# NTSB CEN19FA191: Piper J3C, N98527, Elyria, OH, June 30, 2019 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: June 30, 2019, 14:45 local (18:45 UTC) - Place: Elyria, OH - Coordinates: 41.329723, -82.105834 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=41.3297&lon=-82.1058&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Fuel starvation](https://openairdocs.org/ntsb-events/191) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: Continental Aerospace Technologies, FAA - SAIBs cited in the narratives: [SAIB CE-09-35](https://openairdocs.org/saib/CE-09-35) (OpenAirDocs) - NTSB case key (mKey): 99733 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN19FA191 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99733/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99733 - Page: https://openairdocs.org/ntsb/CEN19FA191 ## Probable cause A loss of engine power due to carburetor icing, and the pilot’s subsequent exceedance of the airplane’s critical angle of attack, which resulted in an aerodynamic stall and impact with terrain. ## 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 · Contributed to outcome (probable cause); cases with it: [Piper J3C-65, 8 cases](https://openairdocs.org/ntsb-findings/03031030/cases.md?model=7100510), [All aircraft, 435 cases](https://openairdocs.org/ntsb-findings/03031030/cases.md) - [Engine fuel and control: fuel control/carburetor](https://openairdocs.org/ntsb-findings/01057322): Aircraft › Aircraft power plant · Not specified; cases with it: [Piper J3C-65, 2 cases](https://openairdocs.org/ntsb-findings/01057322/cases.md?model=7100510), [All aircraft, 195 cases](https://openairdocs.org/ntsb-findings/01057322/cases.md) - [Performance/control parameters: airspeed](https://openairdocs.org/ntsb-findings/01062010): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Piper J3C-65, 8 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=7100510), [All aircraft, 1,681 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md) - [Performance/control parameters: lateral/bank control](https://openairdocs.org/ntsb-findings/01062023): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Piper J3C-65, 4 cases](https://openairdocs.org/ntsb-findings/01062023/cases.md?model=7100510), [All aircraft, 390 cases](https://openairdocs.org/ntsb-findings/01062023/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper J3C-65, 43 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7100510), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff: Fuel starvation](https://openairdocs.org/ntsb-events/191) (defining event); cases with it: [Piper J3C-65, 4 cases](https://openairdocs.org/ntsb-events/191/sequence.md?model=7100510), [All aircraft, 733 cases](https://openairdocs.org/ntsb-events/191/sequence.md) - [Takeoff: Loss of control in flight](https://openairdocs.org/ntsb-events/240); cases with it: [Piper J3C-65, 21 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=7100510), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) ## Analysis Witnesses reported that the airplane performed a touch-and-go landing. Upon reaching an altitude of 75 to 100 ft above the ground, the engine power “seemed to drop off” and the airplane entered a descending left turn. The airplane then made a right turn and descended vertically into an open field. The weather conditions at the time of the accident were conducive to the development of serious carburetor icing at glide power. Impact damage prevented determination of the carburetor heat controls position at the time of the accident. No anomalies were noted with the airframe or engine that would have precluded normal operation. Toxicology testing of the pilot detected the non-impairing high blood pressure medication hydrochlorothiazide. Flecainide, used to treat irregular heartbeat, was detected in heart blood and urine; while it is unknown when the pilot received the diagnosis or treatment of arrhythmia, given the circumstances of the accident, it is unlikely that sudden incapacitation from arrythmia was a factor in this accident. Laudanosine, which is a metabolite of drugs used for general anesthesia, was detected in the pilot’s urine; while it is also unknown what procedure the pilot had that required anesthesia, the laudanosine in urine would not be impairing. The opioid pain medication codeine was detected in the pilot’s blood (8.5 and 10 ng/mL) and codeine and its metabolites, morphine and hydrocodone, were detected in the pilot’s urine. It is unknown why the pilot was using this mild pain medication. While these drugs are generally impairing, the level of codeine in the blood was one-tenth of the lowest therapeutic level and would not be impairing. Given the circumstances of this accident, it is unlikely that the pilot’s medical conditions or the effects from the pilot’s use of codeine and other detected medications were factors in this accident. The accident is consistent with the pilot’s exceedance of the airplane’s critical angle of attack following a loss of engine power due to carburetor icing, which resulted in an aerodynamic stall and impact with terrain. ## Factual narrative Federal Aviation Administration Special Airworthiness Information Bulletin (SAIB) CE-09-35, “Carburetor Icing Prevention:” Pilots should be aware that carburetor icing doesn’t just occur in freezing conditions, it can occur at temperatures well above freezing temperatures when there is visible moisture or high humidity. Icing can occur in the carburetor at temperatures above freezing because vaporization of fuel, combined with the expansion of air as it flows through the carburetor, (Venturi Effect) causes sudden cooling, sometimes by a significant amount within a fraction of a second. Carburetor ice can be detected by a drop in rpm in fixed pitch propeller airplanes and a drop in manifold pressure in constant speed propeller airplanes. In both types, usually there will be a roughness in engine operation. To prevent carburetor icing, the pilot should: • Assure the proper functionality of the carburetor heat during the ground (Before Takeoff) check. • Use carburetor heat on approach and descent when operating at low power settings, or in conditions where carburetor icing is probable. According to the icing probability chart included in SAIB CE-09-35, the weather conditions at the time of the accident placed the airplane in the region of susceptibility to serious carburetor icing at glide power. On June 30, 2019 at 1445 EDT, a Piper J-3C-65 airplane, N98527, was substantially damaged when it was involved in an accident near Elyria, Ohio. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to witnesses, the airplane had just performed a touch-and-go landing to runway 27. As the airplane climbed to an altitude about 75-100 ft above the ground, it rolled left and right and the engine rpm “seemed to drop off.” The airplane entered a left descending turn, then turned right before descending vertically into an open field. The Office of the Lorain County Coroner, Oberlin, Ohio performed an autopsy on the pilot. The pilot’s cause of death was multiple blunt force injuries and manner of death was accident. The coroner’s findings included an enlarged heart (510 grams), mild coronary artery atherosclerosis, sclerotic arteries in the kidneys, and an enlarged fatty liver. No other significant natural disease was identified. The FAA's Forensic Sciences Laboratory performed toxicology testing on the pilot’s tissue samples, which identified codeine in the pilot’s subclavian blood at 10 ng/mL and his urine at 1,035 ng/mL; morphine (204 ng/mL) and hydrocodone were detected in urine. Laudanosine, which is a metabolite of drugs used for general anesthesia, was detected in the pilot’s urine and the irregular heartbeat medication flecainide was detected in his heart blood and urine. The FAA laboratory also detected the non-sedating high blood pressure medication hydrochlorothiazide in the pilots’ heart blood and urine. Codeine is prescribed to relieve mild to moderate pain or to suppresscoughing. It is often prescribed in combination with acetaminophen (commonly marketed as Tylenol with Codeine). Codeine is a narcotic medication and use carries a high risk of addiction, abuse, and misuse. It is an impairing medication and carries the warning that patients should not drive or operate dangerous machinery until they know how they will react to the medication. The plasma half-life of codeine is about three hours and its therapeutic range is 100 to 230 ng/mL. Codeine in metabolized mainly in the liver to morphine and norcodeine. Hydrocodone is a minor metabolite of codeine; as much as 11% of the codeine concentration may be excreted in the urine as hydrocodone. About 10% of codeine is excreted unchanged in the urine. First responders verified they did not administer any medications to the pilot and that the pilot was pronounced dead at the scene. The pilot’s logbooks were not located, and his flight experience could not be determined. The airplane impacted a flat, open field about 330 ft south of the departure end of runway 27. The wreckage was oriented on a westerly heading in a nose-down attitude and was confined to the point of impact. The engine and firewall were pushed aft into the cockpit area. Both wings exhibited impact damage. The fuselage exhibited buckling and twisting to the right. Flight control continuity was verified from cockpit to each control surface. No fuel was found in the fuel tank. The odor of aviation fuel was present at the scene. The fuel system was compromised where the gascolator was impact-damaged and at the carburetor. The engine was partially imbedded in the ground. One of the wooden propeller blades was oriented vertically and displayed no impact damage. The second propeller blade was folded aft under the wreckage. The propeller spinner was partially crushed and showed no indications of rotational scratches or crushing. The four top spark plugs were removed, and engine continuity was verified by rotating the propeller and observing piston movement in each cylinder. Black, sooty deposits were present on the four removed spark plugs consistent with carbon fouling. Compression was verified in each cylinder while rotating the propeller. The left and right magnetos were removed, and spark was verified at each ignition lead by rotating each magneto manually. The carburetor was impact damaged and its operability and the presence of fuel could not be verified. The mixture control lever on the carburetor was found safety-wired to the RICH position. The carburetor heat control located on the forward right side of the cockpit was extended less than 1 inch out from the OFF position. The carburetor heat control lever mounted on the engine airbox was found aft of center toward the “ON” position. The airbox, airbox-mounted control lever, control rod mounting bracket, and control rod each exhibited impact damage. No anomalies were noted with the airframe or engine that would have precluded normal operation. ## Aircraft - Registration: [N98527](https://openairdocs.org/deregistered/N98527-2022-06-04), registration cancelled 2022-06-04, S/N 18735, built 1946 (OpenAirDocs) - Reported make and model: Piper J3C (65) - Registry model: [Piper J3C-65](https://openairdocs.org/model/piper-j3c-65) (registry code 7100510) (OpenAirDocs) - Registry engine: [Continental C85 series](https://openairdocs.org/engine/continental-c85-series) (registry code 17008, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 18735 - Year built: 1946 - Engines: Continental A75-8 75 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Special, Restricted (Special) - Airport: 1G1, Elyria, runway 27, 3,053 × 48 ft, asphalt - Equipment: ADS-B, Electronic flight bag or handheld device ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 63; injuries: fatal; sport pilot; airplane ratings: single-engine land; seat: rear; restraint: lap only; toxicology performed ## Weather - Conditions: Visual (VMC), Day - Wind: 30° at 11 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 79 °F, dew point 54 °F - Altimeter: 30.04 inHg - Observed at: LPR, 3 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 20190630008729A](https://openairdocs.org/incident/20190630008729A), Jun 30, 2019: Piper J3C-65, Elyria, OH, Destroyed, 1 fatal. On June 30th 2019 a Piper J3C-65 tail number N98527 impacted terrain shortly after departing Elyria municipal airport. There was one fatality the pilot… ## Other investigations on N98527 (1) 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. - [NTSB UNK64X2290](https://openairdocs.org/ntsb/UNK64X2290), Jun 14, 1964: Piper J3C (N98527), Hebron, IL, substantial damage ## Docket (9 files) The files NTSB released with the investigation on June 2, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99733. 7.4 MB in all. - GPS device - specialist's factual report (item 1, PDF, 6 pages, 932 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8546786&FileExtension=pdf&FileName=cen19fa191%20stratus%20report-Rel.pdf - Ipad email report (item 2, PDF, 2 pages, 108 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11804529&FileExtension=pdf&FileName=iPad%20Email%20Report_Redacted-Rel.pdf - Memo of record - witness statements (item 3, PDF, 1 page, 141 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11803595&FileExtension=pdf&FileName=Memorandum%20of%20Record%20-%20Witness%20Statements-Rel.pdf - Fire chief email - on scene drug administration (item 4, PDF, 1 page, 39 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9145641&FileExtension=pdf&FileName=Fire%20Chief%20Email_Redacted-Rel.pdf - Statement of party representatives to NTSB investigation (item 5, PDF, 2 pages, 233 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11803879&FileExtension=pdf&FileName=Signed%20NTSB%20Party%20Letter%20-%20Continental_Redacted-Rel.pdf - Photos (item 6, PDF, 10 pages, 10 photos, 4.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11883378&FileExtension=pdf&FileName=Photo%20Array-Rel.pdf - Icing probability chart (item 7, PDF, 1 page, 370 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11887581&FileExtension=pdf&FileName=Icing%20Probability%20Chart-Rel.pdf - E-mail, final medical factual information (item 8, PDF, 5 pages, 251 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12320404&FileExtension=pdf&FileName=FINAL%20medical%20factual%20and%20analytical%20(OUO)%20for%20CEN19FA191,%20Elyria,%20OH-Rel%20(2)_Redacted-Rel.pdf - Toxicological report (item 9, PDF, 2 pages, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11886227&FileExtension=pdf&FileName=Pilot%20Tox%20-%20CEN19FA191_1_Redacted-Rel.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.