WPR18TA236

NTSB accident investigation · Piper PA28 · Mokuleia, HI · August 21, 2018

Accident · Minor injuriesClass 3Final report
Date
August 20, 2018, 17:05 local (Aug 21, 2018, 03:05 UTC)
Place
Mokuleia, HI
Injuries
3 minor
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N98146Piper PA28
Defining event
Initial climb: Fuel starvation
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration
FAA report
20180820011859A
Case key
98131

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

A total loss of engine power due to fuel starvation as a result of the flight instructor's inadequate preflight inspection.

Findings · 4

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.

Fluids: fuelAircraft › Fluids/misc hardware · Fluid managementPiper PA-28-140: 32 casesAll aircraft: 1,695 casesProbable cause
Fluids: fuelAircraft › Fluids/misc hardware · Fluid levelPiper PA-28-140: 32 casesAll aircraft: 1,695 casesProbable cause
Use of equip/info: use of equip/systemPersonnel issues › Task performance · Instructor/check pilotPiper PA-28-140: 16 casesAll aircraft: 1,391 casesProbable cause
Inspection: preflight inspectionPersonnel issues › Task performance · Instructor/check pilotPiper PA-28-140: 5 casesAll aircraft: 551 casesProbable cause

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

The flight instructor reported that, before the flight, he requested that the airplane be refueled, and his subsequent preflight inspection revealed that the airplane had been fueled to the specified level. While conducting touch-and-go takeoffs and landings during the instructional flight, the engine lost power about 300 ft above ground level, and the instructor performed a forced landing to an open field adjacent to the runway. The airplane impacted a fence and came to rest upright. Postaccident examination revealed that the right-wing fuel tank contained about 7 to 8 gallons of fuel, with a slow fuel leak, and the left-wing fuel tank was void of fuel and undamaged. The fuel selector was positioned to the left-wing tank. An engine test run revealed no anomalies. Interviews with the staff of the fixed base operator from which the instructor ordered fuel revealed that a fuel order was received for the accident airplane; however, the airplane was not refueled before the accident flight.

Factual narrative

On August 20, 2018, about 1705 Hawaii standard time, a Piper PA-28-180, N98146, was substantially damaged when it was involved in an accident near Mokuleia, Hawaii. The flight instructor, student pilot, and passenger sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The flight instructor reported that, before the flight, he called the fixed base operator (FBO) and requested that the airplane be refueled "to the tabs." A preflight inspection revealed no anomalies, and the fuel was at the tab level as requested. They departed on the flight and conducted maneuvers at altitude before returning to the airport for touch-and-go takeoffs and landings. While taking off during the third touch-and-go, the engine lost power about 300 feet above ground level. The instructor took control of the airplane and initiated a forced landing to an open field south of the runway. During the landing, the airplane impacted a fence and came to rest upright. The student pilot reported that the flight instructor did the exterior preflight inspection of the airplane, and only recalled him looking in the right-wing fuel tank to verify the fuel level. Examination of the airplane by a Federal Aviation Administration inspector revealed that the right wing and fuselage sustained structural damage. The inspector reported that, during recovery of the wreckage, the left-wing fuel tank contained no fuel and was undamaged, and the right-wing fuel tank contained about 7 to 8 gallons of fuel, with a slow fuel leak. The fuel selector valve inside the airplane was set to the left-wing fuel tank, and all other engine controls were in the "off" position. The instructor reported to the inspector that, after the initial egress, he reentered the airplane and placed all controls in the off position and but did not touch the fuel selector. In order to facilitate an engine run, the starter was replaced, and one ignition lead was repaired. The engine ran uneventfully for an unspecified amount of time before it was shut down. The manager of the FBO reported that they received a request for fuel on the day of the accident for the accident airplane; however, they did not refuel the airplane. The FBO employee that was conducting aircraft refueling the day of the accident reported that he never received a call from his dispatch to refuel the accident airplane.

Aircraft

Registration
N98146
Reported as
Piper PA28 (140)
Category
Airplane
Serial number
28-26072
Built
1969
Engine
Lycoming O-320 SERIES, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
Aviation Academy Hawaii
Registered owner
Alana Aviation Inc Trustee
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · June 16, 2018 · 85 hours before
Departed
HLN · Honolulu, HI
Destination
HLN · Honolulu, HI
Airport
HDH · Dillingham Airfield, runway 08, 9,007 × 75 ft, asphalt
Equipment
Stall warning system

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
72
Injuries
Minor
Certificates
Airline transport, Commercial, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
September 30, 2016
Seat
Right
Restraint
Lap only
Flight hours
8,281.9 total · 2,500 in this make and model · 7,500 as pilot in command · 162.5 in the last 90 days · 57.7 in the last 30 days · 2.5 in the last 24 hours
Role
Student pilot
Age
17
Injuries
Minor
Certificate
Student
Medical
Class 1, With waivers/limitations
Seat
Left
Restraint
Lap only
Flight hours
17 total · 17 in this make and model · 12.1 in the last 90 days · 9.1 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
60° at 9 knots
Visibility
10 statute miles
Temperature
81 °F, dew point 64 °F
Altimeter
30.04 inHg
Observed at
PHHI, 10 nm away

Docket · 5

The files NTSB released with the investigation on June 3, 2021, on NTSB’s docket system: statements, records, photos and specialists’ reports. 10.3 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.