# NTSB WPR19FA251: Piper PA18, N14365, Hood River, OR, September 6, 2019

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Class 3 · Field · Final report
- Date: September 6, 2019, 10:09 local (17:09 UTC)
- Place: Hood River, OR · Airport Environment
- Coordinates: 45.673889, -121.54222
- Nearby events: https://openairdocs.org/map.md?lat=45.6739&lon=-121.5422&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: Fatal
- Injuries: 2 fatal
- Status: Completed
- Report: Approved by Office Director
- Investigation class: Class 3
- NTSB office: Western Pacific Region
- Parties: Federal Aviation Administration, Lycoming Engines, a Division of AVCO Corporation, Piper Aircraft Inc.
- NTSB case key (mKey): 100203
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR19FA251
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/100203/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=100203
- Page: https://openairdocs.org/ntsb/WPR19FA251

## Probable cause

The total loss of engine power shortly after takeoff as a result of the private pilot’s failure to ensure the fuel selector was in the appropriate position and the certified flight instructor’s exceedance of the airplane’s critical angle of attack at the time of the engine power loss, which resulted in an aerodynamic stall and loss of airplane control.

## 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 · Unintentional use/operation (probable cause); cases with it: [Piper PA-18-150, 2 cases](https://openairdocs.org/ntsb-findings/01022823/cases.md?model=7101828), [All aircraft, 176 cases](https://openairdocs.org/ntsb-findings/01022823/cases.md)
- [Performance/control parameters: angle of attack](https://openairdocs.org/ntsb-findings/01062042): Aircraft › Aircraft oper/perf/capability · Capability exceeded (probable cause); cases with it: [Piper PA-18-150, 10 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md?model=7101828), [All aircraft, 990 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md)
- [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-18-150, 20 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=7101828), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md)
- [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Instructor/check pilot (probable cause); cases with it: [Piper PA-18-150, 160 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7101828), [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-18-150, 18 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=7101828), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md)
- [Takeoff: Loss of control in flight](https://openairdocs.org/ntsb-events/240); cases with it: [Piper PA-18-150, 41 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=7101828), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md)
- [Takeoff: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-18-150, 115 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7101828), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md)

## Analysis

Witnesses observed the airplane takeoff, and one witness noted its nose-high attitude during takeoff. They then heard the engine lose power. The airplane subsequently pitched down and began a rotation to the right before impacting the ground just north of the runway. First responders reported that the fuel selector valve was found in the OFF position when they arrived at the accident site, and they also noted fuel leaking from the airplane. Further examination of the airplane revealed the fuel selector indicator plate displayed a red witness mark adjacent to the fuel selector pointer under one of the OFF-indicator marks, which is an indication the selector was in the OFF position at the time of impact. No evidence of mechanical malfunctions or failures were identified that would have precluded normal operation. Because the engine lost power during takeoff, it is possible that there was enough residual fuel in the fuel lines to start the engine and taxi to the runway, even with the selector in the OFF position. The private pilot was seated in the front seat and the certified flight instructor was seated in the rear seat. The fuel selector was located on the left cabin wall closest to the private pilot; it is likely the private pilot failed to check the position before takeoff. When the airplane departed, it was about 21 pounds over the maximum takeoff weight. An increase in the airplane’s weight would have an adverse effect on stability and controllability. Because the airplane was already in a nose-high attitude when the engine lost power, the airplane likely stalled. The increased weight and low altitude when the power loss occurred prevented the pilots from recovering. Postmortem toxicology testing detected quinine in the certified flight instructor’s blood and urine at a level that was not quantified; therefore, the amount detected was likely from a tonic drink containing quinine rather than ingestion of the drug and would not have been impairing.

## Factual narrative

On September 6, 2019, at 1009 Pacific daylight time, a Piper PA-18, N14365, was substantially damaged when it was involved in an accident near Hood River, Oregon. The certificated flight instructor (CFI) and private pilot were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. A witness observed the airplane during takeoff from Ken Jernstedt Airport (4S2), Hood River, Oregon. The witness stated it appeared as if it was in slow flight with a nose-high angle of attack. He observed the nose of the airplane pitch down, which he attributed to corrective action by the pilots, when the engine abruptly lost power. The witness reported the right wing started to drop and the airplane was half-way through a rotation/spin when it impacted the ground. He estimated that the airplane was no more than 100 ft above ground level (agl). Another witness was in the grass area on the west side of the runway marshalling airplanes to parking spots for an annual fly-in. He observed the airplane taxi and takeoff, with the engine producing full power. As the airplane was climbing after takeoff, he heard the engine lose power abruptly. The witness observed the airplane’s nose lower “as if it was trying to gain airspeed,” while the airplane began a turn to the right. The nose continued to lower, and the rate of rotation increased until the witness lost site of the airplane behind the T-hangars. The airplane came to rest on the northside of runway 25 adjacent to T-hangars, about mid-span of the T-hangar row, on a southerly heading facing the runway. The cockpit of the airplane came to rest upright. First responders reported that the fuel selector valve was found in the OFF position when they arrived onsite. They also noted fuel leaking from the airplane. A postaccident examination of the airplane revealed the fuselage/cockpit area sustained impact damage with aft crushing. The carburetor heat lever was out (ON position) and bent down. The mixture lever was in the full rich position. The primer pump was in and locked. The flaps were in the UP position and the throttle lever was positioned between OPEN and CLOSED. Flight control continuity was established from the cockpit to each flight control surface. The fuel selector was in place on the left cabin wall. The selector was in the OFF position and the pointer had been folded over toward the handle. The indicator plate displayed a red witness mark adjacent to the fuel selector pointer under one of the OFF-indicator marks. When the indicator plate was removed, some fuel was leaking from the fuel selector and fuel lines. Air was blown through each fuel inlet with no blockages noted. The selector position was moved from each detent position (OFF, LEFT, RIGHT) without obstruction. The engine remained attached to the engine mounts and was pushed aft into the firewall. Manual rotation of the engine produced mechanical and valve-train continuity, with thumb compressionobtained at all cylinders. Both magnetos remained attached to their respective mounting pads in their normal location on the engine. The magnetos were removed and produced spark at each of the leads when tested. The top four spark plugs were removed; their electrodes exhibited normal wear. When the carburetor was opened, there was fuel in the bowl that was blue in color and smelled like avgas. There was about 1 inch of fuel in the bowl. According to a representative of the airplane manufacturer, the aircraft’s basic empty weight was calculated to be 1,086.2 pounds (lbs.). The weight at the time of the accident was calculated to be 1,771.4 lbs. This calculation factored in the reported weight of the occupants (479 lbs. total), the fuel weight reported by the operator (full tanks less 20 minutes' flight time, 196.2 lbs.) as well as the 10 lbs. of miscellaneous items (oil bottles, documents, etc.) that appeared to be aboard. The Type Certificate Data Sheet for the airplane listed 1,750 lbs. as the Normal Category Max Weight for the PA-18-150. A review of airport security video footage showed the airplane in a right descending turn before it impacted the ground. Autopsies were performed on both occupants by the Oregon State Medical Examiner's Office. The cause of death for the CFI (seated in the rear seat) was listed as “blunt force head injury.” The cause of death for the private pilot (seated in the front seat) was listed as “multiple blunt force injuries.” Toxicology testing was performed at the Federal Aviation Administration (FAA) Forensic Sciences Laboratory, for both occupants. The testing found no drugs of abuse for the private pilot. The results from the CFI’s testing identified 14 (mg/dL) glucose in the vitreous and 6 (mg/dL) glucose in the urine. Quinine was also detected (but not quantified) in the CFI’s blood and urine. Quinine is a prescription medication used alone or with other medications to treat malaria in certain parts of the world. Quinine has also been used to control severe nighttime leg cramps (however, this use is not approved by the Food and Drug Administration). In addition, commercially available tonic water may also have small amounts of quinine. Adverse side effects have been noted depending on the concentration.

## Aircraft

- Registration: [N14365](https://openairdocs.org/aircraft/N14365), registered now, S/N 18-7409092, built 1974 (OpenAirDocs)
- Reported make and model: Piper PA18 (150)
- Registry model: [Piper PA-18-150](https://openairdocs.org/model/piper-pa-18-150) (registry code 7101828) (OpenAirDocs)
- Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: 18-7409092
- Year built: 1974
- Airframe hours: 6142.5
- Engines: Lycoming O-360-A4A 180 horsepower reciprocating
- Damage: Substantial damage
- Flight: Personal, Part 91
- Operator: Pa-18 LLC
- Registered owner: Pa-18 LLC
- Airworthiness certificate: Standard, Normal
- Last inspection: Annual, August 1, 2019
- Destination: Same as departure
- Airport: 4S2, Ken Jernstedt Airfield, runway 25, 3,040 × 75 ft, asphalt
- Equipment: Unknown

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 55; injuries: fatal; airline transport, commercial, flight instructor; airplane ratings: single-engine land, multi-engine land, single-engine sea; instrument ratings: airplane, helicopter; medical: class 1, with waivers/limitations; seat: rear; restraint: 3-point; toxicology performed; flight hours: 21,012 total, 0 in this make and model
- Pilot; age 56; injuries: fatal; private; airplane ratings: single-engine land, single-engine sea; medical: class 3, with waivers/limitations; seat: front; restraint: 3-point; toxicology performed; flight hours: 254 total, 0 in this make and model

## Weather

- Conditions: Visual (VMC), Day
- Wind: calm
- Visibility: 10 statute miles
- Lowest ceiling: none
- Temperature: 73 °F, dew point 59 °F
- Altimeter: 30.04 inHg
- Observed at: K4S2, 1 nm away
- METAR: METAR K4S2 061655Z AUTO 00000KT 10SM CLR 23/15 A3004 RMK AO2=

## 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 20190906012739A](https://openairdocs.org/incident/20190906012739A), Sep 6, 2019: Piper PA-18-150, Hood River, OR, Destroyed, 2 fatal. PIC was departing runway 25 at 4S2 on a VFR instructional flight in N14365, a PA-18-150, on 09-06-2019 at 1010 local time. Witnesses report that this was the…

## Docket (8 files)

The files NTSB released with the investigation on August 30, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=100203. 381 MB in all.

- Witness statements (item 1, PDF, 2 pages, 54 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14265229&FileExtension=pdf&FileName=WPR19FA251%20Witness%20Statements_Redacted-Rel.pdf
- NTSB exam report (item 2, PDF, 17 pages, 14.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14301110&FileExtension=pdf&FileName=Airframe%20and%20Engine%20Examination%20WPR19FA251_Redacted-Rel.pdf
- Excerpt airplane logbook (item 3, PDF, 7 pages, 4.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14171834&FileExtension=pdf&FileName=Aircraft%20Logbook_Redacted-Rel.pdf
- Weight and balance calculations (item 4, PDF, 2 pages, 102 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14267776&FileExtension=pdf&FileName=Summary%20of%20Findings%20Weight%20and%20Balance%20calculations%20Piper%20(NTSB)-Rel.pdf
- Statement of party representatives to NTSB investigation (item 5, PDF, 2 pages, 322 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14285603&FileExtension=pdf&FileName=Party%20Form_Redacted-Rel.pdf
- Toxicological report - pilot (item 6, PDF, 1 page, 172 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14265280&FileExtension=pdf&FileName=BDavidson%20Tox_Redacted-Rel.pdf
- Toxicological report (pilot) (item 7, PDF, 1 page, 213 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14265219&FileExtension=pdf&FileName=MTitus%20Tox_Redacted-Rel.pdf
- Accident video (item 8, MOV, 361 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14204323&FileExtension=mov&FileName=Hood%20River%2009-06-2019-Rel.mov

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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