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NTSB investigation record

ERA13FA096

Completed

Piper Pa-31-350· N78WM

Date
December 24, 2012
Location
Leesburg, FL
Conditions
VMC
Record
Published September 25, 2020

Primary finding

Probable cause

The pilot's inadequate preflight planning, which resulted in fuel exhaustion and a subsequent total loss of power in both engines during cruise flight. Contributing to the accident was the pilot’s use of prescription and illicit drugs, which likely impaired his judgment.

Investigator assessment

Analysis narrative

The pilot and the pilot-rated passenger were flying from their home located at a residential airpark, where no fuel services were available, to an airport located about 37 nautical miles away. Shortly after departing on the flight, the passenger queried the pilot when she noticed the airplane's low fuel state. The pilot responded that one of the fuel gauges always reported a greater quantity of available fuel than the other, and that if necessary they could utilize needed fuel from the tank with the higher reported fuel quantity. About 15 minutes after departure, the pilot advised air traffic control that the airplane was critically low on fuel, and about 5 minutes later the airplane impacted trees and terrain after all fuel had been exhausted and both engines ceased producing power. Examination of the airframe and engines after the accident confirmed that all of the airplane's fuel tanks were essentially absent of fuel, and that the trace amounts of fuel recovered were absent of contamination. Post-accident testing of the fuel quantity senders showed that both of the applicable units failed to meet the indicated electrical resistance tolerances published in the service manual for the full fuel position, and only one of the units was within the tolerance for the empty position. Based on the autopsy and toxicology results, the pilot had emphysema, hypertension, dilated cardiomyopathy, and severe coronary artery disease; however, given that the passenger seated in the right seat of the airplane did not report any signs of acute incapacitation, and that the pilot did not communicate any medical issues to air traffic control, it does not appear that these conditions affected his performance on the day of the accident. The pilot did not report any chronically painful conditions to the FAA in his most recent medical certificate applications, however, the post-accident toxicology identified that the pilot was taking several pain medications (diclofenac, gabapentin, and oxycodone), and one illegal substance (marijuana). Based on the medications' Food and Drug Administration warnings, gabapentin and oxycodone may be individually impairing and sedating; their combined effect may be additive. The effects of the underlying conditions that necessitated the medication could not be determined. It is impossible to determine from the available information what direct effect the marijuana alone may have had on the pilot's judgment and psychomotor functioning; however, the combination of marijuana, oxycodone, and gabapentin likely significantly impaired the pilot's judgment and contributed to his failure to ensure the airplane had sufficient fuel to complete the planned flight.

Source record

Factual narrative

On December 24, 2012, about 1435 eastern standard time, a Piper PA-31-350, N78WM, was substantially damaged when it collided with terrain during a forced landing following a loss of power in both engines near Leesburg, Florida. The private pilot was fatally injured and the pilot-rated passenger was seriously injured. Visual meteorological conditions prevailed, and no flight plan was filed for the flight, which departed Eagles Nest Aerodrome (FD44), Crescent City, Florida, at 1405, and was destined for Leesburg International Airport (LEE), Leesburg, Florida. The personal flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91.According to the pilot-rated passenger, who was also the pilot's wife, the pilot completed the preflight inspection of the airplane and prepared for their departure while she was shopping. Upon returning home, she boarded the airplane, secured the aft cabin door, and prepared the cabin for departure as she would normally do prior to any other flight. She then sat down in the front right seat of the airplane about the time the pilot had taxied onto the runway. Shortly after takeoff, and while reading through the after takeoff checklist, she noticed that the fuel quantity in the left and right fuel tanks appeared to be low, with the left gauge reading slightly above 1/4-tank of fuel and the right gauge reading slightly below 1/4 tank of fuel. When the passenger queried the pilot about the fuel quantities, the pilot replied that the left fuel gauge always indicated a greater quantity of fuel than the right gauge, and that if the fuel quantity in the right tank became too low, they could always use fuel from the left fuel tank. She continued to closely monitor the fuel quantity state and fuel flow to both engines for the next 10 minutes. About that time, and about 6 miles north of LEE, the right engine began to surge. The pilot responded by repositioning the right engine's fuel selector from the inboard to the outboard fuel tank. He then contacted the air traffic control tower at LEE, requested to land, and advised the controller that the airplane was running low on fuel. Shortly after making that transmission, the left engine began to surge, and the pilot again responded by repositioning the fuel selector from the inboard to the outboard fuel tank. The pilot then began searching for an off-airport landing site, and during the descent both engines operated intermittently. The pilot later advised air traffic control that the airplane was "going down," prepared for a forced landing to a field below, and extended the airplane's landing gear. The airplane subsequently struck trees short of the pilot's intended landing area. According air traffic control voice communication information provided by the Federal Aviation Administration (FAA), the pilot initially contacted the LEE air traffic control tower at 1930 and advised the controller that the airplane was about 12 nautical miles north of the airport, that the airplane was "bingo fuel," and that he would like a straight-in approach to the runway. The controller subsequently instructed the pilot to advise him when he was 1 mile from the runway on final approach. When the airplane was about 6 nautical miles from the airport, the pilot advised the controller that one of the airplane's fuel tanks was empty and that he was attempting to make it to the airport "on one." The controller then cleared the pilot to land on runway 13, but shortly thereafter the pilot advised the controller that the airplane was out of fuel and that they were "going in." No further transmissions were received from the pilot. PERSONNEL INFORMATION According to airman records maintained by the FAA, the pilot, age 53, held a private pilot certificate with numerous ratings including airplane multi-engine land. Pilot logs recovered from the wreckage documented flight experience accumulated between 1987 and February 2005. During that time, the pilot logged about 3,000 total hours of flight experience, 1,400 hours of which were in multi-engine land airplanes and 500 hours of which were in multi-engine seaplanes. The logs also contained endorsements for flight reviews completed in April 2008 and January 2012. AIRCRAFT INFORMATION The twin-engine, low wing, retractable landing gear airplane was manufactured in 1978, and was powered by two Lycoming TIO-540, 350-hp engines. Review of maintenance records showed that the airplane's most recent annual inspection was completed on September 9, 2011 at 4,895 total hours of operation. At the time of the accident, the airplane had accumulated 4,912 total hours of operation. According to the passenger, the pilot had most recently serviced the airplane with fuel prior to flying from Gatlinburg Pigeon-Forge Airport (GKT), Gatlinburg, Tennessee, to their home at FD44. Review of fueling records from a fixed based operator at GKT revealed that on October 19, 2012, the airplane's inboard fuel tanks were filled to capacity with 32 gallons of aviation gasoline. METEOROLOGICAL INFORMATION The weather conditions reported at LEE, at 1453, located about 2 nautical miles south of the accident site included wind from 220 degrees at 11 knots, gusting to 16 knots, 10 statute miles visibility, clear skies below 12,000 feet, temperature 21 degrees Celsius (C), dew point 9 degrees C, and an altimeter setting of 30.00 inches of mercury. WRECKAGE AND IMPACT INFORMATION The initial impact point (IIP) was identified as a tree with broken limbs, with various components of wreckage extending from that point on a heading of 135 degrees magnetic. A ground scar approximately 6 feet wide by 100 feet long, began about 50 feet from the IIP, and was oriented along the wreckage path. The fuselage came to rest upright oriented roughly 350 degrees magnetic. First responders reported that no fuel or fuel odor was present at the scene and that all of the airplane's fuel tanks appeared to be absent of fuel. The airplane was subsequently recovered from the scene and examined at an aircraft recovery facility. Control continuity was traced from the cockpit area, through overload separations and cable cuts performed by recovery personnel to each of the flight control surfaces. Measurement of the stabilator trim tab actuator revealed a position consistent with a slight deflection in the nose-up direction. The flaps were in the retracted position, and the position of the left main landing gear door was consistent with the landing gear being extended at impact. Trace amounts of fuel were observed in two of the airplane's six fuel tanks and within both fuel strainer bowls. The fuel had an odor consistent with 100 low-lead aviation gasoline and was absent of debris or water. Each of the fuel filler port caps was intact and secure. The fuel quantity float sensors were recovered from the left and right inboard and outboard fuel tanks for functional testing. Continuity of both engine's crankshaft and valvetrain was confirmed through rotation of the propeller, and thumb compression was confirmed on all cylinders. The top spark splugs from both engines were removed, and all exhibited normal wear and were grey to black in color. Both propellers remained attached to their respective crankshaft flanges and both propeller spinners exhibited non-torsional crush damage. All of the propeller blades were bent aft about the mid span, and each of the blades exhibited spanwise and chordwise scraping. MEDICAL AND PATHOLOGICAL INFORMATION FAA Medical Records According to the pilot's FAA medical record, he first received a third-class medical certification in 1987, with a restriction for corrective lenses. From that time forward until 2006, the pilot did not report use of any medications, any medical problems or procedures, or any traffic or non-traffic convictions. The single exception was a report of a physician visit and use of Axid (nizatidine, a proto

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