WPR22LA271

NTSB accident investigation · Piper PA-32-301 · San Jose, CA · July 23, 2022

Accident · Serious injuriesClass 3 · LimitedFinal report
Date
July 22, 2022, 19:11 local (Jul 23, 2022, 02:11 UTC)
Place
San Jose, CA · residential street
Injuries
1 serious
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N300BHPiper PA-32-301
Defining event
Enroute-climb to cruise: Fuel starvation
Weather
Visual (VMC) · Dusk
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
Piper Aircraft Company, Federal Aviation Administration, Lycoming Engines
FAA report
20220722012949A
Case key
105586

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

The NTSB’s determination of the probable cause, and any contributing factors.

The pilot’s inadequate preflight inspection and fuel management, which resulted in fuel starvation, a total loss of engine power, and an impact with terrain.

Findings · 5

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings.

Analysis

The pilot had planned to fly the airplane on a short flight back to the owner’s hangar following an annual inspection. According to the pilot, the engine lost all power during climbout from the departure airport. The airplane impacted the ground, struck a fence and came to rest upright. Postaccident examination of the airplane revealed no preimpact mechanical anomalies of the airplane or engine that would have precluded normal operation. The airplane contained 15 gallons of fuel in each wing fuel tank before the annual inspection began. The maintenance facility ran the engine at maximum power with the fuel selector positioned on the left fuel tank for at least 45 minutes during the annual inspection. Fuel consumption calculations indicate this would have nearly depleted the left fuel tank of fuel. No additional fuel was added by the mechanics or the pilot before the accident flight nor was there any discussion between the pilot and mechanic regarding the amount of fuel remaining in the airplane. It is likely that the pilot departed without a thorough preflight inspection or he would have observed the low fuel quantity and switched to the right fuel tank before departure. The pilot stated that he switched tanks once during the accident flight after the power loss. As the fuel selector was found in the right tank position at the accident site, it is likely that he departed on the left fuel tank. This evidence suggests that the pilot’s improper fuel management resulted in fuel starvation and a total loss of engine power. Further, the departure airport did not sell the type of fuel required to power the accident airplane. However, it is unlikely that this would have influenced the pilot’s decision as he believed he had sufficient fuel to complete the flight.

Factual narrative

The factual narrative1,325 words

On July 22, 2022, about 1911 Pacific daylight time, a Piper PA-32-301 airplane, N300BH, was substantially damaged when it was involved in an accident near San Jose, California. The pilot was seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 business flight. According to the pilot, the airplane had received an annual inspection after having been out of service for more than 2 months while it awaited a part. The pilot stated that he was notified by the maintenance facility about 1730 on the day of the accident that the airplane was ready. He noted that he had planned to fly the airplane in the airport traffic pattern at Reid-Hillview Airport of Santa Clara County (RHV), San Jose, California before flying the Norman Y Mineta San Jose International Airport (SJC), San Jose, California, located about 5 nm east of the departure airport. According to the pilot’s recount, he spent about 25 minutes talking with the mechanic who showed him some of the work that was completed. The mechanic who spoke with the accident pilot stated that the pilot arrived in the late afternoon and talked with him for about 5 minutes; however, none of the conversation subject matter involved the airplane or the fuel level. The mechanic stated that he heard the airplane start about five minutes after they finished their conversation. The pilot reported that after his conversation with the mechanic he performed a preflight inspection of the airplane. During this time, he noted that the fuel level was 15 gallons in each wing by observing the sight gauges and observed that the fuel had an odor and appearance consistent with 100 low lead aviation grade gasoline when he sumped the fuel system. He also reported that he confirmed that the fuel level from the sight gauges was consistent with fuel quantity indicators in the cockpit. The pilot did not attempt to refuel the airplane. After his preflight inspection the pilot boarded the airplane and spent an additional 5 minutes in the cockpit reviewing his checklists before he taxied to the run-up area for runway 31R. After an uneventful engine run-up, he received clearance from the tower, and then taxied onto the active runway. The airplane departed normally and the pilot transitioned into a climb; as the airplane reached about 500 ft mean sea level it sustained a partial loss of power. The pilot looked for a possible landing site but was unsuccessful, as he was over a densely populated area. The pilot began a left turn to return to RHV, but during the turn the engine lost all power. According to the pilot, he verified the mixture was full rich, the fuel pump was on, and he switched the fuel tank selector to the opposite fuel tank. The pilot did not recall which tank he departed on. The propeller was windmilling during this time and the engine did not restart. After a descent, the airplane impacted the ground and struck a fence before it came to rest about 0.3 nm northwest of thedeparture end of runway 31R. Photographs provided by law enforcement showed that the airplane came to rest upright. The left wing exhibited a steep upward bend about midspan and the right wing outboard leading edge was crushed. The forward fuselage was damaged and the engine was displaced from its normally mounted position. According to a mechanic who worked on the airplane during its recent annual inspection, the airplane had 15 gallons of fuel in each wing before they started the inspection. During the inspection he verified the fuel quantity through both the cockpit fuel gauge and the fuel gauges at each wing. At the time they received the airplane the mechanic noted that the color of the fuel was blue, consistent with 100 low lead aviation grade gasoline. He did not remove or add any fuel. During the inspection, they replaced the wing sight gauges and noted 15 gallons in each wing, which was consistent with the cockpit fuel quantity indicators. After the inspection was completed, they performed a ground engine test run for 45-60 minutes at full throttle and full manifold pressure with the fuel selector on the left fuel tank. They momentarily selected the right fuel tank and then immediately switched back to the left fuel tank and noted that the fuel flow remained stable during the transitions. According to another mechanic who arrived on scene about 20 minutes after the accident, the right wing contained approximately 15 gallons of fuel at the accident site and the left wing was breached and void of fuel. An on scene photograph captured by the Federal Aviation Administration showed the fuel selector in the right tank position. Postaccident examination of the airplane and engine did not reveal any preimpact mechanical anomalies that would have precluded normal operation. Control continuity was traced from each flight control surface to the cockpit through separations made by recovery personnel. Examination of the fuel system also did not reveal any preimpact mechanical anomalies that would have affected fuel flow. A visual inspection of the left wing sight gauge did not reveal any preimpact anomalies and functional testing revealed that the unit defaulted to 0 gallons and movement of the fuel arm produced a movement of the needle. Mechanical continuity was established throughout the engine when the propeller was rotated by hand. Thumb compression was achieved at all six cylinders and the valves displayed normal lift as the crankshaft was rotated. Examination of the cylinders’ combustion chamber interior components using a lighted borescope revealed normal piston face and valve signatures, and no indications of foreign ingestion or detonation. The three-bladed constant speed propeller remained attached at the crankshaft flange. All three blades remained attached to the hub. Two blades were bent aft about midspan and the third blade was bent aft near the blade tip. Fuel testing revealed that the composition of the fuel was consistent with 100low lead aviation grade gasoline. A water reaction analysis of water-soluble components that would allow free water to be incorporated with the fuel indicated 0 mL of volume change. Fuel Consumption According to the pilot’s operating handbook (POH), the airplane had a total capacity of 107 gallons of fuel evenly split between two wing fuel tanks. The unusable fuel quantity was 5 gallons: 2.5 gallons per side. The power setting table from the performance section of the POH showed that the fuel consumption would have ranged from 11.9 gph at 55% power, 13.8 gph at 65%, or 16.0 gph at 75% power depending on the selected power setting. The POH did not indicate how these fuel consumption values would change with altitude. The mechanic reported that they ran the airplane at full throttle and full manifold pressure for the entire engine test. Factoring a left tank usable fuel quantity of 13.5 gallons, fuel performance computations showed that the engine would have depleted the left tank of its fuel supply in approximately 50 minutes. Fuel Availability According to the airport manager, RHV ceased sales of 100 low lead aviation grade gasoline on January 1, 2022, which prompted numerous aircraft to outsource their fuel requirements to fuel depots at nearby airports, such as SJC. Pilot in command and Preflight Action According to 14 CFR §91.103 Preflight Action, “Each pilot in command shall, before beginning a flight, become familiar with all available information concerning that flight. This information must include - (a) For a flight under IFR or a flight not in the vicinity of an airport, weather reports and forecasts, fuel requirements, alternatives available if the planned flight cannot be completed, and any known traffic delays of which the pilot in command has been advised by ATC” As described in 14 CFR §91.3 Responsibility and authority of the pilot in command, “(a) The pilot in command of an aircraft is directly responsible for, and is the final authority as to, the operation of that aircraft.”

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident.

Aircraft

Registration
N300BH
Reported as
Piper PA-32-301
Category
Airplane
Serial number
32-8006011
Built
1980
Airframe hours
5,430.93
Engine
Lycoming IO-540-K165, 300 horsepower, reciprocating
Damage
Substantial damage
Flight
Business · Part 91
Operator
Green Valley Corporation I
Registered owner
Green Valley Corporation I
Airworthiness certificate
Standard, Normal
Last inspection
Annual · July 19, 2022 · 1 hours before
Destination
SJC · San Jose, CA
Airport
RHV · Reid-Hillview Of Santa Clara County
Equipment
Unknown

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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
42
Injuries
Serious
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Without waivers/limitations
Seat
Left
Flight hours
1,039 total

Weather

Conditions
Visual (VMC) · Dusk
Wind
300° at 9 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
79 °F, dew point 50 °F
Altimeter
29.90 inHg
Observed at
KRHV
METAR
KRHV 230147Z 30009KT 10SM SKC 26/10 A2990

Docket · 13

The files NTSB released with the investigation on December 14, 2023, on NTSB’s docket system: statements, records, photos and specialists’ reports. 6.1 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.