Pilot Debrief

PIPER PA38 near Grass Valley, CA — 2020-11-10

Final reportWPR21FA044
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Date
2020-11-10
Location
Grass Valley, CA, USA
Aircraft
PIPER PA38
Registration
N6380A
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Cruise

Probable cause

A total loss of engine power due to the pilot’s improper fuel management, which resulted in fuel starvation.

NTSB narrative

On the day of the accident, the pilot departed on a flight that included two full stops and touch-and-go landings at a third airport. During the first stop, he fueled the airplane and conducted an hour-long flight before departing on the accident flight leg, which was about 80 minutes in duration. While flying over an area of heavily wooded terrain, the pilot reported a total loss of engine power to air traffic control. The pilot then made a series of descending turns, likely searching for a forced landing site, which were limited due to the terrain and vegetation. During the approach to his selected landing site, the airplane collided with a tree before it impacted the ground and came to rest inverted. Postaccident examination of the wreckage revealed no preimpact anomalies that could have precluded normal operation. The fuel selector was set to the left tank, which was void of fuel, and there was no evidence that fuel had leaked from the left tank while the airplane was inverted. About 5 gallons of fuel was drained from the right tank during recovery. There was no evidence of any preimpact anomalies with the fuel system. Although water contamination was observed in the gascolator bowl during postaccident examination, the airplane had been subjected to frequent rain for several months during storage following the accident with the left-wing fuel cap removed; it is therefore unlikely that the loss of engine power was the result of fuel contamination. Examination of the engine revealed no anomalies. Based on the available information, it is likely that the pilot failed to switch fuel tanks during the flight, which resulted in the exhaustion of the fuel supply in the left-wing tank and a subsequent total loss of engine power.

Analysis

Primary failure mode
Fuel management
First missed decision gate
Pilot should have switched fuel tanks before power loss.

NTSB coding

Evidence available

  • ATC audio
  • ADS-B / radar
  • Photos
  • 26 docket documents
View NTSB final reportView NTSB docket

Docket documents26

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