# NTSB WPR12LA315: Piper PA-32S-300, N5212S, Adelanto, CA, July 20, 2012

- Type: NTSB accident investigation
- Classification: Accident · No injuries · Limited investigation · Final report
- Date: July 20, 2012, 12:15 local (19:15 UTC)
- Place: Adelanto, CA
- Coordinates: 34.537498, -117.460556 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=34.5375&lon=-117.4606&mi=10
- Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping)
- Defining event: [Takeoff: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341)
- Highest injury: No injuries
- Injuries: 3 uninjured
- Status: Completed, report March 5, 2013
- Report: Approved by Office Director
- NTSB office: Western Pacific Region
- Parties: Federal Aviation Adminstration FSDO, Piper Aircraft Inc.
- ADs cited in the narratives: [AD 78-23-01](https://openairdocs.org/ad/78-23-01) (OpenAirDocs)
- NTSB case key (mKey): 84394
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR12LA315
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/84394/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=84394
- Page: https://openairdocs.org/ntsb/WPR12LA315

## Probable cause

The pilot’s failure to maintain directional control during the aborted takeoff, which was aborted due to fuel starvation as a result of an inadvertent in-flight activation of the fuel drain activation lever by the passenger. Contributing to the accident was the pilot’s failure to have the fuel drain protective cover repaired prior to flight.

## Findings

NTSB's coded findings; those marked are part of the probable cause.

- [Performance/control parameters: directional control](https://openairdocs.org/ntsb-findings/01062020): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Piper PA-32S-300, 1 case](https://openairdocs.org/ntsb-findings/01062020/cases.md?model=7103214), [All aircraft, 3,958 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md)
- [Fuel system: fuel filter-strainer](https://openairdocs.org/ntsb-findings/01022821): Aircraft › Aircraft systems · Damaged/degraded; cases with it: [Piper PA-32S-300, 1 case](https://openairdocs.org/ntsb-findings/01022821/cases.md?model=7103214), [All aircraft, 52 cases](https://openairdocs.org/ntsb-findings/01022821/cases.md)
- [Maintenance/inspections](https://openairdocs.org/ntsb-findings/01010500): Aircraft › Aircraft handling/service · Not serviced/maintained (probable cause); cases with it: [Piper PA-32S-300, 1 case](https://openairdocs.org/ntsb-findings/01010500/cases.md?model=7103214), [All aircraft, 103 cases](https://openairdocs.org/ntsb-findings/01010500/cases.md)
- [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Not specified (probable cause); cases with it: [Piper PA-32S-300, 1 case](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=7103214), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md)
- [Fuel system: fuel filter-strainer](https://openairdocs.org/ntsb-findings/01022821): Aircraft › Aircraft systems · Unintentional use/operation (probable cause); cases with it: [Piper PA-32S-300, 1 case](https://openairdocs.org/ntsb-findings/01022821/cases.md?model=7103214), [All aircraft, 52 cases](https://openairdocs.org/ntsb-findings/01022821/cases.md)
- [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-32S-300, 1 case](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7103214), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Takeoff: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Piper PA-32S-300, 1 case](https://openairdocs.org/ntsb-events/341/sequence.md?model=7103214), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md)
- [Emergency descent: Fuel starvation](https://openairdocs.org/ntsb-events/191); cases with it: [Piper PA-32S-300, 1 case](https://openairdocs.org/ntsb-events/191/sequence.md?model=7103214), [All aircraft, 733 cases](https://openairdocs.org/ntsb-events/191/sequence.md)
- [Landing-flare/touchdown: Hard landing](https://openairdocs.org/ntsb-events/092); cases with it: [Piper PA-32S-300, 1 case](https://openairdocs.org/ntsb-events/092/sequence.md?model=7103214), [All aircraft, 2,102 cases](https://openairdocs.org/ntsb-events/092/sequence.md)
- [Landing-landing roll: Loss of control on ground](https://openairdocs.org/ntsb-events/230); cases with it: [Piper PA-32S-300, 1 case](https://openairdocs.org/ntsb-events/230/sequence.md?model=7103214), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md)
- [Landing-landing roll: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-32S-300, 1 case](https://openairdocs.org/ntsb-events/470/sequence.md?model=7103214), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md)
- [Landing-landing roll: Runway excursion](https://openairdocs.org/ntsb-events/300); cases with it: [Piper PA-32S-300, 1 case](https://openairdocs.org/ntsb-events/300/sequence.md?model=7103214), [All aircraft, 3,643 cases](https://openairdocs.org/ntsb-events/300/sequence.md)

## Analysis

The pilot departed from the dirt airstrip with two passengers. The takeoff roll was uneventful, and shortly after rotation, the engine emanated an unusual sound and lost power. With half the runway remaining, the pilot elected to land ahead. The airplane subsequently landed hard, departed the runway, and struck a pole. The pilot reported that the electrical fuel pump made an unusual sound during the run-up but still produced nominal fuel pressure. The pump, as well as the airframe and engine, were subsequently examined, and no malfunctions or failures were noted that would have precluded normal operation. The electrical pump is a backup for the engine driven pump and will provide positive fuel pressure in the event of an engine driven pump failure. Therefore, a failure of the electrical pump likely would not cause a loss of engine power. Further examination of the airframe revealed a large fuel streak trailing along the belly of the airplane, emanating from the fuel drain sump port. The pilot stated that the stain was not present when the airplane was washed a few flights prior to the accident. A passenger was seated above the drain activation lever, which is located in the aft area of the footwell at the base of the right middle seat. The protective cover had been damaged previously and had not been repaired prior to the accident flight. As such, the lever was exposed and could easily have been inadvertently activated by the passenger’s foot. Such activation could drain fuel from the sump pump and subsequently starve the engine of fuel and result in a loss of engine power. The inclusion of the protective cover was required per a Federal Aviation Administration Airworthiness Directive in order to prevent inadvertent activation in flight.

## Factual narrative

HISTORY OF FLIGHT On July 20, 2012, about 1215 Pacific daylight time, a Piper PA-32S-300, N5212S, veered of the runway during an aborted takeoff from Adelanto Airport (52CL), Adelanto, California. The pilot was operating the airplane under the provisions of 14 Code of Federal Regulations Part 91. The private pilot/owner and two passengers were not injured. The airplane sustained substantial damage during the accident sequence. The personal flight departed Adelanto about 1215, with a planned destination of Hesperia Airport (L26), Hesperia, California. Visual meteorological conditions prevailed, and no flight plan had been filed. The intent of the flight was to pick up a passenger at Hesperia, then continue the flight to Idaho. The pilot serviced the airplane to capacity with fuel in Bakersfield, California, on the prior flight earlier that day. The airplane’s original configuration was for three rows of seats, but for the accident flight, the rear two seats were removed to make way for baggage. The pilot was positioned in the front left seat, with the passengers located in the front right, and middle right seats. The pilot reported that the preflight check and engine run up was uneventful; however, when he turned on the electrical fuel pump, it did not make the usual sound he was accustomed to hearing, and that the fuel pressure reading was slightly lower than usual. The pressure was still within the green (normal) limit, and as such, he elected to continue with the departure. He stated that the takeoff roll from the dirt airstrip was uneventful. Shortly after rotation, the engine emanated an unusual sound, and the airplane did not climb as expected. He checked the engine tachometer, which indicated 2,400 rpm, and observed the manifold pressure at 20 inches of mercury. With half the length (approximately 2,000 feet) of the runway remaining, he aborted the takeoff. The airplane touched down, bounced, and departed the runway to the left, where it dropped into a ditch and struck a pole. The nose landing gear collapsed, and the left wing and firewall sustained structural damage during the accident sequence. TESTS AND RESEARCH Engine and Airframe Examination The airplane was recovered from the accident site, and examined by the NTSB investigator-in-charge (IIC) and a representative from Piper Aircraft. The right tip tank, when examined through the filler neck, contained fuel to about half of its capacity. All other fuel tanks were full with fuel to their respective capacities. The fuel pump circuit breaker was in the closed position. The fuel lines were examined, and no leaks or loose fittings were noted. The electrically driven fuel pump was turned on, and initially made a metallic grinding sound, consistent with it being void of fuel. After about 5 seconds, the sound ceased as the pump became primed with fuel. The fuel line into the engine driven fuel pump was disconnected, and the fuel selector valve was cycled through each tank position with thepump on. Uninterrupted fuel flow was observed at the line output. The electrical fuel pump was subsequently disassembled. The commutator and brushes were intact, along with the interconnect shear coupling. The electrical armature was intact, and rotated smoothly within the housing, with a slight squeaking sound noted. The fuel rotor rotated freely, and the pump vanes were intact. According to the Piper representative, the electrical pump is provided as a backup to the engine driven pump, and will provide positive fuel pressure in the event of an engine driven fuel pump failure. The engine sustained minimal damage during the accident sequence. All engine controls were continuous from their respective control arms through to the cabin controls, and moved smoothly through full range of travel when operated. The oil sump contained about 12 quarts of oil when viewed utilizing the dipstick. The top spark plugs were removed, and examined. Their electrodes remained mechanically undamaged, coated in light grey deposits, and displayed normal wear signatures when compared with the Champion Spark Plugs AV-27 Check-A-Plug chart. The exhaust pipes exhibited light grey deposits, and were free of oil residue. The crankshaft turned freely when rotated by hand utilizing the propeller, and cylinder compression was noted on all cylinders. Mechanical continuity was established throughout the rotating group, valve train, and accessory section. Sparks were observed at the termination of each top spark plug lead. Visual inspection of the combustion chambers was accomplished through the spark plug bores utilizing a borescope; there was no evidence of foreign object damage and all combustion surfaces exhibited light grey deposits consistent with normal operation. Examination did not reveal any anomalies with the airframe or engine that would have precluded normal operation. Fuel Drain The airplane was equipped with a fuel drain lever located in the aft area of the footwell at the base of the right middle seat. The lever was connected to the combination fuel selector valve/fuel drain, located in the airframe belly. Examination of the belly revealed an expanding streak of skin discoloration, emanating from the drain output port. The streak ran the full length of the belly, and had partially removed dirt in its path. The pilot stated that he had cleaned the underside of the airplane a few days prior to the accident, and did not observe the streak at that time. No active fuel leak was noted at the time of the examination, and fuel flowed from the output port when the drain lever was activated. Federal Aviation Administration Airworthiness Directive AD 78-23-01, applicable to the accident airplane, requires the addition of a fuel drain cover door, to prevent inadvertent drain lever actuation. The door had been installed, however, examination of the assembly revealed that the door was detached from the hinge, and was hanging loose, exposing the lever. A test was performed todetermine if the condition of the door could allow for a passenger to inadvertently activate the lever. The test revealed that an occupant positioned in the middle right seat was able to operate the lever with the heel of his shoe, causing fuel to flow from the drain port at the belly. The pilot stated that the door had been inadvertently damaged by a passenger egressing the airplane about three flights prior, and he did not have the door repaired. Airport Adelanto Airport has two intersecting runways, and is located at an elevation of 3,075 feet mean sea level (msl). The pilot departed utilizing the southern dirt runway, which was 3,930-feet-long. Weather The closest aviation weather observation station was located at Southern California Logistics Airport, Victorville, California, which was located 6 miles northeast of the accident site. The elevation of the weather observation station was 2,885 feet msl. An aviation routine weather report (METAR) was recorded at 1215 PDT. It reported: wind from 110 degrees at 5 knots; visibility 10 miles; temperature 33 degrees C; dew point 08 degrees C; altimeter 30.06 inches of mercury. Based on these values, the calculated density altitude at Victorville was about 5,525 feet.

## Aircraft

- Registration: [N5212S](https://openairdocs.org/aircraft/N5212S), registered now, S/N 32S-40904, built 1970 (OpenAirDocs)
- Reported make and model: PIPER PA-32S-300
- Registry model: [Piper PA-32S-300](https://openairdocs.org/model/piper-pa-32s-300) (registry code 7103214) (OpenAirDocs)
- Registry engine: [Lycoming TI0-540 series](https://openairdocs.org/engine/lycoming-ti0-540-series) (registry code 41533, turbo-prop) (OpenAirDocs)
- Category: Airplane
- Serial number: 32S-40904
- Airframe hours: 3394
- Engines: LYCOMING IO-540 300 horsepower reciprocating
- Damage: Substantial damage
- Flight: Personal, Part 91
- Airworthiness certificate: Standard, Normal
- Last inspection: Annual, July 1, 2011, 38 hours before
- Departed: 52CL, Victorville, CA
- Destination: L26, Hesperia, CA
- Airport: 52CL, Adelanto, runway 18, 3,930 × 100 ft, dirt

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 45; injuries: none; private; airplane ratings: single-engine land; medical: class 3, without waivers/limitations; last flight review September 2, 2011; seat: left; flight hours: 750 total, 124 in this make and model, 24 in the last 90 days, 5 in the last 30 days, 3 in the last 24 hours

## Weather

- Conditions: Visual (VMC), Day
- Wind: 110° at 5 knots
- Visibility: 10 statute miles
- Lowest ceiling: none
- Temperature: 91 °F, dew point 46 °F
- Altimeter: 30.05 inHg
- Observed at: KVCV, 6 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 20120720016779A](https://openairdocs.org/incident/20120720016779A), Jul 20, 2012: Piper PA-32S-300, Adelanto, CA, Substantial damage. Pilot was on take off roll when he encountered a unusual sound and the aircraft was not able to climb. Take off was aborted. Aircraft ran off the runway and…

## Other investigations on N5212S (1)

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.

- [NTSB CHI72FEI45](https://openairdocs.org/ntsb/CHI72FEI45), Jun 11, 1972: Piper PA-32 (N5212S), Mansfield, OH, substantial damage

## Docket (10 files)

The files NTSB released with the investigation on January 16, 2013, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=84394. 6.0 MB in all.

- Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40380351&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF
- Record of Conversation: Pilot (item 2, .PDF, 201 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40380493&FileExtension=.PDF&FileName=Record%20of%20Conversation%3A%20Pilot-Master.PDF
- Photo 1 - Airplane Damage (item 3, .PDF, 929 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40380355&FileExtension=.PDF&FileName=Photo%201%20-%20Airplane%20Damage-Master.PDF
- Photo 2 – Fuel Drain Cover (item 4, .PDF, 151 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40380356&FileExtension=.PDF&FileName=Photo%202%20%E2%80%93%20Fuel%20Drain%20Cover-Master.PDF
- Photo 3 – Belly Streak (item 5, .PDF, 685 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40380357&FileExtension=.PDF&FileName=Photo%203%20%E2%80%93%20Belly%20Streak-Master.PDF
- Photo 4 – Fuel Pump Components (item 6, .PDF, 870 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40380358&FileExtension=.PDF&FileName=Photo%204%20%E2%80%93%20Fuel%20Pump%20Components-Master.PDF
- Photo 5 – Fuel Pump Cavity (item 7, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40380359&FileExtension=.PDF&FileName=Photo%205%20%E2%80%93%20Fuel%20Pump%20Cavity-Master.PDF
- FAA Airworthiness Directive 78-23-01 (item 8, .PDF, 28 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40380360&FileExtension=.PDF&FileName=FAA%20Airworthiness%20Directive%2078-23-01-Master.PDF
- Statement of Party Representatives to NTSB Investigation (item 9, .PDF, 337 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40380361&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF
- Evidence Control Form (item 10, .PDF, 82 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40380362&FileExtension=.PDF&FileName=Evidence%20Control%20Form-Master.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.

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