# NTSB CEN09CA560: Piper PA-12, N2409M, Gonvick, MN, August 28, 2009 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: August 27, 2009, 19:30 local (Aug 28, 2009, 00:30 UTC) - Place: Gonvick, MN - Coordinates: 47.849998, -95.526947 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=47.8500&lon=-95.5269&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report December 15, 2009 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 74654 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN09CA560 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/74654/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=74654 - Page: https://openairdocs.org/ntsb/CEN09CA560 ## Probable cause A loss of engine power due to carburetor icing as a result of the pilot's failure to use carburetor heat. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Temp/humidity/pressure: conducive to carburetor icing](https://openairdocs.org/ntsb-findings/03031030): Environmental issues › Conditions/weather/phenomena · Effect on equipment (probable cause); cases with it: [Piper PA-12, 6 cases](https://openairdocs.org/ntsb-findings/03031030/cases.md?model=7101202), [All aircraft, 435 cases](https://openairdocs.org/ntsb-findings/03031030/cases.md) - [Engine controls](https://openairdocs.org/ntsb-findings/01057600): Aircraft › Aircraft power plant · Not used/operated (probable cause); cases with it: [Piper PA-12, 1 case](https://openairdocs.org/ntsb-findings/01057600/cases.md?model=7101202), [All aircraft, 51 cases](https://openairdocs.org/ntsb-findings/01057600/cases.md) - [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA-12, 2 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md?model=7101202), [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering: Fuel related](https://openairdocs.org/ntsb-events/190); cases with it: [Piper PA-12, 3 cases](https://openairdocs.org/ntsb-events/190/sequence.md?model=7101202), [All aircraft, 361 cases](https://openairdocs.org/ntsb-events/190/sequence.md) - [Maneuvering: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Piper PA-12, 12 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=7101202), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Landing-flare/touchdown: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-12, 42 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7101202), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis According to the pilot, he intended to fly the float-equipped airplane for approximately one hour to practice for his airplane sea rating. During the flight, the engine lost 100 revolutions per minute (RPMs) on four or five different occasions. At 1,000 feet above ground level, the engine sputtered and lost power. The pilot executed a forced landing to a field. During the landing, the airplane impacted terrain and nosed over. Examination of the airplane revealed the fuselage was buckled. A postaccident inspection and test run of the engine failed to reveal any mechanical anomalies. The nearest weather reporting facility, located 10 nautical miles southwest of the accident site, recorded a temperature of 22 degrees Celsius (C) and a dew point of 18 degrees C at the time of the accident. Review of the carburetor ice probability chart revealed that the temperature and dew point were conducive to serious icing conditions at glide power. The airplane was equipped with carburetor heat, but the pilot stated that he did not use it. The pilot reported a total of 1,859 flight hours and 12 flight hours in the accident airplane. ## Factual narrative According to the pilot, he intended to fly the float-equipped airplane for approximately one hour to practice for his airplane sea rating. During the flight, the engine lost 100 revolutions per minute (RPMs) on four or five different occasions. At 1,000 feet above ground level, the engine sputtered and lost power. The pilot executed a forced landing to a field. During the landing, the airplane impacted terrain and nosed over. Examination of the airplane revealed the fuselage was buckled. A postaccident inspection and test run of the engine failed to reveal any mechanical anomalies. The nearest weather reporting facility, located 10 nautical miles southwest of the accident site, recorded a temperature of 22 degrees Celsius (C) and a dew point of 18 degrees C at the time of the accident. Review of the carburetor ice probability chart revealed that the temperature and dew point were conducive to serious icing conditions at glide power. The airplane was equipped with carburetor heat, but the pilot stated that he did not use it. The pilot reported a total of 1,859 flight hours and 12 flight hours in the accident airplane. ## Aircraft - Registration: [N2409M](https://openairdocs.org/aircraft/N2409M), registered now, S/N 12-1526 (OpenAirDocs) - Reported make and model: PIPER PA-12 - Registry model: [Piper PA-12](https://openairdocs.org/model/piper-pa-12) (registry code 7101202) (OpenAirDocs) - Registry engine: [Lycoming 0-235 series](https://openairdocs.org/engine/lycoming-0-235-series) (registry code 41505, 4 cycle) (OpenAirDocs) - Category: Airplane - Serial number: 12-1526 - Airframe hours: 3508 - Engines: LYCOMING O-235 SERIES 115 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Michael Johnson - Registered owner: Michael Johnson - Airworthiness certificate: Standard, Normal - Last inspection: Annual, July 1, 2009 - Departed: Gonvick, MN - Destination: Gonvick, MN ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 48; injuries: none; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, without waivers/limitations; last flight review August 8, 2009; seat: front; flight hours: 1,859 total, 12 in this make and model ## Weather - Conditions: Visual (VMC), Day - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 64 °F ## 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 20090827048769A](https://openairdocs.org/incident/20090827048769A), Aug 27, 2009: Piper PA-12, Gonvick, MN, Substantial damage. On 8/22/09 [privacy data omitted] added approximately 10 gallons of fuel per side. There was some fuel already in the tanks, but [privacy data omitted]… ## Docket (4 files) The files NTSB released with the investigation on December 7, 2009, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=74654. 580 KB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 517 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40319217&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Record of Conversation N2409M (item 2, .PDF, 25 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40322225&FileExtension=.PDF&FileName=Record%20of%20Conversation%20N2409M-Master.PDF - FAA Statement (item 3, .PDF, 17 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40319207&FileExtension=.PDF&FileName=FAA%20Statement-Redacted.PDF - FAA Carburetor Ice Chart (item 4, .PDF, 21 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40319208&FileExtension=.PDF&FileName=FAA%20Carburetor%20Ice%20Chart-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.