Pilot Debrief

PIPER PA 38-112 near Jasper, GA — 2015-10-08

Final reportERA16FA005
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Date
2015-10-08
Location
Jasper, GA, USA
Airport
JZP
Aircraft
PIPER PA 38-112
Registration
N4313E
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Initial climb

Probable cause

The student pilot's failure to accurately determine the airplane's fuel state, subsequent fuel exhaustion, and a total loss of engine power during initial climb. Contributing to the accident was the flight instructor's inadequate oversight of the student pilot's preflight inspection, the flight school's lack of fueling procedures, and the student pilot's exceedance of the airplane's critical angle-of-attack, which resulted in an aerodynamic stall.

Contributing factors

Contributing to the accident was the flight instructor's inadequate oversight of the student pilot's preflight inspection, the flight school's lack of fueling procedures, and the student pilot's exceedance of the airplane's critical angle-of-attack, which resulted in an aerodynamic stall.

NTSB narrative

The student pilot was on his second supervised solo flight. According to the flight instructor, before the airplane departed, he observed the student pilot's preflight inspection of the airplane, and the student reported to him that the airplane had 14 gallons of fuel onboard. The flight instructor could not recall if he visually checked the fuel quantity himself or if the student used a fuel quantity measuring stick when checking the quantity. Further, the flight school's manager stated that he saw the instructor speaking on his phone while the student was performing the preflight. After takeoff, the student pilot flew to the practice area and came back to the airport about 1 hour later. The student pilot then performed a touch-and-go landing. During the climb after the touch-and-go, the flight instructor heard the engine suddenly stop running. The instructor saw the airplane turn to the left like the student pilot was going to return to the airport. The airplane entered an aerodynamic stall and then a spin to the left. It descended rapidly while in the spin until the instructor lost sight of the airplane behind trees; he then heard the impact. Examination of the accident site and wreckage revealed that the airplane impacted the ground about 1,700 ft from the departure end of the runway. Ground scarring and the lack of damage to the propeller indicated that the engine was not producing power during the impact sequence. The examination found no evidence of preimpact mechanical failures that would have precluded normal operation of the airplane. However, the examination revealed that the fuel system was devoid of usable fuel. A broken fuel quantity measuring stick made from a wooden dowel was discovered in the wreckage. Review of the flight log recovered from the wreckage indicated that the airplane had been operated about 4.9 hours since the last refueling. According to the airplane manufacturer's pilot operating handbook, the airplane's endurance was about 4.5 hours when fueled to its maximum capacity of 32 total gallons, of which 30 gallons were usable. Although the student reported to the instructor that 14 gallons of fuel, or about half of its total capacity, were onboard, given the airplane's fuel consumption rate, it is unlikely that the airplane would have been devoid of fuel after 1 hour of flight had this assertion been accurate. Therefore, it is likely that the student erred in measuring the fuel onboard during his preflight inspection. Had the flight instructor personally observed the airplane's fuel state prior to the flight, he might have noticed the discrepancy and corrected the problem. Additionally, the flight school had no written policies or procedures regarding fueling. If a policy had been in place that prescribed a minimum fuel level prior to departure, or required the flight instructor to personally verify the fuel quantity on board before a student departed on a solo flight, the accident may have been prevented.

Analysis

Primary failure mode
Fuel management
First missed decision gate
Student pilot should have verified fuel quantity more thoroughly before flight.

NTSB coding

Evidence available

  • Photos
  • 19 docket documents
View NTSB final reportView NTSB docket

Docket documents19

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