Inadequate Preflight:

Accident occurred Monday, May 28, 2001 in Osage Beach, MO
Date: 7/2/02
Aircraft: Piper PA-24-250
Injuries: 3 Fatal.

During a forced landing the airplane stalled and impacted trees and terrain. Witnesses to the accident reported that the engine was running rough and intermittently prior to the accident. A global positioning system (GPS) receiver was recovered at the accident site and its track data was downloaded. The recovered GPS data showed the airplane's ground speed was between 73.7 - 79.8 mph during the last 10 seconds of data. The stall speed for the accident airplane with flaps retracted is 70 mph. Post-accident fuel samples taken from the fuel strainer and both electric fuel pumps were contaminated with water and particulate. Both electric fuel pumps contained rust, water, and particulate. The carburetor float bowl and accelerator pump-well were contaminated with fine particulate resembling silicon sand. The same fine particulate was observed in the carburetor idle tube passage and nozzle well. Fuel samples taken from the right main fuel cell and fuel selector were clear of debris and water. A fuel sample obtained from the departure airport was clear of debris and water. The accident airplane had been operated approximately 164 hours in the last 35 years, 47 hours in the last 15 years, 35 hours in the last 5 years, and 35 hours in the last year. According to Federal Aviation Regulations (FAR), the pilot-in-command is required to complete an aircraft preflight inspection in order to determine if the aircraft is in an airworthy condition. According to FAA AC 20-43C, "Fuel having a 'cloudy' appearance or definitely 'offcolor' should be suspected of contamination or deterioration and should not be used." According to Airplane Flying Handbook, "Significant and/or consistent water or sediment contamination are grounds for further investigation by qualified maintenance personnel. Each fuel tank sump should be drained during preflight and after refueling."

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:

Aircraft control not being maintained by the pilot during the forced landing and inadequate preflight inspection performed by the pilot. Contributing factors to the accident were the fuel system contamination that resulted in the loss of engine power, the encountered stall, and trees.

Pilot duties and responsibilities:
Policies regarding pilot duties vary sharply from department to department,
airline to airline. Most companies divide preflight responsibilities up in a
way that best suits their operation. Dispatchers can sometimes take a
large role in information gathering, flight planning, weight and balance
and fuel loading. Mechanics sometimes perform a large part of the
preflight inspection. When working with a two pilot crew, the pilots can
divide the duties (including all of the above) in a variety of ways.
Regardless of how a flight department might divide the necessary duties,
what is important to remember is that the tasks that must be completed
are essentially the same for all flights.

Initial flight review and airport qualifications:
Unless you are planning a flight that you perform on a regular basis—
that is, one to a familiar airport with your usual aircraft load—then you
need to perform an initial flight review and check the airport qualifications.
This review should be completed at least a day in advance of the proposed
flight.
First, do a basic weight and balance to evaluate the need for a fuel stop,
and decide where you would make that stop if necessary. Next, review
the airport directory for runway distances, navaids, hours of operation,
special equipment like VASIs, etc., or any other special notes on the
airport. If the flight is IFR, check the approach plates to look for
anything out of the ordinary, such as exceptionally high minimums.
Check all notams for airport or runway closings or other unforeseen
gotchas. Nothing is more embarrassing than having to cancel a flight
right before departure because of a discovery that you could have made
days before during an initial flight review.
Regardless of whether or not this flight is usual, you should always make
at least a cursory check of the forecast weather a day or two in advance.
Sometimes spotting an obvious weather system the day before will save
you hours of time—and a headache—by allowing plenty of time to
reschedule.

Flight Day
Weight and balance:
FARs require that you perform a weight and balance before flight. If you
fly a standard load on a regular basis, you should have copies made up
beforehand of several standard weight and balance scenarios to use as
necessary. Always keep a relevant copy on hand. A weight and balance will
ensure weight within limits and aircraft within CG. It will also produce
runway distance to land and takeoff, takeoff and landing speeds, and power
settings if required. Having these numbers at hand will prove valuable if
a tower asks if you can accept a shorter runway, or if they issue a hold short
request. You will be able to tell at a glance whether you can accept that
clearance. Review FAR 91.103 on Preflight Action.

Weather:
Most pilots consider weather-gathering the most important step in the
preflight process. There are, of course, entire books on aviation weather,
so this will be only a brief review of the real-world process of gathering
weather information. Start with a review of the Surface Analysis Chart.
This will give you a great overview for your day. It will tell you where
the pressure systems and fronts are located, and it can tell you where foul
weather might be expected. Then check the 12 and 24-hour Prog Chart to see
where the Surface Analysis Chart is going to be moving over the day. Next,
check the Radar for areas of precipitation and intensity. Then check the
usual text weather items: Metars, TAFs, Pireps, Notams, TFRs, Winds Aloft.

Computers have made the weather-gathering process much easier in recent
years. Most aviation weather services have some type of "weather route"
request, which basically means you receive a FSS standard route briefing.
Always avail yourself of as much weather information as possible.
Keep in mind emergency contingence plans, alternates and areas of better
or improving weather to head for in an emergency.

The FAA recommends you use only FAA approved sources of weather
information. To avoid any questions or enforcement action, you should
ensure that you are using an approved source. It is also a good idea to
have some type of paper trail to show that you did obtain a proper
preflight briefing. Look at AIM/7-1-3 for information on proper
weather sources.

Route, Navigation requirements, Obstacles, Airport:
Determine your desired route based on winds, weather, navaids, mountains or
other obstacles, preferred routes, DPs, STARs, or by a route or flow
pattern that you know ATC usually prefers. Ensure that you have the navigation
equipment and performance to complete the trip. Review the airport as you
did in the initial flight review to ensure that it meets all your requirements.

Filing a Flight Plan:
According to the AIM, you should file an IFR flight plan at least four
hours before departure. Most of your computer filing systems or DUAT systems
will not transmit a flight plan until two hours before proposed departure.
In reality, it is common for many professional pilots to file just 45 minutes before
departure. To allow ATC to plan for traffic volume and flow, it is better
to file as far in advance as possible. However, to file any sooner than
two hours before proposed departure time, when using DUATs, is a waste of
time. AIM says you should file routes with a fix within every ATC sector.
Many times, in low volume parts of the country, it is easy to file and get a
direct route of flight.
If you are flying from a high-density part of the country, however,
ATC can sometimes get very upset with direct flight plans. Because
of traffic, direct routes are just not possible. This means the controller
must research and plan a route for you. Deciding on a route can
sometimes be frustrating for the pilot when there are no published
preferred routes. With no published preferred routes, it is hard to know
what route ATC wants you to use. This means taking a guess, a process
that is usually wrong—which means ATC will have to figure the route
for you anyway. However, it seems they are usually OK with that (go
figure). Bottom line: if it's high-density, do some research (ask other pilots,
review preferred routes) and file a route other than direct. Read AIM 5-1-7 for
more information on filing flight plans.

Preflight Inspection:
Every good preflight begins with a post flight after the previous flight.
It's great to find something on the preflight before it causes a problem.
Like, for example, a bird strike in a turbine engine inlet. However, the
bird strike occurred on the last flight. This means we will have to cancel
today's flight and have someone "scope" the engine to determine if there
was any internal damage. If the aircraft has been sitting in the hangar
all week, we could have avoided all of this with a good post flight. If we
had caught the bird strike on the post flight, we could have had
someone complete the "engine scope" without disruption to the flight
schedule. Furthermore, some items of an aircraft inspection are easier to
spot on a post flight instead of a preflight. Some leaks are easier to see
when they are new; many bird strikes are easier to see when the blood is
still fresh.
Preflight inspections should cover all items per the manufacturer's
recommended procedures. It is usually standard operating procedure to
perform a full preflight on the first flight of the day, and to abbreviate
the preflight on subsequent legs flown on the same day. However, someone
should perform a post flight after every leg, and a pilot should do a walk-
around before every flight.

Clearance:
The AIM recommends pilots receive their instrument clearance before engine
start. Read AIM 5-2-2. This is not always possible, but pilots should make.
the attempt. This will give the pilot a chance to review the clearance and get
everything clear without engines running, propellers spinning, etc. If
possible, it is also best to program the FMS or navigation equipment before
engine start. Sitting on a ramp with engines running requires focus and a
keen awareness of the situation around the aircraft. This is not the time
to have your head down, going through charts and entering data into a
navigation system.

Taxi:
Pilots should always have a taxi chart in front of them while they taxi.
In addition, taking some time to review this chart will make it much easier
to understand the controller's taxi instructions when the time comes. If you
are unfamiliar with an airport, always ask for "progressives." Progressives
are instructions given to the pilot as they progress or taxi. It lets the
controller know you are unfamiliar with the airport, that you need extra help
and that they need to keep an eye on you. Usually, the controller won't rattle
off a half a dozen taxiways to a pilot who has asked for progressives. The FAA
has many publications out right now that cover aircraft taxing and runway
incursions. A good source of information is runway safety is Advisory
Circular 91-73 http://www.faarsp.org/pdf/9173.pdf.(Note: This is a PDF file).
Professional crews try to keep their heads outside the aircraft while
taxiing. Anytime the aircraft crosses a taxiway, the pilot on the left
announces, "Crossing taxiway Charlie, clear left." The pilot on the right
announces, "Roger, crossing Charlie, clear right." When crossing a runway,
the pilot on the left announces, "Crossing Runway 22, we are cleared to
cross, strobes are on and it is clear to the left." The pilot on the right
announces, "Crossing a runway, clear to the right." This procedure can
very from department to department, but the purpose is the same: situation
awareness. If you are operating as a single pilot, you can complete the same
procedure by playing both roles and saying the lines in your head or out
loud.

Conclusion:
The purpose of these procedures is to be prepared, organized, standardized.
This allows a pilot to maintain great situation awareness. He/she can step
back and look at the situation from above and behind with a clear overview.
They will be more relaxed and have confidence in their decisions. Whether
a pilot flies for work or play, these procedures are necessary for them to be
competent and proficient. Confidence and professionalism will be apparent
to passengers and to other pilots. Good flying.

Additional information on accident cause factors: AIM 7-5-1