GAA19CA534

NTSB accident investigation · Piper PA28 · Sawyer, MI · September 3, 2019

Accident · No injuriesData collectionFinal report
Date
September 2, 2019, 20:25 local (Sep 3, 2019, 00:25 UTC)
Place
Sawyer, MI
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N2909UPiper PA28
Defining event
Enroute-descent: Fuel related
Weather
Visual (VMC) · Dusk
Status
Completed · report February 11, 2020
Report
Approved by Office Director
NTSB office
General Aviation Accidents
Parties
FAA
FAA report
20190902012369A
Case key
100226

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

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Probable cause

The pilot's improper fuel management, which resulted in fuel starvation, a total loss of engine power, and an off-airport landing and impact with vegetation and a ditch. Contributing to the accident was the pilot's failure to follow the Emergency Power Loss During Flight checklist.

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 · Incorrect use/operationPiper PA-28-161: 11 casesAll aircraft: 1,695 casesProbable cause
Fluids: fuelAircraft › Fluids/misc hardware · Fluid levelPiper PA-28-161: 11 casesAll aircraft: 1,695 casesProbable cause
Use of equip/info: use of equip/systemPersonnel issues › Task performance · PilotPiper PA-28-161: 12 casesAll aircraft: 1,391 casesProbable cause
Use of equip/info: use of checklistPersonnel issues › Task performance · PilotPiper PA-28-161: 1 caseAll aircraft: 336 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 reported that, during preflight preparations, he filled the fuel tanks with 50 gallons total fuel and planned to switch between the fuel tanks 1 hour and then 3 hours into the flight. He stated that each fuel tank contained 24 gallons of usable fuel and that the estimated fuel burn was 10 gallons per hour. He departed with the fuel selector on the right fuel tank. One hour into the flight, he switched to the left fuel tank. The pilot stated that, while descending to land at the destination airport, about 3 hours 10 minutes into the flight, he set the mixture to full rich and turned on the fuel pump, and the engine "immediately lost power." He then began an emergency checklist, turned on the carburetor heat, and cycled the fuel pump and throttle, but the engine did not respond. Subsequently, he conducted an off-airport landing on a road. Upon landing, the right wing impacted brush and weeds, and the airplane then veered right and came to rest in a ditch. The airplane sustained substantial damage to the right wing. A Federal Aviation Administrator inspector reported that the fuel selector valve was set to the left fuel tank. The propeller and engine cowl sustained minimal damage, and no fuel was found in the engine fuel sump. The left wing appeared undamaged, and less than 1 quart of fuel was found in the tank. The right wing exhibited extensive aft crushing damage to the outboard leading edge, and the fuel line was crimped and broken by impact forces, and no fuel was found in the fuel tank. The airplane manufacturer's Pilot's Operating Handbook (POH), Chapter 3.3, "EMERGENCY PROCEDURES CHECKLIST," contained an Engine Power Loss During Flight checklist, which stated, in part, the following: Fuel selector: switch to tank containing fuel Electric fuel pump: ON Mixture: RICH Carburetor heat: ON Engine gauges: check for indication of cause of power loss Primer: check locked. If no fuel pressure is indicated check tank selector position to be sure it is on a tank containing fuel. Although no fuel was found in the right fuel tank, this was likely due to the break in the fuel line caused by impact forces. Given the fuel burn rate and the length of the flight, the right tank likely had sufficient fuel onboard for flight, and the pilot's failure to move the fuel selector to the right tank, as called for in the POH, likely led to fuel starvation and the subsequent loss of all engine power.

Factual narrative

The pilot reported that, during preflight preparations, he filled the airplane's fuel tanks to 50 gallons total onboard and planned to switch the fuel tanks at "+1 hour and +3 hours" during the flight. He added that he departed with the fuel selector on the right tank. One hour into the flight, he switched to the left fuel tank. While descending to land at the destination airport, 3 hours and 10 minutes into the flight, he set the mixture at full rich and turned the fuel pump on. The engine "immediately lost power" and the "RPM's fell to 1000-1200 and ran smooth until [the] engine quit." He then began an emergency checklist and began to troubleshoot to no avail. He navigated to an area to make an off-airport landing on a road. Upon landing, the right wing impacted brush and weeds, the airplane veered right and came to rest in a ditch. The pilot reported that each fuel tank contained 24 gallons of usable fuel and his estimated fuel burn was 10 gallons per hour. The airplane sustained substantial damage to the right wing. The Federal Aviation Administrator inspector who examined the airplane reported that the fuel selector valve was set to the left fuel tank. Magnetos were found off with no key in the ignition switch. The propeller and engine cowl showed minimal damage and no fuel was found in the engine fuel sump. The left wing appeared undamaged with less than a quart of fuel remaining in the tank. The right wing exhibited extensive aft crushing damaged to the outboard leading edge and the fuel line was crimped and broken by impact forces with no fuel remaining in the wing tank. The airplane manufacturer's pilot's operating handbook, provided information and guidance in a section titled " ENGINE POWER LOSS IN FLIGHT" which stated in part: Fuel selector: switch to tank containing fuel Electric fuel pump: ON Mixture: RICH Carburetor heat: ON Engine gauges: check for indication of cause of power loss Primer: check locked. If no fuel pressure is indicated check tank selector position to be sure it is on a tank containing fuel.

Aircraft

Registration
N2909U
Reported as
Piper PA28 (161)
Category
Airplane
Serial number
28-7916534
Built
1979
Airframe hours
10,000
Engine
Lycoming, 160 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Marquette County Flying Club Inc
Registered owner
Marquette County Flying Club Inc
Airworthiness certificate
Standard, Normal; Standard, Utility
Last inspection
Annual · February 1, 2019
Departed
OZW · Howell, MI
Destination
SAW · Marquette, MI
Equipment
Auto-pilot, Handheld GPS, Stall warning system, ADS-B, Electronic flight bag or handheld device

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
46
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Last flight review
November 28, 2018
Seat
Left
Restraint
3-point
Flight hours
139 total · 79 in this make and model · 89 as pilot in command · 14 in the last 90 days · 9 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Visual (VMC) · Dusk
Wind
80° at 3 knots
Visibility
10 statute miles
Temperature
54 °F, dew point 46 °F
Altimeter
30.11 inHg
Observed at
KSAW, 5 nm away

Docket · 4

The files NTSB released with the investigation on November 7, 2019, on NTSB’s docket system: statements, records, photos and specialists’ reports. 1.6 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.