NTSB Factual Report

HISTORY OF FLIGHT

On February 20, 2016, at 2305 eastern standard time, a Piper PA-28-181, N29099, was substantially damaged during a ditching in Setauket Harbor about 1.5 nautical miles northwest of Port Jefferson, New York. The flight instructor, student, and one passenger received minor injuries, and one passenger was fatally injured. The airplane was owned and operated by Positive Rate Gear Up, LLC, as a Title 14 Code of Federal Regulations (CFR) Part 91 instructional flight. Night visual meteorological conditions prevailed, and no flight plan was filed. The flight departed Fitchburg Municipal Airport (FIT), Fitchburg, Massachusetts, about 2040 and was destined for Republic Airport (FRG), Farmingdale, New York.

According to the flight instructor, the first leg of the instructional flight departed FRG about 1430; he believed that about 40 gallons of fuel was onboard before departing from FRG. According to the student pilot, the pilot of the previous flight told him that the left-wing fuel tank was full, and the right-wing fuel tank was half full (about 36 gallons total). The student stated that he asked the flight instructor if he wanted to refuel, and the flight instructor advised him that they had plenty of fuel. After takeoff from FRG, they flew to FIT at 2,000 to 2,500 feet above mean sea level (msl). The airplane encountered a strong tailwind and arrived in about 45 minutes. They spent some time in the Fitchburg area, then returned to FIT for the return flight.

After takeoff, they departed the airport traffic area to the southwest on a direct heading for FRG and climbed to 4,500 ft msl because of turbulence at lower levels. The flight instructor estimated that the airplane had a headwind of 30-40 knots, and the airplane's groundspeed was about 81 knots during the cruise portion of the flight. He stated that there was no indication of any malfunction of the airplane. During this time, the student pilot asked the flight instructor about the fuel quantity, stating "does the fuel look good to you?" The flight instructor replied "yes." Just before passing Bridgeport, Connecticut, the flight instructor advised the student pilot that they should change their destination to Long Island MacArthur Airport (ISP) to refuel. As the airplane passed over the Igor I. Sikorsky Memorial Airport, Bridgeport, Connecticut, they turned the airplane southbound, started a slow descent, and crossed Long Island Sound. Upon reaching the area of Port Jefferson, New York, they leveled the airplane about 2,000 ft msl; the engine then "sputtered." The flight instructor immediately turned on the electric fuel pump and instructed the student to switch the fuel selector to the left fuel tank. Once the fuel selector had been selected to the left fuel tank, the engine stopped sputtering.

The flight instructor informed air traffic control that he wanted to divert ISP, which, at the time, was 10 nautical miles south of their location. About 2-3 minutes later, the engine sputtered again and then lost power. The instructor then took control of the airplane from the student pilot and advised the tower controller at ISP that he was declaring an emergency and was going to attempt to land on the north shore of Long Island. The tower controller immediately notified emergency responders. A Suffolk County Police Department (SCPD) helicopter was airborne at the time and immediately proceeded toward the last known location of airplane.

The instructor then made a 180° turn to the right and headed for the shoreline since he believed this was the most suitable place for landing and knew from experience that the area along the shore was normally clear of obstacles and houses. As the airplane descended, the instructor was unable to see the shoreline due to the darkness and decided to ditch the airplane as close as he could to the shoreline, judging his distance from the shore by using the lights from the houses. He then held the airplane off the water for as long as possible to keep from touching down on the water with excessive airspeed and risk nosing over (the airplane was equipped with fixed landing gear).

Upon touchdown, the flight instructor opened the cabin door and instructed everyone to exit the airplane, grab the life vest that was in the baggage compartment of the airplane, and hold on to him. The student pilot then handed the instructor the life vest. One of the passengers then jumped into the water and started swimming for shore. The second passenger also jumped into the water. The student pilot was the last to egress from the airplane. Neither the student pilot nor the passengers were wearing life vests.

About 3 minutes later, the airplane was located by the SCPD helicopter. Patrol officers from SCPD also responded to the shoreline and, after locating several kayaks behind a residence, made their way onto the water. They heard screams for help, paddled out toward the spotlight from the helicopter, rescued one of the passengers, and then, with the assistance of an SCPD marine patrol boat, the flight instructor. The student pilot was rescued by a patrol officer who entered the water on foot and threw a life ring to him and then pulled him to shore.

A search by SCPD and the US Coast Guard for the missing passenger was conducted but he was not found. About 2 months later, on April 11, 2016, his body was discovered on a beach in Setauket Harbor, New York.

PERSONNEL INFORMATION

The flight instructor held a commercial pilot certificate with ratings for airplane single- and multi-engine land, and instrument airplane. He also held a flight instructor certificate with ratings for airplane single-engine and instrument airplane. His most recent Federal Aviation Administration (FAA) first-class medical certificate was issued November 12, 2015. He reported 2,800 total hours of flight experience, of which 1,400 hours were in the accident airplane make and model.

The student pilot reported that he had accrued 20 total hours of flight experience, 19 of which were in the accident airplane make and model.

AIRCRAFT INFORMATION

The accident airplane was a four-seat, low-wing monoplane of conventional metal construction. It was equipped with fixed tricycle-type landing gear and was powered by a four-cylinder, direct-drive, horizontally opposed engine rated at 180 horsepower at 2700 rpm.

The basic airframe, except for a tubular steel engine mount, steel landing gear struts, and other miscellaneous steel parts, was of aluminum alloy construction. The wing tips, engine cowling, and tail surfaces were of fiberglass or ABS thermoplastic.

According to FAA and maintenance records, the airplane was manufactured in 1979. The airplane's most recent 100-hour inspection was completed on January 12, 2016, at 5,091 total hours. At the time of the accident, the airplane had accumulated 5,173.97 total hours of flight time.

Fuel Information

The airplane's fuel was stored in two 25-gallon tanks (24-gallons usable). According to the Piper PA-28-181 Pilot's Operating Handbook (POH), during the preflight inspection, the fuel quantity gauges were to be checked, the fuel tank sumps and fuel strainer were to be drained, and the fuel quantity was to be visually checked by opening the fuel tank caps and looking inside each of the fuel tanks. An aftermarket checklist was found in the airplane. Although the checklist was not specified for use in a Piper PA-28-181, it was similar to the published POH's preflight inspection regarding fuel.

Review of the POH also indicated that:

- At a power setting of 75%, the engine would consume fuel at a rate of 10.5 gallons per hour (gph).

- At a power setting of 65%, the engine would consume fuel at a rate of 9.0 gph.

- At a power setting of 55%, the engine would consume fuel at a rate of 7.8 gph.

At a 65% power setting, with full fuel tanks, endurance would be about 5.3 hours, and at a 65% power setting, with 40 gallons of fuel, endurance would be about 4.4 hours. Examination of aircraft rental and fueling records revealed that the airplane had been operated for 5.1 hours since it was last refueled.

When asked if they had leaned the mixture during the flight, the student pilot advised that he had only seen the flight instructor lean the mixture during taxi on the ground at FRG and FIT.

METEOROLOGICAL INFORMATION

About 9 minutes before the accident (2256), the recorded weather at ISP, which was 11 miles from the accident site, included: wind 220° at 10 knots, 10 miles visibility, sky clear, temperature 7°C, dew point 3°C, and an altimeter setting of 29.82 inches of mercury.

The National Weather Service (NWS) Surface Analysis Chart for 2200 EST depicted surface winds from the south-southwest at 10 to 20 knots, with no significant weather reported in the vicinity of the accident site.

The Upton (OKX) Long Island 1900 sounding depicted a surface-based temperature inversion with a top near 2,000 feet. As a result of light surface winds and an increasing wind component with altitude, a moderate risk of low-level wind shear existed in the lowest 1,000 ft, and predominately light-to-moderate turbulence was predicted below 3,000 ft, and light turbulence through 10,000 ft.

An airplane descending into Providence, Rhode Island, at 2344 provided an in-situ measurement of the low-level winds. The airplane's track into the airport was from the southwest, parallel to Long Island Sound, and along the accident airplane's general route of flight. The airplane detected a surface-based temperature inversion to about 2,500 ft with westerly winds of 58 knots at that level. Another limited report from an airplane descending into LaGuardia reported a low-level wind maximum of 52 knots at 1,800 feet.

The winds aloft forecast current at the time of departure for stations near the route of flight indicated:

General Edward Lawrence Logan International Airport (BOS), Boston, Massachusetts:

- 3,000 ft: 270° at 34 kts

- 6,000 ft: 260° at 38 kts

Bradley International Airport (BDL), Windsor Locks, Connecticut:

- 3,000 ft: 280° at 26 kts

- 6,000 ft: 270° at 36 kts

John F. Kennedy International Airport (JFK), New York, New York:

- 3,000 ft: 270° at 40 kts

- 6,000 ft: 280° at 40 kts

According to the United States Naval Observatory, sunset occurred at 1732 and the end of civil twilight occurred at 1800. At the time of the accident, the moon was located at an azimuth of 187° and an altitude of 62° above the horizon, and the phase of the moon a waxing gibbous with 97% of the visible disk illuminated.

A query to Lockheed Martin Flight Services (LMFS) found that there was no record that the pilot or instructor obtained a weather briefing either through the Direct User Access Terminal Service or LMFS.

WRECKAGE AND IMPACT INFORMATION

After the ditching, the airplane remained afloat for about 5 minutes before it sank nose first to the bottom of the bay and came to rest on its landing gear, about 100 ft northwest of Buoy S8. Charted water depth in the area was between 1 ft and 3.5 ft; however, the airplane ditched just after high tide so an additional 5 ft of water was present. Only 1 ft of the vertical stabilizer was visible above the water's surface after the airplane sank.

Airplane Examination

Examination of the airplane after recovery revealed substantial damage due to salt water immersion, a broken engine mount, damage to the right wing inboard leading edge, damage to the bottom of the inboard right wing, and damage to the aft fuselage structure just forward of the stabilator.

The pitot tube was clear, and the stall vane moved freely. Flight control continuity was established from the flight controls in the cockpit to the ailerons, stabilator, and rudder. The stabilator trim was neutral. The wing flaps were in the fully extended (40°) position. Both wing flaps exhibited impact damage, and the right wing flap actuating linkage was fractured.

Visual examination of the fuel tanks through the filler ports revealed that only a small amount of liquid with the odor of seawater was visible in the fuel tanks. About 4 gallons of a semi-opaque liquid was drained from both fuel tanks. When the liquid was tested with water-finding paste, the paste turned pink indicating the presence of water. The outlet screens from each tank were free of blockages.

The throttle was full forward, the mixture was full rich, the carburetor heat control was in the "OFF" position, and the primer was in and locked. The fuel selector was in the left fuel tank position.

The master switch, fuel pump switch, landing light switch, navigation lights switch, anti-collision lights switch, and radio master switch were all in the "ON" position.

All the seats were in place and secure, and the seatbelts were in place, unbuckled, and secure at their attachment points. Both front shoulder straps were hanging loose and were not attached to the lap belts.

Propeller and Engine Examination

The propeller was a one-piece alloy forging and remained attached to the front of the engine crankshaft; it displayed light leading-edge erosion and no evidence of S-bending.

Drive train continuity was established from the front to the back of the engine, and thumb compression was present on all four cylinders. Internal examination of the cylinders using a borescope did not reveal any anomalies of the cylinders, piston heads, or valves.

Both magnetos were found secure to their respective mounts. The magnetos were removed and disassembled. Internal examination of the magnetos revealed no evidence of any preimpact anomalies; corrosion consistent with salt water immersion was present on the internal case and gear region.

The spark plugs and ignition harness were removed and examined. The massive electrode plugs indicated a worn-out service life. The fine wire plugs indicated a normal service life when compared to the Champion Aviation Check-A-Plug Card (AV-27). The ignition harness exhibited some damage to the outer overbraid near the magneto caps and near the spark plug leads.

The starter, alternator, and vacuum pump remained attached to their mounting locations.

The engine oil system was intact. The engine contained oil in the galleries and rocker box covers. The oil suction screen was removed and a liquid consistent with diesel fuel (which had been added after recovery to help stop corrosion due to the salt water), oil, and salt water drained from the oil sump. The oil suction screen contained a piece of material that was consistent with a disposable paper rag. It was lodged within the suction screen and covered about 25% of the length of the screen. The oil filter was removed and drained, and no metal was found. The oil cooler was impact-broken from its mount; however, it had not been breached and all attached hoses remained secure to the inlet and outlet ports of the oil cooler.

The engine's fuel system remained intact. The fuel strainer was devoid of fuel. The carburetor was found secure on its mount. The carburetor float bowl was drained through the drain plug into a container, and the liquid was primarily water with a faint odor consistent with 100LL aviation fuel. The engine-driven diaphragm pump provided suction and compression at the inlet and outlet ports of the pump.

MEDICAL AND PATHOLOGICAL INFORMATION

The Suffolk County Office of the Medical Examiner, Suffolk County, New York, performed an autopsy and toxicological testing of the deceased passenger. The autopsy listed the cause of death as drowning; the toxicological specimens were negative for any drugs of abuse.

ORGANIZATIONAL AND MANAGEMENT INFORMATION

Positive Rate Gear Up, LLC, was a flying club based at FRG. The club's primary goal was to provide its members with basic general aviation airplanes. The club's airplanes were available for both training and leisure purposes. The fleet consisted of several Piper PA-28 models, a PA-34-200, and two Cessna 172s. The club offered discovery flights, primary flight training, and advanced flight training, including private pilot, instrument pilot, commercial pilot, flight instructor, instrument ratings, and multi-engine ratings.

ADDITIONAL INFORMATION

Fuel Requirements in Visual Flight Rules (VFR) Conditions

Accor

NTSB Probable Cause

The flight instructor's inadequate preflight fuel planning, which resulted in a total loss of engine power due to fuel exhaustion.