Primary finding
Probable cause
The pilot's inadequate preflight inspection, which resulted in his failure to note the water in the fuel tank due to condensation, which subsequently shut down the engine in flight. Contributing to the accident was the pilot's self-induced pressure to expedite the departure.
Investigator assessment
Analysis narrative
Before the accident flight, the airplane had sat in its hangar for the previous 2 months with its fuel tanks half full under varying temperature conditions. The pilot had planned on flying to a safety seminar that began at 1630, so he had the airplane pulled out of its hangar, and its main fuel tanks were topped off from a fuel truck. After his arrival at the airport shortly before 1700, the pilot performed a preflight inspection. The manager of the hangar facility described the pilot's preflight inspection as "real quick." A lineman observed the pilot in a position to reach the fuel strainer valve, but he did not see the pilot sumping the main fuel tanks. When the lineman drove by the airplane, he saw a puddle about 1 foot in diameter on the tarmac beneath the fuel strainer, but he did not note anything under either main fuel tank drain. The lineman also noted that the airplane had an underinflated tire, but, due to other duties, he could not warn the pilot before he taxied the airplane away. About 2 minutes after takeoff, the pilot reported an "engine problem" to air traffic control and turned the airplane back toward the airport. The airplane subsequently descended at a steep angle, consistent with a stall, into a house located in a populated area. The airplane impacted the roof, came to rest upside down, and was subsequently mostly consumed in a postcrash fire. Postaccident examination of the airplane revealed evidence indicating that the airplane was not under power at the time of the accident; the fuel-injected engine was charred and the propeller did not exhibit torsional bending or leading edge damage that would have been present if it had been under power. No preexisting mechanical anomalies were found that would have precluded normal engine operation. However, when the fuel flow divider was opened, water was found in it, which likely resulted in the loss of engine power. Water typically enters fuel tanks via three sources: leakage, normally through a fuel cap; contaminated fuel sources; and fuel tank condensation. The fuel cap was likely not the source of water since the airplane was stored in a hangar. Contaminated fuel from the fuel truck was also not the likely source of water since the truck was reportedly sumped daily. Further, on the day of the accident, five airplanes received fuel from the same truck before the accident airplane with no reports of any performance anomalies, and a clean fuel sample was taken from the truck about 20 minutes after the accident. It is more likely that condensation occurred in the half-filled fuel tanks during the previous 2 months that the airplane was sitting in the hangar under varying temperature conditions. Regardless, the pilot had an opportunity to eliminate the condensation during the preflight inspection. However, as noted previously, not enough evidence existed to determine whether the pilot actually drained each main tank to ensure that all of the water was removed. It is likely that the pilot either did not sufficiently drain the main fuel tanks or that he was relying on draining the main fuel tanks through the fuel strainer and fuel lines and did not sufficiently drain them all. Given witness statements indicating that the pilot was in a hurry and his oversight of the underinflated tire, it is likely that the pilot's preflight inspection was inadequate, which resulted in his failure to notice the fuel tank condensation.
Source record
Factual narrative
- Fuel System – From the Cherokee Six 300 flight manual, "Standard fuel capacity…is 84 gallons, all of which is useable except for approximately one pint in each of the four tanks. The two main inboard tanks…hold 25 gallons each…the tip tanks hold 17 gallons each. The fuel selector control is located below the center of the instrument panel on the sloping face of the control tunnel…When using less than the standard 84 gallon capacity of the tanks, fuel should be distributed equally between each side, filling the tip tanks first." The fuel system should be drained daily prior to first flight and after refueling to avoid the accumulation of water or sediment. Each fuel tank is equipped with an individual quick drain located at the lower inboard rear corner of each tank. The fuel strainer and a system quick drain valve are located in the fuselage at the lowest point of the fuel system. It is important that the fuel system be drained in the following manner: 1. Drain each tank through its individual quick drain located at the lower inboard rear corner of the tank, making sure that enough fuel has been drained to ensure that all water and sediment is removed. 2. Place a container under the fuel sump drain outlet, which is located under the fuselage. 3. Drain the fuel strainer by pressing down on the lever located on the right-hand side of the cabin below the forward edge of the rear seat. The fuel selector must be positioned in the following sequence: off position, left tip, left main, right main, and right tip while draining the strainer to ensure that the fuel lines between each tank outlet and each strainer are drained as well as the strainer. When the fuel tanks are full, it will take approximately 11 seconds to drain all the fuel in one of the lines between a tip tank and the fuel selector, and approximately 6 seconds to drain all the fuel in one of the lines from a main tank to the fuel strainer. When the tanks are less than full, it will take a few seconds longer. 4. Examine the contents of the container placed under the fuel sump drain outlet for water and sediment and dispose of the contents. - Fuel Quality - According to the manager of the FBO, the fuel truck was sumped daily. A fuel sample was taken from the truck after the accident by FBO personnel within 20 minutes of the accident, examined, and found to contain no water, debris or other anomalies. It was not retained by authorities prior to NTSB visit to HKS, but remained with the FBO and was not subsequently tested. According to the FBO fueling log, on the date of the accident, the airplane received 28.4 gallons of fuel from the FBO's fuel truck. The log also indicated that five airplanes had been fueled before the accident airplane, receiving a total of 279.1 gallons from the fuel truck, and after the fuel sample was taken subsequent to the accident, one additional airplane was fueled, receiving a total of 44.9 gallons from the fuel truck. There were no reports received of fuel quality issues with any of the other fueled airplanes. - Drain Test - An exemplar PA-32-260 (according to the Piper representative to the investigation, the fuel system is the same for the -260 as the -300) was utilized to attempt a comparison with the approximately 1-foot the fuel stain seen on the ramp after the preflight inspection. After an initial 1-2 second initial draining of the fuel from the exemplar airplane, there was about a 1-foot stain on the asphalt underneath it. Due to the amount of fuel to be drained, subsequent attempts were drained into a calibrated beaker with stopwatch timings for each attempt, and the fuel was then returned to the airplane. For 6 seconds of draining, the quantity averaged about 130 ml per draining, and for 12 seconds of draining, the quantity averaged about 260 ml per draining. Pour tests were then made utilizing water, resulting initially in about a 1 ½-foot puddle for each 130 ml pour, and about a 2-foot puddle for each 260 ml pour. After about 10 minutes, the puddles had expanded significantly more, but in irregular shapes. Noted, however, was because of possible differences, such as slope and surface roughness between the test and the prevailing conditions at HKS, an exact comparison could not be made. Autopsies were conducted on all occupants at the Mississippi State Medical Examiner's Office, Jackson Mississippi, where cause of death was determined to be "inhalation of products of combustion, aircraft crash." The Medical Examiner also confirmed that the occupant of the left front seat was the ATP. Toxicological testing was subsequently performed by the FAA Forensic Toxicology Research Team, Oklahoma City, Oklahoma, where it was determined that all three occupants had elevated levels of carbon monoxide in their blood. The ATP had no evidence of drugs in his system. The HKS Tower observation, at 1715, included clear skies, wind from 010 degrees true at 3 knots, visibility 10 statute miles, temperature 11 degrees C, dew point -2 degrees C, altimeter setting 30.33 inches Hg. The airplane, manufactured in 1972, was powered by a Lycoming TIO-540-series engine. The airplane's latest annual inspection occurred on March 2, 2012, at 4,385 total airframe hours, and 751 hours since engine overhaul. Based on the ATP's logbook, the airplane flew an estimated 28 additional hours before the accident. According to the owner, the airplane had been sitting in its hangar with the fuel tanks half full. A fuel log and the FBO lineman indicated that just prior to the flight, the ATP requested that the main fuel tanks be topped off with fuel, which resulted in 28.4 gallons being pumped. The ATP, age 65, held an airline transport pilot certificate with airplane single engine land, airplane multiengine land, and rotorcraft-helicopter ratings. He also had commercial privileges for airplane single engine sea, glider, and lighter-than-air balloon aircraft. In addition, he held type ratings for four helicopter types and a Lear 45. He was also a certificated flight instructor, ground instructor, and mechanic. The pilot's latest FAA second class medical certificate was dated August 14, 2012. According to the ATP's logbook, he had accumulated 17,775 total flight hours, with 2,664 hours in single engine land airplanes, 2,804 hours in multiengine land airplanes, and 9 hours in the 30 days prior to the accident. On an insurance application for the accident airplane dated March 30, 2012, the ATP indicated 294 hours in make and model. Logbook entries indicated that subsequent to that date, he had an additional 28 hours in make and model. Logbook entries also indicated 142 hours in the accident airplane, with the last flight in that airplane prior to the accident flight occurring on September 3, 2012. The majority of the airplane came to rest upside down in a house located in a populated area about 185 degrees true, 0.8 nautical miles south of the departure end of runway 16, in the vicinity of 32 degrees, 18.93 minutes north latitude, 090 degrees, 13.28 minutes west longitude. Tree damage indicated an approximately 60-degree descent, heading 310 degrees magnetic. Except for the left wing, which was lying in the yard next door, the airplane was mostly consumed in a postcrash fire, inside the house. All flight control surfaces were accounted for at the scene. Fire damage precluded flight control continuity beyond cable separation points. The airplane's instrument panel was completely destroyed; however, charred remnants from a hand-held GPS receiver were recovered and forwarded to the NTSB Recorders Laboratory for a data recovery attempt which was not successful. Engine power control positions could not be determined, and the fuel tank selector position at the time of impact could also not be ascertained. The fuel tank selector was examined at the NTSB Materials Laboratory; however, no witness marks or other identifying features wer