Orlando, FL, USA
N98304
PIPER PA-28-140
The purpose of the cross-country flight was so that the private pilot could accrue flight time to meet the requirements for a commercial pilot certificate. During the flight, the private pilot was in the left seat and a flight instructor was in the right seat. During the descent to their destination airport, the private pilot switched fuel tanks and, about 700 feet above mean sea level (msl), there was a loss of engine power. The flight instructor assumed control of the airplane, declared an emergency and conducted a forced landing. During the forced landing, the airplane was substantially damaged, and the private pilot was seriously injured. During recovery of the wreckage form the accident site, 5 gallons of fuel were drained from the left wing fuel tank and 10 gallons of fuel were drained from the right wing fuel tank. Examination of the wreckage revealed that the fuel selector and fuel selector valve cover were not installed per the manufacturer’s guidance. The selector valve cover had been improperly installed directly to the interior side panel with oversize screws, which interfered with the movement of the selector handle. The cover was not in the correct mounting orientation, the selector cover attach bracket was not installed, nor was the spring-loaded metal stop (which would keep the fuel selector valve from inadvertently being placed in the FUEL OFF position). The fuel selector was observed between the L TANK (left fuel tank) and FUEL OFF position. Prior to verification of the fuel selector position, fuel line continuity could not be established with low pressure air from the left or right wing root fuel lines to the gascolator. Removal of the cover also confirmed that the fuel selector valve was positioned between the left fuel tank and fuel off positions. Detents in the fuel selector valve were also confirmed, but the fuel selector valve cover selector position labeling did not align with the detent positions as the fuel selector valve cover had not been properly indexed. After the examination, when the fuel selector valve was placed in either the correct left fuel tank or right fuel tank positions, the engine was able to be run without any anomalies. Based on this information, the loss of engine power was most likely the result of fuel starvation, after the flight crew inadvertently placed the fuel selector into a position between the left fuel tank and off positions. Maintenance records indicated that the airplane had undergone a 100-hour inspection 20 days before the accident. However, 13 days before the accident, a Federal Aviation Administration (FAA) inspector performed an inspection of the airplane and identified 42 discrepancies, including that the fuel selector valve handle should be painted red and that the installed fuel tank selector placard was unsatisfactory. After discussing the condition of the airplane with one of the owners, the inspector was advised that they were not going to use the aircraft at the flight school. Maintenance records indicated that 8 days before the accident, a mechanic installed a fuel selector valve cover and certified that all work was accomplished in accordance with the manufacturer’s maintenance manual. None of the sections explicitly listed in the maintenance log entry, however, addressed the installation of the fuel selector valve or fuel selector valve cover. Based on this information, the improper installation of the fuel selector valve cover, which was accomplished at the direction of the operator/owner, likely directly contributed to the flight crew’s incorrection positioning of the fuel selector valve.
On August 16, 2021, about 2032 eastern standard time, a Piper PA-28-140, N98304, operated by Airline Training Academy Inc., dba ATA Flight School, was substantially damaged when it was involved in an accident in Orlando, Florida. The private pilot was seriously injured, and the flight instructor received minor injuries. The airplane was being operated as a Title 14 Code of Federal Regulations (CFR) Part 91 instructional flight. According to the flight instructor, the purpose of the flight was so that the private pilot could accrue flight time to meet the requirements for a commercial pilot certificate. The flight departed North Perry Airport (HWO), Hollywood, Florida, about 1855, destined for Orlando Executive Airport (ORL), Orlando, Florida. During the accident flight, the private pilot was in the left seat and the flight instructor was in the right seat and was “acting as safety pilot.” Prior to departing HWO, they completed the preflight checklist, added oil to the engine and assured that the fuel tanks were full. They planned to fly to ORL, land, and later return to HWO. About 30 miles from ORL, the flight instructor requested visual flight rules flight following services from air traffic control. He received a weather update and was asked to remain outside the Orlando Class B airspace. As a result, they had to fly around weather that was in the area, and then were eventually handed off to ORL tower at approximately 2020. As they were approaching the airport, the private pilot was flying the airplane. He switched fuel tanks and, about 700 feet msl, he determined that the throttle was not responding to his commands. He then alerted the flight instructor and handed over control of the airplane to him. Once the flight instructor confirmed that the throttle was not responsive, the private pilot went through the emergency checklist while the flight instructor pitched the nose of the airplane up to decrease the rate of descent. The flight instructor radioed ORL tower and declared an emergency and then conducted a forced landing. When the airplane came to rest, the flight instructor observed that the private pilot was not conscious. He then tried to wake him up and began to remove him from the airplane. At some point the private pilot regained some level of consciousness and the flight instructor assisted him to an urgent care center that was located about 100 yards from the accident site. They both received medical attention at the urgent care center and were then transported to a hospital. After the accident, the flight instructor stated to an Orange County Sheriff’s officer that there had been prior issues with the airplane. According to an FAA inspector, the pilots had advised that the engine stoppage had occurred when they switched fuel tanks. During the recovery, 5 gallons of fuel were drained from the left wing fuel tank, and 10 gallons of fuel were drained from the right wing fuel tank. Examination of the wreckage by the NTSB revealed that the fuselage exhibited impact damage to its firewall and cockpit belly skin. Downward deformation was observed at the tail cone area. The nose gear was impact-separated and the engine cowlings exhibited impact damage. All control cables remained attached to their respective attach points and control continuity was established. Two Hobbs meters were installed each showing different times. The carburetor heat control was in the OFF position. The wing flap lever was in the up (0°) position. The manual primer was stowed and the electric fuel pump switch was in the ON position. The pilot and copilot seats where the pilot and flight instructor were seated remained attached to their respective mounts. The pilot and copilot seats were in poor condition displaying torn fabric with missing and protruding cushion material. Their lap belt restraints remained attached to their respective attach points. The rear bench seat remained attached to its mounts. The bench seat’s inboard seat belt latches were not installed. Examination of the fuel selector and fuel selector valve revealed that the fuel selector valve cover was not installed per manufacturer’s guidance. Instead, it had been installed directly to the interior side panel with oversize screws, which interfered with the movement of the selector handle. Further examination also revealed that the cover was not in the correct mounting orientation/clocked position; no selector cover attach bracket was installed, nor was the spring-loaded metal stop. The fuel selector was observed between the L TANK (left fuel tank) and FUEL OFF position. Prior to verification of the fuel selector position, fuel line continuity could not be established with low pressure air from the left or right wing root fuel lines to the gascolator. Removal of the cover confirmed the valve was positioned between the left fuel tank and fuel off positions. Detents in the fuel selector valve were confirmed. Fuel line continuity was confirmed with low pressure air when the selector was placed in the left fuel tank and right fuel tank positions, respectively. The interior of the left wing also displayed an area where high-expansion foam was visible through the breaks in the wing. A residual amount of blue liquid consistent in color and odor to that of aviation type gasoline was observed within the fuel tank. Fuel line continuity was established from the wing root to the fuel tank with low pressure air. The fuel cap was not attached to its receptacle and was not located within the recovered wreckage. The engine remained attached to the impact damaged mount. The induction air box was impact damaged and the carburetor heat was observed in the “off/filtered air” position. No anomalies were noted to the heat muff, and the exhaust tailpipe was crushed at its lower area. The induction air filter assembly exhibited impact damage and no obstructions were observed. Examination of the induction air hose/duct revealed it was not a Piper part/correct hose. The induction Scat type hose exhibited impact damage. The electric fuel pump’s filter was clear of debris and fuel was observed during the examination. The gascolator exhibited impact damage and its filter was clear of debris. The aluminum two-bladed fixed pitch propeller remained attached to the engine. Both propeller blades were deformed aft about mid-span with no leading-edge damage observed. The propeller spinner remained attach to the propeller with leading edge impact or recovery damage noted. The engine was subsequently prepared for a ground test run. Both propeller blades were cut inboard of their bent areas. The gascolator was bypassed with a fuel line due to impact damage of the gascolator. A fuel supply was attached to the aircraft’s fuel line at the right wing root and the fuel selector was placed in the right fuel tank position. The engine was then started and ran to about 100° of oil temperature; about 80 psi of oil pressure, and about 6 psi of fuel pressure were observed. The magneto drop was observed about 400 RPM between the left and right magnetos. The engine was then run to 2,500 rpm with no anomalies noted. The engine was shut down via mixture control and the fuel supply tank was then attached to the fuel line at the leftwing root area. The fuel selector was then placed in the left fuel tank position. The engine was then started and ran to 2,500 rpm with no anomalies noted. On July 27, 2021 (20 days prior to the accident), the individual who listed himself as the operator on an NTSB Form 6120 Pilot/Operator Accident/Incident Report, certified in the airplane maintenance records “that this aircraft was inspected with accordance with a 100hr Inspection was determined to be in airworthy condition.” Review of State of Florida records at the time indicate that he was the Registered Agent for Airline Training Academy Inc., which was a Florida Profit Corporation. On August 03, 2021 (13 days prior to the accident), an FAA inspector performed a ramp inspection on airplanes that were being operated at HWO. During the inspection of the accident airplane, the inspector identified 42 discrepancies with the airplane including that the fuel selector valve handle should be painted red and visible from normal viewing angles, and the installed fuel tank selector placard was unsatisfactory. After discussing the condition of the airplane with one of the owners, the inspector was advised that they were not going to use the airplane at the flight school. On August 8, 2021 (8 days prior to the accident), a mechanic “Installed customer supplied fuel selector valve cover” and certified that “all work was accomplished in accordance with Piper PA28-140 service manual section 2, 4, and 8.” None of these sections, however, addressed installation of the fuel selector valve or fuel selector valve cover. The company name that was listed on the maintenance entry was Aviation Maintenance Technologies Inc. Review of publicly available business information indicated that the president of Aviation Maintenance Technologies Inc. was also the same individual listed on the bill of sale for the accident airplane under “purchaser” when it was purchased by Florida General Aviation Corporation. A comparison of FAA registration records to a Florida Profit Corporation Annual Report filed with the Florida Secretary of State, also indicated that the president of Florida General Aviation Corporation was also the president of the Airline Training Academy Inc. According to Title 14 CFR 91.403 (a), the owner or operator of an aircraft is primarily responsible for maintaining that aircraft in an airworthy condition, and a review of published Piper Aircraft guidance documents indicated that documentation was available for proper installation and inspection of the fuel selector valve and fuel selector valve cover.
A total loss of engine power due to fuel starvation that resulted from improper maintenance of the fuel selector valve and fuel selector valve cover.
Source: NTSB Aviation Accident Database
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