ERA14FA232

The pilot's mismanagement of the onboard fuel supply, which resulted in fuel starvation to the engine and a subsequent loss of engine power. Contributing to the death of the right front passenger was the inadequate occupant restraint.

The commercial pilot was traveling to attend an air show the following day. Upon arrival at the destination, he attempted a night instrument landing system approach but, due to low visibility, flew a missed approach. He subsequently requested and received vectors for a second attempt of the same approach. However, as the airplane neared the final approach course, the controller advised the pilot of worsening weather conditions, and the pilot then requested vectors to an alternate airport. After receiving a clearance, the pilot added power to the engine and initiated a climb, but the engine lost power, which the pilot attributed to either a fuel or an electrical problem. The airplane subsequently descended into trees and stuck the ground nose-low, on its left side, in a "violent deceleration." The pilot stated that he had checked the fuel quantity in both of the airplane's wing tip tanks and the connected main tanks before the flight using a calibrated stick and found about 10 gallons of fuel in each tip tank and 15 gallons of fuel in the main tanks. He also stated that he always took off and landed using the main fuel tanks and used the tip tanks in transit. The pilot further stated that, during the flight, he used the left tip tank for 22 minutes 40 seconds and was certain of the time because he used a stopwatch. He then used the main fuel tanks for the first approach and, after the missed approach, switched to the right tip tank. About 1 minute before the engine quit, he switched from the right tip tank to the main tanks again. Once the engine quit, the pilot moved the fuel selector through various positions and then checked the ignition, throttle, and mixture. The airplane was equipped with an engine monitor, which, among other parameters, tracked fuel flow. Data revealed that, at one point, fuel flow dropped to 0, with a concurrent reduction in all engine temperatures. Before the end of the recording, fuel flow spiked briefly up to 4 gallons per hour on four occasions before returning to 0, consistent with the pilot's statement that he moved the fuel selector to different positions. Two of the spikes occurred for 2 seconds, and the other two occurred for 3 seconds. The pilot reported that, after intentionally running a tank out of fuel during en route operations, the engine would restart about 5 to 10 seconds after switching fuel tanks. At the accident site, fuel was found in all tanks except the left tip tank. Although compromised upon impact, there was no evidence of fuel leakage underneath or in the vicinity of that tank. Fuel supply system continuity, with no blockages noted, was later confirmed from all tanks to the engine, and after replacing some impact-damaged items, the engine was run from idle to full throttle multiple times with no anomalies noted. Although fuel was not found in the left tip tank at the accident site, a small amount was likely still present when the pilot initiated the climb after the missed approach, which then sloshed toward the aft end of the tank, unporting the fuel pickup. This introduced air into the engine fuel supply, which led to the loss of engine power. The lack of fuel found in the left tip tank, the absence of anomalies noted in either the fuel supply system or when the engine was test run, the cessation of fuel flow noted in the engine monitor data, and the fluctuation of fuel flow as the pilot subsequently moved the fuel selector through the tanks-with-fuel and tank-without-fuel positions cumulatively indicated the likelihood that the pilot inadvertently moved the fuel selector to the left tip tank when he began the climb to the alternate airport and was operating the engine from an almost depleted left wing tip tank when the engine lost power. The airplane was manufactured at a time when only seat belts were required; front-seat shoulder harnesses or other restraints with an equal level of protection were not mandatory. The airplane did not have shoulder harnesses at the time of the accident, and the Federal Aviation Administration does not mandate retrofit, instead relying on voluntary installation. The pilot-rated passenger in the right front seat was fatally injured when her head impacted the engine controls and instrument panel, an outcome that likely would have been mitigated with the presence and use of adequate shoulder restraints or other equal-level protection.

ACY had crossing runways, designated 13/31 and 4/22. Runway 13 was 10,000 feet long and 150 feet wide with a touchdown elevation of 75 feet. The inbound course for the ILS RWY 13 approach was 128 degrees magnetic and the decision height was 275 feet above mean sea level. Fuel Selector During the final compilation of factual information, about 18 months after the accident, confirmation was requested as to how the pilot established what position the fuel selector was in, and whether he visually checked it with a flashlight, or used feel, or some combination. The pilot, who had returned to his home country, responded by email: "It's been a long time so I'm not sure I can be 100% certain but the changes to the fuel selection prior to the loss of power were checked visually. [The pilot-rated passenger] had a light which I used to reselect main but once we lost power I used feel only. I thought I secured the fuel after the crash but I honestly cannot be certain as that again was by feel." Occupant Protection According to the NTSB Safety Study, "Safety Airbag Performance in General Aviation Restraint Systems," adopted by the Board in January, 2011, NTSB has issued over 30 recommendations concerning general aviation (GA) occupant safety, "many of which have focused on the design, installation, testing, and use of shoulder harnesses." A 1985 safety study conducted by the NTSB looked at 535 accidents in which at least one occupant was fatally or seriously injured. It found that shoulder harnesses were available for only 40 percent of occupants in those accidents and that only 40 percent of occupants used the shoulder harnesses that were available, resulting in a total usage rate of 16 percent. The study estimated that about 20 percent of the occupants who were fatally injured could have survived if they had worn shoulder harnesses and 88 percent of those who experienced serious injury would have had their injures mitigated by using shoulder harnesses. In 1977, the FAA published an amendment to 14 CFR Part 23 that required shoulder harness installations in all newly manufactured GA aircraft starting in 1978, but only for front seats. Concurrently, 14 CFR Part 91 was revised to state that "required flight crewmembers" must use available shoulder harnesses during takeoff and landing. In response, the NTSB issued Safety Recommendations A-77-70 and -71, which respectively recommended that the FAA strengthen the rules to require installation of shoulder harnesses at all seat locations and require their installation on all GA aircraft, including those manufactured before 1978. In 1985, the FAA modified 14 CFR 91.33 to require shoulder harnesses in all seats of GA airplanes manufactured after December 12, 1986, and amended 14 CFR Part 91 to require all occupants to wear shoulder harnesses, when available, during takeoff and landing. However, the FAA never modified its regulations to require retrofitting of aircraft manufactured before the 1978 and 1986 regulatory changes." In June 1993, the FAA promulgated Advisory Circular (AC) 21-34, "Shoulder Harness – Safety Belt Installations," in which it provided benefits of shoulder harnesses and installation guidance. It noted that, "Shoulder harness-safety belt systems prevent serious head, neck, and upper torso injuries in what may be relatively minor accidents in terms of aircraft damage, and they can prevent irreversible or fatal injuries in more severe accidents. Therefore, the major benefits of shoulder harnesses occur in an accident environment, but they can be of no benefit if they are not available for use in an accident." The 2011 NTSB Safety Study also found that, "Because of the longevity of aircraft, a large proportion of the active GA and air taxi fleet were manufactured before shoulder harnesses were required. For example, the 2008 FAA General Aviation and Air Taxi Survey found that 69 percent of active aircraft were manufactured prior to 1984, and 56 percent were manufactured prior to 1979. Although it is possible that many owners of older aircraft have retrofitted those aircraft to include shoulder harnesses without being required to do so, the NTSB continues to investigate numerous accidents in which shoulder harnesses are not present." The 2011 NTSB Safety Study also included an evaluation of real-world performance of lap belt/shoulder harness combinations compared to lap belts only. An additional goal was to look at the relationships between shoulder harness effectiveness and other factors that might potentially influence survivability, such as whether there was a fire or a loss of control, whether the accident happened at or away from an airport, the phase of flight when the accident occurred, and pilot factors such as gender and age. Data sampling included pilots involved in GA accidents between 1983 and 2008 for non-amateur-built airplanes with single reciprocating engines, with the primary outcome of interest being whether the pilot was fatally or seriously injured as a result of the accident. Other variables that were examined can be found in the Study. Of the 37,344 pilots in the final sample, 15.2 percent were fatally injured and 8.7 percent sustained serious injuries. Over half (55.3 percent) of the pilots were reported to have used an shoulder harnesses, 23.9 percent used lap belts only, and 0.6 percent used no restraint. Restraint use was unknown in 18.9 percent of the cases. Shoulder harness use was found to consistently reduce the risk of pilot fatalities and serious injuries when compared to lap belt only. The risk of fatality and serious injury with a lap belt alone was 50 percent higher than with shoulder harnesses. The benefits conveyed by shoulder harnesses were significant for multiple subgroups within the larger sample. "Overall, the findings strongly suggest that lap belt/shoulder harness combinations provide significant protection beyond that offered by wearing only a lap belt and that there would be reductions in pilot fatalities and injuries if lap belt/shoulder harness combinations were installed and used in all GA airplanes." As a result of the Safety Study, a number of recommendations were submitted to the FAA. One of those, A-11-004, referenced previous NTSB recommendations that the FAA require the installation of shoulder harnesses on aircraft manufactured before 1978, but also noted that the FAA never took steps to do so, using as its explanation that there was insufficient justification to impose additional costs on owners of older aircraft. A-11-004 then recommended again the required retrofit of shoulder harnesses on all GA airplanes in accordance with AC 21-34. On February 15, 2012, the FAA responded that thousands of airplanes manufactured before December 12, 1986, do not have the structural provisions necessary for the installation of shoulder harnesses, and that the installation would "impose a severe economic burden, especially on airplanes requiring substantial structural modifications." The FAA suggested a two-point inflatable lap belt that would offer impact protection to the occupant's head and torso, and serve as a barrier between the occupant and cockpit structure. And, the FAA would permit the installation as a minor change. On June 10, 2012, the FAA advised the NTSB that it intended to require that older airplanes be equipped with either a shoulder harness or inflatable lap belt. On September 6, 2013, the FAA again advised the NTSB that many GA airplanes manufactured before December 12, 1986, did not have the necessary structure to install a shoulder harness, and that a two-point inflatable restraint would be the only possible solution. The FAA also noted that mandating the retrofit of aircraft manufactured before December 12, 1986, with a two-point inflatable restraint or a shoulder harness would require the determination that an unsafe condition existed and the issuance of an airworthiness directive. The cost of retrofit