Pilot Debrief

PIPER PA34 near Kuttawa, KY — 2015-01-02

Final reportERA15FA088
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Date
2015-01-02
Location
Kuttawa, KY, USA
Aircraft
PIPER PA34
Registration
N81291
Category
Airplane
Highest injury
Fatal
Fatalities
4
Phase of flight
Descent

Probable cause

The pilot's failure to properly set the left engine fuel selector before takeoff and to recognize the incorrect setting during the flight, which resulted in fuel starvation and a loss of engine power on both engines.

NTSB narrative

The commercial pilot departed on a cross-country flight in night instrument meteorological conditions with the airplane's fuel tanks full, providing an estimated fuel endurance of 4 hours 50 minutes. Two hours 50 minutes into the flight, the pilot reported a loss of engine power on the right engine, which was followed by a loss of engine power on the left engine. The pilot attempted to land at a nearby airport; however, the airplane impacted trees about 8 miles short of the airport. A review of weather information revealed no evidence of in-flight icing or other weather conditions that may have contributed to the accident. Postaccident examination of the airframe and engines revealed no preimpact failures or malfunctions that would have precluded normal operation. All fuel tanks were compromised; however, an undetermined amount of fuel spilled from the left fuel tank during recovery of the wreckage. The left engine fuel selector valve was found in the "X-FEED" (crossfeed) position, and the corresponding cockpit fuel selector switch was found in an intermediate position, which was likely the result of impact damage. The right engine fuel selector valve and the corresponding cockpit fuel selector switch were found in the "ON" position. With the valves in these positions, both the left and right engines would have consumed fuel from the right fuel tank. Review of performance charts and fueling records indicated that if the flight was conducted with the valves in the as-found positions, exhaustion of the fuel in the airplane's right fuel tank would have occurred about the time the pilot reported the dual engine failure. In addition, the yaw trim was found in the full nose-right position. It is possible that the pilot used nose-right yaw trim to counteract an increasing left-turning tendency during the flight as fuel was burned from only the right wing's fuel tank making it relatively lighter than the left wing. According to the expanded checklist in the pilot's operating handbook for the airplane, during taxi, the pilot was to move each fuel selector to "X-FEED" for a short time, while the other selector was in the "ON" position, before returning both fuel selectors to the "ON" position before takeoff. According to a checklist found in the airplane, the fuel selectors were to be set to "X-FEED" during taxi and then to "ON" during engine run up. GPS data recovered from onboard devices indicated that the pilot taxied from the ramp and onto the active runway without stopping in about 3 minutes, indicating that it is unlikely he performed a complete run up of both engines before takeoff. He likely failed to return the left engine fuel selector from the "X-FEED" to the "ON" position, where it remained throughout the flight and resulted in fuel starvation and a loss of engine power on both engines. Toxicological testing revealed that the pilot was taking citalopram (an antidepressant) and rosuvastatin (a statin); however, it is unlikely these drugs contributed to the accident. Review of medical and pathological information revealed no evidence of any medical condition that may have contributed to the accident.

Analysis

Primary failure mode
Engine power loss
First missed decision gate
Pilot could have chosen to divert to a nearby airport earlier.

NTSB coding

Evidence available

  • ATC audio
  • FDR / data
  • Photos
  • 28 docket documents
View NTSB final reportView NTSB docket

Docket documents28

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