CEN23LA161

NTSB accident investigation · Piper PA-28-181 · Flint Township, MI · April 20, 2023

Accident · No injuriesClass 3 · LimitedFinal report
Date
April 20, 2023, 10:05 local (14:05 UTC)
Place
Flint Township, MI
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N419WPiper PA-28-181
Defining event
Approach-VFR pattern final: Fuel related
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
FAA
FAA report
20230420007919A
Case key
107095

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

The pilot’s failure to apply carburetor heat during the landing approach, which resulted in a loss of engine power from carburetor ice.

Findings · 2

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.

Temp/humidity/pressure: conducive to carburetor icingEnvironmental issues › Conditions/weather/phenomena · Effect on operationPiper PA-28-181: 6 casesAll aircraft: 435 casesProbable cause
Use of equip/info: use of equip/systemPersonnel issues › Task performance · PilotPiper PA-28-181: 10 casesAll aircraft: 1,391 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 planned a short cross-country flight to two different airports with a return to his original airport. Due to concerns with weather conditions in the area, the pilot requested to air traffic control to execute the option and then return to his original departure airport. While on a 1-mile final approach, about 500 ft above ground level, the engine lost total power. An attempt to restart the engine was unsuccessful. Unable to make the runway, the pilot executed a forced landing on a railroad track. During the forced landing, the airplane sustained substantial damage to both wings and engine mount. Postaccident examination of the airframe and engine revealed no preimpact mechanical malfunctions or failures that would have precluded normal operation. An undetermined amount of fuel remained in the fuel tanks at the accident site. Weather conditions reported at the time of the accident were conducive for serious icing at any power setting. The pilot stated that he did not apply carburetor heat during the approach. Therefore, it is likely that carburetor ice accumulated during the approach and descent, which resulted in a loss of engine power.

Factual narrative

On April 20, 2023, about 1005 eastern daylight time, a Piper PA-28-181 airplane, N419W, sustained substantial damage when it was involved in an accident near Flint Township, Michigan. 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, before departure the airplane contained about 34 gallons of fuel. The airplane departed the Ann Arbor Municipal Airport (ARB), Ann Arbor, Michigan, and the pilot planned a short cross-country flight to two different airports with a return to ARB. Due to concerns with weather conditions in the area, the pilot contacted air traffic control and requested to execute the option at Bishop International Airport (FNT), Flint, Michigan, and then return to ARB. While on a 1-mile final approach to FNT, about 500 ft above ground level, the engine lost total power. An attempt to restart the engine was unsuccessful. Unable to make the runway, the pilot executed a forced landing on a railroad track. During the forced landing, the airplane sustained substantial damage to both wings and the engine mount. The pilot stated that he did not use carburetor heat during the approach. Postaccident examination revealed that both magnetos produced spark on all spark plugs. Thumb compression and suction were noted on all cylinders when the propeller was manually rotated. The carburetor, venturi, and throttle valve were intact, and no anomalies were noted. The oil filter was clear of contaminants. A review of the local area meteorological data showed that at the time of the accident the airplane was operating in conditions that were conducive to serious icing at any power setting. Federal Aviation Administration Special Airworthiness Information Bulletin (CE-09-35) – Carburetor Icing Prevention, stated that: “…pilots should be aware that carburetor icing doesn't just occur in freezing conditions, it can occur at temperatures well above freezing temperatures when there is visible moisture or high humidity. Icing can occur in the carburetor at temperatures above freezing because vaporization of fuel, combined with the expansion of air as it flows through the carburetor, (Venturi Effect) causes sudden cooling, sometimes by a significant amount within a fraction of a second. Carburetor ice can be detected by a drop in rpm in fixed pitch propeller airplanes and a drop in manifold pressure in constant speed propeller airplanes. In both types, usually there will be a roughness in engine operation.”

Aircraft

Registration
N419W
Reported as
Piper PA-28-181
Category
Airplane
Serial number
2843001
Built
1995
Airframe hours
6,635.4
Engine
Lycoming O-360-A4M, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · July 8, 2022
Departed
ARB · Ann Arbor, MI
Airport
FNT · Bishop Intl
Equipment
Electronic primary flight display, ADS-B, Auto-pilot, Electronic multifunction display

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
44
Injuries
None
Certificates
Commercial, Flight instructor, Private
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
March 20, 2022
Seat
Left
Restraint
3-point
Flight hours
653 total · 133 in this make and model · 561 as pilot in command · 45 in the last 90 days · 20 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
120° at 12 knots
Visibility
10 statute miles
Lowest ceiling
11,000 ft broken
Temperature
48 °F, dew point 37 °F
Altimeter
30.06 inHg
Observed at
KFNT, 2 nm away
METAR
KFNT 201353Z 12012KT 10SM BKN110 09/03 A3006 RMK AO2 SLP184 T00940033

Docket · 8

The files NTSB released with the investigation on March 28, 2024, on NTSB’s docket system: statements, records, photos and specialists’ reports. 4.2 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.