# NTSB WPR10LA210: Piper PA-44-180, N331GP, Tooele, UT, April 21, 2010 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: April 20, 2010, 19:00 local (Apr 21, 2010, 01:00 UTC) - Place: Tooele, UT - Coordinates: 40.595275, -112.33889 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=40.5953&lon=-112.3389&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: Minor injuries - Injuries: 1 minor, 1 uninjured - Status: Completed, report August 12, 2010 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Salt Lake FSDO - NTSB case key (mKey): 75804 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR10LA210 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/75804/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=75804 - Page: https://openairdocs.org/ntsb/WPR10LA210 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Fuel system: fuel selector/shutoff valve](https://openairdocs.org/ntsb-findings/01022823): Aircraft › Aircraft systems · Incorrect use/operation (probable cause); cases with it: [Piper PA-44-180, 2 cases](https://openairdocs.org/ntsb-findings/01022823/cases.md?model=7104402), [All aircraft, 176 cases](https://openairdocs.org/ntsb-findings/01022823/cases.md) - [Action: forgotten action/omission](https://openairdocs.org/ntsb-findings/02041035): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA-44-180, 8 cases](https://openairdocs.org/ntsb-findings/02041035/cases.md?model=7104402), [All aircraft, 440 cases](https://openairdocs.org/ntsb-findings/02041035/cases.md) - [Attention/monitoring: monitoring other person](https://openairdocs.org/ntsb-findings/02021535): Personnel issues › Psychological · Instructor/check pilot (probable cause); cases with it: [Piper PA-44-180, 2 cases](https://openairdocs.org/ntsb-findings/02021535/cases.md?model=7104402), [All aircraft, 200 cases](https://openairdocs.org/ntsb-findings/02021535/cases.md) - [Attention/monitoring: monitoring equip/instruments](https://openairdocs.org/ntsb-findings/02021525): Personnel issues › Psychological · Instructor/check pilot (probable cause); cases with it: [Piper PA-44-180, 1 case](https://openairdocs.org/ntsb-findings/02021525/cases.md?model=7104402), [All aircraft, 142 cases](https://openairdocs.org/ntsb-findings/02021525/cases.md) - [Action: incorrect action selection](https://openairdocs.org/ntsb-findings/02041010): Personnel issues › Action/decision · Instructor/check pilot (probable cause); cases with it: [Piper PA-44-180, 2 cases](https://openairdocs.org/ntsb-findings/02041010/cases.md?model=7104402), [All aircraft, 397 cases](https://openairdocs.org/ntsb-findings/02041010/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid management; cases with it: [Piper PA-44-180, 6 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=7104402), [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. - [Standing-engine(s) operating: Miscellaneous/other](https://openairdocs.org/ntsb-events/900); cases with it: [Piper PA-44-180, 2 cases](https://openairdocs.org/ntsb-events/900/sequence.md?model=7104402), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) - [Initial climb: Fuel starvation](https://openairdocs.org/ntsb-events/191); cases with it: [Piper PA-44-180, 2 cases](https://openairdocs.org/ntsb-events/191/sequence.md?model=7104402), [All aircraft, 733 cases](https://openairdocs.org/ntsb-events/191/sequence.md) - [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Piper PA-44-180, 7 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=7104402), [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-44-180, 6 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=7104402), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing: Landing gear collapse](https://openairdocs.org/ntsb-events/094); cases with it: [Piper PA-44-180, 11 cases](https://openairdocs.org/ntsb-events/094/sequence.md?model=7104402), [All aircraft, 1,787 cases](https://openairdocs.org/ntsb-events/094/sequence.md) ## 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](https://openairdocs.org/aircraft/N331GP), registered now, S/N 44-7995277, built 1979 (OpenAirDocs) - Reported make and model: PIPER PA-44-180 - Registry model: [Piper PA-44-180](https://openairdocs.org/model/piper-pa-44-180) (registry code 7104402) (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: 44-7995277 - Airframe hours: 6908 - Engines: LYCOMING O-360-E1A6D 180 horsepower reciprocating; LYCOMING 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 30; injuries: none; 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 - Pilot; age 29; injuries: minor; 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 ## 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 20100420032629A](https://openairdocs.org/incident/20100420032629A), Apr 20, 2010: Piper PA-44-180, Toole, UT, Substantial damage. Flight instructor stated that after a touch and go, the student throttled up both engines and over the departure end of the runway numbers the left engine went… ## Docket (4 files) The files NTSB released with the investigation on June 6, 2010, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=75804. 1.5 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 647 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40329865&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Student Statement (item 2, .PDF, 13 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40329866&FileExtension=.PDF&FileName=Student%20Statement-Redacted.PDF - Leading Edge Checklist (item 3, .PDF, 563 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40329867&FileExtension=.PDF&FileName=Leading%20Edge%20Checklist-Master.PDF - Checkmate Checklist (item 4, .PDF, 235 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40329872&FileExtension=.PDF&FileName=Checkmate%20Checklist-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.