CEN16LA133

NTSB accident investigation · Mathieu Cassutt · Louisville, NE · March 28, 2016

Accident · Serious injuriesLimited investigationFinal report
Date
March 27, 2016, 19:10 local (Mar 28, 2016, 00:10 UTC)
Place
Louisville, NE
Injuries
1 serious
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N78RMMathieu Cassutt
Defining event
Enroute: Fuel related
Weather
Visual (VMC) · Day
Status
Completed · report October 6, 2016
Report
Approved by Office Director
NTSB office
Central Region
Parties
FAA FSDO
FAA report
20160327004009A
Case key
92902

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 decision to operate with partial carburetor heat while operating in conditions conducive to the formation of carburetor ice, which resulted in a loss of engine power due to carburetor icing.

Findings · 3

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.

Engine fuel and control: fuel control/carburetorAircraft › Aircraft power plant · Incorrect use/operationMathieu CASSUTT: 1 caseAll aircraft: 195 casesProbable cause
Temp/humidity/pressure: conducive to carburetor icingEnvironmental issues › Conditions/weather/phenomena · Effect on operationMathieu CASSUTT: 1 caseAll aircraft: 435 casesProbable cause
Action: incorrect action performancePersonnel issues › Action/decision · PilotMathieu CASSUTT: 1 caseAll aircraft: 1,386 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

During a local flight, the pilot noticed the engine was running rough when he added power. He attempted to troubleshoot the problem; however, the engine continued to run rough, and the pilot performed a forced landing to a field. The landing gear collapsed, and the airplane came to rest upright. A postaccident examination of the airplane and engine found no mechanical malfunctions or failures that would have precluded normal operation. The pilot reported that he routinely flew with a partially-open carburetor heat setting. Since the weather conditions around the time of the accident were conducive to the formation of carburetor ice at glide and cruise power, it is likely that the partial carburetor heat setting and the lower power setting increased the engine's susceptibility to the formation of carburetor ice, resulting in the rough-running engine. When the pilot changed the throttle setting, full power was not available due to the ice formation.

Factual narrative

On March 27, 2016, about 1910 central daylight time, an amateur-built Mathieu Cassutt airplane, N78RM, was substantially damaged during a forced landing to a field near Louisville, Nebraska. The private pilot sustained serious injuries. The personal flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and no Federal Aviation Administration (FAA) flight plan had been filed for the flight. The local flight departed Millard Airport (MLE), Omaha, Nebraska, about 1850. The pilot reported that he had been flying for about 20 minutes and decided to return to the airport. He "gave it some throttle" at which time the engine started running rough. The pilot troubleshot the engine roughness by priming the engine and adjusting the throttle position without resolve. During the forced landing to the field the main landing gear collapsed and the airplane came to rest upright. Both wings and the fuselage were substantially damaged. A farmer in the area heard the engine "cutting in and out and sputtering". The airplane was observed to circle around a field and the famer lost sight of the airplane after it descended below his view. The injured pilot was not able to exit the airplane without assistance. First responders cut into the airplane and fuselage to extricate the pilot. Fuel was observed leaking from the airplane. A post accident examination of the airplane and engine, conducted by an FAA inspector, revealed no preimpact malfunctions or failures that would have precluded normal operation. During the examination the inspector noted that the mixture control was wired in the full rich position. The carburetor heat was supplied by unfiltered air from inside the lower engine cowling. The pilot reported to the inspector that he routinely flew with the carburetor heat 1/2 way out. The closest weather reporting station was located at Plattsmouth Municipal Airport (PMV), Plattsmouth, Nebraska, 15 miles east of the accident location. The weather report taken at 1915 reported a temperature of 45 degrees Fahrenheit (F) and a dew point temperature of 23 F. The carburetor icing probability chart from the FAA special Airworthiness Information Bulletin (SAIB): CE-09-35 Carburetor Icing Prevention, illustrated a probability of icing at glide and cruise power at the temperature and dew point temperatures reported at the time of the accident. The FAA Pilot Handbook of Aeronautical Knowledge states that "partial heat or leaving heat on for an insufficient time might aggravate the situation."

Aircraft

Registration
N78RM
Reported as
Mathieu Cassutt (NO SERIES)
Category
Airplane, amateur-built
Serial number
1978
Built
1978
Airframe hours
619.44
Engine
Continental Motors A75-8F, 75 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Special, Experimental (Special)
Last inspection
Condition · October 1, 2015
Departed
MLE · Omaha, NE
Destination
MLE · Omaha, NE
Equipment
None

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
44
Injuries
Serious
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Without waivers/limitations
Last flight review
June 5, 2014
Seat
Single
Restraint
4-point
Flight hours
525.7 total · 125.6 in this make and model · 461.7 as pilot in command · 6 in the last 90 days

Weather

Conditions
Visual (VMC) · Day
Wind
310° at 4 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
45 °F, dew point 23 °F
Altimeter
30.05 inHg
Observed at
KPMV, 15 nm away

Docket · 3

The files NTSB released with the investigation on July 27, 2016, on NTSB’s docket system: statements, records, photos and specialists’ reports. 1.1 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.