# NTSB CEN23LA266: Piper PA-28-181, N4008Q, Howell, MI, June 24, 2023 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: June 24, 2023, 10:30 local (14:30 UTC) - Place: Howell, MI - Coordinates: 42.623547, -83.971755 - Nearby events: https://openairdocs.org/map.md?lat=42.6235&lon=-83.9718&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-VFR pattern downwind: Fuel related](https://openairdocs.org/ntsb-events/190) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: FAA East Michigan FSDO - SAIBs cited in the narratives: [SAIB CE-09-35](https://openairdocs.org/saib/CE-09-35) (OpenAirDocs) - NTSB case key (mKey): 192460 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN23LA266 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192460/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=192460 - Page: https://openairdocs.org/ntsb/CEN23LA266 ## Probable cause A loss of engine power due to the formation of carburetor ice that resulted from the pilot’s delayed use of carburetor heat during the landing approach. ## 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 equipment (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) - [Object/animal/substance: airport structure](https://openairdocs.org/ntsb-findings/03022042): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Piper PA-28-181, 1 case](https://openairdocs.org/ntsb-findings/03022042/cases.md?model=7102807), [All aircraft, 50 cases](https://openairdocs.org/ntsb-findings/03022042/cases.md) - [Action: delayed action](https://openairdocs.org/ntsb-findings/02041025): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA-28-181, 11 cases](https://openairdocs.org/ntsb-findings/02041025/cases.md?model=7102807), [All aircraft, 894 cases](https://openairdocs.org/ntsb-findings/02041025/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 downwind: 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: Landing area undershoot](https://openairdocs.org/ntsb-events/370); cases with it: [Piper PA-28-181, 1 case](https://openairdocs.org/ntsb-events/370/sequence.md?model=7102807), [All aircraft, 201 cases](https://openairdocs.org/ntsb-events/370/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 reported that during a local flight, while in the traffic pattern, the airplane’s engine power decreased to 900 rpm. He attempted to restore engine power but was unsuccessful and attempted to make a forced landing to the runway. He landed on the grass about 1,000 ft short of the runway surface, bounced, and impacted the localizer antenna. The airplane sustained substantial damage to the fuselage and both wings. Postaccident examination of the engine and fuel systems revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. The weather conditions at the time of the accident were conducive to a serious accumulation of carburetor ice at glide power. The pilot reported that he used carburetor heat while attempting to restore engine power, but not before he made his descent in the traffic pattern and the loss of engine power. Based on the available information, the loss of engine power was likely due to carburetor ice accumulation. Additionally, the low altitude at which the loss of engine power occurred significantly reduced the amount of time available to the pilot to troubleshoot and restore engine power before the forced landing. ## Factual narrative On June 24, 2023, about 1030 eastern daylight time, a Piper PA-28-181, N4008Q, was substantially damaged when it was involved in an accident near Livingston County Spencer J Hardy Airport (OZW), Howell, Michigan. The pilot and passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, a 100-hour inspection had just been completed. The pilot reported that the engine run-up was completed with no anomalies noted. After liftoff, the pilot remained in the traffic pattern for runway 31 at OZW. The first traffic pattern and touch-and-go landing was uneventful. On the second traffic pattern, the pilot extended his downwind leg by five seconds for spacing from another airplane in the traffic pattern. When the pilot reduced power and added 10° of flaps for the descent, he noticed that engine rpms had decreased to 900. The pilot attempted to restore engine power by turning on carburetor heat and verifying the electric fuel pump was on. The pilot was unable to restore engine power and transitioned to attempt a forced landing to runway 31. During the forced landing attempt, the pilot glided underneath powerlines and over the airport perimeter fence. The airplane touched down in the grass short of runway 31. The airplane bounced on an embankment, impacted the localizer antenna, and came to rest upright. The airplane came to rest 1,000 ft before the arrival end of runway 31. The right wing separated at the wing root. The left wing was damaged and leaked fuel. A postaccident examination did not reveal any preimpact mechanical malfunctions or failures that would have precluded normal operation. The carburetor linkage was connected and moved freely. The carburetor heat valve moved freely from open to closed. The electric fuel pump was tested and fuel flow was noted from the output line. Fuel was present throughout the fuel system, carburetor, and fuel filters, and no water or debris was detected in the fuel. The engine-driven fuel pump was observed to pump fuel during engine rotation. The carburetor accelerator pump had positive pressure during manual actuation. The fuel selector moved freely to all positions. The oil filter was new and appeared to be installed properly. An oil sample was obtained and no contaminants or metal were noted. The engine’s crankshaft was rotated by hand and internal and valvetrain continuity was established. The top spark plugs were removed from the cylinders and remained attached to the magneto leads. The spark plugs produced spark when the engine was rotated. At 1035, the weather reported at OZW included a temperature of 22°C and a dew point of 20°C. The calculated relative humidity at that temperature and dewpoint was 88%. Review of the icing probability chart contained in Federal Aviation Administration (FAA) Special Airworthiness Information Bulletin CE-09-35 revealed that the weather conditions at the time of the accident were "conducive toserious icing at glide [idle] power." According to FAA Advisory Circular 20-113, "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." The circular recommended that when operating in conditions where the relative humidity is greater than 50%, "…apply carburetor heat briefly immediately before takeoff, particularly with float type carburetors, to remove any ice which may have been accumulated during taxi and runup." It also stated, "Remain alert for indications of induction system icing during takeoff and climb-out, especially when the relative humidity is above 50 percent, or when visible moisture is present in the atmosphere." ## Aircraft - Registration: [N4008Q](https://openairdocs.org/deregistered/N4008Q-2024-04-27), registration cancelled 2024-04-27, S/N 28-7790468, built 1977 (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: 28-7790468 - Year built: 1977 - Airframe hours: 5335.68 - Engines: Lycoming O-360A4M 180 hp reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Registered owner: Dippold Lois Marie - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, June 24, 2023, 0.2 hours before - Destination: Same as departure - Flight plan: VFR - Airport: OZW, Livingston County Spencer J Hardy, runway 31, 5,000 × 100 ft, concrete - Equipment: ADS-B, Auto-pilot, Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 39; injuries: none; private; airplane ratings: single-engine land; medical: class 1, with waivers/limitations; last flight review November 1, 2021; seat: left; restraint: lap only; flight hours: 328 total, 109 in this make and model, 241 as pilot in command, 10.2 in the last 90 days, 1.7 in the last 30 days, 0 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: 1,300 ft broken - Temperature: 72 °F, dew point 68 °F - Altimeter: 29.96 inHg - Observed at: KOZW, 1 nm away - METAR: KOZW 241435Z AUTO 00000KT 10SM BKN013 BKN085 OVC110 22/20 A2996 RMK AO2 T02200197 ## 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 20230624009199A](https://openairdocs.org/incident/20230624009199A), Jun 24, 2023: Piper PA-28-181, Howell, MI, Substantial damage. During approach for a touch and go the pilot applied power to arrest descent and the engine did not respond, carb heat was on at the time and then turned off… ## Other investigations on N4008Q (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 CHI06CA239](https://openairdocs.org/ntsb/CHI06CA239), Aug 16, 2006: Piper PA-28-181 (N4008Q), Napoleon, MI, substantial damage. Probable cause: The pilot's failure to maintain a proper glidepath during the landing approach, and his excessive airspeed during the landing which resulted in the overrun. A factor was the fence that the airplane… ## Docket (5 files) The files NTSB released with the investigation on May 9, 2024, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=192460. 6.7 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 9 pages, 5.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16123063&FileExtension=pdf&FileName=6120%20N4008Q_Redacted-Rel.pdf - Carburetor icing probability chart (item 2, PDF, 1 page, 335 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16093396&FileExtension=pdf&FileName=Carburetor%20Icing%20Probability%20Graph%20(CEN23LA266)-Rel.pdf - FAA inspector's statement (item 3, PDF, 2 pages, 195 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16104200&FileExtension=pdf&FileName=N4008Q%20INSPECTOR%20STATEMENT-Rel.pdf - Email from FAA maintenance inspector (item 4, PDF, 1 page, 109 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16104866&FileExtension=pdf&FileName=N4008Q%20fuel%20selector_Redacted-Rel.pdf - Photos (item 5, PDF, 3 pages, 566 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16123098&FileExtension=pdf&FileName=Photo%20Array-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.