# NTSB CEN22LA377: Piper PA-28-140, N6460R, Vernon Hills, IL, August 6, 2022 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: August 5, 2022, 22:15 local (Aug 6, 2022, 03:15 UTC) - Place: Vernon Hills, IL - Coordinates: 42.2588, -87.948 - Nearby events: https://openairdocs.org/map.md?lat=42.2588&lon=-87.9480&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute: Fuel starvation](https://openairdocs.org/ntsb-events/191) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: FAA - Greater Chicago FSDO - NTSB case key (mKey): 105705 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN22LA377 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105705/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=105705 - Page: https://openairdocs.org/ntsb/CEN22LA377 ## Probable cause The pilot’s improper in-flight fuel management, which led to a loss of engine power due to fuel starvation. Contributing to the accident was the collapsed carburetor heat induction tube that restricted airflow to the engine preventing engine restart. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Planning/preparation: fuel planning](https://openairdocs.org/ntsb-findings/02061030): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-28-140, 18 cases](https://openairdocs.org/ntsb-findings/02061030/cases.md?model=7102802), [All aircraft, 719 cases](https://openairdocs.org/ntsb-findings/02061030/cases.md) - [Engine (reciprocating)](https://openairdocs.org/ntsb-findings/01058500): Aircraft › Aircraft power plant · Damaged/degraded; cases with it: [Piper PA-28-140, 10 cases](https://openairdocs.org/ntsb-findings/01058500/cases.md?model=7102802), [All aircraft, 497 cases](https://openairdocs.org/ntsb-findings/01058500/cases.md) - [Fuel system: fuel selector/shutoff valve](https://openairdocs.org/ntsb-findings/01022823): Aircraft › Aircraft systems · Incorrect use/operation (probable cause); cases with it: [Piper PA-28-140, 7 cases](https://openairdocs.org/ntsb-findings/01022823/cases.md?model=7102802), [All aircraft, 176 cases](https://openairdocs.org/ntsb-findings/01022823/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute: Fuel starvation](https://openairdocs.org/ntsb-events/191) (defining event); cases with it: [Piper PA-28-140, 17 cases](https://openairdocs.org/ntsb-events/191/sequence.md?model=7102802), [All aircraft, 733 cases](https://openairdocs.org/ntsb-events/191/sequence.md) ## Analysis The pilot was on the return leg of a cross-country flight when the airplane’s engine lost power. He reported that he performed emergency procedures that included applying carburetor heat, switching the selected fuel tank from the left fuel tank to the right fuel tank, activating the electric fuel pump, and attempting to restart the engine. He noted that he made about 3 such attempts without success in restarting the engine. He landed on a road and the airplane’s right wing was substantially damaged when it impacted a road sign during rollout. Flight track data indicated that the airplane had been airborne on the round-trip flight for about 3 hours and 35 minutes. Postaccident examination revealed that the airplane’s left fuel tank was nearly empty, and the right tank contained about 10 gallons of fuel and 1-1/2 ounces of water. Examination of the engine revealed that the flexible tube from the heat shroud to the carburetor heat box was partially collapsed. The damage to the tube did not appear to be impact related and investigators were not able to establish when the collapse occurred. During the engine run the collapsed induction tube was reinstalled as-found following the accident. The engine started normally and ran smoothly; however, when the carburetor heat check was performed, the engine rpm reduced by 700 rpm, but returned to full rpm when the carburetor heat was turned off. No other anomalies were detected during the engine test run that would have precluded normal operations. During the second engine run the collapsed flexible tube was removed and the carburetor heat system performed as expected during the carburetor heat check. Based on the available information, the loss of engine power was likely due to fuel starvation. The collapsed induction hose only affected engine operation when carburetor heat was applied, so it would not have resulted in the initial power loss. However, the collapsed induction tube could have hampered the pilot’s attempts to restart the engine following the loss of power. ## Factual narrative On August 5, 2022, about 2215 central daylight time, a Piper PA-28-140 airplane, N6460R, was substantially damaged when it was involved in an accident near Vernon Hills, Illinois. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, he departed from Campbell Airport (C81), Grayslake, Illinois, earlier in the day and flew to Reese Airport (7I2), Muncie, Indiana. He was returning to C81 when the accident occurred. The route took the airplane along the southeast shore of Lake Michigan and the pilot reported that shortly after crossing the lake’s shore the airplane’s engine began losing power. He reported that he performed emergency procedures that included applying carburetor heat, switching the selected fuel tank from the left to the right, activating the electric fuel pump, and attempting to restart the engine. He noted that he made about 3 such attempts without success in restarting the engine. The airplane’s altitude was about 2,000 ft mean sea level when the engine lost power because it was operating below the outer layers of the O’Hare Airport Class B airspace. The pilot attempted to turn the airplane and glide to the Waukegan National Airport (UGN), Waukegan, Illinois, but realized that there was insufficient altitude. He executed a forced landing to a road. During the landing rollout, the airplane sustained substantial damage to its right wing when it impacted a road sign. Automatic dependent surveillance-broadcast (ADS-B) data indicated that the airplane departed C81 at 1724 and arrived at 7I2 at 2023, a flight of 1 hour 59 minutes. ADS-B data further indicated that the return flight from 7I2 began at 2039, and the last recorded position was at 2215, a flight duration of 1 hour 36 minutes. The total flight duration for the round trip was 3 hours 35 minutes. Postaccident examination of the airplane confirmed substantial damage to the right wing. The left fuel tank fuel gauge read empty and the right fuel tank fuel gauge read between 5 and 6 gallons. All remaining fuel was drained from both wing fuel tanks. The left fuel tank contained about 1 quart of fuel and the right fuel tank contained about 10 gallons of fuel and 1-1/2 ounces of water. Examination of the engine revealed that the flexible tube from the heat shroud to the carburetor heat box was partially collapsed. The damage to the tube did not appear to be impact related. Investigators were not able to establish when the damage occurred. Several of the engine spark plug ignition leads were loose. The engine rotated freely, and compression was felt on all cylinders. The fuel that was drained was placed back into the tanks and an engine run was performed. The ignition leads and collapsed induction tube were reinstalled as-found following the accident for the engine run. The engine started normally and ran smoothly. The engine rpm was increased, and a magneto check performed at 2,000 rpm withnormal rpm drop. When the carburetor heat check was performed, the engine rpm reduced by 700 rpm, but returned to normal rpm when the carburetor heat was turned off. The induction tube could not be seen from the cockpit during the engine run. No other anomalies were detected during the engine test run that would have precluded normal operations. Investigators then disconnected the induction hose and ran the engine a second time. During the second engine run the carburetor heat system performed as expected during the carburetor heat check. A review of the airplane maintenance records showed that an annual inspection was completed on April 11, 2022. There was no mention of the collapsed induction tube in the entries for the annual inspection, or any previous entries provided. The recorded temperature and dew point, 25° C and 22°C respectively, were in the range of susceptibility for serious carburetor icing at glide power settings. ## Aircraft - Registration: [N6460R](https://openairdocs.org/deregistered/N6460R-2024-03-09), registration cancelled 2024-03-09, S/N 28-21646, built 1966 (OpenAirDocs) - Reported make and model: PIPER PA-28-140 - 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: 28-21646 - Year built: 1966 - Airframe hours: 3338.2 - Engines: Lycoming O-320 150 hp reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, April 11, 2022 - Departed: 7I2, Muncie, IN - Destination: C81, Grayslake, IL - Equipment: Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 30; injuries: none; commercial, flight instructor; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 1; last flight review March 11, 2021; seat: right; restraint: lap only; flight hours: 1,000 total ## Weather - Conditions: Visual (VMC), Night - Wind: 80° at 3 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 77 °F, dew point 72 °F - Altimeter: 30.07 inHg - Observed at: KPWK, 8 nm away - METAR: METAR KPWK 060252Z 08003KT 10SM CLR 25/22 A3007 RMK AO2 SLP178 T02500222 51009= ## 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 20220805014159A](https://openairdocs.org/incident/20220805014159A), Aug 5, 2022: Piper PA-28-140, Vernon Hills, IL, Substantial damage. While enroute to campbell airport (C81), the pilot lost engine power. Attempts to restart engine were unsuccessful. Airspeed and altitude were insufficient to… ## Docket (7 files) The files NTSB released with the investigation on December 20, 2023, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=105705. 45.4 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 9 pages, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15771340&FileExtension=pdf&FileName=6120_1web_Reader_Redacted-Rel.pdf - ADS-B data (item 2, CSV, 39.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15774605&FileExtension=csv&FileName=20220805_A87DED_491602898_ADSB-Rel.csv - Photos (item 3, PDF, 2 pages, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15774507&FileExtension=pdf&FileName=Docket%20Photo%20array%20template-Rel.pdf - FAA SAIB CE-09-35 carb icing prevention (item 4, PDF, 3 pages, 107 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15774346&FileExtension=pdf&FileName=5%20-%20FAA%20SAIB%20CE-09-35%20Carb%20Icing%20Prevention-Rel.pdf - Maintenance record excerpts (item 5, PDF, 8 pages, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15780751&FileExtension=pdf&FileName=Maintenance%20Records_Redacted-Rel.pdf - Record of conversation with pilot (item 6, PDF, 1 page, 66 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15781182&FileExtension=pdf&FileName=Pilot%20ROC-Rel.pdf - Aircraft examination summary (item 7, PDF, 7 pages, 846 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15781087&FileExtension=pdf&FileName=Aircraft%20exam-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.