# NTSB CEN24LA184: Piper PA-22, N669A, Enderlin, ND, May 13, 2024 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Class 3 · Limited · Final report - Date: May 13, 2024, 10:07 local (15:07 UTC) - Place: Enderlin, ND - Coordinates: 46.6268, -97.6202 - Nearby events: https://openairdocs.org/map.md?lat=46.6268&lon=-97.6202&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Fuel contamination](https://openairdocs.org/ntsb-events/193) - Highest injury: Minor injuries - Injuries: 3 minor - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: FAA - NTSB case key (mKey): 194253 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN24LA184 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/194253/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=194253 - Page: https://openairdocs.org/ntsb/CEN24LA184 ## Probable cause The pilot’s failure to properly inspect and sump the fuel system before the flight and the maintenance personnel’s inadequate maintenance of the fuel system which resulted in fuel starvation and the subsequent loss of engine power due to the contamination of the right tank fuel gascolator and fuel lines. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Maintenance: scheduled/routine maintenance](https://openairdocs.org/ntsb-findings/02062010): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Piper PA-22, 1 case](https://openairdocs.org/ntsb-findings/02062010/cases.md?model=7102202), [All aircraft, 320 cases](https://openairdocs.org/ntsb-findings/02062010/cases.md) - [Performance/control parameters: descent/approach/glide path](https://openairdocs.org/ntsb-findings/01062040): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Piper PA-22, 1 case](https://openairdocs.org/ntsb-findings/01062040/cases.md?model=7102202), [All aircraft, 809 cases](https://openairdocs.org/ntsb-findings/01062040/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid condition (probable cause); cases with it: [Piper PA-22, 5 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=7102202), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Inspection: preflight inspection](https://openairdocs.org/ntsb-findings/02061510): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-22, 1 case](https://openairdocs.org/ntsb-findings/02061510/cases.md?model=7102202), [All aircraft, 551 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Aircraft maintenance event](https://openairdocs.org/ntsb-events/040); cases with it: [Piper PA-22, 1 case](https://openairdocs.org/ntsb-events/040/sequence.md?model=7102202), [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md) - [Takeoff: Fuel contamination](https://openairdocs.org/ntsb-events/193) (defining event); cases with it: [Piper PA-22, 2 cases](https://openairdocs.org/ntsb-events/193/sequence.md?model=7102202), [All aircraft, 225 cases](https://openairdocs.org/ntsb-events/193/sequence.md) - [Landing: Roll over](https://openairdocs.org/ntsb-events/097); cases with it: [Piper PA-22, 1 case](https://openairdocs.org/ntsb-events/097/sequence.md?model=7102202), [All aircraft, 261 cases](https://openairdocs.org/ntsb-events/097/sequence.md) ## Analysis According to the pilot, shortly after takeoff about 200 ft above ground level (agl), the engine started to run rough. The pilot turned on the carburetor heat and there was a slight improvement in engine performance, but then the engine lost all power. The pilot made an off-airport landing. Upon touchdown, the nosewheel dug into the ground and the airplane flipped inverted. The airplane sustained substantial damage to the left wing, rudder, and engine mount. A postaccident examination of the engine revealed no anomalies that would have precluded normal operation. Examination of the fuel system revealed that the gascolator and bowl for the right tank rear fuel line were full of sediment and debris. Additionally, the fuel lines going to and coming out of the gascolator contained the same deposits that were found in the fuel bowl. The airplane owner said that he assumed the strainer that was under the right front seat was part of the brake system. He was unaware that it was a quick drain gascolator for the right fuel tank and he never sumped that drain. It could not be determined when maintenance personnel last inspected the gascolator. The pilot reported that she flew a total of about 1 hour before the loss of power occurred and had been operating solely on the right fuel tank. Each fuel tank held 18 gallons of fuel and operated independently of each other depending on fuel selector valve selection. Fuel consumption was between 4.5 to 11 gallons per hour, so it is possible there was only about 7 gallons of fuel remaining in the right fuel tank. Although the owner’s handbook cautioned that operating solely on the right fuel tank should only be done if operating in straight and level flight and when the right fuel tank is at 1/3 capacity or lower, the right fuel tank likely contained more than 1/3 its capacity. The sediment and debris clogging the gascolator filter bowl and fuel lines for the right tank’s rear fuel line likely prevented fuel from flowing freely to the engine, which resulted in a loss of engine power due to fuel starvation. ## Factual narrative On May 13, 2024, at 1007 central daylight time, a Piper PA-22 airplane, N669A, was substantially damaged when it was involved in an accident near Enderlin, North Dakota. The pilot and two passengers sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, she departed Edgeley Municipal Airport (51D) in Edgeley, North Dakota, and flew to Sky Haven Airport (5N4), Enderlin, North Dakota, where she performed two landings. After the second landing, she taxied to the parking area and shut down the airplane. Two passengers boarded the airplane, and the pilot started the engine, performed a run-up, took-off, flew around the traffic pattern once, and landed. After landing, she taxied back to the parking area, the passengers disembarked, and two more passengers boarded the airplane. The pilot took off to perform another circuit in the traffic pattern. Shortly after takeoff, while in a climb and about 100 to 200 ft agl, the engine started to run rough. The pilot turned on the carburetor heat and there was a slight engine power improvement, but then the engine started to run rough again, and the airplane started to descend. About 50 ft agl, the engine lost power and the pilot made an off-airport landing. Upon touchdown, the nosewheel dug into the ground and the airplane flipped inverted. The airplane sustained substantial damage to the left wing, rudder, and engine mount. A review of a carburetor ice chart revealed that the temperature, 53°F, and the dewpoint, 39°F, at the time of the accident were conducive to carburetor ice, but only at cruise power setting and not at a climb power setting. The pilot stated that on the day of the accident, both fuel tanks were filled to maximum capacity (18 gallons per fuel tank) before leaving 51D. She also stated that she was operating solely on the right fuel tank and had flown for a total of about 1 hour when the accident occurred. The left and right fuel tanks drain individually of each other according to the position of the fuel selector valve. The performance chart in the manufacturer’s owner’s handbook states that fuel consumption is about 4.5 to 11 gallons per hour. The owner’s handbook cautions against operating solely on the right fuel tank in a climb if fuel in the right tank is below 1/3 capacity. A postaccident examination of the engine and fuel system revealed no anomalies with the engine that would have precluded normal operation. Upon examining the right tank gascolator strainer housing and bowl, debris and sediment were found (figure 1, 2, & 3). The fuel lines going to and coming out of the fuel strainer contained the same build up and deposits that were found in the fuel bowl. According to the manufacturer, the gascolator should be checked frequently for water or sediment. Additionally, the manufacturer’s inspection report, which meets the requirements for Federal Aviation Regulations Part 43 Maintenance, PreventiveMaintenance, Rebuilding, and Alterations, stated that the right tank filter bowl should be drained and cleaned at least every 90 days. The airplane owner said that he assumed the strainer that was under the right front seat was part of the brake system. He was unaware that it was a quick drain gascolator for the right fuel tank and he never sumped that drain. The airframe and powerplant mechanic who performed the three prior annual inspections on the airplane did not return the investigator’s phone call; accordingly, the investigation was unable to determine if he used the manufacturer’s inspection report checklist. ## Aircraft - Registration: [N669A](https://openairdocs.org/aircraft/N669A), registered now, S/N 22-71, built 1951 (OpenAirDocs) - Reported make and model: PIPER PA-22 - Registry model: [Piper PA-22](https://openairdocs.org/model/piper-pa-22) (registry code 7102202) (OpenAirDocs) - Registry engine: [Lycoming 0-290 series](https://openairdocs.org/engine/lycoming-0-290-series) (registry code 41506, 4 cycle) (OpenAirDocs) - Category: Airplane - Serial number: 22-71 - Year built: 1951 - Airframe hours: 4067 - Engines: Lycoming O--320-A2B 150 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, September 23, 2023 - Destination: Same as departure - Airport: 5N4, Enderlin Airport, runway 30, 2,855 × 40 ft, dirt - Equipment: Unknown ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 33; injuries: minor; commercial, flight instructor; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, without waivers/limitations; last flight review October 10, 2023; seat: left; restraint: lap only; flight hours: 834 total, 59 in this make and model, 745 as pilot in command, 15 in the last 90 days, 7.7 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 30° at 8 knots, gusting 13 - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 54 °F, dew point 39 °F - Altimeter: 29.93 inHg - Observed at: KGWR, 25 nm away - METAR: KGWR 131455Z AUTO 03008G13KT 10SM CLR 12/04 A2993 ## 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 20240513008399A](https://openairdocs.org/incident/20240513008399A), May 13, 2024: Piper PA-22, Enderlin, ND, Substantial damage. Pilot reported that after takeoff the engine started running rough. Pilot pulled carb heat and engine got better momentarily, but then started running rough… ## Docket (10 files) The files NTSB released with the investigation on May 14, 2025, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=194253. 8.4 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18642664&FileExtension=pdf&FileName=6120_1_Fillable_unlocked_Redacted-Rel.pdf - Photos (item 2, PDF, 5 pages, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18599445&FileExtension=pdf&FileName=photos-Rel.pdf - Carburetor ice chart (item 3, PDF, 1 page, 291 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18494274&FileExtension=pdf&FileName=carb%20ice%20chart-Rel.pdf - Owner's manual excerpts (item 4, PDF, 3 pages, 171 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18494403&FileExtension=pdf&FileName=Owner%27s%20Manual%20Excerpt-Rel.pdf - Airplane inspection report checklist (item 5, PDF, 4 pages, 924 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18483127&FileExtension=pdf&FileName=Tri%20Pacer%20Inspection%20Report-Rel.pdf - Maintenance records (item 6, PDF, 7 pages, 3.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18488549&FileExtension=pdf&FileName=Maintenance%20Logbook%20Entries_Redacted-Rel.pdf - Mor - airplane owner (item 7, PDF, 1 page, 68 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18491652&FileExtension=pdf&FileName=MOR-Airplane%20Owner-Rel.pdf - Mor-pilot (item 8, PDF, 1 page, 68 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18483153&FileExtension=pdf&FileName=MOR-Pilot-Rel.pdf - Mor-mechanic (item 9, PDF, 1 page, 69 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18489393&FileExtension=pdf&FileName=MOR-John%20Nyberg-Rel.pdf - Mor-examination notes summary (item 10, PDF, 2 pages, 94 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18494557&FileExtension=pdf&FileName=MOR-Examination%20Notes%20Summary-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.