Pilot Debrief

PIPER PA-44-180 near Tooele, UT — 2010-04-21

Final reportWPR10LA210
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Date
2010-04-21
Location
Tooele, UT, USA
Airport
KTVY
Aircraft
PIPER PA-44-180
Registration
N331GP
Category
Airplane
Highest injury
Minor
Fatalities
0
Phase of flight
Initial climb

Probable cause

The complete loss of power in one engine due to fuel starvation as a result of the pilot's failure to reposition the cross-feed valve prior to takeoff and the flight instructor's failure to monitor the pilot's actions. Contributing to the accident was the instructor pilot's failure to monitor the fuel level during the flight and his decision to turn left (into the failed engine) after the loss of power.

NTSB narrative

Prior to starting the before-takeoff checklist in preparation for the instructional flight in the twin-engine airplane, the private pilot-rated student performed the required engine/fuel tank cross-feed check. At the completion of that check, she inadvertently forgot to reposition the right engine fuel selector to the "ON" position, but instead left it in "Cross-Feed." Therefore, as the flight progressed with both engines using fuel from the left tank, it ultimately led to the consumption of all usable full in that tank. Therefore, the left engine lost all power during the initial climb after takeoff from a practice short-field landing. When the engine lost power, the student realized the right engine fuel selector was in "Cross-feed"and repositioned it to the "ON" position, but did not advise the flight instructor that she had done so. The flight instructor, who took control of the airplane after the loss of power, was unable to get the left propeller to fully feather due to the low oil pressure created by the low engine rpm. He therefore decided to attempted to turn back to the airport, but in doing so turned left (into the failed engine), and the airplane therefore began to descend at a rate that made it unlikely that he could safely reach the runway. He therefore landed in a nearby open field, whereupon the airplane encountered rough terrain and experienced a collapse of the left main landing gear. The commercially produced expanded checklist that the student was using did not have an added step in the "Before-Takeoff" section calling for a recheck of the fuel valves in the "ON" position. The expanded checklist produced by the airplane's operator did have such a step, but the operator did not have a written policy requiring the use of their checklist.

Analysis

Primary failure mode
Fuel management
First missed decision gate
Repositioning the fuel selector to the ON position before takeoff.

NTSB coding

Evidence available

  • 4 docket documents
View NTSB final reportView NTSB docket

Docket documents4

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