Pilot Debrief

Piper PA-24-250 near Aberdeen, ID — 2018-12-17

Final reportWPR19FA042
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Date
2018-12-17
Location
Aberdeen, ID, USA
Airport
U36
Aircraft
Piper PA-24-250
Registration
N6283P
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Initial climb

Probable cause

The pilot's diverted attention during the takeoff climb due to a loss of engine power, which resulted in the airplane’s exceedance of the critical angle of attack and subsequent stall/spin.

NTSB narrative

Security camera video captured the airplane during the initial climb after takeoff. The video showed that as the airplane entered the view of the camera, it appeared to be in a shallow climb; however, about 14 seconds later, the airplane descended in a near vertical manner, out of view of the camera. The airplane impacted open terrain about 1,850 ft west of the departure end of the runway. Examination of the airframe revealed no mechanical anomalies that would have precluded normal operation; however, the left fuel selector valve was in the left wingtip tank position, and the right selector valve was in in a position between the right main fuel tank and right wingtip tank position. The Airplane Flight Manual Supplement for the wingtip fuel tank installation stated that the wingtip tank fuel was to be used in level flight only. It is likely that because of the placement of the fuel port in the wingtip fuel tanks, when the airplane was in a climb attitude, the fuel may not have reached the fuel port in the tank. As a result, the pilot’s improper positioning of the fuel valves could have led to fuel starvation during the takeoff climb and resulted in a loss of engine power. Additionally, examination of the engine revealed that both magnetos were found in poor condition and showed evidence of little maintenance being performed. The left magneto drive shaft would not rotate. Disassembly of the left magneto revealed excessive wear on the bearing race that is attached to the drive shaft. The excessive wear allowed the magnets to contact the magneto housing, which resulted in the magneto being grounded, thus inoperative. The inoperative magneto would have partially reduced engine power. It is likely that the pilot experienced a loss of engine power to some degree during takeoff initial climb and his attention could have been diverted as part of troubleshooting the loss of engine power. The pilot's diverted attention most likely allowed for the airplane to exceed its critical angle of attack, resulting in a stall and subsequent spin at an altitude too low for recovery.

Analysis

Primary failure mode
Fuel management
First missed decision gate
Pilot could have avoided using auxiliary fuel tanks during climb.

NTSB coding

Evidence available

  • Video
  • Photos
  • 9 docket documents
View NTSB final reportView NTSB docket

Docket documents9

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