Fuel Exhaustion & Starvation · NTSB CEN12FA654
PIPER PA-28R-180 — Roanoke, TX
| Date | September 22, 2012 |
| Location | Roanoke, TX |
| Aircraft | PIPER PA-28R-180 |
| Purpose of flight | Instructional |
| Conditions | Day · Visual Meteorological Cond |
| Phase / occurrence | Takeoff Collision during takeoff/land |
| Pilot age | 41 |
| Pilot total time | 477 hrs · Building experience |
| Time in type | 20 hrs |
| Fatalities | 2 |
Probable cause
NTSB findings
- Aircraft-Fluids/misc hardware-Fluids-Fuel-Fluid condition
- Aircraft-Aircraft systems-Fuel system-(general)-Not serviced/maintained
- Personnel issues-Task performance-Maintenance-(general)-Maintenance personnel
- Aircraft-Aircraft systems-Equipment/furnishings-Flight compartment equipment-Not installed/available
- Aircraft-Aircraft systems-Equipment/furnishings-Passenger compartment equip-Not installed/available
- Aircraft-Aircraft systems-Equipment/furnishings-Emergency locator beacon-Not used/operated
What happened
The pilot, who had purchased the airplane about 2 months earlier, and the flight instructor departed on an instructional flight. Two witnesses reported that the airplane's engine did not sound right during the takeoff and the ground roll was longer than normal. Just beyond the runway, the airplane turned slightly left and then impacted the top of several trees. Both wings separated and remained lodged in the treetops; first responders noted fuel running from the wings. The emergency locater transmitter (ELT) was in found in the off position. Examination of the engine revealed water and contaminants in the fuel system, especially in the injection servo and fuel pump, which would have resulted in the rough-running engine and loss of engine power.
A review of the airplane's maintenance records did not reveal any entries since the pilot had purchased the airplane. The airplane's last maintenance entry was at the annual inspection, which was about the time the airplane was purchased. The entry stated "found water in tanks - sumped tanks, cleaned flow divider, fuel screens and lines." The log also had the entry that stated "c/w FAR 91.207 ELT insp by installing new batteries, due March 2017." The airport manager had witnessed the same pilot depart in the accident airplane about a month earlier; however, the airplane's engine did not sound right, and the pilot returned to the airport. A review of the pilot's logbook revealed an entry "aborted X-country, lost engine power, so landed" on that date. About 2 weeks later, an e-mail from the pilot to family members stated that a clogged fuel injection system was found after the aborted flight. Two days after that, the pilot's logbook reflected 1.1 flight hours with a note that stated "test flight, perfect." On that same date, the pilot wrote a check to a maintenance company at the airport on which the airplane's registration number and "Maint" were written in the memo field. It is likely that either at the annual inspection and/or 2 weeks before the accident, maintenance personnel did not appropriately address the fuel contamination issues that persisted at the time of the accident.
The airplane was not equipped with shoulder belts. During the impact sequence, the pilot likely rotated about his lap belt, braced himself with his arms and fractured his shoulders, but his head struck the instrument panel, resulting in his fatal skull injury. The flight instructor similarly rotated forward about his lap belt; his chest and abdomen struck the instrument panel resulting in his fatal injuries. Had the airplane been equipped with single or double shoulder restraints, the pilots' injuries likely would have been less severe and they might have survived.