Aircraft Accident/Incident Report

Gulf Hammock, Florida 32639
Thursday, June 12, 2003 13:40 EDT

NTSB Narrative Summary Released at Completion of Accident

The pilot stated that the flight departed with 120 gallons of usable fuel on-board, and approximately 1 hour into the flight while flying between 2,000 and 2,500 feel mean sea level with fuel being supplied from the main fuel tank, he turned on the boost pump and the fuel selector for the larger fuel tank (auxiliary fuel tank). The flight continued and approximately 30-45 minutes later with both fuel tank on/off valves "on", the engine experienced a loss of power. He applied carburetor heat but engine power was not restored. He maneuvered the airplane for a forced landing on an east/west oriented dirt road, but recognized that he would be unable to land on the road due to trees. He set up for landing south of and parallel to the dirt road. While descending, the left wing collided with a tree approximately 20 feet above ground level. He did not recall any other part of the accident but remembers waking up and exiting the airplane. Examination of the airplane at the scene by an FAA airworthiness inspector revealed the original fuel tank installed when the airplane was manufactured was empty, and an aluminum fuel tank installed in place of the hopper tank was full. Examination of the cockpit revealed yellow colored placards with black letters by the 2 fuel on/off valves that indicated usable fuel quantity, orientation in terms of position, i.e. "push-on" and "pull-off"; there was no placard that indicated both should not be on at the same time. Check valves which were oriented properly in terms of flow direction were installed at the outlets of both fuel tanks; both check valves were removed for further examination. Examination of the check valves was performed with FAA oversight at a military installation with calibrated equipment. The check valve from the original fuel tank was found to open at less than 1/4 psi, but the check valve from the auxiliary fuel tank was found to open at 3/4 psi. Review of the maintenance records revealed an entry dated May 25, 2003, which indicates the mechanic removed all optional agricultural equipment and installed a 77-gallon aluminum fuel tank and boost pump in place of the hopper tank. The entry references a FAA 337 form, and that all work was performed in accordance with the airplane type certificate data sheet and flight manual, and Advisory Circular 43.132A. The mechanic who signed off the logbook entry for the 77-gallon aluminum tank installation stated the installation into the accident airplane was based on a previous installation of the same system another mechanic had done to an airplane he owned. The previous installation included stainless steel check valves at the outlet of both fuel tanks and the new owner of the airplane wanted them installed as well. The check valves that were installed were purchased from a Yacht company. As part of the installation in the accident airplane, the mechanic stated that he installed a placard by the fuel on/off valves which indicated that both should not be opened at the same time. Following the installation, the engine was operated with fuel being supplied only from the auxiliary fuel tank and the engine driven fuel pump operating. Static testing showed that with fuel in the fuel tank and the fuel line disconnected downstream of the check valve, but only a trickle of fuel was noted. He questioned that with the representative of the company where he purchased the check valves and the response was that was normal. Further testing with pressure applied to the tank revealed fuel flowed from the disconnected line. Additionally, he stated the pilot had asked him if it was acceptable to have both on/off valves "on" at the same time, and he advised the pilot it was not. Both he and the pilot checked the main fuel tank before the accident flight departed and both noted that the fuel level was down 2-3 inches which he estimated was 4-5 gallons less than full. According to the FAA inspector-in-charge, the installation of the 77-gallon fabricated fuel tank (auxiliary tank) was performed without FAA approved data. He also stated that the airplane flight manual (AFM) did not have a supplement indicating how to operate the auxiliary fuel tank system.

NTSB Probable Cause Narrative

The insufficient information provided to the pilot by the mechanic that installed the auxiliary fuel tank for his failure to install a placard to indicate that both fuel on/off valves should not be on at the same time resulting in a total loss of engine power due to fuel starvation. Also, the unsuitable terrain encountered by the pilot during the forced landing. Findings in the investigation was the installation by the mechanic of FAA check valves into the airplane purchased at a yacht company, and modification of the airplane by the mechanic without FAA approval.

Event Information

Type of Event Accident
Event Date 6/12/2003
Event Day of the Week Thursday
Time of Event 1340
Event Time Zone Eastern Daylight Time
Event City Gulf Hammock
Event State FLORIDA
Event Country --
Zipcode of the event site 32639
Event Date Year 2003
Event Date Month 6
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 291400N
Event Location Longitude 0824830W
Event Location Airport --
Event Location Nearest Airport ID --
Indicates whether the acc/inc occurred off or on an airport Off Airport/Airstrip
Distance from airport in statute miles --
Degrees magnetic from airport --
Airport Elevation --
Weather Briefing Completeness Full
Investigator's weather source Weather Observation Facility
Time of the weather observation 1335 Eastern Daylight Time
Direction of event from weather observation facility (degrees) --
Weather Observation Facility ID KOCF
Elevation of weather observation facility 89
Distance of event from weather observation facility (units?) --
Time Zone of the weather observation EDT
Lighting Conditions Day
Lowest Ceiling Height --
Lowest Non-Ceiling Height 4200
Sky/Lowest/Cloud Conditions Few
Sky Condition for Lowest Ceiling None
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) 10
Air Temperature at event time (in degrees celsius) 31
Dew Point at event time (in degress fahrenheit) 22
Wind Direction (degrees magnetic) --
Variable Wind Indicator --
Wind Speed (knots) --
Wind Velocity Indicator Calm
Wind Gust Indicator Not Gusting
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) 30.02
Density Altitude (feet) --
Intensity of Precipitation --
METAR weather report --
Event Highest Injury Minor
On Ground, Fatal Injuries --
On Ground, Minor Injuries --
On Ground, Serious Injuries --
Injury Total Fatal --
Injury Total Minor 1
Injury Total None --
Injury Total Serious --
Injury Total All 1
Investigating Agency NTSB
NTSB Docket Number (internal use) 15348
NTSB Notification Source KTLH Arpt. Ops.
NTSB Notification Date Jun 12 2003 12:00AM
NTSB Notification Time 1449
Fiche Number and/or location -used to find docket information DMS
Date of most recent change to record Apr 28 2004 3:34PM
User who most recently changed record NTSB\MONR
Basic weather conditions Visual Meteorological Cond
FAA District Office Tampa, Florida

Aircraft Involved

Aircraft #1

Aircraft Registration Number N6981Z
NTSB Number MIA03LA121
Missing Aircraft Indicator --
Federal Aviation Reg. Part Part 91: General Aviation
Type of Flight Plan filed None
Flight plan Was Activated? No
Damage Substantial
Aircraft Fire None
Aircraft Explosion None
Aircraft Manufacturer's Full Name Piper
Aircraft Model PA-25-235
Aircraft Series Identifier --
Aircraft Serial Number 25-2727
Certified Max Gross Weight 2900
Aircraft Category Airplane
Aircraft Registration Class U.S. Registered/U.S. Soil
Aircraft is a homebuilt? No
Flight Crew Seats --
Cabin Crew Seats --
Passenger Seats --
Total number of seats on the aircraft 1
Number of Engines 1
Fixed gear or retractable gear Fixed
Aircraft, Type of Last Inspection Annual
Date of Last Inspection Jun 3 2003 12:00AM
Airframe hours since last inspection --
Airframe Hours --
ELT Installed Yes
ELT Activated Yes
ELT Aided Location of Event Site Unknown
ELT Type --
Aircraft Owner Name CBR, Inc.
Aircraft Owner Street Address P.O. Box 2339
Aircraft Owner City Santa Fe Springs
Aircraft Owner State CA
Aircraft Owner Country USA
Aircraft Owner Zipcode 90670
Operator is an individual? No
Operator Name --
Operator Same as Owner? Yes
Operator Is Doing Business As --
Operator Address Same as Owner? Yes
Operator Street Address --
Operator City --
Operator State --
Operator Country --
Operator Zip code --
Operator Code --
Owner has at least one certificate None
Other Operator of large aircraft? --
Certified for Part 133 or 137 Operation --
Operator Certificate Number --
Indicates whether an air carrier operation was scheduled or not --
Indicates Domestic or International Flight --
Operator carrying Pax/Cargo/Mail --
Type of Flying (Per_Bus / Primary) Ferry
Second Pilot on Board No
Departure Point Same as Event No
Departure Airport Code KHWO
Departure City Hollywood
Departure State FL
Departure Country USA
Departure Time 1145
Departure Time Zone EDT
Destination Same as Local Flt --
Destination Airport Code KTLH
Destination City Tallahassee
Destination State FL
Destination Country USA
Specific Phase of Flight Descent
Report sent to ICAO? No
Evacuation occurred Yes
Date of most recent change to record Mar 15 2004 9:22AM
User who most recently changed record KENJ
Since inspection or accident --
Event Location Runway Number and Location --
Runway Length --
Runway Width --
Sight Seeing flight No
Air Medical Flight No
Medical Flight --