Pilot Debrief

PIPISTREL ALPHA TRAINER near Pampa, TX — 2013-06-11

Final reportCEN13FA338
Sign in to save
Date
2013-06-11
Location
Pampa, TX, USA
Aircraft
PIPISTREL ALPHA TRAINER
Registration
N477PA
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Cruise

Probable cause

The loss of engine power due to fuel exhaustion as a result of the manufacturer providing the incorrect Pilot’s Operating Handbook to the owner, which prevented the pilot from accurately calculating the fuel requirements before the flight. Contributing to the accident were the pilot’s inadequate preflight planning and poor decision-making.

Contributing factors

Contributing to the accident were the pilot's inadequate preflight planning and poor decision-making.

NTSB narrative

The airline transport pilot (ATP) had volunteered to deliver the airplane to a maintenance facility and had made the arrangements for the flight, including preflight planning. The commercial pilot chose to ride along with the ATP to gain flight experience and familiarity with the airplane. After stopping to refuel, the airplane took off on the last leg of the cross-country flight that night. The commercial pilot reported that, about 10 minutes from their destination, the fuel gauge was reading "close to empty." About 5 minutes later, the engine lost power, at which time, the ATP took control of the airplane. The pilots attempted to deploy the ballistic parachute just before the forced landing; however, due to the low altitude, it did not fully deploy. The airplane impacted the ground hard, and the high surface winds dragged the airplane across rough and uneven terrain before it became entangled in a barbed wire fence. No fuel was found in the fuel pump or tank. An examination of the engine and fuel system revealed no mechanical anomalies that would have prevented the engine from producing power if fuel had been available. The fuel capacity information in the Pilot's Operating Handbook (POH) provided to the pilots and on the placard created by the ATP (based on the POH) was inaccurate. Although the manufacturer reported that it provided the correct POH to the owner when the airplane was delivered, the owner had the incorrect POH, and the investigation determined that several other owners of this airplane model had received the wrong POH upon delivery of their aircraft. The POH indicated that the airplane had 15 gallons total fuel capacity and 14.5 gallons usable fuel capacity. However, the airplane's actual total fuel capacity was 13.2 gallons and the usable fuel capacity was 12.7 gallons. The calculated fuel requirement for the accident leg of the flight would have been at least 13.2 gallons of fuel; thus, the engine stopped producing power due to fuel exhaustion. Even if the fuel capacity information had been accurate, visual flight rules night flights require a 45-minute fuel reserve, and that would not have been met on the accident leg. Thus, the ATP did not properly calculate the flight's fuel requirements. Further, he failed to adequately monitor the airplane's in-flight fuel consumption and recognize that the airplane was low on fuel. In addition, the airplane was not equipped to fly at night nor was it approved for night flight, yet the pilot planned the flight legs such that the airplane would be flying at night. The ATP's most recent application for a Federal Aviation Administration airman medical certificate had been denied; the commercial pilot did not know this before the accident. Although the ATP was acting in the capacity of the pilot-in-command , because his medical certificate had been denied, he was not qualified to serve in this role. The ATP had severe heart disease, hypertension, and a history of stroke, which increased his risk for a cardiac arrhythmia; however, the autopsy found no evidence of a recent heart attack. The ATP also had a history of depression, and toxicological tests were positive for therapeutic levels of the antidepressant medication citalopram, which has an acceptable side effect profile. It could not be determined if the pilot was impaired by cardiac symptoms or depression around the time of the accident; however, the circumstances of the accident make it unlikely. The manufacturer's instruction manual for the parachute stated that the minimum height for deploying the parachute ranged between 100 and 250 feet. However, the POH does not provide any information or guidance regarding the recommended altitude for deployment.

Analysis

Primary failure mode
Fuel management
First missed decision gate
Refueling before the last leg of the flight could have prevented fuel exhaustion.

NTSB coding

Evidence available

  • ADS-B / radar
  • Photos
  • 26 docket documents
View NTSB final reportView NTSB docket

Docket documents26

Related mishaps