# NTSB ATL90LA032: Piper PA-23-160, N4359P, New Bern, NC, November 26, 1989

- Type: NTSB accident investigation
- Classification: Accident · No injuries · Limited investigation · Final report
- Date: November 26, 1989, 16:40 local (21:40 UTC)
- Place: New Bern, NC
- Coordinates: 35.109405, -77.07022 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=35.1094&lon=-77.0702&mi=10
- Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping)
- Highest injury: No injuries
- Injuries: 2 uninjured
- Status: Completed, report June 26, 1992
- Report: Approved by Office Director
- NTSB case key (mKey): 8184
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ATL90LA032
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/8184/pdf
- Page: https://openairdocs.org/ntsb/ATL90LA032

## Probable cause

THE FAILURE OF THE INSTRUCTOR PILOT TO ENSURE THAT THE ENGINE FUEL SELECTOR VALVES WERE PROPERLY POSITIONED PRIOR TO TAKEOFF, WHICH LED TO FUEL STARVATION AND A LOSS OF ENGINE POWER DURING TAKEOFF.

## Sequence of events

In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf).

- Loss of engine power(total) - nonmechanical, takeoff - initial climb
  - fluid,fuel - starvation (cause)
  - fuel tank selector position - improper, pilot in command(cfi) (cause)
- Forced landing, descent - emergency
- On ground/water encounter with terrain/water, landing - roll
  - terrain condition - ditch

## Analysis

THE AIRPLANE EXPERIENCED A LOSS OF POWER IN BOTH ENGINES SHORTLY AFTER TAKEOFF. A FORCED LANDING WAS SUBSEQUENTLY MADE IN A FIELD; THE AIRPLANE COLLIDED WITH A DITCH DURING ROLLOUT. THE INSTRUCTOR PILOT REPORTED THAT BOTH ENGINES HAD MADE A 'POPPING NOISE' WHEN THEY LOST POWER. POST-CRASH EXAMINATION OF THE AIRPLANE REVEALED NO EVIDENCE OF ANY PRE-EXISTING MECHANICAL PROBLEMS. DURING A SUBSEQUENT ENGINE TEST-RUN ATTEMPT, BOTH ENGINES STARTED NORMALLY AND DEVELOPED POWER. THE RIGHT-ENGINE RUN WAS LIMITED TO 55% POWER DUE TO AIRPLANE DAMAGE. THE LEFT-ENGINE WAS RUN UP TO FULL POWER WITH NO PROBLEMS. DURING THE LEFT-ENGINE RUN-UP, FUEL TO THE ENGINE WAS SHUT OFF; AFTER ABOUT 30 SECONDS, THE ENGINE BEGAN TO MAKE A POPPING NOISE AND LOST POWER.

## Aircraft

- Registration: [N4359P](https://openairdocs.org/deregistered/N4359P-2018-01-19), registration cancelled 2018-01-19, S/N 23-1859, built 1959 (OpenAirDocs)
- Reported make and model: PIPER PA-23-160
- Registry model: [Piper PA-23-160](https://openairdocs.org/model/piper-pa-23-160) (registry code 7102304) (OpenAirDocs)
- Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: 23-1859
- Airframe hours: 5137
- Engines: LYCOMING O-320-B2B 160 horsepower reciprocating
- Damage: Substantial damage
- Flight: Instructional, Part 91
- Registered owner: Air New Bern
- Airworthiness certificate: Standard, Normal
- Last inspection: 100 hour, June 4, 1989, 55 hours before
- Airport: EWN, Craven County Regional, runway 22, 4,804 × 150 ft, asphalt

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 29; flight instructor, commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, valid medical--w/ waivers/lim; seat: right; flight hours: 495 total, 54 in this make and model, 375 as pilot in command, 213 in the last 90 days, 84 in the last 30 days, 2 in the last 24 hours

## Weather

- Conditions: Visual (VMC), Day
- Wind: 200° at 5 knots
- Visibility: 7 statute miles
- Lowest ceiling: 12,000 ft broken
- Temperature: 68 °F, dew point 57 °F
- Altimeter: 30.00 inHg
- Observed at: EWN, 1 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 19891126046659A](https://openairdocs.org/incident/19891126046659A), Nov 26, 1989: Piper PA23160, New Bern, NC, Substantial damage. Indicates aircraft departed with fuel selector in off position. Struck a ditch on forced landing.

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.

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