# NTSB CHI03LA051: Piper PA-38-112, N2400K, Mansfield, MO, January 13, 2003 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: January 13, 2003, 16:00 local (22:00 UTC) - Place: Mansfield, MO - Coordinates: 37.127777, -92.620834 - Nearby events: https://openairdocs.org/map.md?lat=37.1278&lon=-92.6208&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report June 25, 2003 - Report: Approved by Office Director - Parties: FAA - Kansas City FSDO - NTSB case key (mKey): 56344 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CHI03LA051 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/56344/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=56344 - Page: https://openairdocs.org/ntsb/CHI03LA051 ## Probable cause The pilot's failure to use carburetor heat, which resulted in the formation of carburetor ice and the loss of engine power. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(total) - nonmechanical, approach - vfr pattern - final approach - weather condition - carburetor icing conditions (contributing factor) - fuel system,carburetor - ice (cause) - carburetor heat - not used, pilot in command (contributing factor) - Forced landing, emergency descent/landing - On ground/water collision with object, landing - roll - object - tree(s) (contributing factor) ## Analysis The airplane contacted a tree during an off airport forced landing. The pilot reported that she flew to 03B to practice a couple of takeoffs and landings. She stated she entered the traffic pattern and pulled the power back when she was 180 degrees from the end of the runway. When she made the base leg turn, she realized that the wind was pushing her away from the runway so she added power, but there was no response from the engine. The pilot stated she tried adding a little more power, but again there was no response. She stated she then pulled the throttle back and advanced it to the full power setting, but there was still no response from the engine. The pilot stated she chose a two-lane dirt lane on wooded farmland on which to land. The left wing contacted a tree during the landing roll and the airplane spun around 180 degrees before coming to rest. Following the accident, the engine was started and it operated normally. The temperature and dewpoint reported 41 nautical miles northwest of the accident site, were 1 degree Celsius and -1 degree Celsius, respectively. These conditions are conducive for serious icing at any power setting. The Lycoming O-235-C Series engine manual, page 3-7, states, "(3) Landing Approach - In making an approach for a landing, carburetor air heat should generally be in the "Full Cold" position. However, if icing conditions are suspected, the "Full Heat" should be applied. In the case that full power need be applied under these conditions, as for an aborted landing, the carburetor heat should be returned to "Full Cold" after power application. See aircraft flight manual for specific instructions." The PA-38-112, Pilot Operating Handbook, pages 4-21and 22, state, "Carburetor heat should not be applied unless there is an indication of carburetor icing, since the use of carburetor heat causes a reduction in power which may be critical in case of a go-around. Full throttle operation with carburetor heat on can cause detonation." ## Factual narrative On January 13, 2003, at 1600 central standard time, a Piper PA-38-112, N2400K, collided with a sapling during an off airport forced landing while on approach to land on runway 25 at the Mansfield Municipal Airport (03B), Mansfield, Missouri. The pilot was not injured. The airplane was substantially damaged. The 14 CFR Part 91 flight was operating in visual meteorological conditions without a flight plan. The flight last departed the Mountain Grove Memorial Airport, Mountain Grove, Missouri, at 1535. The pilot reported that she flew to 03B to practice a couple of touch-and-goes. She stated she entered the traffic pattern and pulled the power back when she was 180 degrees from the end of the runway. She stated that after she leveled off on base leg, she realized that the wind was pushing her away from the runway so she added power, but there was no response from the engine. The pilot stated she tried adding a little more power, but again there was no response. She stated she then pulled the throttle back and advanced it to the full power setting, but there was still no response from the engine. The pilot stated she chose a two-lane dirt lane on wooded farmland on which to land. She stated the landing gear width was wider than the lane, and the land on both sides of the lane was uncut grass, brush, and trees. She continued to report, "There were soft spots in the earth to the side of the lane. This caused the airplane to rock somewhat from side to side as it rolled, alternately dragging one wingtip then the other on the ground. There was a very large, very solid-looking dead tree coming up on the right side of the lane. Ultimately, the left wing clipped a sapling surrounded by brush, ground-looping the airplane 180 [degrees], then it slid sideways to the outside of the loop for another 10 or 12 feet and came to rest suddenly." The pilot reported that the airplane had just had an annual inspection and the engine was overhauled. During the overhaul an STC was installed upgrading the engine from 112 to 125 horsepower. She stated that her A&P mechanic instructed her to keep the engine rpm up for a while since the engine was just overhauled. She stated because of this, she flew the entire flight at 2,400 rpm until pulling the power back in the traffic pattern at 03B. The pilot reported that she did not use carburetor heat at anytime during the flight. Following the accident, the engine was started and it operated normally. The temperature and dewpoint reported at Springfield, Missouri, 41 nautical miles northwest of the accident site, at 1553, were 1 degree Celsius and -1 degree Celsius, respectively. According to the Transport Canada Carburetor Icing Chart, these conditions are conducive for serious icing at any power setting. The Lycoming O-235-C Series engine manual, page 3-7, states, "(3) Landing Approach - In making an approach for a landing, carburetor air heat should generally be in the "Full Cold" position. However, if icing conditions are suspected, the "Full Heat" should be applied. In the case that full power need be applied under these conditions, as for an aborted landing, the carburetor heat should be returned to "Full Cold" after power application. See aircraft flight manual for specific instructions." The PA-38-112, Pilot Operating Handbook, pages 4-21and 22, state, "Carburetor heat should not be applied unless there is an indication of carburetor icing, since the use of carburetor heat causes a reduction in power which may be critical in case of a go-around. Full throttle operation with carburetor heat on can cause detonation." ## Aircraft - Registration: [N2400K](https://openairdocs.org/deregistered/N2400K-2005-09-28), registration cancelled 2005-09-28, S/N 38-79A0617, built 1979 (OpenAirDocs) - Reported make and model: Piper PA-38-112 - Registry model: [Piper PA-38-112](https://openairdocs.org/model/piper-pa-38-112) (registry code 7103812) (OpenAirDocs) - Registry engine: [Lycoming 0-235 series](https://openairdocs.org/engine/lycoming-0-235-series) (registry code 41505, 4 cycle) (OpenAirDocs) - Category: Airplane - Serial number: 38-79A0617 - Airframe hours: 2223 - Engines: Lycoming O-235-L2C 125 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Registered owner: Friedrich & Susan Kalhoefer - Airworthiness certificate: Standard, Normal - Last inspection: Annual, January 2, 2003, 3 hours before - Departed: MNF, Mountain Grove, MO - Destination: 03B, Mansfield, MO - Airport: 03B, Mansfield Municipal ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 61; injuries: none; private; airplane ratings: single-engine land; medical: class 3, valid medical--w/ waivers/lim; seat: left; flight hours: 140 total, 139 in this make and model, 63 as pilot in command, 3 in the last 90 days, 3 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 230° at 5 knots - Visibility: 5 statute miles - Lowest ceiling: 800 ft broken - Temperature: 34 °F, dew point 30 °F - Altimeter: 30.21 inHg - Observed at: SGF, 41 nm away ## 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 20030113001279A](https://openairdocs.org/incident/20030113001279A), Jan 13, 2003: Piper PA38112, Mansfield, MO, Substantial damage. (-23) When on the downwind leg to land at Mansfield, MO airport (O3B), the pilot reduced power to land. On the base leg she determined that the wind had… ## Docket (8 files) The files NTSB released with the investigation on May 11, 2003, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=56344. 1.8 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 577 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40439348&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Record of Interview (item 2, .PDF, 39 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40378175&FileExtension=.PDF&FileName=Record%20of%20Interview-Redacted.PDF - Carburetor Icing Chart (item 3, .PDF, 44 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40182438&FileExtension=.PDF&FileName=Carburetor%20Icing%20Chart-Master.PDF - PA-38-112 Pilot Operating Handbook (item 4, .PDF, 135 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40182439&FileExtension=.PDF&FileName=PA-38-112%20Pilot%20Operating%20Handbook-Master.PDF - Lycoming Operator's Manual 0-235-C (item 5, .PDF, 126 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40182440&FileExtension=.PDF&FileName=Lycoming%20Operator%27s%20Manual%200-235-C-Master.PDF - Photo 1. Accident Site (item 6, .PDF, 306 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40182441&FileExtension=.PDF&FileName=Photo%201.%20%20Accident%20Site-Master.PDF - Photo 2. Left Wing Damage (item 7, .PDF, 340 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40182442&FileExtension=.PDF&FileName=Photo%202.%20%20Left%20Wing%20Damage-Master.PDF - Photo 3. Impact Damage To Left Wing (item 8, .PDF, 272 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40182443&FileExtension=.PDF&FileName=Photo%203.%20%20Impact%20Damage%20To%20Left%20Wing-Master.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.