Pilot Debrief

Piper PA22 near Kingman, AZ — 2019-01-13

Final reportWPR19LA063
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Date
2019-01-13
Location
Kingman, AZ, USA
Aircraft
Piper PA22
Registration
N9227D
Category
Airplane
Highest injury
Fatal
Fatalities
1

Probable cause

The student pilot's failure to secure the fuel caps, which led to the fuel being siphoned overboard, fuel exhaustion, and the total loss of engine power.

NTSB narrative

The student pilot was conducting a cross-country flight with one passenger onboard. According to the passenger’s sister, at 1001, her sister sent her a text, which stated that she and the pilot had taken off and were heading to an airport about 50 miles to the south to obtain fuel. The investigation was unable to determine whether the pilot obtained fuel at this airport. At 1038, while at the second airport, the passenger telephoned a relative and stated that they would take off shortly for the destination airport. Although the actual departure time from the second airport could not be determined, the sister stated that she expected the airplane to arrive at the destination airport about 1130. By 1215, the sister called the local Sheriff’s Office and search and rescue to locate the airplane because it was overdue. First responders found the airplane, which had impacted trees and came to rest inverted in a ravine in a park about 10 miles south of the second airport. The pilot was seriously injured, and the passenger was fatally injured. The pilot reported to the first responders that the airplane experienced an electrical failure and he tried to turn around, however the engine lost power. Almost all the airplane components remained attached to the wreckage. The propeller damage signatures were consistent with a complete lack of engine power at impact. Examination of the airframe, engine, and propeller revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. First responders did not note the presence of any fuel on scene. The airplane was equipped with two separate fuel tanks, one in each wing. Each tank had a dedicated filler neck with a removable cap. Neither fuel cap was found at the accident site or in the recovered wreckage. There was no evidence of the caps being installed at impact. The wreckage evidence was consistent with a loss of engine power due to fuel exhaustion. The absence of the fuel caps likely resulted in the fuel being siphoned overboard during flight. Aside from the absence of fuel caps and fuel, no evidence was found of any other preimpact mechanical malfunctions or failures that would have precluded normal operation. It is likely that, when the pilot stopped at the second airport to obtain fuel, he did not put the fuel caps back on the airplane; whether he actually obtained fuel or not could not be determined because it was likely all siphoned out during the flight. The pilot was hospitalized for several days, and a review the pilot’s postaccident hospital records revealed that he had diabetes and used an insulin pump, which was corroborated by a review of his previous medical records. However, insufficient evidence was found to determine whether the pilot was impaired due to diabetic complications at the time of the accident. Thus, whether the pilot's diabetes or some other medical factor contributed to the accident could not be determined. Several attempts were made to obtain a statement from the pilot however he refused to provide any information to the investigation.

Analysis

Primary failure mode
Engine power loss
First missed decision gate
Pilot could have ensured proper fuel management before departure.

NTSB coding

Evidence available

  • 14 docket documents
View NTSB final reportView NTSB docket

Docket documents14

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