Pilot Debrief

PIPER PA-23 near Baltic, OH — 2012-06-28

Final reportCEN12LA401
Sign in to save
Date
2012-06-28
Location
Baltic, OH, USA
Aircraft
PIPER PA-23
Registration
N3170P
Category
Airplane
Highest injury
Serious
Fatalities
0
Phase of flight
Initial climb

Probable cause

Loss of engine power due to fuel starvation as a result of particulate contaminant on the carburetor screens.

NTSB narrative

Shortly after takeoff, the left engine lost power so the pilot diverted to an alternate airport for landing. After the left engine was secured, the airplane was not maintaining altitude so the pilot selected an off-airport site short of the alternate airport to land. While approaching the off-airport site, the right engine lost power, and the airplane was substantially damaged during the forced landing. An examination of the fuel system revealed an extensive amount of corrosion consistent with the continued presence of water over an extended period. Both engine carburetor screens were occluded with particle contaminants, which likely resulted in the loss of power in both engines. The pilot reported that before the flight, he conducted a normal preflight inspection, had 54 gallons of fuel added to both main fuel tanks, and sumped one fuel sump cup full of fuel out of each main tank. Neither the previous owner nor the accident pilot was aware of an airworthiness directive (AD) requiring a special fuel sumping procedure before every flight. The AD also specifies that the procedure should be incorporated into the owner handbook and pilot’s operating manual. The required documentation advising pilots of this preflight procedure was not in the airplane.

Analysis

Primary failure mode
Fuel management
First missed decision gate
Pilot did not follow required fuel sumping procedures before flight.

NTSB coding

Evidence available

  • 4 docket documents
View NTSB final reportView NTSB docket

Docket documents4

Related mishaps