CEN19FA170

NTSB accident investigation · Piper PA28 · Huntsville, TX · June 14, 2019

Accident · FatalClass 2 · FieldFinal report
Date
June 14, 2019, 18:28 local (23:28 UTC)
Place
Huntsville, TX
Injuries
1 fatal, 1 serious
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N9754JPiper PA28
Defining event
Enroute-cruise: Fuel starvation
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 2
NTSB office
Central Region
Parties
Piper Aircrafr, FAA - Houston FSDO
FAA report
20190614006959A
Case key
99629

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

A total loss of engine power as a result of the pilot's inadvertent placement of the fuel selector to the "off" position.

Findings · 4

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Fluids: fuelAircraft › Fluids/misc hardware · Fluid managementPiper PA-28-180: 32 casesAll aircraft: 1,695 casesProbable cause
Knowledge: knowledge of equipmentPersonnel issues › Experience/knowledge · PilotPiper PA-28-180: 1 caseAll aircraft: 69 casesProbable cause
Fuel system: fuel selector/shutoff valveAircraft › Aircraft systems · Incorrect use/operationPiper PA-28-180: 6 casesAll aircraft: 176 casesProbable cause
Use of equip/info: use of equip/systemPersonnel issues › Task performance · PilotPiper PA-28-180: 16 casesAll aircraft: 1,391 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The pilot was in cruise flight nearing the destination airport when the engine lost total power. The pilot reported that his low altitude precluded him from completing emergency procedures for a loss of engine power and he attempted to glide the airplane to an open field, but impacted trees short of the field. The fuel selector was found in the "off" position at the accident site. Examination of the airplane and a subsequent engine run did not reveal any anomalies with the airplane, engine, or systems. The fuel selector installed on the accident airplane was located on the airplane's sidewall by the pilot's knee and allowed the pilot to freely rotate the selector handle through its four available positions; right tank, left tank, and two "off" positions. Two upgraded designs were subsequently provided by the manufacturer; the most recent design required the pilot to depress a spring-loaded stop while positioning the fuel selector to "off" in order to prevent the inadvertent selection of that position. Most of the pilot's experience was in airplanes equipped with the most recent fuel selector design. The manufacturer issued a mandatory service bulletin to upgrade to the most recent design, but the Federal Aviation Administration did not issue an airworthiness directive, which would have required operators to comply with that service bulletin. It is likely that the pilot inadvertently selected the off position of the fuel selector due to his unfamiliarity with the design/operation of the installed selector, which resulted in fuel starvation and a total loss of engine power. Although the pilot was familiar with the accident airplane/make model, he had very limited experience in airplanes equipped with a fuel selector of the design on the accident airplane. Further, the loss of engine power may have been prevented if the accident airplane had been required to be equipped with the most recent fuel selector design.

Factual narrative

The accident airplane was equipped with the manufacturer's original fuel selector valve and bezel design; the detent positions formed an "X" pattern. The fuel selector was mounted on the airplane's left sidewall near the pilot's left leg. The lower two detents of the "X" pattern were both "off" positions, while the forward and aft upper detents selected the right and left tanks, respectively. The valve and bezel design on the accident airplane allowed the valve to be rotated without stops to any of the available positions. The design of the fuel selector bezel and handle was subsequently modified twice by the manufacturer. The second-generation design was a 3-position design with off, left, and right selections. Rotating the handle fully counterclockwise selected the off position, while rotation fully clockwise selected the right tank. The intermediate position selected the left tank. The third-generation fuel selector added a spring-loaded stop that prevented the pilot from inadvertently selecting the off position. In order to select the off position, the pilot must simultaneously depress the spring-loaded stop and rotate the lever to the off position. The airplane manufacturer issued several Service Letters (SL) and Service Bulletins (SB) concerning replacement of the fuel selector valve cover and handle. Following the issuance of SL 588 in 1971 notifying operators of an optional service kit to upgrade from the second to third generation design, the Federal Aviation Administration (FAA) issued airworthiness directive (AD) 71-21-08. This AD required operators of airplanes equipped with second-generation fuel selectors to comply with SL 588, but did not require operators of first-generation-equipped airplanes to upgrade their fuel selectors. The manufacturer issued SL 590 in 1972, which offered the option for airplanes equipped with first generation fuel selectors to upgrade to third generation fuel selectors. SB 840A, issued on November 7, 2013, recommended the installation of third-generation fuel selectors in order to reduce the possibility of pilot mismanagement of the fuel system through inadvertent selection of the "off" position. The accident airplane was included in this SB. There were no FAA ADs requiring the upgrade of first-generation design fuel selectors. A review of the pilot's airplane rental and flight training history revealed that, of his 89.3 hours of experience in PA28 airplanes, at least 87.4 hours were in airplanes equipped with the third generation fuel selector design. (Only a single 1.9-hour flight, 10 months prior to the accident, could not be verified as to the type of fuel selector installed.) On June 14, 2019, about 1828 central daylight time, a Piper PA-28-180 airplane, N9754J, was destroyed when it impacted trees and terrain following a loss of engine power while approaching to land at the Huntsville Municipal Airport (UTS), Huntsville, Texas. The pilot received serious injuries and the passenger was fatallyinjured. The airplane was registered to AMWR LLC and operated by the General Chennault Flying Tiger Academy (GCFTA) under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed for the flight, which was not operated on a flight plan. The flight originated from the Conroe-North Houston Regional Airport (CXO), Conroe, Texas, and was en route to UTS with a planned approach to Livingston Municipal Airport (00R). The pilot reported, and GPS/ADS-B data confirmed, that he departed about 1754 and flew to 00R where he made a low approach before he proceeded toward UTS. He stated that the leg from 00R to UTS was flown at 2,500 ft mean sea level (msl). The pilot recalled switching fuel tanks, and about 15 minutes later, the engine started to "give out." He stated that he was too low to complete the emergency procedures for a loss of engine power, and he attempted to glide to an open field but was unable to make it. The airplane subsequently impacted trees. The airplane impacted trees and terrain about 6 nautical miles east-northeast of UTS. The accident site was heavily wooded, and the first tree strike was about 50 ft above ground level. The fuselage came to rest about 100 ft and 300° degrees from the initial tree impact. The outboard right wing was located between the initial tree impact and the fuselage. The left wing and the right wing root were located next to the fuselage. One half of the stabilator was located near the outboard right wing, and the other half was located near the fuselage. The engine came to rest at the forward end of the fuselage. It was separated from the fuselage at the engine mounts and remained partially attached by hoses and engine control cables. The elevator and rudder control remained intact from the control yokes aft to the center stabilator spar. The rudder control system remained intact from the rudder pedals aft to the rudder. The aileron control system exhibited two breaks in the control cable leading to the right aileron control bellcrank. The breaks exhibited signatures consistent with overload failure. The right aileron bellcrank remained attached to the wing structure and the pushrod remained attached to the aileron and the bellcrank. The left aileron bellcrank was separated from the structure and the pushrod was broken at the pushrod spherical end fitting. The remainder of the pushrod remained attached to the aileron. The aileron cables from the wing roots forward to the control yokes remained intact. No anomalies consistent with a preimpact failure or malfunction of the flight control system were observed. Examination of the cockpit revealed that the fuel selector valve was positioned forward and down, which was in the "off" position. The airplane's engine was removed from the airframe and mounted onto a surrogate airframe to facilitate a test run. The engine was started and allowed to warm up to about 1,500 rpm. The engine was then advancedto 2,000 rpm, and a magneto check was performed with no anomalies noted. The engine was able to produce power up to 2,200 rpm with the throttle fully advanced.

Aircraft

Registration
N9754J
Reported as
Piper PA28 (180)
Category
Airplane
Serial number
28-3854
Built
1967
Airframe hours
4,405
Engine
Lycoming O-360-A4A, 180 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Operator
Awmr Llc
Registered owner
Awmr Llc
Airworthiness certificate
Standard, Normal
Last inspection
Annual · June 13, 2019 · 4 hours before
Departed
CXO · Conroe, TX
Destination
CXO · Conroe, TX
Airport
UTS · Huntsville Muni
Equipment
Stall warning system, ADS-B

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
20
Injuries
Serious
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
May 27, 2019
Seat
Left
Restraint
Lap only
Flight hours
89.3 total · 76.5 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
160° at 7 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
90 °F, dew point 66 °F
Altimeter
29.93 inHg
Observed at
KUTS, 6 nm away

Docket · 11

The files NTSB released with the investigation on October 16, 2020, on NTSB’s docket system: statements, records, photos and specialists’ reports. 21.3 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.

Other investigations on N9754J · 1

Matched to the same aircraft by N-number and date.