# NTSB CEN24LA360: Piper PA-44-180, N2083D, Shakopee, MN, September 20, 2024 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Class 3 · Limited · Final report - Date: September 20, 2024, 12:04 local (17:04 UTC) - Place: Shakopee, MN - Coordinates: 44.784167, -93.499167 - Nearby events: https://openairdocs.org/map.md?lat=44.7842&lon=-93.4992&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: Serious injuries - Injuries: 2 serious - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: FAA, Piper Aircraft Inc - NTSB case key (mKey): 195153 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN24LA360 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/195153/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=195153 - Page: https://openairdocs.org/ntsb/CEN24LA360 ## Probable cause The pilots’ failure to apply carburetor heat during the descent, which resulted in a loss of power on both engines due to carburetor ice. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Ice/rain protection system: intake anti-ice, deice](https://openairdocs.org/ntsb-findings/01023020): Aircraft › Aircraft systems · Not used/operated (probable cause); cases with it: [Piper PA-44-180, 2 cases](https://openairdocs.org/ntsb-findings/01023020/cases.md?model=7104402), [All aircraft, 108 cases](https://openairdocs.org/ntsb-findings/01023020/cases.md) - [Temp/humidity/pressure: conducive to carburetor icing](https://openairdocs.org/ntsb-findings/03031030): Environmental issues › Conditions/weather/phenomena · Response/compensation (probable cause); cases with it: [Piper PA-44-180, 2 cases](https://openairdocs.org/ntsb-findings/03031030/cases.md?model=7104402), [All aircraft, 435 cases](https://openairdocs.org/ntsb-findings/03031030/cases.md) - [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · Flight crew (probable cause); cases with it: [Piper PA-44-180, 5 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md?model=7104402), [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md) - [Use of equip/info: use of checklist](https://openairdocs.org/ntsb-findings/02063030): Personnel issues › Task performance · Flight crew; cases with it: [Piper PA-44-180, 4 cases](https://openairdocs.org/ntsb-findings/02063030/cases.md?model=7104402), [All aircraft, 336 cases](https://openairdocs.org/ntsb-findings/02063030/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-44-180, 1 case](https://openairdocs.org/ntsb-events/190/sequence.md?model=7104402), [All aircraft, 361 cases](https://openairdocs.org/ntsb-events/190/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Piper PA-44-180, 6 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=7104402), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) ## Analysis One of the pilots, a flight instructor, was recently hired to instruct in the airplane and was receiving a check out flight from the assistant chief flight instructor. The pilots reported that they were preparing to enter the traffic pattern, so they began a descent from their cruising altitude of about 5,500 ft msl to 1,000 ft msl. About three miles from the airport, both engines on the multi-engine airplane began to run rough. Shortly thereafter, both engines lost all power. Despite the pilots advancing the propellers, mixtures, and throttles to their full forward position, engine power was not restored. The airplane continued to descend, and the pilots performed an off-airport landing onto a field. One of the pilots stated that they did not perform an emergency checklist because there was no checklist for a dual engine failure. Also, due to their proximity to the ground, they did not have time to perform an emergency checklist. The airplane sustained substantial damage to the fuselage and both wings. A postaccident examination revealed that there were about 25 gallons of fuel in each nacelle, and both fuel selectors were in the “ON” position. The carburetor heat for each engine was in the “OFF” position. Examination of the engines and fuel system did not reveal any mechanical anomalies or failures that would have precluded normal operation. The recorded temperature and dew point near the accident site were conducive to “serious icing” at glide power settings. The pilot operating handbook for the airplane stated that carburetor heat should be used “as required” during approach and landing or if engine roughness occurs. Based on this information, it is likely that carburetor ice formed while the throttles were retarded during the descent which resulted in the initial engine roughness and subsequent loss of engine power due to carburetor ice. ## Factual narrative On September 20, 2024, at 12:04 central daylight time, a Piper PA-44-180 airplane, N2083D, was substantially damaged when it was involved in an accident near Shakopee, Minnesota. Both pilots were seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. One of the pilots, a flight instructor, was recently hired to instruct in the airplane and was receiving a check out flight from the assistant chief flight instructor. According to both pilots, they departed Flying Cloud Airport (FCM) for a local one-hour flight. The run-up, taxi, and takeoff were all normal. The airplane departed to the southwest and climbed to about 5,500 ft mean sea level. The flight instructor receiving the check-out performed several flight maneuvers in the airplane, then began a descent and proceeded back to FCM. About 3 miles from FCM, and about 800 ft to 1,000 ft above ground level, the right engine began to lose power followed by a loss of manifold pressure. Shortly thereafter, the left engine lost power accompanied by a decrease in manifold pressure. Then both engines lost power completely. The assistant chief flight instructor took control of the airplane while the other pilot pushed the mixture, propeller, and throttle controls to their full forward position, but the airplane continued to lose altitude. The pilots executed a forced landing to a field southwest of FCM. The assistant chief flight instructor stated that they did not execute an emergency checklist because there was no checklist for a dual engine failure, nor did they have time due to their proximity to the ground. The wings, fuselage, and empennage sustained substantial damage. A postaccident examination revealed that there were about 25 gallons of fuel in each nacelle, and both fuel selectors were in the “on” position. No water was detected in the fuel contained in either engine carburetor float bowl. Valvetrain continuity was established in both engines. Compression was achieved on all cylinders when the crankshaft was rotated in each engine. The magnetos on both engines produced spark when their respective impulse couplings were rotated. The carburetor heat for both engines were in the up or “off” position. The temperature, 24°C, and dew point, 12°C, recorded at the destination airport were conducive to “serious icing” at glide power setting. According to the pilot operating handbook for the airplane, carburetor heat should be used “as required” during approach and landing and if engine roughness occurs. ## Aircraft - Registration: [N2083D](https://openairdocs.org/aircraft/N2083D), registered now, S/N 44-7995126, built 1978 (OpenAirDocs) - Reported make and model: PIPER PA-44-180 - Registry model: [Piper PA-44-180](https://openairdocs.org/model/piper-pa-44-180) (registry code 7104402) (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: 44-7995126 - Year built: 1978 - Airframe hours: 12593 - Engines: Lycoming O-360-E1A6D 180 horsepower reciprocating; Lycoming O-360-E1A6D 180 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Operator: Thunderbird Aircraft Co - Registered owner: Thunderbird Aircraft Co - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, September 18, 2024 - Departed: FCM, Eden Prairie, MN - Airport: FCM, Flying Cloud AIrport - Equipment: Unknown ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 69; injuries: serious; flight instructor, commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review September 13, 2023; seat: left; flight hours: 8,654 total, 1,021 in this make and model, 7,853 as pilot in command, 89 in the last 90 days, 34 in the last 30 days - Co-pilot; age 47; injuries: serious; flight instructor, commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; seat: right; flight hours: 0 total, 0 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: 270° at 9 knots, gusting 17 - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 75 °F, dew point 54 °F - Altimeter: 29.83 inHg - Observed at: KFCM, 3 nm away - METAR: KFCM 201653Z 27009G17KT 10SM CLR 24/12 A2983 ## 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 20240920014009A](https://openairdocs.org/incident/20240920014009A), Sep 20, 2024: Piper PA-44-180, Shakopee, MN, Substantial damage. The assistant chief pilot of a FAA part 141 flight school was acting as pilot in command (PIC) during a required part 141 checkout flight with a newly hired… ## Docket (8 files) The files NTSB released with the investigation on June 4, 2025, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=195153. 5.1 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 10 pages, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18727309&FileExtension=pdf&FileName=6120_Redacted-Rel.pdf - Memorandum for record a�� telephone interview, pilots (item 2, PDF, 2 pages, 75 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18681458&FileExtension=pdf&FileName=MORs-%20Pilots-Rel.pdf - Examination summary (item 3, PDF, 5 pages, 149 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18681534&FileExtension=pdf&FileName=Exam%20Summary%20N2083D-Rel.pdf - Memorandum of record FAA (item 4, PDF, 1 page, 63 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18681216&FileExtension=pdf&FileName=MOR%20-%20Greg%20Thurston-Rel.pdf - Carburetor ice chart (item 5, PDF, 1 page, 290 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18673490&FileExtension=pdf&FileName=Carb%20ice%20chart-Rel.pdf - Excerpt from POH (item 6, PDF, 2 pages, 194 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18673559&FileExtension=pdf&FileName=Excerpt%20from%20POH-Rel.pdf - Investigation photos (item 7, PDF, 5 pages, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18747247&FileExtension=pdf&FileName=Photo%20Array-Rel.pdf - Party form (item 8, PDF, 1 page, 659 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18747857&FileExtension=pdf&FileName=PF-Piper-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.