# NTSB GAA19CA534: Piper PA28, N2909U, Sawyer, MI, September 3, 2019 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: September 2, 2019, 20:25 local (Sep 3, 2019, 00:25 UTC) - Place: Sawyer, MI - Coordinates: 46.318889, -87.281944 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=46.3189&lon=-87.2819&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-descent: Fuel related](https://openairdocs.org/ntsb-events/190) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report February 11, 2020 - Report: Approved by Office Director - NTSB office: General Aviation Accidents - Parties: FAA - NTSB case key (mKey): 100226 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA19CA534 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/100226/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=100226 - Page: https://openairdocs.org/ntsb/GAA19CA534 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Incorrect use/operation (probable cause); cases with it: [Piper PA-28-161, 11 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=7102803), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid level (probable cause); cases with it: [Piper PA-28-161, 11 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=7102803), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-28-161, 12 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=7102803), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) - [Use of equip/info: use of checklist](https://openairdocs.org/ntsb-findings/02063030): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-28-161, 1 case](https://openairdocs.org/ntsb-findings/02063030/cases.md?model=7102803), [All aircraft, 336 cases](https://openairdocs.org/ntsb-findings/02063030/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-descent: Fuel related](https://openairdocs.org/ntsb-events/190) (defining event); cases with it: [Piper PA-28-161, 4 cases](https://openairdocs.org/ntsb-events/190/sequence.md?model=7102803), [All aircraft, 361 cases](https://openairdocs.org/ntsb-events/190/sequence.md) - [Landing: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Piper PA-28-161, 19 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=7102803), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-28-161, 58 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102803), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/deregistered/N2909U-2021-09-21), registration cancelled 2021-09-21, S/N 28-7916534 (OpenAirDocs) - Reported make and model: Piper PA28 (161) - Registry model: [Piper PA-28-161](https://openairdocs.org/model/piper-pa-28-161) (registry code 7102803) (OpenAirDocs) - Category: Airplane - Serial number: 28-7916534 - Year built: 1979 - Airframe hours: 10000 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 46; injuries: none; 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 ## 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 20190902012369A](https://openairdocs.org/incident/20190902012369A), Sep 2, 2019: Piper PA-28-161, Marquette Count, MI, Substantial damage. On Monday September 2, 2019 at 20:10 eastern daylight time, a Piper PA-28-161 aircraft, N2909U, registered to a flying club and operated by a private pilot,… ## Docket (4 files) The files NTSB released with the investigation on November 7, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=100226. 1.6 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 968 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40477847&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Record of Email Correspondence (FAA) (item 2, .PDF, 96 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40477848&FileExtension=.PDF&FileName=Record%20of%20Email%20Correspondence%20(FAA)-Master.PDF - Airplane POH (item 3, .PDF, 449 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40477849&FileExtension=.PDF&FileName=Airplane%20POH-Master.PDF - Damage Photo (item 4, .PDF, 1 photo, 113 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40477850&FileExtension=.PDF&FileName=Damage%20Photo-Master.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.