PIPER PA28
Clinton, MI, June 10, 2024
Event Information
| Date | June 10, 2024 |
| Event Type | ACC |
| Location | Clinton, MI |
| Country | USA |
| Coordinates | 42.08330, -83.94780 |
| Highest Injury | FATL |
| NTSB Number | CEN24FA215 |
| Event ID | 20240610194430 |
Aircraft
| Make | PIPER |
| Model | PA28 |
| Registration # | N1039X |
| Operator | Solo Aviation Inc |
| Owner | SILVERED WINGS LLC |
| Category | AIR |
| FAR Part | 091 |
| Aircraft Damage | SUBS |
Conditions
| Light Condition | DAYL |
| Weather | VMC |
Injuries
| Fatal | 1 |
| Serious | 1 |
| Minor | 0 |
| None | 0 |
| Total Injured | 2 |
Event Location
Probable Cause
The flight instructor’s failure to maintain airplane control while maneuvering for a forced landing. Contributing to the accident was the student pilot’s or flight instructor’s inadvertent positioning of the fuel selector valve between the Left Tank and Off positions, which resulted in fuel starvation and a total loss of engine power. Also contributing to the accident was the flight instructor’s inadequate fuel monitoring.
Full Narrative
HISTORY OF FLIGHTOn June 10, 2024, about 1311 eastern daylight time, a Piper PA-28-140 airplane, N1039X, was substantially damaged when it was involved in an accident near Clinton, Michigan. The flight instructor was fatally injured, and the student pilot sustained serious injury. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight.
According to the airplane’s operator, the purpose of the flight was for the instructor and student pilot to conduct initial flight training maneuvers during their first flight together. ADS-B data indicated that the airplane departed Ann Arbor Municipal Airport (ARB), Ann Arbor, Michigan, about 1132 and proceeded south of the airport, where it performed several maneuvers.
At 1311:36, ADS-B data showed that the airplane descended about 200 ft while losing nearly 30 kts of airspeed. The airplane then regained most of its airspeed while maintaining altitude. The pilot contacted the Ann Arbor air traffic control tower controller and was instructed to proceed straight in for runway 6. The pilot did not report any difficulties.
ADS-B data ceased from 1308:45 to 1310:00 and, when the data resumed, the airplane was on the same general track toward the airport, but had descended about 300 ft. The airplane continued descending for the remainder of the flight. About 1310, the airport was about 14 miles away, and an NTSB performance study confirmed this was beyond the airplane’s glide distance. The airplane made a 270° left turn to a track that aligned it with a field and a local road. At 1311:36, when the airplane was about 200 ft agl and at 74 kts calibrated airspeed, it began a right turn away from the road. The final ADS-B data point showed the airplane about 150 ft agl at 57 kts calibrated airspeed and decreasing. PERSONNEL INFORMATIONA review of the student pilot’s logbook revealed that he had amassed 46.4 hours of flight experience. The last flight recorded in his logbook was conducted on June 6, 2021. There was no record of the student pilot operating a PA28-140 or similar airplane before the accident flight. AIRCRAFT INFORMATIONThe FAA obtained airplane maintenance records from the operator; however, these documents were not forwarded to the NTSB. AIRPORT INFORMATIONThe FAA obtained airplane maintenance records from the operator; however, these documents were not forwarded to the NTSB. WRECKAGE AND IMPACT INFORMATIONThe airplane impacted a field about 13 nautical miles southwest of ARB. The first identified point of impact contained pieces of the right wingtip. The main wreckage came to rest south of the initial impact point. All major structural components were located at the accident site.
Wreckage signatures are consistent with the airplane initially impacting terrain with the right wingtip and then the nose. The right wing was separated from the fuselage at the wing root. The forward fuselage and cabin area were significantly impact damaged, and the forward fuselage was partially separated forward of the cabin door frame. The left main landing gear and nose landing gear separated from the airplane. The flaps were retracted.
Flight control continuity was established from the primary flight control surfaces to the cockpit area through separations consistent with tensile overload and cuts made by recovery personnel. The pitch trim corresponded to about a neutral setting.
The throttle and mixture controls were found fully forward. The carburetor heat control was found in the On position and the engine primer was stowed.
The engine was rotated by hand and compression and suction were observed on all cylinders. Valvetrain continuity was established throughout the rotating group. The engine-driven fuel pump produced suction and pressure when actuated by hand, and disassembly revealed no anomalies. The carburetor bowl contained only a trace amount of fuel, with no sediment observed. The carburetor inlet screen was free of debris. Both magnetos produced spark when rotated. The spark plug coloration and wear were consistent with normal engine operation. The propeller remained attached and displayed minimal damage.
During postaccident recovery, about 1.25 gallons of blue liquid consistent with 100LL aviation fuel were collected from the left fuel tank. An unknown quantity of fuel leaked from the left fuel tank’s severed fuel line during recovery. The right fuel tank contained only a trace amount of fuel. No water was detected in the fuel in either tank. Both fuel caps were secure and the cap seals were intact and pliable. The tanks were tested with water after recovery and were not breached. No fuel blight, moistened soil, or fuel staining were observed near the right wing.
The fuel selector handle and valve were found between the Left Tank and Off positions, rotated toward Off beyond the lockout (see figure). When tested with low air pressure, the valve did not flow in this intermediate selector position. The valve operated normally when positioned in the detents. The fuel feed line was separated and pinched about 3 inches forward of the fuel selector valve. The electric fuel pump switch was in the On position. The fuel strainer and gascolator were clean and contained no fuel. The electric fuel pump was clean, tested successfully for rotation, and contained no fuel.
The fuel selector was located on the left side of the cockpit, next to the left seat occupant’s left leg.
Figure. NTSB-generated illustration of the fuel selector in the as-found position. ADDITIONAL INFORMATIONAccording to the airplane’s operator, they regularly fueled their airplanes used for instructional flights to the tabs. Fuel records indicated that the accident airplane was fueled to the tabs with 13.9 gallons two days before the accident. One 1.2-hour flight was conducted after that fueling and before the accident flight, and no additional fueling was recorded before the accident flight, which lasted about 1.7 hours.
A fuel burn calculation was completed using the Piper PA-28-140 Pilot’s Operating Manual. The calculation used two manual-derived power settings: instructional power cruise at 60% power, and cruise at 75% power.
The manual listed the instructional power cruise speed at sea level and 60% power as 110 mph. The 36-gallon standard fuel range chart listed approximate fuel burn values of 7.3 gph at 65% power and 6.2 gph at 55% power. Interpolating between those values, the estimated fuel burn at 60% power was about 6.8 gph. The manual also listed fuel consumption at 75% power as 8.4 gph.
The manual stated that filling the tanks to the bottom of the filler neck indicator (tabs) provided the standard fuel quantity of 36 gallons, or 18 gallons per tank. Flight records showed that one 1.2-hour flight was completed after that fueling and before the accident flight. At 7.6 gph, the previous flight would have used about 9.1 gallons. Assuming the previous flight used fuel equally from both tanks, each tank would have contained about 13.5 gallons at the start of the accident flight.
If one fuel tank was used for the entire accident flight at 60% power, 95 minutes of operation at 6.8 gph would have used about 10.8 gallons, leaving about 2.7 gallons in the selected tank. At 102 minutes, the selected tank would have used about 11.6 gallons, leaving about 1.9 gallons in the selected tank.
If one fuel tank was used for the entire accident flight at 75% power, 95 minutes of operation at 8.4 gph would have used about 13.3 gallons, leaving about 0.2 gallons in the selected tank. At 102 minutes, the selected tank would have used about 14.3 gallons, which would have depleted the selected tank below its capacity by about 0.8 gallons.
This calculation does not account for engine operation on the ground, fuel used during takeoff and climb at power settings greater than cruise power, maneuvering power changes during the instructional flight, the actual tank-selection sequence, or unusable fuel. COMMUNICATIONSThe pilot contacted the Ann Arbor air traffic control tower controller during the return toward the airport. The controller issued the local altimeter setting and instructed the pilot to proceed straight in for runway 6. After the airplane began descending and turning left, the controller attempted to contact the airplane, but received no further communication. MEDICAL AND PATHOLOGICAL INFORMATIONMichigan Medicine Pathology and Clinical Laboratories performed the flight instructor’s autopsy. According to the autopsy report, the cause of death was blunt force injuries, and the manner of death was accident. The medical examiner described the ventricles of the heart as dilated and identified increased fatty infiltration of the right ventricular heart muscle, with microscopic findings of increased fibrosis and mild heart muscle cell enlargement.
Postmortem toxicological testing of the flight instructor by the FAA Forensic Sciences Laboratory detected delta-9-THC at 12.8 ng/mL in iliac blood and at 4.1 ng/mL in urine. Carboxy-delta-9- THC was detected at 47.6 ng/mL in iliac blood and at 447.2 ng/mL in urine. 11-hydroxy-THC was detected at 2.2 ng/mL in iliac blood and at 62.7 ng/mL in urine.
Toxicology testing of the student pilot’s hospital specimens detected carboxy-delta-9-THC at 29.4 ng/mL in blood. Fentanyl, ketamine, and norketamine were also detected and were attributed to medications administered during postaccident medical care.
Delta-9-THC is the primary psychoactive chemical in cannabis, including marijuana, hashish, and cannabis edibles. Delta-9-THC may be inhaled or ingested recreationally by users seeking mind-altering effects. It may also be used medicinally, such as to treat illness-associated nausea and appetite loss. Psychoactive effects of delta-9-THC vary depending on the user, dose, and route of administration, and may impair motor coordination, reaction time, decision making, problem solving, and vigilance.
Acute impairing effects of cannabis generally last at least 1-2 hours after use, typically with return to baseline within about 3-7 hours, although some residual effects may persist longer, and the duration of acute effects may be increased at higher cannabis doses or when cannabis is used orally. An occasional cannabis user's blood delta-9-THC concentration may fall to a very low or undetectable level within hours after use, whereas a frequent cannabis user's blood delta-9-THC concentration may remain elevated substantially longer while delta-9-THC sequestered in tissues redistributes into blood.
The instantaneous level of delta-9-THC in a living person’s blood does not directly predict impairing effects. Interpretation of postmortem levels of delta-9-THC is further complicated by the fact that such levels may differ from antemortem levels. 11-hydroxy-THC is a psychoactive metabolite of delta-9-THC that undergoes further metabolism to the non-psychoactive metabolite carboxy-delta-9-THC. Carboxy-delta-9-THC may be detected in blood for days after last cannabis use. Published FAA guidance indicates that marijuana use by pilots is unacceptable, regardless of state medical and recreational marijuana laws.
About This NTSB Record
This aviation event was investigated by the National Transportation Safety Board (NTSB). NTSB investigates all U.S. civil aviation accidents to determine probable cause and issue safety recommendations to prevent future accidents.