# NTSB CEN20LA329: Piper PA22, N6849B, Burlington, WI, August 9, 2020 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Class 3 · Limited · Final report - Date: August 9, 2020, 14:30 local (19:30 UTC) - Place: Burlington, WI - Coordinates: 42.680278, -88.302223 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=42.6803&lon=-88.3022&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Fuel related](https://openairdocs.org/ntsb-events/190) - Highest injury: Serious injuries - Injuries: 1 serious, 1 minor - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: FAA - NTSB case key (mKey): 101762 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN20LA329 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/101762/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=101762 - Page: https://openairdocs.org/ntsb/CEN20LA329 ## Probable cause A partial loss of engine power due to the formation of carburetor ice while on the ground, which resulted in reduced climb capability and impact with trees during the initial climb. ## 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 · Effect on operation (probable cause); cases with it: [Piper PA-22-150, 3 cases](https://openairdocs.org/ntsb-findings/03031030/cases.md?model=7102210), [All aircraft, 435 cases](https://openairdocs.org/ntsb-findings/03031030/cases.md) - [Object/animal/substance: tree(s)](https://openairdocs.org/ntsb-findings/03022020): Environmental issues › Physical environment · Effect on operation (probable cause); cases with it: [Piper PA-22-150, 4 cases](https://openairdocs.org/ntsb-findings/03022020/cases.md?model=7102210), [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. - [Initial climb: Fuel related](https://openairdocs.org/ntsb-events/190) (defining event); cases with it: [Piper PA-22-150, 3 cases](https://openairdocs.org/ntsb-events/190/sequence.md?model=7102210), [All aircraft, 361 cases](https://openairdocs.org/ntsb-events/190/sequence.md) - [Initial climb: Attempted remediation/recovery](https://openairdocs.org/ntsb-events/060); cases with it: [Piper PA-22-150, 12 cases](https://openairdocs.org/ntsb-events/060/sequence.md?model=7102210), [All aircraft, 1,422 cases](https://openairdocs.org/ntsb-events/060/sequence.md) - [Initial climb: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-22-150, 41 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102210), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) - [Post-impact: Roll over](https://openairdocs.org/ntsb-events/097); cases with it: [Piper PA-22-150, 2 cases](https://openairdocs.org/ntsb-events/097/sequence.md?model=7102210), [All aircraft, 261 cases](https://openairdocs.org/ntsb-events/097/sequence.md) ## Analysis The pilot reported that the engine was not developing the expected rpm during the takeoff and initial climb. He noticed the airplane was not climbing well and could have trouble clearing small trees near the end of the runway. The pilot maneuvered the airplane through a low spot in the trees after he realized he did not have sufficient runway remaining to land. The pilot attempted to gain altitude and airspeed but only gained minimal altitude. The pilot considered applying carburetor heat but realized it would guarantee a loss of engine power with another line of trees ahead of the airplane. The pilot cleared the line of trees, but then impacted the next line of trees. The airplane nosed down, impacted the terrain, and came to rest inverted in a residential yard. The pilot speculated the reduced engine power was due to carburetor ice. Postaccident examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operations. Weather conditions reported at the time of the accident were conducive for carburetor icing at glide and cruise power. The pilot reported that during the takeoff and initial climb, the carburetor heat was off. Therefore, it is likely that carburetor ice accumulated during taxi and run-up before the takeoff, which resulted in a partial loss of engine power and reduced takeoff performance. ## Factual narrative On August 9, 2020, about 1430 central daylight time, a Piper PA-22-150 airplane, N6849B, was substantially damaged when it was involved in an accident near Burlington, Wisconsin. The pilot sustained minor injuries and the passenger was seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that the engine was not developing the expected engine RPMs during the takeoff and initial climb. He noticed the airplane was not climbing well and may have trouble clearing small trees near the end of the runway. The pilot maneuvered the airplane through a low spot in the trees after he realized he did not have sufficient runway remaining to land. The pilot performed a couple pitch maneuvers in an attempt to gain altitude and airspeed which resulted in a minimal gain in altitude. The pilot considered applying carburetor heat but realized it would guarantee a loss of engine power with another line of trees ahead of the airplane. The pilot cleared the line of trees, but then impacted the next line of trees. The airplane nosed down, impacted the terrain, and came to rest inverted in a residential yard. The pilot speculated the reduced engine power was due to carburetor ice. According to witnesses and a surveillance video at the Burlington Municipal Airport (BUU), Burlington, Wisconsin, the airplane departed the turf runway 19. The airplane appeared to have a gradual takeoff climb to about 30 to 35 ft above ground level. The airplane continued at that altitude before it disappeared from the witnesses and video view behind some trees south of BUU. The airplane sustained substantial damage to the fuselage, both wings, and empennage. Postaccident examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operations. According to a carburetor ice probability chart, the atmospheric conditions at the time of the accident were conducive to icing at glide and cruise power. Federal Aviation Administration Advisory Circular 20-113 explains, "To prevent accidents due to induction system icing, the pilot should regularly use [carburetor] heat under conditions known to be conducive to atmospheric icing and be alert at all times for indications of icing in the fuel system." ## Aircraft - Registration: [N6849B](https://openairdocs.org/aircraft/N6849B), registered now, S/N 22-4148 (OpenAirDocs) - Reported make and model: Piper PA22 (150) - Registry model: [Piper PA-22-150](https://openairdocs.org/model/piper-pa-22-150) (registry code 7102210) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 22-4148 - Engines: Lycoming O-320 SERIES reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, July 1, 2020 - Departed: Burlington, WI - Destination: Burlington, WI - Equipment: Unknown ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 68; injuries: minor; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: basicmed, unknown; seat: left; flight hours: 952 total, 371 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: 190° at 7 knots, gusting 16 - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 86 °F, dew point 72 °F - Altimeter: 29.97 inHg - Observed at: BUU, 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 20200809009879A](https://openairdocs.org/incident/20200809009879A), Aug 9, 2020: Piper PA-22-150, Burlington, WI, Destroyed. On August 9, 2020 at approximately 14:37 pm the PIC departed Burlington Municipal Airport (kbuu)using runway 19 a grass runway. The pilot said he did a normal… ## Other investigations on N6849B (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 CEN12LA182](https://openairdocs.org/ntsb/CEN12LA182), Mar 5, 2012: Piper PA-22-150 (N6849B), East Troy, WI, substantial damage. Probable cause: The pilot's inadequate fuel management, which resulted in a total loss of engine power due to fuel exhaustion. ## Docket (6 files) The files NTSB released with the investigation on October 9, 2020, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=101762. 6.5 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 9 pages, 3.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=10654522&FileExtension=pdf&FileName=6120_Redacted-Rel.pdf - Pilot narrative (item 2, PDF, 2 pages, 442 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=10643326&FileExtension=pdf&FileName=Flight%20Narrative-Rel.pdf - Record of conversation pilot (item 3, PDF, 1 page, 114 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=10641189&FileExtension=pdf&FileName=ROC%20Pilot-Rel.pdf - Witness statements (item 4, PDF, 3 pages, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=10639726&FileExtension=pdf&FileName=N6849B%20Accident%20Witness%20Statements%2008-10-2020_Redacted-Rel.pdf - FAA inspector statement (item 5, PDF, 2 pages, 14 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=10657228&FileExtension=pdf&FileName=Inspector%20statement%20Michael%20J-Rel.pdf - Carburetor ice chart (item 6, PDF, 1 page, 247 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=10935446&FileExtension=pdf&FileName=Carb%20Ice%20Chart-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.