Pilot Debrief

PIPER PA-28R-200 near Page, AZ — 2021-09-22

Final reportWPR21FA352
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Date
2021-09-22
Location
Page, AZ, USA
Airport
PGA
Aircraft
PIPER PA-28R-200
Registration
N3906X
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Descent

Probable cause

The pilot’s improper fuel planning for a cross-country flight, which resulted in fuel exhaustion and a total loss of engine power.

NTSB narrative

The pilot and the passenger (the pilot’s wife) were making their first cross-country flight in their private airplane. After loading the airplane with several items, including a boat motor, camping gear, a raft, and two dogs, the pilot completed the airplane’s weight and balance calculations, and the airplane departed. The climb and cruise portions of the flight were uneventful. About 3 hours 15 minutes into the flight, the pilot began to descend the airplane to an altitude of about 7,700 ft mean sea level (msl) and, about 12 minutes before the accident, descended the airplane to about 6,600 ft msl. The passenger stated that the pilot became upset a few minutes before the accident, and the airplane began to descend about 1 minute before the accident until it impacted the ground. The propeller blade signatures at the accident site were consistent with low rotational energy. Postaccident examination of the wreckage revealed no evidence of a preimpact mechanical malfunction or anomaly with the engine or airframe. The examination found no fuel in either fuel tank, neither of which was breached, and there was no evidence of a fuel odor or staining on the airframe. Fuel performance computations suggested that the airplane likely lost power due to fuel exhaustion about 1 minute before the accident. These computations also suggested that the airplane departed with 42 gallons instead of the 48 gallons indicated in the pilot’s operating handbook, likely to accommodate the weight of the cargo. Although the pilot had completed weight and balance calculations for the accident flight, no evidence indicated that he considered the airplane’s performance. If the pilot had properly computed the airplane’s fuel consumption for the planned flight, he should have recognized that the airplane had insufficient fuel to reach its destination. Instead, fuel exhaustion occurred, which led to a total loss of engine power. The airplane was also slightly over gross weight at the time of departure, which likely didn’t affect his forced landing as the airplane landed upright and the center of gravity was within published limitations. Both occupants were wearing their three-point restraints, and they sustained serious traumatic injuries during the impact. Evidence showed that the heaviest portion of the boat motor had contacted the pilot’s seat at the time of impact, which caused the seat to move forward during impact and compress the pilot between the seatback and forward control panel. This loss of occupiable space likely contributed to the severity of his injuries. Toxicology testing of the pilot’s blood detected the presence of two sedating antihistamines. At the time of the pilot’s death, one of the medications was likely at therapeutic levels, and the other was at subtherapeutic levels but was likely at therapeutic levels when the airplane departed. The medications can impair cognitive and psychomotor performance; however, the investigation could not determine, based on the available evidence, if the effects from the pilot’s use of the medications contributed to the accident.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot could have recognized fuel exhaustion and returned to airport before descent.

NTSB coding

Evidence available

  • Video
  • Photos
  • 19 docket documents
View NTSB final reportView NTSB docket

Docket documents19

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