What Happened
On January 13, 2013, Piper PA-28R-200 N4975S departed Sandersville, Georgia, for Middletown, Delaware. After multiple approaches and diversions in night instrument conditions, the pilot reported that he was out of fuel. The airplane crashed in woods about two miles from Dover Air Force Base. The pilot died.
The flight plan estimated three hours and 45 minutes en route, with five hours and 30 minutes of fuel. Fueling records showed that the airplane was fully fueled before departure at about 1330 eastern standard time. The planned destination was Summit Airport, and Baltimore/Washington International was listed as the alternate.
At 1647, the airplane was descending toward Summit. The controller passed a warning from another airplane’s experience: that aircraft had missed approaches at Summit and Wilmington before diverting again. About 15 miles short of Summit, the pilot chose Salisbury, Maryland, instead.
Salisbury offered a 6,400-foot runway and an instrument landing system to runway 32. The pilot attempted two GPS approaches to runway 14, the opposite direction. The published decision altitude for the GPS approach with vertical guidance was 355 feet mean sea level, or 306 feet above the ground.
On the first approach, recorded GPS data showed the airplane discontinue its descent at 581 feet GPS altitude, about 1.7 miles from the runway. On the second, it descended to 928 feet while aligned with the runway, then veered right and continued down to 529 feet before another missed approach. The pilot said his GPS was not working correctly.
He did not request the ILS to the opposite runway. Instead, at 1753, he diverted to Georgetown, Delaware. The earlier Georgetown ceiling had been 700 feet, but the controller passed an updated 300-foot overcast before the pilot began that approach.
The Georgetown GPS approach had a published minimum of 360 feet mean sea level, or 310 feet above ground. The airplane reached approximately 250 feet GPS altitude before another missed approach. The recorded GPS altitude and the chart’s altitude references were not interchangeable measures, but the NTSB found that the flight had descended below the published minimum.
At 1826, nearly five hours after departure, the pilot said he was running low on fuel. He initially requested another approach, then asked whether an easier option was available. The controller suggested Delaware Airpark, which had a VOR approach.
At 1830, while being vectored toward that airport, the pilot asked whether he could land at Dover Air Force Base. The controller said that would require an emergency. The pilot continued toward Delaware Airpark and received its approach clearance at 1835.
Six minutes later, he declared an emergency and reported fuel exhaustion. Now the airplane was about 2,000 feet mean sea level and seven miles north of Dover, flying away from it. The controller turned him back toward the military airport. By 1845:33, GPS data placed the airplane at about 500 feet on an approximate three-mile final. It struck trees before reaching the runway.
Investigation Findings
The NTSB identified both the missed landing opportunities and the delayed emergency declaration. The airplane had reached the region with fuel still available, but successive approaches and diversions consumed it before a landing was completed.
Salisbury was a particularly important decision point. Its runway 32 ILS had a decision height of 200 feet above the ground, compared with 306 feet for the GPS approach attempted twice. The report described calm wind during the relevant attempts. An ILS was available, but the pilot continued to seek solutions through GPS approaches and further diversions.
The next destination did not provide an ILS. Georgetown’s cloud ceiling had fallen to 300 feet, below the published 310-foot height associated with the GPS approach used. The pilot received that weather update before continuing. The available margin was shrinking both in weather and in fuel.
The final planned VOR approach at Delaware Airpark carried a published notation that it was not authorized at night. The accident flight was in night conditions. Dover, which the pilot had overflown and was communicating with, had an ILS available if he declared an emergency. The declaration came only after the engine lost its fuel supply.
The pilot had about 598 total hours, including about 77 hours of actual instrument time and 35 hours simulated. In the preceding 30 days, he had flown about 0.8 hours in actual instrument conditions and one instrument approach. The airplane’s autopilot could fly the lateral portion of a GPS approach but not the vertical portion. The descent remained a task for the pilot.
Investigators found no preimpact mechanical malfunction. Both main fuel tanks were compromised by the crash; no fuel was observed in the right tank and about half a gallon in the left. Those wreckage observations were considered with the pilot’s report of exhaustion and the elapsed flight time.
The report’s handbook comparison used 48 gallons of usable fuel and a cruise consumption of 9.16 gallons per hour at 65 percent power. Over five hours and 15 minutes, that calculation reached 48.09 gallons before adding the fuel needed for takeoff and climbs during missed approaches. It was a comparison using handbook figures, not a recovered second-by-second fuel-flow record.
The pilot was a surgeon with an operation scheduled the next morning. That background did not establish his thoughts or prove that professional pressure caused a particular decision. The probable cause remained grounded in the flight: unsuccessful use of available approaches, continued diversion, and waiting too long to declare the fuel emergency.
NTSB Probable Cause
The pilot’s failure to land the airplane at multiple airports that were equipped with adequate instrument approach procedures while operating in low instrument meteorological conditions and his delay in declaring a fuel-related emergency, which resulted in a loss of engine power due to fuel exhaustion.
Safety Lessons
The following takeaways apply the investigation to flight planning and training. They do not replace the aircraft flight manual or instruction in the airplane.
- Set a fuel decision point that preserves a landing option. Recalculate after a missed approach or diversion, including climb fuel and the time required to reach a suitable runway. The original fuel estimate does not remain a reserve after the original route has changed repeatedly.
- Choose the approach the conditions and equipment support. Compare actual weather, minimums, procedure restrictions, and your ability to fly the installed equipment. A familiar GPS interface is not a reason to ignore a more suitable approach at the same airport.
- Communicate the emergency while there is still useful performance. When fuel jeopardizes a safe landing, state the situation clearly and seek priority before power is lost. Early communication gives controllers and the pilot more options than a declaration made after exhaustion.
Watch the Full Analysis
Frequently Asked Questions
Q: Why did the Piper Arrow run out of fuel near Dover?
A: Repeated approaches and diversions extended the flight, and the pilot delayed declaring a fuel emergency. The NTSB identified his failure to land at airports with adequate instrument procedures as part of the cause.
Q: Was an ILS available?
A: Yes. Salisbury had an ILS to runway 32, and Dover Air Force Base also had ILS approaches. The pilot did not use the Salisbury ILS and declared an emergency for Dover only after reporting fuel exhaustion.
Q: Did the Arrow depart without enough fuel for the planned flight?
A: Records showed full fuel and a plan listing five hours and 30 minutes of endurance for a three-hour-45-minute flight. The accident involved the subsequent approaches, diversions, and delayed emergency declaration, not a finding that the tanks were left unfilled.
Sources and References
