WPR10LA210

NTSB accident investigation · Piper PA-44-180 · Tooele, UT · April 21, 2010

Accident · Minor injuriesLimited investigationFinal report
Date
April 20, 2010, 19:00 local (Apr 21, 2010, 01:00 UTC)
Place
Tooele, UT
Injuries
1 minor, 1 uninjured
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N331GPPiper PA-44-180
Defining event
Initial climb: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report August 12, 2010
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Salt Lake FSDO
FAA report
20100420032629A
Case key
75804

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 complete loss of power in one engine due to fuel starvation as a result of the pilot's failure to reposition the cross-feed valve prior to takeoff and the flight instructor's failure to monitor the pilot's actions. Contributing to the accident was the instructor pilot's failure to monitor the fuel level during the flight and his decision to turn left (into the failed engine) after the loss of power.

Findings · 6

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.

Fuel system: fuel selector/shutoff valveAircraft › Aircraft systems · Incorrect use/operationPiper PA-44-180: 2 casesAll aircraft: 176 casesProbable cause
Action: forgotten action/omissionPersonnel issues › Action/decision · PilotPiper PA-44-180: 8 casesAll aircraft: 440 casesProbable cause
Attention/monitoring: monitoring other personPersonnel issues › Psychological · Instructor/check pilotPiper PA-44-180: 2 casesAll aircraft: 200 casesProbable cause
Attention/monitoring: monitoring equip/instrumentsPersonnel issues › Psychological · Instructor/check pilotPiper PA-44-180: 1 caseAll aircraft: 142 casesProbable cause
Action: incorrect action selectionPersonnel issues › Action/decision · Instructor/check pilotPiper PA-44-180: 2 casesAll aircraft: 397 casesProbable cause
Fluids: fuelAircraft › Fluids/misc hardware · Fluid managementPiper PA-44-180: 6 casesAll aircraft: 1,695 cases

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.

Analysis

Prior to starting the before-takeoff checklist in preparation for the instructional flight in the twin-engine airplane, the private pilot-rated student performed the required engine/fuel tank cross-feed check. At the completion of that check, she inadvertently forgot to reposition the right engine fuel selector to the "ON" position, but instead left it in "Cross-Feed." Therefore, as the flight progressed with both engines using fuel from the left tank, it ultimately led to the consumption of all usable full in that tank. Therefore, the left engine lost all power during the initial climb after takeoff from a practice short-field landing. When the engine lost power, the student realized the right engine fuel selector was in "Cross-feed"and repositioned it to the "ON" position, but did not advise the flight instructor that she had done so. The flight instructor, who took control of the airplane after the loss of power, was unable to get the left propeller to fully feather due to the low oil pressure created by the low engine rpm. He therefore decided to attempted to turn back to the airport, but in doing so turned left (into the failed engine), and the airplane therefore began to descend at a rate that made it unlikely that he could safely reach the runway. He therefore landed in a nearby open field, whereupon the airplane encountered rough terrain and experienced a collapse of the left main landing gear. The commercially produced expanded checklist that the student was using did not have an added step in the "Before-Takeoff" section calling for a recheck of the fuel valves in the "ON" position. The expanded checklist produced by the airplane's operator did have such a step, but the operator did not have a written policy requiring the use of their checklist.

Factual narrative

On April 20, 2010, about 1900 mountain daylight time, a Piper PA-44-180, N331GP, experienced a gear collapse during a forced landing about two miles southeast of Tooele Valley Airport, Tooele, Utah. The certified flight instructor was not injured, but his private pilot-rated student received minor injuries. The airplane, which was operated by Leading Edge Aviation, sustained substantial damage to both its fuselage and wings. The 14 Code of Federal Regulation Pat 91 instructional flight departed Salt Lake City International Airport about 60 minutes prior to the accident. The flight was being operated in visual meteorological conditions. No flight plan had been filed. According to the flight instructor, after departing the Salt Lake City area the student executed a simulated engine-out instrument landing system (ILS) approach to Tooele Valley Airport. During that approach the right engine was set at idle. At the completion of that approach, a touch-and-go landing was performed with both engines being brought up to full power during the takeoff. The student then stayed in the VFR (visual flight rules) pattern, and performed a short field landing using both engines, followed by a normal takeoff using both engines. During the initial climb, as the airplane reached a height of about 200 to 300 feet above ground level (agl), it suddenly lost all power in the left engine. At that time the flight instructor took control of the airplane, confirmed that the left engine had lost all power, checked the position of the fuel selector valves, and then attempted to feather the left engine. The left engine did not fully feather due to insufficient oil pressure as a result of the low engine rpm, and soon thereafter the instructor pilot turned to the left in an attempt to get back around to the airport. After he initiated the turn to the left (into the power-out engine) the airplane started to descend, and it became obvious to the instructor that the airplane was losing altitude too quickly for him to safely maneuver back around to the airport. He therefore picked out an area for a forced landing and headed toward that location. While he was about 50 feet in the air he lowered the landing gear, but he left the flaps in the full up position. Although the touchdown was successful, during the landing roll the airplane encountered rough terrain that resulted in the collapse of the left main landing gear. Two days after the accident, the private pilot, who was receiving instruction in preparation for a multi-engine rating proficiency check, revealed that after performing the engine cross-feed check prior to departing Salt Lake International Airport, she had inadvertently forgotten to correctly reposition the right fuel selector to the "ON" position. The result of that omission created a situation where both engines were feeding off of the left fuel tank (right engine in cross-feed). She further stated that when the left engine lost power during the initial climb, shenoticed the incorrect fuel selector position, and reset it to the "ON" position so that the right engine was feeding off of the right fuel tank. She further stated that she did not mention the repositioning of the fuel selector valve to the flight instructor during the accident sequence, and therefore when he checked the position of the fuel selectors after taking control of the airplane, he had no idea that the selector had been incorrectly positioned and then repositioned. In a phone conversation with the NTSB Investigator-In-Charge, the flight instructor said he had not noticed the incorrectly positioned fuel selector, and neither he nor the private pilot noticed the unequal fuel tank quantity that developed as the flight progressed. The investigation also revealed that the private pilot was using an expanded checklist produced by CheckMate Aviation Inc., instead of the expanded checklist produced by Leading Edge Aviation (the operator). A review of those two checklists revealed that both were expanded to include items/steps beyond those found in the Pilot's Operating Handbook (POH) provided by the airplane's manufacturer. Both checklists called for the cross-feed check to be completed prior to the initiation of the Before-Takeoff portion of the checklist, but only the Leading Edge Aviation version included an extra step in the Before-Takeoff section that called for the pilot to recheck that the fuel selector valves had been reset in the "ON" position (as opposed to still in cross-feed). A further discussion with Leading Edge Aviation personnel revealed that although it was expected that instructor pilots, students, and renters would use the Leading Edge Aviation checklist, there was no written policy that required them to do so.

Aircraft

Registration
N331GP
Reported as
Piper PA-44-180
Category
Airplane
Serial number
44-7995277
Airframe hours
6,908
Engines
Lycoming O-360-E1A6D, 180 horsepower, reciprocatingLycoming LO-360-E1A6D, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
Leading Edge Aviation
Registered owner
Logan Air Services LLC
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · March 24, 2010
Departed
KSLC · Salt Lake City, UT
Destination
KSLC · Salt Lake City, UT
Airport
KTVY · Tooele Valley

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Flight instructor
Age
30
Injuries
None
Certificates
Flight instructor, Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
August 21, 2008
Seat
Right
Flight hours
2,207 total · 127 in this make and model · 2,108 as pilot in command · 174 in the last 90 days · 56 in the last 30 days · 4 in the last 24 hours
Role
Pilot
Age
29
Injuries
Minor
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Without waivers/limitations
Last flight review
November 8, 2008
Seat
Left
Flight hours
268 total · 34 in this make and model · 20 in the last 90 days

Weather

Conditions
Visual (VMC) · Day
Wind
190° at 14 knots, gusting 23
Visibility
10 statute miles
Lowest ceiling
20,000 ft broken
Temperature
73 °F
Altimeter
29.60 inHg

Docket · 4

The files NTSB released with the investigation on June 6, 2010, on NTSB’s docket system: statements, records, photos and specialists’ reports. 1.5 MB in all.

FAA reports on this event · 1

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