# NTSB WPR09LA164: Piper PA-28-181, N1857H, Firebaugh, CA, March 24, 2009 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: March 23, 2009, 18:00 local (Mar 24, 2009, 01:00 UTC) - Place: Firebaugh, CA - Coordinates: 36.859722, -120.464447 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=36.8597&lon=-120.4644&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report December 29, 2009 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration FSDO - NTSB case key (mKey): 73546 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR09LA164 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/73546/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=73546 - Page: https://openairdocs.org/ntsb/WPR09LA164 ## Probable cause A total loss of engine power due to fuel exhaustion as a result of the pilot's inadequate fuel planning and monitoring. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Planning/preparation: fuel planning](https://openairdocs.org/ntsb-findings/02061030): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-28-181, 12 cases](https://openairdocs.org/ntsb-findings/02061030/cases.md?model=7102807), [All aircraft, 719 cases](https://openairdocs.org/ntsb-findings/02061030/cases.md) - [Attention/monitoring: monitoring equip/instruments](https://openairdocs.org/ntsb-findings/02021525): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Piper PA-28-181, 3 cases](https://openairdocs.org/ntsb-findings/02021525/cases.md?model=7102807), [All aircraft, 142 cases](https://openairdocs.org/ntsb-findings/02021525/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid level (probable cause); cases with it: [Piper PA-28-181, 20 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=7102807), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) (defining event); cases with it: [Piper PA-28-181, 12 cases](https://openairdocs.org/ntsb-events/192/sequence.md?model=7102807), [All aircraft, 804 cases](https://openairdocs.org/ntsb-events/192/sequence.md) - [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Piper PA-28-181, 26 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=7102807), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Approach-VFR pattern final: Fuel exhaustion](https://openairdocs.org/ntsb-events/192); cases with it: [Piper PA-28-181, 12 cases](https://openairdocs.org/ntsb-events/192/sequence.md?model=7102807), [All aircraft, 804 cases](https://openairdocs.org/ntsb-events/192/sequence.md) - [Approach-VFR pattern final: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Piper PA-28-181, 26 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=7102807), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Piper PA-28-181, 23 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=7102807), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) ## Analysis The pilot reported departing with about 45 gallons of fuel onboard. She initiated a climb to 10,500 feet, and turned on course direct to the destination airport. About 3 1/2 hours into the flight, she checked the fuel gauges, and estimated that there was enough fuel remaining for about 1 hour 10 minutes of flight. About 15 minutes later the engine stopped producing power. The pilot observed one of the gauges was now reading empty, so she switched to the other tank; the engine then regained power, and she diverted to an alternate airport. During the landing approach, the engine then lost power again, and the pilot performed a forced landing in a plowed field. The airplane sustained substantial damage to the right wing during the accident sequence. Post accident inspection revealed that both tanks were intact and absent of fuel. No obvious sources of a fuel leak were noted. The pilot reported encountering strong headwinds during the flight, and further stated that she was not comfortable with the leaning procedure for the airplane type. ## Factual narrative On March 23, 2009, about 1800 Pacific daylight time, a Piper PA-28-181, N1857H, experienced a loss of engine power followed by a forced-landing in a field short of Firebaugh Airport, Firebaugh, California. The pilot was operating the airplane under the provisions of 14 Code of Federal Regulations Part 91. The certificated private pilot was not injured. The airplane sustained substantial damage to the left wing spar. The personal flight departed Palm Springs International Airport, Palm Springs, California, at 1400, with a planned destination of Reid-Hillview Airport, San Jose, California. Visual meteorological conditions prevailed, and no flight plan had been filed. The pilot reported departing Palm Springs with about 45 gallons of fuel onboard. She initiated a northbound climb to an altitude of 10,500 feet and then changed course to the northwest. About 3 1/2 hours into the flight, she checked the fuel gauges, and observed slightly less than 5 gallons remaining in the right tank and less than 10 gallons in the left tank. The fuel selector was set to the right tank, and she presumed that there was enough fuel remaining for about 1 hour 10 minutes of flight. About 15 minutes later, the engine stopped producing power. She checked the fuel gauges, and observed the right needle was indicating zero fuel. She switched to the left tank, and the engine regained power. The pilot then diverted to the northeast with the intention of landing at Firebaugh Airport. According to a statement made to the Fresno County Sheriff, she was initially unable to locate the airport, and circled around the city of Firebaugh. She then located the airport, and during the landing attempt the engine lost power again. The pilot force-landed in a plowed field. An FAA Inspector responded to the accident site. He examined the airplane, and reported that both fuel tanks were intact and absent of fuel. The inspector did not observe fuel leaks on the external surfaces of the airplane. Recovery personnel drained approximately 32 ounces of fuel from the airplane, and observed no indications of fuel leakage. Additionally, all fuel lines within the engine compartment were intact. The pilot stated that she was certain she leaned the fuel mixture during the flight. However, she further reported that she often had difficulty accurately adjusting the fuel mixture on the accident airplane type, due to its mixture lever. She stated that she was more familiar, and comfortable, adjusting the mixture on an airplane equipped with a Vernier mixture control. The accident location was approximately 71 miles south of Reid-Hillview Airport. The pilot reported encountering 35 knot headwinds during the flight. In a written statement the pilot reported that the accident could have been prevented with, "better planning/execution." ## Aircraft - Registration: [N1857H](https://openairdocs.org/deregistered/N1857H-2012-02-15), registration cancelled 2012-02-15, S/N 28-7790348, built 1977 (OpenAirDocs) - Reported make and model: PIPER PA-28-181 - Registry model: [Piper PA-28-181](https://openairdocs.org/model/piper-pa-28-181) (registry code 7102807) (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: 28-7790348 - Airframe hours: 10751 - Engines: LYCOMING O360 180 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Utility; Standard, Normal - Last inspection: Annual, February 1, 2009, 21 hours before - Departed: PSP, Palm Springs, CA - Destination: RHV, San Jose, CA - Airport: F34, Firebaugh, runway 30, 3,102 × 60 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 54; injuries: none; private; airplane ratings: single-engine land; medical: class 3, without waivers/limitations; last flight review April 11, 2008; seat: left; flight hours: 122 total, 21 in this make and model, 58 as pilot in command, 4 in the last 90 days, 4 in the last 30 days, 0 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 320° at 11 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 57 °F, dew point 28 °F - Altimeter: 30.25 inHg - Observed at: MAE, 19 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 20090323003849A](https://openairdocs.org/incident/20090323003849A), Mar 23, 2009: Piper PA28181, Firebaugh, CA, Substantial damage. (-23) Pilot states she physically checked both fuel tanks as being topped off for a nonstop flight from palm springs, CA to sanjose, CA. She had been switching… ## Docket (2 files) The files NTSB released with the investigation on October 29, 2009, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=73546. 770 KB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 690 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40317676&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Record of Conversation: Pilot and Recovery Personnel (item 2, .PDF, 80 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40319728&FileExtension=.PDF&FileName=Record%20of%20Conversation%3A%20Pilot%20and%20Recovery%20Personnel-Redacted.PDF 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.