# NTSB CEN20LA043: Cessna 172, N5406R, Harrison, OH, December 19, 2019

- Type: NTSB accident investigation
- Classification: Accident · No injuries · Class 3 · Limited · Final report
- Date: December 18, 2019, 19:10 local (Dec 19, 2019, 00:10 UTC)
- Place: Harrison, OH
- Coordinates: 39.259166, -84.774444 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=39.2592&lon=-84.7744&mi=10
- Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping)
- Defining event: [Approach-VFR pattern final: Fuel related](https://openairdocs.org/ntsb-events/190)
- Highest injury: No injuries
- Injuries: 2 uninjured
- Status: Completed
- Report: Approved by Office Director
- Investigation class: Class 3
- NTSB office: Central Region
- Parties: FAA Flight Standards
- NTSB case key (mKey): 100724
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN20LA043
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/100724/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=100724
- Page: https://openairdocs.org/ntsb/CEN20LA043

## Probable cause

A total loss of engine power during approach to land due to carburetor icing during a simulated engine failure, which resulted in impact with trees.

## 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: [Cessna 172F, 1 case](https://openairdocs.org/ntsb-findings/03031030/cases.md?model=2072414), [All aircraft, 435 cases](https://openairdocs.org/ntsb-findings/03031030/cases.md)
- [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna 172F, 3 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=2072414), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md)
- [Performance/control parameters: descent/approach/glide path](https://openairdocs.org/ntsb-findings/01062040): Aircraft › Aircraft oper/perf/capability · Attain/maintain not possible (probable cause); cases with it: [Cessna 172F, 5 cases](https://openairdocs.org/ntsb-findings/01062040/cases.md?model=2072414), [All aircraft, 809 cases](https://openairdocs.org/ntsb-findings/01062040/cases.md)
- [Object/animal/substance: tree(s)](https://openairdocs.org/ntsb-findings/03022020): Environmental issues › Physical environment · Contributed to outcome (probable cause); cases with it: [Cessna 172F, 3 cases](https://openairdocs.org/ntsb-findings/03022020/cases.md?model=2072414), [All aircraft, 933 cases](https://openairdocs.org/ntsb-findings/03022020/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Approach-IFR missed approach: Simulated/training event](https://openairdocs.org/ntsb-events/600); cases with it: [Cessna 172F, 1 case](https://openairdocs.org/ntsb-events/600/sequence.md?model=2072414), [All aircraft, 173 cases](https://openairdocs.org/ntsb-events/600/sequence.md)
- [Approach-VFR pattern final: Fuel related](https://openairdocs.org/ntsb-events/190) (defining event); cases with it: [Cessna 172F, 1 case](https://openairdocs.org/ntsb-events/190/sequence.md?model=2072414), [All aircraft, 361 cases](https://openairdocs.org/ntsb-events/190/sequence.md)
- [Emergency descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cessna 172F, 22 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2072414), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md)
- [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Cessna 172F, 9 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=2072414), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md)

## Analysis

The flight instructor and pilot were conducting simulated instrument training when, following a missed approach, the flight instructor simulated an engine failure. The pilot responded by entering a power-off approach to the nearest runway and applied the carburetor heat as part of his loss-of-engine-power procedure. About 200 ft above ground level, the flight instructor advanced the throttle to clear the engine; however, the engine lost all power. The flight instructor took control of the airplane but was unable to avoid impacting trees during the approach. The airplane touched down momentarily on a road before becoming airborne again and landing on the runway. After inspecting the airplane and observing no damage to the landing gear or propeller, the flight instructor started the engine and taxied to the hangar. The engine started without difficulty and seemed to run normally during the taxi. The left wing sustained substantial damage during the impact with trees and the fence. A postaccident engine examination did not reveal any anomalies consistent with an inability to produce rated power. FAA guidance regarding carburetor icing indicated the possibility of icing at glide power given the atmospheric conditions at the time of the accident. The airplane owner's manual did not include a specific emergency checklist for a loss of engine power. The before landing checklist noted that the carburetor heat should be applied before reducing power. Although there was only a slight possibility of carburetor icing, the delay from the time the flight instructor reduced engine power to idle to the time that the pilot applied the carburetor heat likely allowed some level of carburetor icing to accumulate, which resulted in a loss of engine power when power was applied during the approach.

## Factual narrative

On December 18, 2019, about 1910 eastern standard time, a Cessna 172 airplane, N5406R, impacted trees and a fence during a forced landing following a loss of engine power at the Cincinnati West Airport (I67), Harrison, Ohio. The pilot and flight instructor were not injured. The airplane sustained substantial damage. The airplane was registered to and operated by the flight instructor as a Title 14 Code of Federal Regulations Part 91 instructional flight. Night visual meteorological conditions prevailed, and the flight was not operated on a flight plan. The local flight originated from I67 about 1730. The flight instructor and pilot were conducting instrument training at the time of the accident. The pilot had initiated a missed approach following a practice instrument approach to runway 19 at I67. During the climb out, the flight instructor simulated an engine failure. The pilot responded by entering a power-off approach to runway 1 and applied the carburetor heat as part of his loss of engine power procedure. About 200 ft above ground level, the flight instructor advanced the throttle in order to clear the engine; however, the engine stopped producing power. The flight instructor took control of the airplane from the pilot at that time. The airplane struck trees during the approach before landing on the runway. After inspecting the airplane on the runway and observing no damage to the landing gear or propeller, the flight instructor started the engine and taxied to the hangar. The engine started without difficulty and appeared to run normally during the taxi. An examination of the runway environment by Federal Aviation Administration (FAA) inspectors indicated that the airplane struck trees and a 3-ft high wire fence about 400 ft short of the runway. Skid marks on a two-lane road running immediately adjacent to the fence were consistent with the airplane touching down momentarily before becoming airborne again. Additional skid marks on the paved stopway/overrun preceding the runway 1 displaced threshold were consistent with the airplane contacting the pavement at this point. A postaccident engine examination conducted by the FAA inspectors did not reveal any anomalies consistent with an inability to produce rated power. Engine control continuity was confirmed. The airplane sustained substantial damage to the outboard portion of the left wing. The temperature and dew point recorded by the I67 Automated Weather Observing System (AWOS) at 1915, were -5° Celsius and -10° Celsius, respectively. Information published by the FAA regarding carburetor icing indicated the possibility of icing at glide power existed under those conditions. Although, the temperature/dew point combination was on the cusp of the region for icing at glide power on the probability chart. A review of an owner's manual applicable to the airplane revealed that there was not a specific emergency checklist for a loss of engine power. The descent (let-down) checklist noted,"Carburetor Heat – As required to prevent carburetor icing." The before landing checklist noted, "Carburetor Heat – Apply before closing throttle."

## Aircraft

- Registration: [N5406R](https://openairdocs.org/aircraft/N5406R), registered now, S/N 17252945, built 1965 (OpenAirDocs)
- Reported make and model: Cessna 172 (F)
- Registry model: [Cessna 172F](https://openairdocs.org/model/cessna-172f) (registry code 2072414) (OpenAirDocs)
- Registry engine: [Continental 0-300 series](https://openairdocs.org/engine/continental-0-300-series) (registry code 17022, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: 17252945
- Year built: 1965
- Airframe hours: 3186.8
- Engines: Continental O-300-D 145 horsepower reciprocating
- Damage: Substantial damage
- Flight: Instructional, Part 91
- Airworthiness certificate: Standard, Normal
- Last inspection: Annual, September 25, 2019, 35 hours before
- Departed: I67, Harrison, OH
- Destination: I67, Harrison, OH
- Airport: I67, Cincinnati West, runway 01, 2,808 × 60 ft, asphalt
- Equipment: Stall warning system, ADS-B

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Flight instructor; age 47; injuries: none; airline transport, flight instructor; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review March 7, 2019; seat: right; restraint: 4-point; flight hours: 14,898 total, 786 in this make and model, 6,019 as pilot in command, 47 in the last 90 days, 7 in the last 30 days, 2 in the last 24 hours
- Pilot; age 19; injuries: none; private; airplane ratings: single-engine land; medical: class 1, without waivers/limitations; last flight review June 3, 2019; seat: left; restraint: 4-point; flight hours: 147 total, 126 in this make and model, 50 as pilot in command, 25 in the last 90 days, 5 in the last 30 days, 2 in the last 24 hours

## Weather

- Conditions: Visual (VMC), Night
- Wind: calm
- Visibility: 10 statute miles
- Lowest ceiling: none
- Temperature: 23 °F, dew point 14 °F
- Altimeter: 30.37 inHg
- Observed at: I67, 1 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 20191219020059A](https://openairdocs.org/incident/20191219020059A), Dec 19, 2019: Cessna 172F, Harrison, OH, Substantial damage. On December 18, 2019, at approximately 19:15 p.m. eastern daylight time (0015 zulu), Cessna 172F, N5406R collided with trees at the approach end of runway 01…

## Docket (8 files)

The files NTSB released with the investigation on February 28, 2020, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=100724. 6.4 MB in all.

- Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40480881&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF
- Flight Instructor Statement (item 2, .PDF, 56 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40480882&FileExtension=.PDF&FileName=Flight%20Instructor%20Statement-Master.PDF
- Pilot Statement (item 3, .PDF, 183 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40480883&FileExtension=.PDF&FileName=Pilot%20Statement-Master.PDF
- E-mail Correspondence -- Flight Instructor (item 4, .PDF, 103 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40480884&FileExtension=.PDF&FileName=E-mail%20Correspondence%20--%20Flight%20Instructor-Master.PDF
- Accident Site Diagram (item 5, .PDF, 527 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40480885&FileExtension=.PDF&FileName=Accident%20Site%20Diagram-Master.PDF
- FAA Inspector Statement (item 6, .PDF, 55 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40480886&FileExtension=.PDF&FileName=FAA%20Inspector%20Statement-Master.PDF
- FAA Information Bulletin -- Carburetor Icing (item 7, .PDF, 111 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40480887&FileExtension=.PDF&FileName=FAA%20Information%20Bulletin%20--%20Carburetor%20Icing-Master.PDF
- 1965 Cessna 172 Owner's Manual (item 8, .PDF, 3.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40480888&FileExtension=.PDF&FileName=1965%20Cessna%20172%20Owner%27s%20Manual-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.

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