- Location: Clinton, Michigan
- Accident Number: CEN24FA215
- Date & Time: June 10, 2024, 13:11 Local
- Registration: N1039X
- Aircraft: Piper PA28
- Aircraft Damage: Substantial
- Defining Event: Fuel starvation
- Injuries: 1 Fatal, 1 Serious
- Flight Conducted Under: Part 91: General aviation - Instructional
https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/194430/pdf
https://data.ntsb.gov/Docket?ProjectID=194430
On 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.
The flight instructor and student pilot were conducting an instructional flight in the singleengine airplane. ADS-B data and an NTSB performance study showed that, after completing training maneuvers south of the departure airport, there was a possible reduction in engine power. The flight instructor contacted air traffic control to return to the airport, but did not report any difficulties. Shortly after, the airplane was on a heading toward the airport in a descent consistent with the best glide prescribed by the airplane manufacturer’s Pilot’s Operating Manual. The airplane then turned about 270° to the left toward a local road and field, consistent with the pilots maneuvering for a forced landing. While about 200 ft above ground level (agl) and at an airspeed higher than the wings-level, flaps-retracted stall speed, the airplane began a right turn away from the road. The wreckage and impact signatures, including initial right wingtip contact followed by nose impact, were consistent with a loss of airplane control while maneuvering at a low altitude during the forced landing.
Postaccident examination of the airframe and engine revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. The examination also showed that the right fuel tank was intact and there was no evidence of blighting or moistened soil beneath the right wing at the accident site that would indicate fuel leaking from the wing tank. The left fuel tank was intact and contained some amount of usable fuel after the accident. In addition, the left fuel cap was secure and intact, and no water was detected in the fuel. The fuel selector handle and valve were found between the Left Tank and Off positions, which would have prevented fuel flow. The entire fuel system forward of the fuel selector contained either no or trace amounts of fuel.
Fuel records and the airplane’s flight history indicated that the airplane had been fueled to 36 gallons (18 gallons per fuel tank) two days before the accident flight. Only one 1.2-hour flight was completed after the airplane was refueled and before the accident flight. At an estimated fuel consumption of 7.6 gallons per hour (gph) and assuming the fuel was evenly distributed between the tanks, this would have resulted in 27 total gallons for the accident flight when it departed the airport (13.5 gallons per fuel tank). Fuel calculations suggest that the engine was operated between 60 and 75% power during the accident flight, consistent with a fuel consumption rate between 6.8 and 8.4 gph. Assuming the flight departed with evenly distributed fuel tanks, this fuel consumption for the 1.7-hour accident flight is consistent with the airplane having been operated on one fuel tank for the entire accident flight was completed after the airplane was refueled and before the accident flight. At an estimated fuel consumption of 7.6 gallons per hour (gph) and assuming the fuel was evenly distributed between the tanks, this would have resulted in 27 total gallons for the accident flight when it departed the airport (13.5 gallons per fuel tank). Fuel calculations suggest that the engine was operated between 60 and 75% power during the accident flight, consistent with a fuel consumption rate between 6.8 and 8.4 gph. Assuming the flight departed with evenly distributed fuel tanks, this fuel consumption for the 1.7-hour accident flight is consistent with the airplane having been operated on one fuel tank for the entire accident flight.
The lack of fuel in the downstream fuel system components, the fuel selector valve’s as-found position, the remaining usable fuel in the left tank, and the lack of evidence of fuel leakage or contamination were consistent with a total loss of engine power due to fuel starvation. It is likely that, after the selected fuel tank was depleted, the fuel selector was inadvertently moved past the Left Tank detent toward the Off position during an attempt to restore engine power, which prevented fuel in the left tank from reaching the engine. The fuel selector was located on the left side of the cockpit, next to the student pilot’s left leg. The student pilot did not recall the flight or accident sequence. Therefore, the investigation could not determine when the fuel selector was moved or which occupant moved it.
The flight instructor’s autopsy findings revealed some evidence of heart disease that increased the risk of an impairing or incapacitating cardiac event; however, there was no autopsy evidence that such an event occurred. Toxicology results also indicated that the flight instructor had used a cannabis product. The measured levels of delta-9-THC and its metabolites indicated a possibility that, at the time of the accident, the instructor pilot may have been experiencing acute psychoactive effects of cannabis. However, delta-9-THC levels as high as those found in this case may persist well beyond the time window of acute psychoactive effects in frequent cannabis users. Whether the pilot was a frequent cannabis user is unknown. Accordingly, the toxicology results alone do not establish whether the pilot was experiencing significant cannabis-related cognitive or psychomotor impairment at the time of the accident or during preflight preparations.
A long-lived non-psychoactive metabolite of delta-9-THC was detected in the student pilot’s blood, indicating that he likely had used a cannabis product sometime in the days before the accident. FAA testing did not detect delta-9-THC or psychoactive metabolites of delta-9-THC in his blood collected about 1.7 hours after the accident. These toxicology results provide no specific evidence that the student pilot was experiencing impairing cannabis effects at the time of the accident or during preflight preparations.
Therefore, the available evidence was insufficient to determine whether impairment contributed to the accident.
- 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.
A 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.
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