper PA-28-180](https://openairdocs.org/model/piper-pa-28-180) (registry code 7102808) (OpenAirDocs) - Registry engine: [Lycoming O&VO-360 series](https://openairdocs.org/engine/lycoming-o-vo-360-series) (registry code 41514, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-5749 - Airframe hours: 4600 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 60; injuries: minor; 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 (OpenAirDocs). - [Accident 20081125853899A](https://openairdocs.org/incident/20081125853899A), Nov 25, 2008: Piper PA28180, Monterey, CA, Substantial damage. On November 25th, 2008 at approximately 2:30 local time the pilot of N2383R, a Piper cherokee PA-28-180 departed calexico airport (cxl) for Monterey airport… From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.