ANC20LA002

NTSB accident investigation · Cessna 172 · Palmer, AK · October 13, 2019

Accident · No injuriesClass 3 · LimitedFinal report
Date
October 12, 2019, 16:20 local (Oct 13, 2019, 00:20 UTC)
Place
Palmer, AK
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N7267ACessna 172
Defining event
Enroute: Fuel related
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Alaska Regional Office
Parties
FAA
FAA report
20191013022809A
Case key
100431

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 delayed application of carburetor heat in weather conditions conducive to carburetor icing, which resulted in a partial loss of engine power, a precautionary landing, and impact with terrain.

Findings · 6

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.

Use of equip/info: use of equip/systemPersonnel issues › Task performance · PilotCessna 172: 7 casesAll aircraft: 1,391 casesProbable cause
Temp/humidity/pressure: conducive to carburetor icingEnvironmental issues › Conditions/weather/phenomena · Effect on equipmentCessna 172: 4 casesAll aircraft: 435 casesProbable cause
Action: delayed actionPersonnel issues › Action/decision · PilotCessna 172: 8 casesAll aircraft: 894 casesProbable cause
Action: lack of actionPersonnel issues › Action/decision · PilotCessna 172: 4 casesAll aircraft: 792 casesProbable cause
Object/animal/substance: tree(s)Environmental issues › Physical environment · Contributed to outcomeCessna 172: 8 casesAll aircraft: 933 casesProbable cause
Engine fuel and control: fuel control/carburetorAircraft › Aircraft power plant · Incorrect use/operationCessna 172: 2 casesAll aircraft: 195 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, about 15 minutes after departure, the engine began to run rough and experienced a partial loss of power. He provided conflicting statements about the phase of flight when this occurred; he was either in cruise flight or was flying at a reduced power setting during a low approach to a remote site. After completing emergency engine procedures, which included applying carburetor heat, the pilot was unable to restore engine power and selected an all-terrain vehicle trail as a forced landing site. Just before touchdown, when the airplane was about 15 ft above the ground, the left wing struck a tree, and the airplane yawed left and touched down in a nose-low, off-center angle. The airplane sustained substantial damage to both wings and the fuselage. Postaccident examination of the engine, including a test run, revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. Weather conditions about 15 nautical miles from the accident site were conducive for carburetor icing at cruise power and serious icing at glide power. The pilot only reported applying carburetor heat to restore engine power. Therefore, it is likely that carburetor ice accumulated before he applied the heat, which resulted in a partial loss of engine power. Further, the delayed application of carburetor heat was insufficient to melt the ice and restore power.

Factual narrative

On October 13, 2019, about 1620 Alaska daylight time, a Cessna 172 airplane, N7267A, sustained substantial damage when it was involved in an accident about 15 nautical miles southeast of the Palmer Municipal Airport (PAAQ) Palmer, Alaska. The private pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that, after departing the off-airport airstrip near the Knik Glacier, he made a low approach to the same airstrip before continuing the flight to Birchwood Airport (PABV) Birchwood, Alaska. About 15 minutes later, while in cruise flight, the engine began to run rough and the rpm "rolled back." In an attempt to restore engine power, he applied carburetor heat, confirmed a rich mixture, checked the fuel tank levels, and placed the fuel selector from BOTH to the LEFT tank. In addition, he verified the oil pressure, confirmed the magneto switch was selected to BOTH, and that the primer was in and locked. The pilot subsequently selected an all-terrain vehicle trail as a forced landing site. Just before touchdown, about 15 feet above the ground, the left wing struck a small tree and the airplane yawed to the left and touched down in a nose low, off-center angle. Subsequently, the right main landing gear and nose-gear separated, and the right wing struck the ground; the pilot was able to egress the airplane without further incident. The airplane sustained substantial damage to both wings and the fuselage. A post-accident examination of the engine, which included a test run, revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. According to a carburetor icing probability chart, using the nearest weather observation station located about 15 nautical miles away, an airplane operating in the ambient conditions near the accident site would expect carburetor icing at cruise power, and serious icing at glide power.

Aircraft

Registration
N7267A
Reported as
Cessna 172 (Undesignat)
Category
Airplane
Serial number
29367
Built
1956
Airframe hours
2,818.85
Engine
Continental O-300-B, 145 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · May 5, 2019
Departed
4AK6 · Palmer, AK
Destination
BCV · Birchwood, AK
Equipment
Handheld GPS, Electronic flight bag or handheld device, Stall warning system

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
50
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Last flight review
May 15, 2018
Seat
Left
Restraint
4-point
Flight hours
190 total · 144 in this make and model · 125 as pilot in command · 26 in the last 90 days · 11 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
200° at 3 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
41 °F, dew point 27 °F
Altimeter
29.96 inHg
Observed at
PAAQ, 15 nm away

Docket · 3

The files NTSB released with the investigation on October 9, 2020, on NTSB’s docket system: statements, records, photos and specialists’ reports. 1.7 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.