Pilot Debrief

PIPER PA-28R-200 near Dover, DE — 2013-01-13

Final reportERA13LA111
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Date
2013-01-13
Location
Dover, DE, USA
Airport
DOV
Aircraft
PIPER PA-28R-200
Registration
N4975S
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Approach

Probable cause

The pilot's failure to land the airplane at multiple airports that were equipped with adequate instrument approach procedures while operating in low instrument meteorological conditions and his delay in declaring a fuel-related emergency, which resulted in a loss of engine power due to fuel exhaustion.

NTSB narrative

The pilot had planned a night instrument cross-country flight of 3 hours 45 minutes, with 5 hours 30 minutes of fuel onboard. About 3 hours 20 minutes into the flight, when the airplane was approximately 15 miles from the intended destination airport, the pilot diverted as the airplane ahead of him had to perform a missed approach due to a low cloud ceiling. The pilot diverted to a nearby airport with calm wind and an instrument landing system (ILS) approach; however, he attempted two GPS approaches to the opposite end of the 6,400-foot-long runway. He performed a missed approach on both GPS approaches before reaching the decision altitude of 306 feet above ground level (agl), when an overcast ceiling at 400 feet prevailed. The pilot did not attempt the ILS approach. The pilot then diverted a second time, about 4 hours 20 minutes into the flight, to an airport that was not equipped with an ILS approach. He performed a GPS approach to that airport, down to about 250 feet GPS altitude, which was below the published minimum descent altitude of 310 feet agl, when an overcast ceiling of 300 feet prevailed, which resulted in a missed approach. After the missed approach, about 5 hours into the flight, the pilot reported to air traffic control that he was low on fuel. The pilot then diverted for a third time, to another airport that did not have an ILS approach, but he planned to attempt a VOR approach at that airport. The pilot could have declared an emergency and performed an ILS approach to a military airport that he overflew enroute to the VOR approach, and was in radio and radar contact with; however, he continued on and was cleared for the VOR approach about 5 hours 5 minutes into the flight and declared emergency 6 minutes later, reporting fuel exhaustion. At that time, the airplane was provided radar vectors to the military airport, but impacted wooded terrain about 2 miles prior to the runway.

Analysis

Primary failure mode
Fuel management
First missed decision gate
Pilot could have diverted to an alternate airport earlier to avoid fuel exhaustion.

NTSB coding

Evidence available

  • ATC audio
  • Photos
  • 26 docket documents
View NTSB final reportView NTSB docket

Docket documents26

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