# NTSB CEN19LA299: Piper PA28, N55633, Conroe, TX, August 31, 2019 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Class 3 · Limited · Final report - Date: August 31, 2019, 07:58 local (12:58 UTC) - Place: Conroe, TX - Coordinates: 30.403888, -95.437225 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=30.4039&lon=-95.4372&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) - Highest injury: Minor injuries - Injuries: 2 minor - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: FAA Houston FSDO, Piper Aircraft - SAIBs cited in the narratives: [SAIB CE-09-35](https://openairdocs.org/saib/CE-09-35) (OpenAirDocs) - NTSB case key (mKey): 100185 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN19LA299 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/100185/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=100185 - Page: https://openairdocs.org/ntsb/CEN19LA299 ## Probable cause A partial loss of engine power for reasons that could not be determined based on the available evidence. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Power plant](https://openairdocs.org/ntsb-findings/01057100): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [Piper PA-28-140, 1 case](https://openairdocs.org/ntsb-findings/01057100/cases.md?model=7102802), [All aircraft, 198 cases](https://openairdocs.org/ntsb-findings/01057100/cases.md) - [Not determined](https://openairdocs.org/ntsb-findings/05000000): Not determined › Not determined · Unknown/Not determined (probable cause); cases with it: [Piper PA-28-140, 27 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md?model=7102802), [All aircraft, 2,247 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach: Unknown or undetermined](https://openairdocs.org/ntsb-events/000); cases with it: [Piper PA-28-140, 10 cases](https://openairdocs.org/ntsb-events/000/sequence.md?model=7102802), [All aircraft, 1,703 cases](https://openairdocs.org/ntsb-events/000/sequence.md) - [Approach: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) (defining event); cases with it: [Piper PA-28-140, 47 cases](https://openairdocs.org/ntsb-events/342/sequence.md?model=7102802), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) - [Approach: Attempted remediation/recovery](https://openairdocs.org/ntsb-events/060); cases with it: [Piper PA-28-140, 19 cases](https://openairdocs.org/ntsb-events/060/sequence.md?model=7102802), [All aircraft, 1,422 cases](https://openairdocs.org/ntsb-events/060/sequence.md) - [Approach: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Piper PA-28-140, 56 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=7102802), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Approach: Collision during takeoff/land](https://openairdocs.org/ntsb-events/490); cases with it: [Piper PA-28-140, 29 cases](https://openairdocs.org/ntsb-events/490/sequence.md?model=7102802), [All aircraft, 1,309 cases](https://openairdocs.org/ntsb-events/490/sequence.md) ## Analysis The pilot reported that he departed with 36 gallons of fuel on board. He completed a 25-minute flight to pick up the passenger before departing on the accident flight. About 1 hour into the flight, as the airplane approached the destination airport, the pilot performed the before landing checklist and the engine lost partial power after the pilot turned on the carburetor heat. He immediately turned the carburetor heat off then back on. The pilot continued to troubleshoot the partial loss of engine power as he maneuvered the airplane for a forced landing, and the airplane came to rest inverted in a pond. The left wing sustained substantial damage from the water impact. Postaccident photographs showed a visible fuel sheen on the water near the submerged inverted airplane. Examination revealed that the left wing fuel tank contained no fuel. About 3 gallons of a clear liquid, which contained about 1 pint of fuel, was drained from the right wing fuel tank. The amount of fuel onboard at the time of the accident could not be determined. A postaccident examination of the engine revealed no mechanical failures or malfunctions that would have precluded normal operation. Atmospheric conditions at the time of the accident were conducive to the accumulation of serous carburetor icing at glide power settings. However, the pilot reported the partial loss of engine power occurred when he activated the carburetor heat. Based on the available evidence, the partial loss of engine power could not be determined. ## Factual narrative On August 31, 2019, about 0758 central daylight time, a Piper PA-28-140 airplane, N55633, sustained substantial damage when it was involved in an accident near Conroe, Texas. The private pilot and passenger sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that he departed with the airplane fueled “to the tabs” (36 gallons total) on the 25-minute flight to pick up the passenger. They subsequently departed on the accident flight about 0700. The pilot planned to use the right fuel tank until the descent into the destination airport. About 15 nautical miles north of the destination, the pilot turned on the electric fuel pump and switched to the left fuel tank. As the airplane approached traffic pattern altitude and with the airport in sight, the pilot performed the before landing checklist, which included adjusting the mixture to full rich and turning on the carburetor heat. The pilot reported that, as soon as he turned the carburetor heat on, the engine went to idle. He immediately turned the carburetor heat off. He surmised that having the carburetor heat off would not fix the problem and subsequently turned the carburetor heat back on. The pilot continued to troubleshoot as he maneuvered the airplane for a forced landing to a nearby road; however, realizing that he would not be able to land on the road, he chose to land in a pond. The airplane came to rest inverted in the water. The left wing sustained substantial damage from the water impact. The airplane began to fill with water and the pilot turned the safety latch at the center top of the cockpit door, which was under his feet, and reported "it didn't feel right." He then pulled the locking latch located on the rearward side of the door, but it would not move. Since he could not open the door to egress, he then punctured and pushed out the acrylic door window. The pilot and passenger waded to shore without further incident. Postaccident photographs showed a visible fuel sheen on the water near the submerged inverted airplane. The airplane was recovered from the pond after being submerged for several hours and moved to a secure location. The left wing fuel tank contained no fuel. The right wing fuel tank was drained through the gascolator; about 3 gallons of a clear liquid was collected, which contained about 1 pint of fuel. The amount of fuel onboard at the time of the accident could not be determined. The carburetor heat control cable was found connected to the carburetor heat box. The carburetor heat valve reacted properly to the position selected on the handle at the control panel; however, the valve did not travel to the full close position when heat was selected. A postaccident examination of the engine revealed no mechanical failures or malfunctions that would have precluded normal operation. The weather conditions reported about the time of the accident included an outside air temperature of 73°Fand a dew point of 72°F. Federal Aviation Administration Special Airworthiness Information Bulletin No. CE-09-35, Carburetor Icing Prevention, indicated that the airplane was operating in an area that was associated with a risk of serious carburetor ice accumulation at glide power settings. During the postaccident examination, both interior door handles worked properly. The top exterior door handle was broken off and was missing. The bottom exterior door handle worked properly. No door operation instruction placards were located on the interior or exterior of the airplane. The NTSB has previously identified egress difficulties with the Piper PA-28 series, particularly with an accident involving a fire or water egress. NTSB Safety Recommendation Letter A-81-26 through -28, based upon several Piper PA-28 accidents, states in part: The cabin door on the Cherokee, like several other single-engine aircraft designed for five or less persons, is the only available exit. Therefore, when the cabin door becomes jammed, blocked, or otherwise unusable during an accident, there are no alternate means of egress. Furthermore, the Cherokee door is designed with two separate latches: a locking latch located on the rearward side of the door, and a safety latch at the center top of the door which should be latched prior to the flight to provide a proper seal around the door. The prompt location and operation of the top safety latch can be difficult for occupants and rescuers alike. ## Aircraft - Registration: [N55633](https://openairdocs.org/deregistered/N55633-2021-07-31), registration cancelled 2021-07-31, S/N 28-7325447, built 1973 (OpenAirDocs) - Reported make and model: Piper PA28 (140) - Registry model: [Piper PA-28-140](https://openairdocs.org/model/piper-pa-28-140) (registry code 7102802) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-7325447 - Year built: 1973 - Airframe hours: 4486.32 - Engines: Lycoming Engines O-320-E3D 150 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, August 1, 2019 - Departed: PSN, Palestine, TX - Destination: CXO, Houston, TX - Airport: CXO, Conroe-North Houston Rgnl, runway 14, 7,501 × 150 ft, water - Equipment: Handheld GPS ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 47; injuries: minor; private; airplane ratings: single-engine land; medical: basicmed, without waivers/limitations; last flight review November 11, 2018; seat: left; flight hours: 72.5 total, 8.1 in this make and model, 4.6 in the last 90 days ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: 2,200 ft broken - Temperature: 73 °F, dew point 72 °F - Altimeter: 30.04 inHg - Observed at: KCXO, 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 20190831014699A](https://openairdocs.org/incident/20190831014699A), Aug 31, 2019: Piper PA-28-140, Conroe, TX, Substantial damage. On August 31, 2019, at 0851 central daylight time (CDT) the reporting inspector received a call from the FAA southwest region operations center indicating that… ## Docket (8 files) The files NTSB released with the investigation on February 15, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=100185. 10.0 MB in all. - Pilot statement (item 1, PDF, 2 pages, 58 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11207031&FileExtension=pdf&FileName=Pilot%20Statement%20Redacted-Rel.pdf - Accident photographs (item 2, PDF, 3 pages, 362 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11268389&FileExtension=pdf&FileName=Accident%20Photographs-Rel.pdf - Federal aviation administration airframe and engine examination report (item 3, PDF, 8 pages, 6.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11207041&FileExtension=pdf&FileName=FAA%20Airframe%20and%20Engine%20Examination%20Report%20Redacted-Rel.pdf - Additional documents (item 4, PDF, 2 pages, 251 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11207051&FileExtension=pdf&FileName=Additional%20Documents%20Redacted-Rel.pdf - Carburetor icing probability graph (item 5, PDF, 1 page, 336 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11207224&FileExtension=pdf&FileName=Carbuertor%20Icing%20Probability%20Graph-Rel.pdf - Piper communication (item 6, PDF, 5 pages, 2.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11431205&FileExtension=pdf&FileName=Piper%20Communication%20Redacted-Rel.pdf - National transportation safety board safety recommendation Piper PA-28 series door (item 7, PDF, 3 pages, 306 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11214630&FileExtension=pdf&FileName=NTSB%20Safety%20Recommendations%20Piper%20PA-28%20Series%20Door%20Redacted-Rel.pdf - NTSB party member form (item 8, PDF, 1 page, 57 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11207061&FileExtension=pdf&FileName=NTSB%20Party%20Member%20Form%20Redacted-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.