# NTSB CEN20LA258: Piper PA28, N6530W, Bridgeport, TX, July 2, 2020 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: July 1, 2020, 19:32 local (Jul 2, 2020, 00:32 UTC) - Place: Bridgeport, TX - Coordinates: 33.162776, -97.824165 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=33.1628&lon=-97.8242&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: No injuries - Injuries: 3 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: FAA Flight Standards - SAIBs cited in the narratives: [SAIB CE-09-35](https://openairdocs.org/saib/CE-09-35) (OpenAirDocs) - NTSB case key (mKey): 101524 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN20LA258 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/101524/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=101524 - Page: https://openairdocs.org/ntsb/CEN20LA258 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Power plant: air intake](https://openairdocs.org/ntsb-findings/01057160): Aircraft › Aircraft power plant · Damaged/degraded (probable cause); cases with it: [Piper PA-28-140, 3 cases](https://openairdocs.org/ntsb-findings/01057160/cases.md?model=7102802), [All aircraft, 50 cases](https://openairdocs.org/ntsb-findings/01057160/cases.md) - [Power plant: air intake](https://openairdocs.org/ntsb-findings/01057160): Aircraft › Aircraft power plant · Inadequate inspection (probable cause); cases with it: [Piper PA-28-140, 3 cases](https://openairdocs.org/ntsb-findings/01057160/cases.md?model=7102802), [All aircraft, 50 cases](https://openairdocs.org/ntsb-findings/01057160/cases.md) - [Inspection: scheduled/routine inspection](https://openairdocs.org/ntsb-findings/02061520): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Piper PA-28-140, 5 cases](https://openairdocs.org/ntsb-findings/02061520/cases.md?model=7102802), [All aircraft, 167 cases](https://openairdocs.org/ntsb-findings/02061520/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Piper PA-28-140, 42 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=7102802), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Emergency descent: 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) ## 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](https://openairdocs.org/deregistered/N6530W-2021-11-20), registration cancelled 2021-11-20, S/N 28-20609, built 1964 (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: 28-20609 - Year built: 1964 - Airframe hours: 4807 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 52; injuries: none; 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 ## 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 20200702018209A](https://openairdocs.org/incident/20200702018209A), Jul 2, 2020: Piper PA-28-140, Bridgeport, TX, Substantial damage. From PIC: Wx: clear below 12,000?, winds 160/07 (earlier AWOS had gusts up to 14 but not reported prior to takeoff). Wx briefing: n/a Takeoff runway: 18 Flight… ## Other investigations on N6530W (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 OAK65F0021](https://openairdocs.org/ntsb/OAK65F0021), Feb 18, 1965: Piper PA-28 (N6530W), Palo Alto, CA, destroyed ## Docket (6 files) The files NTSB released with the investigation on February 16, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=101524. 93.9 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 9 pages, 638 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11416334&FileExtension=pdf&FileName=NTSB%20Accident%20Report_redacted-Rel.pdf - Examination summary (item 2, PDF, 2 pages, 19 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11414875&FileExtension=pdf&FileName=Examination%20Summary%20--%20CEN20LA258-Rel.pdf - Accident photos (item 3, PDF, 10 pages, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11389182&FileExtension=pdf&FileName=Accident%20Photos%20--%20CEN20LA258-Rel.pdf - Maintenance records -- airframe (item 4, PDF, 4 pages, 5.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=10117797&FileExtension=pdf&FileName=Airframe%20Log_redacted-Rel.pdf - Maintenance records -- engine (item 5, PDF, 22 pages, 85.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=10118123&FileExtension=pdf&FileName=Engine%20Log_redacted-Rel.pdf - FAA SAIB -- carburetor icing prevention (item 6, PDF, 3 pages, 107 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11416924&FileExtension=pdf&FileName=FAA%20SAIB%20--%20CE-09-35-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.