NTSB Factual Report

On December 28, 2011, about 1600 eastern standard time, a Piper PA-28-180, N994NC, sustained substantial damage when it impacted trees and terrain after a loss of power during a go-around at the Lebanon-Warren County Airport (I68), Lebanon, Ohio. The private pilot and two passengers received minor injuries, and one passenger received serious injuries. The airplane was registered to and operated by the Warren County Airport LTD under the provisions of the 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed at the time of the accident, and no flight plan was filed. The airplane departed I68 on a local flight about 1545.

The pilot reported he had taken other passengers on an earlier flight that lasted about 35 minutes. The accident flight was the second flight of the day. Soon after he departed I68, the top of the passenger door cracked open. The pilot decided to return to the airport and land. While he was on the 45-degree approach to the downwind leg, he turned on the fuel boost pump and switched the fuel selector from the left tank to the right tank since the checklist called for switching the fuel selector to the fullest tank. He reported that during the flare, the airplane was descending too fast and a gust of wind caused it to drift left. He initiated a go-around by pushing in the carburetor heat and applying full power. He reported that as he was making a climbing, left crosswind turn at 500 feet above ground level (agl), the engine made a “loud popping sound” and immediately lost all power. The pilot pulled out the carburetor heat and he felt the airplane buffet as it began to stall. He pushed the yoke forward and maintained about 82 mph as he prepared to execute a forced landing to a narrow strip of grass between some houses and a grove of trees. The pilot extended full flaps, checked the fuel boost pump, magnetos, and fuel pressure, and attempted to restart the engine. He reported that the engine power increased “a few hundred rpm and immediately went to zero power again.” The airplane was about 150 agl which was too low to clear the trees and power lines and make it to the open field. The pilot reported that the airplane’s right wing hit a pole. The airplane subsequently hit the trees and impacted the ground in a nose down attitude, and came to rest inverted. The pilot and the two passengers in the rear seats were able to exit the airplane unaided, but the front seat passenger was pulled out of the airplane before a fire ensued.

The airplane was a single-engine Piper PA-28-180, serial number 28-2590, with a 180-horsepower Lycoming O-360-A4A engine. The four seat airplane had a maximum gross weight of 2,400 pounds. The last annual and 100-hour maintenance inspection were conducted on January 24, 2011, at an aircraft total time of 6,833.0 hours. The airplane had 6,864.2 hours at the time of the accident. A review of the aircraft maintenance log books showed no overdue airworthiness directives (AD’s) or time controlled items. Two Piper Service Bulletins (SB’s) were not signed off as being accomplished. There were no indications in the maintenance records that Piper SB No. 355 “Fuel Selector Valve Lubrication” and a mandatory Piper SB No. 840 “Fuel Selector Valve Cover Replacement” had been accomplished.

Federal Aviation Administration (FAA) inspectors conducted an on-site examination of the accident site. Trees and power lines leading to the main wreckage had been impacted during the forced landing. Approximately 30 inches of the left outboard wing tip, a section of the left aileron, and the left main landing gear were found in the wreckage path. The main fuselage was inverted and mostly intact. There was some fire damage to the right side of the fuselage, and no apparent fire damage to the inside of the cabin. The engine and propeller were intact and still attached to the fuselage. The right wing and tail section were still attached to the main fuselage. There was fire damage to the right wing and fuselage with part of the middle section of the wing melted away. The aileron was still attached to the wing and control cable continuity was established. The left wing was separated from the fuselage and was found lying on top of the right wing tip. There was fire damage to the leading edge upper and lower surfaces. The flap was still attached to the wing and the aileron was separated from the left wing. There was continuity of the aileron cable from the aileron attaching point to the control column. The empennage was largely intact with the elevators and rudder still attached. There was control cable continuity between the control surfaces to the control column. Bird nests were found inside the tail section where the control cables intersect with the control services and pulleys, and bird nest material could be observed protruding from the tailcone area of the empennage.

The engine was mainly intact and still attached to the airplane. A bird nest was found in the oil cooler duct. The carburetor was separated from the engine but the control cables were still attached to the carburetor. The starter/generator was separated from the engine. The engine was rotated and drive train continuity was confirmed. Suction and compression were confirmed to each cylinder. The left and right magnetos both sparked when tested. The dry air pump showed normal wear to the brushes and the pump functioned. The engine driven fuel pump was tested by pumping water through the pump when the pump’s arm was actuated. The electric fuel boost pump was found operating at the accident site by the first responders, and the fire department cut the battery cable to reduce the fire hazard.

The examination of the propeller revealed that one propeller blade exhibited no damage; the other blade was bent aft from the hub and the tip was bent forward. There were no chordwise scratches or leading edge gouges on either blade.

The fuel tank selector valve was found in a partially OFF position (between the right tank and OFF position) at the accident site. When the valve was rotated, it was stiff to move and there were no apparent detents for the fuel tanks and OFF position. A teardown of the valve revealed that the inside of the valve contained dirt and contamination, and that the position washer was worn.

The Piper SB No. 355 “Fuel Selector Valve Lubrication” was issued June 5, 1972. The primary objective of this SB is to insure that these valves are periodically and properly inspected and lubricated. The SB states the following concerning Compliance Time:

1. Within the next 10 hours of operation from Effectivity Date, below, check fuel selector valve for ease of rotation. Repeat at 100 hour intervals.

A. If selector is difficult to rotate, comply with provisions of Instructions on page 2.

The SB states the following concerning Instructions (Steps 1, 2, and 6):

1. With the valve removed from the aircraft, remove the valve cap and interior parts (see attached sketch for an exploded view of valve components).

2. Inspect position washer to ascertain that it will not allow the valve to rotate beyond its stop positions. Also, inspect position washer inner perimeter surface for indications of extreme wear; should this be evident, replace position washer (see Material Required, below).

6. Clean valve of foreign matter, lubricate plug cock with a light film of MIL-G-6032 (Type (1) grease, turn the plug several times in its seat and wipe off any excess, especially in the valve ports. Also, lubricate position washer with a light film of MIL-G-6032 (Type 1) grease. Reassemble valve with a new “O” ring, Piper part number 752 822.

The fuel tank selector valve was reassembled and the handle was placed in the same position as it was found at the accident site. The test of the fuel selector valve showed that the water used for the flow test was exiting the fuel tank selector valve at a greatly reduced flow rate as compared to when the handle was placed on the left or right tank.

The pilot held a private pilot certificate with a single-engine land rating. He received his private pilot certificate on September 19, 2011, and had about 62.2 total flight hours, with about 1.9 hours in a PA-28-180. The majority of the pilot’s flight experience was in Cessna 152’s and Cessna 172’s. The pilot had received 1.1 hours of dual instruction in a PA-28-180 in August 2011. He obtained 0.8 hours of dual instruction in the PA-28-180 from a certificated flight instructor (CFI) at the flight school at I68 on December 26, 2011, and was endorsed to fly the aircraft as pilot in command. He held a third class medical certificate dated July 26, 2011.

A FAA operations inspector interviewed the pilot concerning the use of the fuel selector valve in the PA-28-180. The pilot reported that he told the CFI who performed the airplane checkout on December 26, 2011, that he was familiar with the airplane’s fuel system since he had received 1.1 hours of dual instruction in a PA-28-180 in August 2011. The CFI told him to switch tanks every fifteen minutes or so, but gave no instructions on how to switch the tanks. The CFI did not have the pilot physically move the fuel tank lever. The pilot reported that when he switched the fuel selector valve from the left tank to the right tank during the accident flight, he did not look to confirm what position the lever was in.

The estimated Weight and Balance (W&B) of the accident flight indicates that the total weight exceeded the maximum gross weight of the airplane at the time of the accident. The center of gravity (CG) was within the CG limits. The estimated W&B was based on the following information:

1. Aircraft weight: 1359

2. Oil 15.0

3. Pilot and Passenger 365

4. Fuel (43 gallons at impact) 258

5. Rear seat passengers 425

6. Baggage 10

Total: 2,432

Maximum Gross Weight 2,400

CG 92.39

CG Range 85.1 – 95.9

NTSB Probable Cause

The pilot’s inadvertent positioning of the fuel selector valve between the right tank and OFF position, which resulted in fuel starvation and a total loss of engine power. Contributing to the accident was the inadequate inspection of the fuel valve and failure to replace the worn fuel valve's position washer.