CEN15LA106

NTSB accident investigation · Diamond Aircraft Ind DA 20 C1 · Shipshewana, IN · January 19, 2015

Accident · No injuriesLimited investigationFinal report
Date
January 19, 2015, 17:00 local (22:00 UTC)
Place
Shipshewana, IN
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N979DCDiamond Aircraft Ind DA 20 C1
Defining event
Maneuvering-low-alt flying: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report March 17, 2015
Report
Approved by Office Director
NTSB office
Central Region
Parties
FAA, Continental Motors Inc
FAA report
20150119000499A
Case key
90617

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 total loss of engine power due to impact ice obstructing the primary air induction system, which resulted from the student pilot’s failure to operate the alternate air control. Contributing to the accident was the student pilot’s lack of knowledge about using the alternate air control during an engine power loss.

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.

Power plant: air intakeAircraft › Aircraft power plant · Incorrect use/operationDiamond Aircraft Ind DA20-C1: 1 caseAll aircraft: 50 casesProbable cause
Environmental issuesEnvironmental issues › Conditions/weather/phenomena · Effect on equipmentDiamond Aircraft Ind DA20-C1: 1 caseAll aircraft: 57 casesProbable cause
Knowledge: knowledge of equipmentPersonnel issues › Experience/knowledge · Student/instructed pilotDiamond Aircraft Ind DA20-C1: 1 caseAll aircraft: 69 casesProbable cause
Training: training with equipmentPersonnel issues › Experience/knowledge · Student/instructed pilotDiamond Aircraft Ind DA20-C1: 1 caseAll aircraft: 32 cases
Action: lack of actionPersonnel issues › Action/decision · Student/instructed pilotDiamond Aircraft Ind DA20-C1: 6 casesAll aircraft: 792 casesProbable cause
Use of equip/info: use of equip/systemPersonnel issues › Task performance · Student/instructed pilotDiamond Aircraft Ind DA20-C1: 4 casesAll aircraft: 1,391 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 student pilot reported that he was practicing solo ground reference maneuvers about 1,600 ft above ground level when the engine began operating erratically. He further stated that the airplane might have entered an aerodynamic stall. He advanced the throttle to full forward, but the engine did not respond and subsequently experienced a total loss of power. He attempted to restart the engine by completing the emergency procedures that he remembered. The engine "turned over" but did not restart. He then prepared for a forced landing to a nearby field. During the base-to-final turn, he lost control of the airplane, and it descended to the ground. The airplane impacted the field and continued into a propane tank and then a house where it came to rest. A postaccident examination of the airplane revealed that most of the induction air filter was obstructed by ice; no other anomalies were noted. The engine was test run with and without the ice in the air filter, and the engine produced full power under both conditions. The alternate air lever, which selects a second induction air intake in case the primary air intake (air filter) becomes restricted, was found in the "off" position. The aircraft flight manual states that, in the event of an in-flight engine failure, the alternate air control should be opened (or "on"). A Federal Aviation Administration advisory circular warns pilots of induction system icing known as "impact ice," which can build up on components like the air filter when moisture-laden air is near freezing. Based on the near-freezing outside air temperature and clouds in the area in which the flight was operating and the lack of any apparent engine malfunctions, it is likely that the primary air induction system became obstructed with impact ice during the flight. When asked about the airplane's alternate air lever, the student pilot indicated that he was unfamiliar with the lever and did not know its intended use. If the student pilot had opened the alternate air control during the initial power loss, it is likely that engine power would have been restored.

Factual narrative

On January 19, 2015, about 1700 eastern standard time, a Diamond Aircraft Inc. DA 20 C1 airplane, N979DC, made a forced landing into a field near Shipshewana, Indiana. The solo student pilot was not injured and the airplane sustained substantial damage. The airplane was registered to and operated by New Horizons Aviation Inc. under the provisions of 14 Code of Federal Regulations Part 91 as a solo instructional flight. Visual meteorological conditions prevailed and no flight plan was filed. The local flight departed from the Goshen Municipal Airport (GSH), Goshen, Indiana about 1645. According to the student pilot, he was about 1,600 feet above ground level practicing ground reference maneuvers. He reported that the engine operation became erratic and the airplane might have entered an aerodynamic stall. He advanced the throttle to full forward, but the engine did not respond and experienced a total loss of power. He attempted to restart the engine by completing the emergency procedures that he remembered. The engine "turned over" but did not restart. He then prepared for a forced landing into a nearby field. During the base to final turn, he lost control of the airplane and descended to the ground. The airplane impacted the field and continued into a propane tank and then a house where it came to rest. The student pilot reported having accumulated 12 total flight hours, all of which were logged in the preceding 30 days, and in the same make and model airplane. The airplane was a two seat, low wing, tricycle landing gear, training airplane which was manufactured in 2005. It was powered by a 125-horsepower Continental Motors Inc. IO-240 engine, which drove a Sensenich two-bladed, fixed pitched, wooden propeller. On January 22, 2015, the airplane was examined after the accident by a Federal Aviation Administration (FAA) Inspector and a representative from Continental Motors Inc. The examination revealed that the majority of the induction air filter was covered with ice. The alternate air lever in the airplane was OFF. The engine cylinders each displayed normal operating signatures. The spark plugs displayed normal wear signatures when compared to a Champion Aviation Service Manual No. AV6-R. Internal crankshaft continuity was established by rotating the propeller. Additionally, all four cylinders displayed thumb suction and compression. The top spark plugs and ignition leads were reinstalled for an engine operational test run. The air filter remained impacted with ice during the first engine run; the engine was capable of running with the throttle full forward and produced about 2,200 RPM which is normal for a fixed pitch propeller. The alternate air lever was moved to ON and the engine was still capable of producing about 2,200 RPM. The engine was then shut down and the ice removed from the air filter. The engine was subjected to a second test run; the engine produced 2,200 RPM with the throttle advanced to full forward. The ignition switch wasactuated to test both magnetos and the decreases in RPM were normal and the engine indications displayed normal operating parameters. Other than the ice in the air induction filter there were no anomalies noted that would have precluded normal operation. The airplane sustained substantial damage to the fuselage and empennage. During the postaccident investigation, the pilot was asked about the airplane's alternate air lever. He reported that he was unfamiliar with the lever and did not know its intended use. He also stated that he flew through some low clouds during the flight, but they did not obstruct his view of the ground and he was able to maintain visual flight rules (VFR) the entire time. At 1653 the weather observation station at GSH, which was located 13 miles southwest, reported the following conditions: wind from 200 degrees at 3 knots, visibility 10 miles, few clouds at 12,000 feet, temperature 36° Fahrenheit (F), dew point 30° F, altimeter setting 29.94 inches of mercury. Using the average temperature lapse rate, 3.5° F per 1,000 feet, the temperature at 1,600 feet would have been about 30° F. The Diamond Aircraft Airplane Flight Manual (AFM) stated in Chapter 7.9.2 Engine Controls: The alternate air control selects a second induction air intake in case of restriction of the primary air intake (air filter). AFM Chapter 3.3.1 (c) Engine Failure during Flight – ENGINE RUNNING ROUGHLY – the pilot should perform the following checklist: 1. Mixture – FULL RICH 2. Alternate Air – OPEN 3. Fuel Shut-off – OPEN 4. Fuel Pump – ON 5. Ignition Switch – cycle L – BOTH – R – BOTH 6. Throttle – at present position 7. No Improvement – reduce throttle to minimum required power, land as soon as possible. FAA Advisory Circular 20-113. The Advisory Circular states that one form of induction system icing is impact ice and states in part: "Impact ice is formed by moisture-laden air at temperatures below freezing, striking and freezing on elements of the induction system which are at temperatures of 32° F or below. Under these conditions, ice may build up on such components as the air scoops, heat or alternate air valves, intake screens, and protrusions in the carburetor. Pilots should be particularly alert for such icing when flying in snow, sleet, rain, or clouds, especially when they see ice forming on the windshield or leading edge of the wings. The ambient temperature at which impact ice can be expected to build most rapidly is about 25° F, when the super cooled moisture in the air is still in a semi liquid state. This type of icing affects an engine with fuel injection, as well as carbureted engines. It is usually preferable to use carburetor heat or alternate air as an ice prevention means..."

Aircraft

Registration
N979DC
Reported as
Diamond Aircraft Ind DA 20 C1
Category
Airplane
Serial number
C0314
Built
2005
Airframe hours
3,195
Engine
Continental Motors IO-240, 125 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
New Horizons Aviation Inc
Registered owner
New Horizons Aviation Inc
Airworthiness certificate
Standard, Utility
Departed
GSH · Goshen, IN
Destination
GSH · Goshen, IN
Airport
GSH · Goshen Muni

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
Student pilot
Age
18
Injuries
None
Certificate
Student
Medical
Class 2, Without waivers/limitations
Seat
Left
Restraint
4-point
Flight hours
12 total · 12 in this make and model · 2 as pilot in command · 12 in the last 90 days · 12 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
Temperature
36 °F, dew point 30 °F
Altimeter
29.94 inHg
Observed at
KGSH, 13 nm away

Docket · 12

The files NTSB released with the investigation on February 19, 2015, on NTSB’s docket system: statements, records, photos and specialists’ reports. 30.4 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.