# NTSB CEN23LA161: Piper PA-28-181, N419W, Flint Township, MI, April 20, 2023 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: April 20, 2023, 10:05 local (14:05 UTC) - Place: Flint Township, MI - Coordinates: 42.963555, -83.796115 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=42.9636&lon=-83.7961&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-VFR pattern final: Fuel related](https://openairdocs.org/ntsb-events/190) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: FAA - SAIBs cited in the narratives: [SAIB CE-09-35](https://openairdocs.org/saib/CE-09-35) (OpenAirDocs) - NTSB case key (mKey): 107095 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN23LA161 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/107095/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=107095 - Page: https://openairdocs.org/ntsb/CEN23LA161 ## 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 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-28-181, 6 cases](https://openairdocs.org/ntsb-findings/03031030/cases.md?model=7102807), [All aircraft, 435 cases](https://openairdocs.org/ntsb-findings/03031030/cases.md) - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-28-181, 10 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=7102807), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach-VFR pattern final: Fuel related](https://openairdocs.org/ntsb-events/190) (defining event); cases with it: [Piper PA-28-181, 6 cases](https://openairdocs.org/ntsb-events/190/sequence.md?model=7102807), [All aircraft, 361 cases](https://openairdocs.org/ntsb-events/190/sequence.md) - [Emergency descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-28-181, 70 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102807), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/aircraft/N419W), registered now, S/N 2843001, built 1995 (OpenAirDocs) - Reported make and model: PIPER PA-28-181 - Registry model: [Piper PA-28-181](https://openairdocs.org/model/piper-pa-28-181) (registry code 7102807) (OpenAirDocs) - Registry engine: [Lycoming O&VO-360 series](https://openairdocs.org/engine/lycoming-o-vo-360-series) (registry code 41514, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 2843001 - Year built: 1995 - Airframe hours: 6635.4 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 44; injuries: none; 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 ## 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 20230420007919A](https://openairdocs.org/incident/20230420007919A), Apr 20, 2023: Piper PA-28-181, Flint, MI, Substantial damage. On approach to Flint Bishop, aircraft flew through a temperature inversion and experienced loss of power. Pilot stated carb heat not applied when he noticed a… ## Docket (8 files) The files NTSB released with the investigation on March 28, 2024, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=107095. 4.2 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=15392096&FileExtension=pdf&FileName=6120.1%20Pilot_Operator%20Aircraft%20Accident_Incident%20Report%20(1)_Redacted-Rel.pdf - Pilot statement (item 2, PDF, 1 page, 233 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15391571&FileExtension=pdf&FileName=Pilot%20Statement-Rel.pdf - Pilot statement on carburetor heat (item 3, PDF, 1 page, 142 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15392290&FileExtension=pdf&FileName=Pilot%20Carb%20Heat_Redacted-Rel.pdf - Examination summary (item 4, PDF, 4 pages, 445 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15391743&FileExtension=pdf&FileName=Exam%20Summary%20FAA-Rel.pdf - Carburetor ice probability chart (item 5, PDF, 1 page, 335 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15392106&FileExtension=pdf&FileName=CEN23LA161%20-%20Carburetor%20Icing%20Probability%20Graph-Rel.pdf - Excerpt of pilot operating handbook (item 6, PDF, 1 page, 262 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15391823&FileExtension=pdf&FileName=POH%20Excerpt%201-Rel.pdf - Accident photographs (item 7, PDF, 3 pages, 979 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15391889&FileExtension=pdf&FileName=Photo%20Array-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 8, PDF, 1 page, 302 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15391470&FileExtension=pdf&FileName=Signed%20release_Redacted-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.