Fort Lauderdale, FL, USA
N257SH
Piper PA31
The pilot of the on-demand passenger flight about 10 to 15 miles from the destination when the twin-engine airplane’s left engine stopped producing power. The pilot opened the fuel cross-feed valve, switched on both fuel boost pumps, and restored power to the left engine. The pilot continued to the original destination rather than land at a closer airport because he believed that the right engine fuel gauge indicated adequate fuel to complete the flight. When the airplane was on a left base leg for landing, both engines lost total power. The pilot made a forced landing on the grass between the runway and a taxiway, during which the airplane was substantially damaged. Postaccident examination of the airplane found that all of the fuel tanks were intact and empty of useable fuel. When the fuel system was tested, no leaks or other mechanical deficiencies were observed that would have precluded normal operation at the time of the accident. The airplane’s inboard fuel tanks had most recently been topped off 3 days before the accident (the outboard tanks were kept empty for weight reasons), after which the pilot performed a round trip passenger flight. Before the accident flight, the pilot did not visually check the fuel level in fuel tanks as prescribed by the preflight checklist. He stated that the fuel gauges, which he did not believe were accurate, indicated that the inboard tanks were more than half full. Based on his previous experience with the airplane’s typical fuel consumption, he estimated that he had about 2 hours of fuel remaining onboard the airplane to complete the planned round-trip flight, plus a 30-minute reserve. Following the accident, the pilot stated that he was “stubbornly overconfident” that there was enough fuel to complete the flight and, based on his extensive experience flying the airplane, he calculated a fuel consumption of 40 gallons per hour (gph); but he admitted that he should have calculated a fuel consumption of 50 gph. Based on the lack of fuel in the fuel tanks after the accident, as well as the confirmed postaccident integrity of the fuel system, it is likely that the pilot’s failure to verify the quantity of fuel onboard the airplane prior to the flight and his miscalculation of the airplane’s fuel consumption rate resulted in fuel exhaustion and the subsequent total loss of engine power. The accident likely also could have been avoided if the pilot landed immediately after the first loss of engine power rather than continuing to the originally planned destination. Based on available medical and operational evidence, it is unlikely that the pilot’s diagnosed tremors or other medical conditions contributed to the accident. There was no evidence that the pilot’s use of medications or alcohol contributed to the accident; however, available evidence was limited and did not include postaccident toxicology results.
HISTORY OF FLIGHT On September 19, 2020, about 1142 eastern daylight time, a Piper PA-31-350, N257SH, sustained substantial damage during a forced landing at Fort Lauderdale Executive Airport (FXE), Fort Lauderdale, Florida. The pilot and the seven passengers were not injured. The airplane was operated by Island Air Charters as a Title 14 Code of Federal Regulations Part 135 scheduled passenger flight. The airplane departed about 1120 from Grand Bahama International Airport (FPO), Freeport, Bahamas. The pilot stated that when the airplane was about 10 to 15 miles offshore over the Atlantic Ocean, the left engine stopped producing power. He opened the fuel cross-feed valve, switched on both fuel boost pumps, and restored power to the left engine. When they reached land, the pilot thought about landing at Pompano Beach Airpark (PMP), Pompano Beach, Florida, but elected to continue to FXE (6 miles away) because the right engine fuel gauge indicated that there was enough fuel to make it to FXE. The pilot said that when he turned onto a left base for runway 13 at FXE, both engines stopped producing power. The airplane was “too low and too slow” to land on the runway and the pilot made a forced landing on the grass between the runway and taxiway B. A review of airport surveillance video revealed that the airplane impacted two taxiway signs then spun 90° to a stop, which resulted in the nose gear collapsing and substantial damage to the fuselage. The left main gear and propeller blades were also damaged. According to airplane journey logs and fueling records, the airplane was last refueled on September 16, 2020, 3 days before the accident. The pilot, who was the last person to fly the airplane, said he requested only the inboard fuel tanks (56 gallons each) to be topped off, for a total of 112 gallons. The outboard tanks were left empty due to weight and balance restrictions. The pilot then flew round-trip from FXE to FPO without incident. The trip was logged as 1 hour in duration. The pilot said that he did not visually check the fuel level in the inboard tanks after it was fueled or before this flight. The airplane did not fly again until the day of the accident, when the pilot was again scheduled to fly a round-trip flight from FXE to FPO. He did not visually check the level of fuel in the inboard fuel tanks. He assumed there was 2 hours of fuel onboard, which was sufficient to conduct the flight to FPO and back, plus have a 30-minute fuel reserve. The pilot explained that he was unable to visually check the fuel level before departing because the design of the airplane’s wings did not allow him to see inside the tanks or to use a device to “stick” the tanks to determine fuel level. The pilot stated that the fuel gauges indicated that both inboard tanks were more than half full before he departed FXE, but the left gauge read less than the right fuel gauge. He said, “In my experience over the last fifty years, [fuel] gauges are notorious for not being real accurate. I trusted my fuel burn rate calculations, which were 40 gph for the first hour, and then 34 to 36 gph, that always worked. I was stubbornly overconfident there was enough fuel when I took-off. However, the fuel burn premise of 40 gph should have been 50 gph with all the stops involved.” The Island Air Charters Operations Manual, Performance and Weight and Balance section, 4-1 indicated that: Island Air Charters used a computer-based program that “automatically calculates aircraft ramp weight, takeoff gross weight, and landing weight, as well as the center of gravity at takeoff and landing. To derive this information, pilots merely enter the applicable actual weight of the flight crew, the actual weight of each passenger, the actual weight of the passenger’s baggage, freight and/or cargo, plus the fuel loaded, and anticipated fuel burn in the appropriate fields. A review of the operator’s Commuter Loading Weight and Balance form for the accident flight revealed the Inboard and Outboard Fuel Burn calculation data were not entered but were both signed off by the pilot. PERSONNEL INFORMATION The pilot held an airline transport pilot certificate with ratings for airplane multi-engine land and sea. He also held a flight instructor certificate with ratings for airplane single-engine, airplane multiengine, and instrument airplane. The pilot reported 19,234 total hours of flight experience on the application for his most recent Federal Aviation Administration (FAA) first-class medical certificate on July 16, 2020. He reported 3,000 total hours of flight experience in the accident airplane make/model. In addition to his flying duties, the pilot was the director of operations and the general manager of Island Air Charters. AIRPLANE INFORMATION The Piper PA-31-350, commonly known as a Chieftain, was a multi-engine airplane powered by two Lycoming TIO-540-J2BD engines each rated at 350 hp. The airplane was configured with 2 pilot seats and 8 passenger seats. There was no one seated in the front right passenger seat on the accident flight. The airplane was equipped with four fuel bladder tanks. Each wing was equipped with an inboard main fuel tank and an outboard auxiliary fuel tank. Each main fuel tank held 56 gallons and each auxiliary fuel tank held 40 gallons, totaling 192 gallons, of which, 182 gallons were useable. A review of the airplane’s Pilot Operating Handbook (POH), Section 4, Amplified Normal Procedures, page 4-11 to 4-13, stated: Upon entering the cockpit, release the controls if they have been secured. After ensuring that magneto switches, electrical switches, and flap switch are OFF and that mixture levers are in IDLE CUT-OFF, turn the master switch ON. Check that the fuel quantity gauges are operating and that there is sufficient fuel for the flight. Fuel quantity gauges indicate the amount of fuel in the tanks selected on the fuel selector valves…The fuel supply should be checked visually, and fuel caps securely in place. WRECKAGE INFORMATION Examination of the airplane revealed that all four fuel tanks remained intact and undamaged. The bottom of the airplane was visually inspected and wiped down with clean cloths. No evidence of fuel staining or leaks were found. About ½-ounce of fuel and 2 ounces of water were drained from the left wing fuel filter drain. No fuel was drained from the left inboard tank or outboard tank. About 6 ounces of fuel was drained from the right wing fuel filter quick drain. About 12 ounces of fuel was drained from the right inboard tank and no fuel was drained from the outboard tank. The fuel system was tested by adding 10 gallons of fuel to each tank and turning on the airplane’s power to pressurize the fuel system. The system was pressurized for about 30 minutes and no signs of leaks were noted in the airframe or engine cowlings. Both fuel gauges indicated about 10 gallons of fuel in each inboard tank. Fuel pressure and boost pump pressure remained in the normal operating range as the fuel selector was moved to each tank and the cross-feed position. The airplane was not equipped with an electronic fuel totalizer or gauges, and no nonvolatile memory components were installed. No mechanical discrepancies were noted with the airplane’s fuel system that would have precluded fuel from being delivered to either engine. MEDICAL INFORMATION Several of the passengers stated that the pilot’s hands were shaking uncontrollably before and after the accident. A review of his medical information revealed that he was being treated for long-standing tremor that caused hand shaking, as well as for high blood pressure and high cholesterol. For his tremor, the FAA had granted him an authorization for special issuance of medical certification in October 2019, after receiving a letter from his treating neurologist recommending full clearance for flying. The FAA had requested the letter in September 2019 after receiving a hotline complaint about the pilot’s hands shaking. Older FAA records mentioned the pilot’s tremor as early as the 1980s. For his high blood pressure, the pilot’s aviation medical examiner (AME) had previously issued medical certification according to the Conditions AMEs Can Issue (CACI) criteria, most recently in July 2019. The pilot’s last aviation medical examination before the accident was on July 16, 2020. His tremor/special issuance requirements and high blood pressure/CACI requirements should have been addressed at that examination but were not. The AME issued the pilot a first-class medical certificate. A review of the pilot’s primary care records indicated he was taking the medications propranolol, atorvastatin, and aspirin. These medications generally are not considered impairing and are consistent with the medications reported by the pilot in a postaccident interview. In that interview, the pilot also reported that he drank alcohol every night, maybe three or four drinks, but usually went to bed around 1900 and always allowed more than 8 hours after drinking alcohol before flying. According to FAA records, the pilot had participated in alcohol abuse programs as conditions of parole from prison around the 1990s; a 1997 evaluation by a psychologist found no evidence of ongoing alcohol abuse. The pilot did not undergo postaccident testing for alcohol or other prohibited drugs, although FAA regulation requires such testing of pilots in Part 135 charter operations. The Island Air Charters General Operations Manual (GOM) did not explicitly cover postaccident testing procedures. Instead, Chapter 2 of their GOM, “Policies and Procedures”, subsection 2.7.2.2 “Company Employee Post-Accident Drug and Alcohol Testing”, addressed the use of alcohol by a “covered employee” postaccident only. The manual stated: Federal Aviation Regulations stipulate that a “covered employee” who has actual knowledge of an accident involving a Company aircraft for which that “covered employee” performed a “safety sensitive” function near the time of the accident, shall not use any alcohol for 8 hours following an accident, unless the “covered employee” has either been given a post-accident test, or Island Air Charters management has determined that the covered employee’s performance could not have contributed to the accident. In the case of an accident, “covered employees” who may qualify for post-accident drug or alcohol screening shall not use any alcohol following an aircraft accident, or incident, for a period of 8 hours after the accident or incident, or until given the required test, or been excluded by Company management from inclusion in the post-accident test group. According to the chief pilot of Island Air Charters, he was in another state when the accident occurred and did not ask the accident pilot about being drug/alcohol tested. He spoke to the pilot, who was also his supervisor, shortly after the accident and asked if he needed any assistance. The pilot said he had everything under control.
The pilot’s improper preflight fuel planning, which resulted in a total loss of engine power due to fuel exhaustion. Contributing to the accident was the pilot’s decision to continue to the destination following the loss of engine power to the first engine.
Source: NTSB Aviation Accident Database
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