The National Transportation Safety Board did not travel to the scene of this accident.
Additional Participating Entity: Federal Aviation Administration / Flight Standards District Office; Orlando, Florida
Aviation Accident Final Report - National Transportation Safety Board: https://app.ntsb.gov/pdf
Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms
Location: St. Augustine, FL
Accident Number: ERA17LA300
Date & Time: 08/20/2017, 1120 EDT
Registration: N9431N
Aircraft: PIPER PA 28R-200
Aircraft Damage: Substantial
Defining Event: Loss of engine power (total)
Injuries: 2 Minor
Flight Conducted Under: Part 91: General Aviation - Instructional
Analysis
The flight instructor reported that, during a training flight to practice touch-and-go landings, while the airplane was climbing through 500 ft, the engine started to "sputter." The student pilot, who was flying the airplane, stated that she switched the fuel tanks just before the engine lost power but that she was unsure which tank she had selected. Due to the low altitude, the flight instructor took control of the airplane and performed an emergency landing in a marsh, during which the right wing and airframe sustained substantial damage.
An examination of the airplane and engine did not reveal evidence any preimpact mechanical malfunctions or failures that would have precluded normal operation. Before takeoff, the airplane had 25 gallons of fuel onboard, and the airplane had been flown about 1 hour before the engine lost power. According to the engine operating manual, the engine's fuel consumption rate was 12.5 gallons per hour, which would have resulted in about half of the fuel supply still being available when the engine lost power, assuming that the supply of fuel in the selected fuel tank had not already been exhausted. However, the postaccident quantity of fuel onboard the airplane could not be verified due to the airplane having rested in the marsh after the accident. Therefore, based on the available evidence, the reason for the loss of engine power could not be determined.
Probable Cause and Findings
The National Transportation Safety Board determines the probable cause(s) of this accident to be:
A total loss of engine power for reasons that could not be determined because examination of the airplane and engine did not reveal evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation and because the amount of fuel onboard the airplane could not be verified.
Findings
Not determined
Not determined - Unknown/Not determined (Cause)
Factual Information
On August 20, 2017, about 1120 eastern daylight time, a Piper PA-28R-200, N9431N, was substantially damaged during a forced landing after takeoff from Northeast Florida Regional Airport (SGJ) St Augustine, Florida. The flight instructor and student pilot sustained minor injuries. The airplane was privately owned, and the instructional flight was operated under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed at the time, and no flight plan was filed for the local flight, which originated from SGJ about 1035.
According to the flight instructor, the purpose of the flight was to practice traffic pattern touch-and-go landings. The instructor said that during the run-up he told the student "not to forget to change the fuel tanks every 30 minutes." The flight instructor stated that they were on their fourth takeoff and were climbing through 500 ft when the engine started to "sputter." The flight instructor took control of the airplane, declared an emergency and landed the airplane in a marsh area.
According to the student pilot, as they were climbing through 500 ft, she switched the fuel tanks while climbing and the engine "failed." The student pilot did not recall which fuel tank she switchd to prior to the loss of engine power. She passed the controls over to the instructor to perform the emergency landing.
Examination of the airplane by a Federal Aviation Administration Inspector revealed the right wing and airframe was buckled. A cursory examination of the engine did not reveal any anomalies that would have precluded normal operation. Due to the airplane resting in the marsh the amount of fuel remaining in the wing tanks could not be determined. Prior to take off the airplane had a total of 25 gallons of fuel on board. According to the Lycoming engine operator's manual, the IO-360C series engine fuel consumption is 12.5 gallons per hour at performance cruise. The airplane was flown for about an hour prior to the loss of engine power.
History of Flight
Initial climb
Loss of engine power (total) (Defining event)
Landing
Off-field or emergency landing
Flight Instructor Information
Certificate: Flight Instructor; Commercial
Age: 25, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Right
Other Aircraft Rating(s): None
Restraint Used: 4-point
Instrument Rating(s): Airplane
Second Pilot Present: Yes
Instructor Rating(s): Airplane Multi-engine; Airplane Single-engine
Toxicology Performed: No
Medical Certification: Class 2 Without Waivers/Limitations
Last FAA Medical Exam: 01/21/2015
Occupational Pilot: Yes
Last Flight Review or Equivalent: 05/17/2017
Flight Time: 1340 hours (Total, all aircraft), 4 hours (Total, this make and model), 1267 hours (Pilot In Command, all aircraft), 336 hours (Last 90 days, all aircraft), 122 hours (Last 30 days, all aircraft), 6 hours (Last 24 hours, all aircraft)
Pilot Information
Certificate: Private
Age: 20, Female
Airplane Rating(s): Single-engine Land
Seat Occupied: Right
Other Aircraft Rating(s): None
Restraint Used: 4-point
Instrument Rating(s): Airplane
Second Pilot Present: Yes
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 3 With Waivers/Limitations
Last FAA Medical Exam: 10/31/2016
Occupational Pilot: Yes
Last Flight Review or Equivalent: 07/02/2017
Flight Time: (Estimated) 228 hours (Total, all aircraft), 3 hours (Total, this make and model), 167 hours (Pilot In Command, all aircraft), 48 hours (Last 90 days, all aircraft), 17 hours (Last 30 days, all aircraft)
Aircraft and Owner/Operator Information
Aircraft Make: PIPER
Registration: N9431N
Model/Series: PA 28R-200 200
Aircraft Category: Airplane
Year of Manufacture: 1969
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 28R-35144
Landing Gear Type: Retractable - Tricycle
Seats: 4
Date/Type of Last Inspection: 05/19/2017, Annual
Certified Max Gross Wt.: 2150 lbs
Time Since Last Inspection: 60 Hours
Engines: 1 Reciprocating
Airframe Total Time: 6942.8 Hours as of last inspection
Engine Manufacturer: LYCOMING
ELT: C91 installed, not activated
Engine Model/Series: I0360 SER
Registered Owner: MARTIN ROBERT S
Rated Power: 200 hp
Operator: On file
Operating Certificate(s) Held: None
Meteorological Information and Flight Plan
Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: SGJ, 10 ft msl
Distance from Accident Site: 0 Nautical Miles
Observation Time: 1056 EDT
Direction from Accident Site: 0°
Lowest Cloud Condition: Few / 2700 ft agl
Visibility: 10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: Calm /
Turbulence Type Forecast/Actual: /
Wind Direction:
Turbulence Severity Forecast/Actual: /
Altimeter Setting: 30.08 inches Hg
Temperature/Dew Point: 31°C / 25°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: St. Augustine, FL (SGJ)
Type of Flight Plan Filed: None
Destination: St. Augustine, FL (SGJ)
Type of Clearance: None
Departure Time: 1035 EDT
Type of Airspace: Class D
Airport Information
Airport: NORTHEAST FLORIDA RGNL (SGJ)
Runway Surface Type: Asphalt
Airport Elevation: 9 ft
Runway Surface Condition: Vegetation; Water--calm
Runway Used: 13
IFR Approach: None
Runway Length/Width: 8002 ft / 150 ft
VFR Approach/Landing: Forced Landing
Wreckage and Impact Information
Crew Injuries: 2 Minor
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 2 Minor
Latitude, Longitude: 29.959167, -81.339722 (est)
A timely example of how moving the fuel selector is riskier than people think. There are several ways this can go wrong and result in fuel starvation.
ReplyDeleteBefore switching tanks, pick out where you would land if the engine quit. It's a good exercise anyway, but will save time messing with the NRST button. If you don't like the answer, consider deferring the switch until you have an acceptable option.
Why on earth would you need to switch tanks every 30 minutes in the first place? How unbalanced is a Cherokee going to get? Not very. Just keep track of how much you burned out of each tank and get onto the best choice before you get down in the pattern.
I'm wondering what the position of the fuel selector valve was in? Was it against the stop or was it "in between" thus disrupting the fuel flow? Also, my instructor told me to not switch the tanks until we were at pattern altitude in case the engine died we could hopefully dead stick it in.
ReplyDelete
ReplyDeleteYou have to switch tanks sometimes no matter what.
Best practice is to be well above but within glide distance of an airport and not at relatively low altitude such as a pattern.
That is not hard to achieve. Since I have flown low wing more recently, on a couple of occasions the engine has sputtered momentarily on a tank switch over. It causes me to think in a non-gravity fed fuel system some air is able to get into the fuel line between the valve and tank of the formerly unselected fuel line.
The fuel pump should be on to minimized the amount of liquid fuel disruption if air is present.
The respective POH should be the guide.
I would be interested to know if the PIC was used to flying Cessnas. When you switch tanks in a piper and go to the left tank its the fuel cut-off compared to a Cessna where it'll be a different wing. I've seen pilots mentally memorize the Cessna fuel selector and assume its the same in a Piper and unintentionally hit the fuel cut-off.
ReplyDeleteShe was used to fly Cessna's indeed, she only did commercial in the piper for some reason.
DeleteI should have clarified in my previous post about switching fuel tanks at pattern altitude. I meant when we're actually in the airport traffic pattern and switching the tanks on downwind that way if you lose an engine you just make a short approach and land easy peasy. You never want to switch tanks on climb-out.
ReplyDeleteWell that's something, but really, why are you messing with the fuel selector in the traffic pattern AT ALL. How badly planned is your flight that you would need to do that. The engine out landing is more dangerous than you might think, and I just don't see how taking risk gets you any big benefit.
Delete