CEN20LA258

NTSB accident investigation · Piper PA28 · Bridgeport, TX · July 2, 2020

Accident · No injuriesClass 3 · LimitedFinal report
Date
July 1, 2020, 19:32 local (Jul 2, 2020, 00:32 UTC)
Place
Bridgeport, TX
Injuries
3 uninjured
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N6530WPiper PA28
Defining event
Initial climb: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
FAA Flight Standards
FAA report
20200702018209A
Case key
101524

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

Maintenance personnel’s inadequate inspection, which resulted in a total loss of engine power due to a restricted air intake-induction system.

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.

Power plant: air intakeAircraft › Aircraft power plant · Damaged/degradedPiper PA-28-140: 3 casesAll aircraft: 50 casesProbable cause
Power plant: air intakeAircraft › Aircraft power plant · Inadequate inspectionPiper PA-28-140: 3 casesAll aircraft: 50 casesProbable cause
Inspection: scheduled/routine inspectionPersonnel issues › Task performance · Maintenance personnelPiper PA-28-140: 5 casesAll aircraft: 167 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 pilot reported the engine seemed to lose power shortly after takeoff. His attempts to restore engine power were not successful, and he executed a forced landing. A postaccident engine examination revealed evidence of an insect (mud dauber) nest within the carburetor heat induction system. The pilot purchased the airplane 2 days before the accident. Airplane maintenance records indicated that an annual inspection was completed on the day the airplane was sold to the accident pilot. The records also indicated the airplane had not been flown between the annual inspection in 2017 and the most recent inspection 2 days before the accident. Furthermore, the markings on the oil filter suggested that the oil was not changed during the most recent annual inspection. The airplane was operated 1.16 hours since that most recent inspection. The insect nest in the carburetor heat system likely became dislodged during airplane operation and subsequently restricted air flow to the carburetor resulting in a loss of engine power. The location of the insect nest was not in an area visible to the pilot during a preflight inspection. However, the presence of the nest could have been detected during a thorough and complete annual maintenance inspection. In addition, the failure of the mechanic to change the engine oil and filter during the most recent annual inspection suggested that the inspection was less than thorough and complete. Although there was a slight possibility of carburetor icing at glide and cruise power, it is unlikely to have been the cause of the power loss since the loss of engine power occurred shortly after takeoff.

Factual narrative

On July 1, 2020, about 1932 central daylight time, a Piper PA-28-140 airplane, N6530W, was involved in an accident near Bridgeport, Texas. The pilot and two passengers were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported the before takeoff engine run-up was normal. After takeoff, about 150 ft. above ground level, the engine seemed to lose power without any associated vibration, abnormal noise, or indications. The pilot’s attempts to determine the cause of the problem and restore engine power were not successful. He executed a forced landing “to a field of medium-maturity mesquite trees.” A post-recovery engine examination revealed evidence consistent with an insect (mud dauber) nest within the carburetor heat induction system. Specifically, the inside surface of the carburetor heat shroud exhibited residue consistent with dirt/mud accretion. The engine exhaust tube common to the carburetor heat shroud exhibited a discoloration consistent with debris accretion. The discolored area on the exhaust tube coincided with the residue observed on the inside of the carburetor heat shroud. A fragment of compacted dirt was recovered from inside the carburetor heat duct, and the outboard end of the muffler exhibited a similar dirt/mud residue. No other anomalies were observed with respect to the engine installation. According to the airplane maintenance records, an annual inspection was completed on September 14, 2017, at a recording tachometer of 2,701.58 hours. The next annual inspection based on the maintenance records was completed on June 29, 2020. The tachometer time corresponding to that inspection was 2,701.68 hours. The pilot reported that he purchased the airplane the same day as the most recent annual inspection. The accident occurred 2 days later, on July 1. The tachometer indicated 2,702.84 hours at the time of the postaccident examination. The oil filter installed on the engine at the time of the postaccident examination was dated September 15, 2017. The tachometer time noted on the filter was 2,701.58 hours. The most recent inspection logbook entry did not include any reference to changing the engine oil and filter. However, the logbook entry corresponding to the prior inspection in 2017, which was conducted by the same mechanic, specifically noted that the engine oil and filter were replaced, and the old filter was opened and inspected for debris. According to a graph in FAA Special Airworthiness Information Bulletin CE-09-35, Carburetor Icing Prevention, the weather conditions at the time of the accident corresponded to a slight possibility of carburetor icing at glide or cruise power.

Aircraft

Registration
N6530W
Reported as
Piper PA28 (140)
Category
Airplane
Serial number
28-20609
Built
1964
Airframe hours
4,807
Engine
Lycoming O-320-E2A, 150 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · June 29, 2020 · 1 hours before
Departed
XBP · Bridgeport, TX
Destination
XBP · Bridgeport, TX
Airport
XBP · Bridgeport Muni, runway 18, 5,005 × 75 ft, asphalt
Equipment
Stall warning system

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
52
Injuries
None
Certificate
Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Medical
Class 1, Without waivers/limitations
Last flight review
March 10, 2019
Seat
Left
Restraint
3-point
Flight hours
6,042 total · 1.2 in this make and model · 1,360 as pilot in command · 22 in the last 90 days · 1.2 in the last 30 days · 1.2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
160° at 6 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
90 °F, dew point 75 °F
Altimeter
29.82 inHg
Observed at
XBP, 1 nm away

Docket · 6

The files NTSB released with the investigation on February 16, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 93.9 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.

Other investigations on N6530W · 1

Matched to the same aircraft by N-number and date.