# NTSB CEN24FA215: Piper PA28, N1039X, Clinton, MI, June 10, 2024 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: June 10, 2024, 13:11 local (17:11 UTC) - Place: Clinton, MI - Coordinates: 42.0833, -83.9478 - Nearby events: https://openairdocs.org/map.md?lat=42.0833&lon=-83.9478&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach: Fuel starvation](https://openairdocs.org/ntsb-events/191) - Highest injury: Fatal - Injuries: 1 fatal, 1 serious - Status: Completed, report September 8, 2026 - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: Lycoming, FAA, Piper Aircraft - NTSB case key (mKey): 194430 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN24FA215 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/194430/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=194430 - Page: https://openairdocs.org/ntsb/CEN24FA215 ## 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. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Fuel system: fuel selector/shutoff valve](https://openairdocs.org/ntsb-findings/01022823): Aircraft › Aircraft systems · Incorrect use/operation (probable cause); cases with it: [Piper PA-28-140, 7 cases](https://openairdocs.org/ntsb-findings/01022823/cases.md?model=7102802), [All aircraft, 176 cases](https://openairdocs.org/ntsb-findings/01022823/cases.md) - [Performance/control parameters: engine out control](https://openairdocs.org/ntsb-findings/01062025): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Piper PA-28-140, 1 case](https://openairdocs.org/ntsb-findings/01062025/cases.md?model=7102802), [All aircraft, 35 cases](https://openairdocs.org/ntsb-findings/01062025/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Instructor/check pilot (probable cause); cases with it: [Piper PA-28-140, 103 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7102802), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Fuel system: fuel distribution](https://openairdocs.org/ntsb-findings/01022820): Aircraft › Aircraft systems · Incorrect use/operation; cases with it: [Piper PA-28-140, 3 cases](https://openairdocs.org/ntsb-findings/01022820/cases.md?model=7102802), [All aircraft, 141 cases](https://openairdocs.org/ntsb-findings/01022820/cases.md) - [Attention/monitoring: monitoring equip/instruments](https://openairdocs.org/ntsb-findings/02021525): Personnel issues › Psychological · Instructor/check pilot; cases with it: [Piper PA-28-140, 5 cases](https://openairdocs.org/ntsb-findings/02021525/cases.md?model=7102802), [All aircraft, 142 cases](https://openairdocs.org/ntsb-findings/02021525/cases.md) - [Impairment/incapacitation: illicit drug](https://openairdocs.org/ntsb-findings/02012020): Personnel issues › Physical · Instructor/check pilot; cases with it: [Piper PA-28-140, 1 case](https://openairdocs.org/ntsb-findings/02012020/cases.md?model=7102802), [All aircraft, 67 cases](https://openairdocs.org/ntsb-findings/02012020/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach: Fuel starvation](https://openairdocs.org/ntsb-events/191) (defining event); cases with it: [Piper PA-28-140, 17 cases](https://openairdocs.org/ntsb-events/191/sequence.md?model=7102802), [All aircraft, 733 cases](https://openairdocs.org/ntsb-events/191/sequence.md) - [Emergency descent: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241); cases with it: [Piper PA-28-140, 21 cases](https://openairdocs.org/ntsb-events/241/sequence.md?model=7102802), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md) ## Analysis The flight instructor and student pilot were conducting an instructional flight in the single-engine 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. 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 fuelleakage 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. ## Factual narrative According 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. The FAA obtained airplane maintenance records from the operator; however, these documents were not forwarded to the NTSB. The 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. 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. 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. Michigan 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 usedmedicinally, 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. 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. The 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. ## Aircraft - Registration: [N1039X](https://openairdocs.org/aircraft/N1039X), registered now, S/N 28-7525265, built 1975 (OpenAirDocs) - Reported make and model: PIPER PA28 (140) - Registry model: [Piper PA-28-140](https://openairdocs.org/model/piper-pa-28-140) (registry code 7102802) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-7525265 - Year built: 1975 - Airframe hours: 3263.7 - Engines: Lycoming O-320E3D 150 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Operator: Solo Aviation Inc, doing business as Solo Aviation Inc - Registered owner: Silvered Wings LLC - Airworthiness certificate: Standard, Normal - Departed: ARB, Ann Arbor, MI - Destination: ARB, Ann Arbor, MI ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 46; injuries: fatal; commercial, flight instructor; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; last flight review August 11, 2023; seat: right; restraint: 3-point; toxicology performed; flight hours: 887 total, 838 in this make and model, 185 in the last 90 days, 65 in the last 30 days, 1 in the last 24 hours - Student pilot; age 22; injuries: minor; student; seat: left; restraint: 3-point; flight hours: 58 total, 0 in this make and model, 0 as pilot in command, 0 in the last 90 days, 0 in the last 30 days, 0 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 360° at 11 knots, gusting 18 - Visibility: 10 statute miles - Temperature: 64 °F, dew point 45 °F - Altimeter: 29.87 inHg - Observed at: KARB, 13 nm away - METAR: KARB 101753Z 36011G18KT 10SM FEW048 SCT060 18/07 A2987 RMK AO2 SLP114 T01830067 10189 20111 51000 ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20240610009279A](https://openairdocs.org/incident/20240610009279A), Jun 10, 2024: Piper PA-28-140, Clinton, MI, Substantial damage, 1 fatal. A student and instructor were on an instructional flight. The flight was approximatly 1 hour and 39 minutes. The aircraft was returning to the home base and… ## Docket (9 files) The files NTSB released with the investigation on September 8, 2026, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=194430. 20.1 MB in all. - Fuel records and consumption calculation (item 1, PDF, 3 pages, 595 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=20658550&FileExtension=pdf&FileName=Fuel%20Computations-Rel.pdf - Aircraft performance study (item 2, PDF, 8 pages, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18676572&FileExtension=pdf&FileName=CEN24FA215_PerformanceStudy-Rel.pdf - ADS-B data (item 3, CSV, 14.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18675655&FileExtension=csv&FileName=N1039X_ADSB-Rel.csv - Exam summary (item 4, PDF, 8 pages, 273 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=20660332&FileExtension=pdf&FileName=Exam%20Summary-Rel.pdf - Fuel selector figure and source material a�� POH excerpt (item 5, PDF, 2 pages, 2 photos, 339 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=20829776&FileExtension=pdf&FileName=Fuel%20Selector%20Figures%20and%20Source%20Material-Rel.pdf - Toxicological report (item 6, PDF, 1 page, 177 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=20660261&FileExtension=pdf&FileName=Tox%20Redacted%201-Rel.pdf - Toxicological report 2 (item 7, PDF, 1 page, 285 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=20660271&FileExtension=pdf&FileName=Tox%20Redacted%202-Rel.pdf - Statements of party representatives to NTSB investigation (item 8, PDF, 2 pages, 469 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=20660281&FileExtension=pdf&FileName=Party%20Forms_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 9, PDF, 1 page, 735 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=20829665&FileExtension=pdf&FileName=Release%20of%20Bulk%20Wreckage_Redacted-Rel.pdf From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.