CEN13FA338

The loss of engine power due to fuel exhaustion as a result of the manufacturer providing the incorrect Pilot’s Operating Handbook to the owner, which prevented the pilot from accurately calculating the fuel requirements before the flight. Contributing to the accident were the pilot’s inadequate preflight planning and poor decision-making.

The airline transport pilot (ATP) had volunteered to deliver the airplane to a maintenance facility and had made the arrangements for the flight, including preflight planning. The commercial pilot chose to ride along with the ATP to gain flight experience and familiarity with the airplane. After stopping to refuel, the airplane took off on the last leg of the cross-country flight that night. The commercial pilot reported that, about 10 minutes from their destination, the fuel gauge was reading "close to empty." About 5 minutes later, the engine lost power, at which time, the ATP took control of the airplane. The pilots attempted to deploy the ballistic parachute just before the forced landing; however, due to the low altitude, it did not fully deploy. The airplane impacted the ground hard, and the high surface winds dragged the airplane across rough and uneven terrain before it became entangled in a barbed wire fence. No fuel was found in the fuel pump or tank. An examination of the engine and fuel system revealed no mechanical anomalies that would have prevented the engine from producing power if fuel had been available. The fuel capacity information in the Pilot's Operating Handbook (POH) provided to the pilots and on the placard created by the ATP (based on the POH) was inaccurate. Although the manufacturer reported that it provided the correct POH to the owner when the airplane was delivered, the owner had the incorrect POH, and the investigation determined that several other owners of this airplane model had received the wrong POH upon delivery of their aircraft. The POH indicated that the airplane had 15 gallons total fuel capacity and 14.5 gallons usable fuel capacity. However, the airplane's actual total fuel capacity was 13.2 gallons and the usable fuel capacity was 12.7 gallons. The calculated fuel requirement for the accident leg of the flight would have been at least 13.2 gallons of fuel; thus, the engine stopped producing power due to fuel exhaustion. Even if the fuel capacity information had been accurate, visual flight rules night flights require a 45-minute fuel reserve, and that would not have been met on the accident leg. Thus, the ATP did not properly calculate the flight's fuel requirements. Further, he failed to adequately monitor the airplane's in-flight fuel consumption and recognize that the airplane was low on fuel. In addition, the airplane was not equipped to fly at night nor was it approved for night flight, yet the pilot planned the flight legs such that the airplane would be flying at night. The ATP's most recent application for a Federal Aviation Administration airman medical certificate had been denied; the commercial pilot did not know this before the accident. Although the ATP was acting in the capacity of the pilot-in-command , because his medical certificate had been denied, he was not qualified to serve in this role. The ATP had severe heart disease, hypertension, and a history of stroke, which increased his risk for a cardiac arrhythmia; however, the autopsy found no evidence of a recent heart attack. The ATP also had a history of depression, and toxicological tests were positive for therapeutic levels of the antidepressant medication citalopram, which has an acceptable side effect profile. It could not be determined if the pilot was impaired by cardiac symptoms or depression around the time of the accident; however, the circumstances of the accident make it unlikely. The manufacturer's instruction manual for the parachute stated that the minimum height for deploying the parachute ranged between 100 and 250 feet. However, the POH does not provide any information or guidance regarding the recommended altitude for deployment.

A Garmin Aera 500 GPS was installed in the accident airplane. The GPS was sent to the National Transportation Safety Board (NTSB) Vehicle Recorders Lab in Washington D.C. for download. Flight track information, including time, latitude, longitude, altitude, ground speed, and heading was recovered from the unit for the accident flight. The flight departed Anderson, Indiana, and stopped in Mexico, Missouri, and El Dorado, Kansas. According to the data recovered from the GPS, the flight departed a location consistent with El Dorado, Kansas, around 2113. The flight track record was consistent with a relatively direct flight to KBGD. The altitude increased to 6,200 feet and ground speed varied throughout the flight but averaged 72 knots. At 0033:47, the airplane started to descend. At 0037:44, at an altitude of 2,765, the ground speed decreased to 15 knots consistent with the deployment of the ballistic parachute. The last line of data was recorded at 0038:13, at an elevation of 2,748 feet msl. The wreckage was recovered to a facility in Greeley, Colorado, for storage and further examination. Investigators from the NTSB, Pipistrel, and Rotax examined the wreckage. The wreckage consisted of the fuselage, empennage, both wings, and the canopy. The wings and canopy were removed from the airplane during the recovery. The fuselage included the engine and propeller assembly, the fuel tank, both seats, and the instrument panel. The composite material on the bottom aft portion of the fuselage in addition to the engine cowling was torn and cracked. The instrument panel was not impact damaged. The fuel gauge read empty and the Hobbs meter showed 32.6. The Kollsman window was set to 30.03 inches. All other instruments indicated zero. The fuel tank was not impact damaged. The fuel lines were intact and approximately 1 tablespoon of fuel was observed at the bottom of the fuel tank. The fuel vent line separated and the fuel filter at the tank was clean and dry. Neither the rocket nor the cover for the parachute system were recovered. The canopy had several tears in the fabric on one side and was dirty. The risers were tangled and one area of Kevlar was abraded, as if it rubbed on something. The right wing assembly included the right flaperon. The leading edge exhibited scratches and scrapes. There was a circular puncture on the inboard bottom portion of the wing and multiple small punctures on the upper skin of the wing. The right flaperon was unremarkable. The left wing assembly included the left flaperon. The leading edge exhibited scratches and scrapes. There were multiple punctures on the upper and lower wing skin. The outboard portion of the wing tip was fragmented. The outboard portion of the left flaperon was fragmented. The aileron push/pull tubes were continuous from the control stick to the aileron. The empennage included the vertical stabilizer and rudder. The empennage was separated from the fuselage, just aft of the fuel tank. The composite material was broken and cracked in multiple locations. The lower leading edge of the vertical stabilizer was crushed aft and broken. The rudder was separated partially at the top of the assembly. The horizontal stabilizer and elevator assembly was separated from the empennage and was located within the debris field. The right side of the elevator was cracked at midspan, and the left side of the elevator was intact. The composite material on the upper center portion of the horizontal stabilizer was torn. The elevator push/pull tube was continuous from the flight control stick in the cabin, aft to the point of separation. The tube was continuous from that point, aft through the empennage to the vertical stabilizer. The rudder cables were continuous from the cabin, aft to the point where they were cut for the purposes of recovery. The cables were continuous from the cut point, aft through the empennage to the rudder control. The engine remained attached to the fuselage at the engine mounts. The spark plugs were clean and 1/8 cup of fuel, yellow in color, was recovered from the carburetor bowl. Trace fuel was recovered from the engine drain, and a teaspoon of fuel was recovered from the second carburetor bowl. Both propeller blades were broken. For examination purposes, the impact-damaged fuel line was repaired, and fuel was added to the engine. The fuel system was primed, and the engine started without hesitation. The engine was run for several minutes at varying power settings. During the magneto check, the rpm dropped between 150 and 200 rpm. Fuel Capacity When the airplane was originally sold and delivered to the owner, a Pipistrel Pilot's Operating Handbook (POH) was included with the delivery. The POH applied to the ALPHA Trainer LSA equipped with the Rotax 912 engine and was marked as Revision 1 (March 19, 2012). This POH was printed on A4 paper and was bound with clear plastic page covers and a black spiral binding coil. At several points in the POH, including Performance Specifications, Chapter 1 – General, Chapter 2 – Aircraft and System Description, and Chapter 3 – Limitations, the full fuel capacity was written as 15 US gallons and the fuel capacity (usable – all flight conditions) was written as 14.5 US gallons. A Pipistrel POH, Revision 1 was located in the personal effects of the ATP in the wreckage of the airplane. Digital copies of several pages from the POH were provided to investigators including the cover page and several other pages reflecting fuel performance specifications. The POH serial number and registration number (for the accident airplane) had been hand written on the front page of the POH. This POH appeared to have been printed on 8 ½ inch by 11 inch paper. The fuel capacity reflected in this POH was identical to the fuel capacity in the POH for the accident airplane – 15 gallons total and 14.5 gallons usable. Pipistrel representatives reported that the airplane was delivered with revision 3 of the POH. It is unknown how or why the Revision 1 POH was supplied with the airplane at delivery and why the owner did not have the later revisions of the POH. In subsequent revisions of the POH, including Revision 4 which was provided to the NTSB by Pipistrel, the total fuel capacity was written as 13.2 US gallons, and the usable fuel capacity was written as 12.7 gallons. According to the owner of the accident airplane, fuel placards for the airplane's fuel filler cap did not arrive with the airplane when it was delivered. He said that the airline transport pilot had created a label/placard to affix near the fuel filler cap on the fuselage that indicated 15 gallons fuel capacity and 14.5 gallons usable. During the course of the investigation, it was also established that several owners had received the wrong revision of the POH with the fuel capacity error. As a result of this discovery, on August 8, 2013, Pipistrel notified all owners worldwide of the error and requested that they ensure the proper placard with fuel information was affixed adjacent to the fuel filler cap. On August 12, 2013, Pipistrel printed out and issued to all owners, the most recent POH revision with the correct fuel information. Fuel Burn Calculations According to both the Revision 1 and Revision 4 Pipistrel POH, the fuel flow at cruise speed is 3.6 gallons per hour. The Pipistrel POH does not provide fuel usage for engine start, taxi, and takeoff and climb. The following parameters were used by investigators to estimate the fuel requirements for the last leg of the accident flight based upon this fuel flow rate: - 260 nm between KAID and KBGD - 72 knot average ground speed based upon GPS data - 3.6 gallons per hour - 3 hours and 40 minute flight (estimate) - 3 hours and 20 minutes (actual to the loss of engine power) Based upon the fuel flow information provided in the POH and the estimated flight time, the flight would have required no less than 13.