Pilot Debrief

PIPER PA-28-180 near Lebanon, OH — 2011-12-28

Final reportCEN12LA116
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Date
2011-12-28
Location
Lebanon, OH, USA
Airport
I68
Aircraft
PIPER PA-28-180
Registration
N994NC
Category
Airplane
Highest injury
Serious
Fatalities
0
Phase of flight
Go-around

Probable cause

The pilot’s inadvertent positioning of the fuel selector valve between the right tank and OFF position, which resulted in fuel starvation and a total loss of engine power. Contributing to the accident was the inadequate inspection of the fuel valve and failure to replace the worn fuel valve's position washer.

Contributing factors

Contributing to the accident was the inadequate inspection of the fuel valve and failure to replace the worn fuel valve's position washer.

NTSB narrative

Shortly after departure, the top of the passenger door cracked open and the pilot decided to return to the airport and land. While on the 45-degree approach to the downwind leg, he turned on the fuel boost pump and switched the fuel selector from the left tank to the right tank, since the checklist called for switching the fuel selector to the fullest tank. During the flare, the airplane was descending too fast, and a gust of wind caused it to drift left, so the pilot initiated a go-around. As the airplane was making a climbing, left-crosswind turn at 500 feet above ground level, the engine made a loud “popping sound” and immediately lost all power. The pilot initiated a forced landing and attempted to restart the engine but was not successful. The airplane hit trees and power lines before it came to rest inverted. The postaccident examination of the airplane revealed that the fuel tank selector valve was in a partial OFF position (between the right tank and OFF position). When the valve was rotated, it was stiff to move and there were no apparent detents for either the fuel tanks or the OFF position. A teardown of the fuel selector valve revealed that the inside of the valve contained dirt and contamination, and that the position washer was worn. The airplane manufacturer issued Service Bulletin No. 355 on June 5, 1972, that stated: “Inspect position washer to ascertain that it will not allow the valve to rotate beyond its stop positions. Also, inspect position washer inner perimeter surface for indications of extreme wear; should this be evident, replace position washer.” The service bulletin called for repetition of this inspection at 100-hour intervals and for replacement of the position washer if the valve was difficult to rotate or if the washer did not allow the valve to rotate beyond the stop position. The fuel tank selector valve was reassembled and tested with the fuel selector handle in the same position as it was found at the accident site. The test indicated that the stream of fluid exiting the fuel selector valve was at a greatly reduced flow rate as compared to when the handle was positioned on the left or right fuel tank. The test indicated that there was not enough fuel flow to the engine at maximum power used during the go-around, which resulted in the engine’s total loss of power. The pilot reported that when he switched the fuel selector valve from the left tank to the right tank during the accident flight, he did not look to confirm the position of the lever.

Analysis

Primary failure mode
Engine power loss
First missed decision gate
Pilot did not confirm fuel selector position before switching tanks.

NTSB coding

Evidence available

  • ADS-B / radar
  • Photos
  • 31 docket documents
View NTSB final reportView NTSB docket

Docket documents31

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