# NTSB ERA17LA165: Ganjoo Amit Sonex, N212AG, Leesburg, VA, April 22, 2017 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: April 22, 2017, 09:15 local (13:15 UTC) - Place: Leesburg, VA - Coordinates: 39.068332, -77.552497 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=39.0683&lon=-77.5525&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-VFR pattern final: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report April 4, 2019 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - SAIBs cited in the narratives: [SAIB CE-09-35](https://openairdocs.org/saib/CE-09-35) (OpenAirDocs) - NTSB case key (mKey): 95042 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA17LA165 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/95042/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=95042 - Page: https://openairdocs.org/ntsb/ERA17LA165 ## Probable cause The pilot's failure to use carburetor heat appropriately, which resulted in a total loss of engine power due to the formation of 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: [All aircraft, 108 cases](https://openairdocs.org/ntsb-findings/01023020/cases.md) - [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md) - [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: [All aircraft, 435 cases](https://openairdocs.org/ntsb-findings/03031030/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: Other weather encounter](https://openairdocs.org/ntsb-events/400); cases with it: [All aircraft, 1,127 cases](https://openairdocs.org/ntsb-events/400/sequence.md) - [Approach-VFR pattern final: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Approach-VFR pattern final: Loss of control in flight](https://openairdocs.org/ntsb-events/240); cases with it: [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Landing: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) ## Analysis The private pilot checked the weather conditions before departure for the personal flight, and he noted that it was drizzling but that the cloud/ceilings were "good." Once airborne, the weather conditions began to deteriorate, and the pilot chose to return to the airport. The pilot added that, while the airplane was on final approach to land at 700 ft above ground level (agl), the engine "just stopped." The pilot attempted to restart the engine to no avail, and he subsequently initiated a forced landing just short of the runway. The pilot said that the airplane "ran out of airspeed" when it was about 100 ft agl and that it then landed hard and slid about 100 ft before coming to a stop. Postaccident examination of the engine revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. Weather conditions reported at the time of the accident were conducive for serious icing at cruise power. The pilot acknowledged that the weather conditions were conducive to carburetor icing but that he did not apply carburetor heat until he tried to restart the engine, and even then, that he did not use full carburetor heat. Therefore, it is likely that carburetor ice accumulated during the flight, which resulted in a total loss of engine power. ## Factual narrative On April 22, 2017, about 0915 eastern daylight time, an experimental amateur-built Sonex, N212AG, was substantially damaged during a forced landing, while attempting to land at the Leesburg Executive Airport (JYO), Leesburg, Virginia. The private pilot was not injured. The airplane was registered to and operated by the pilot as a 14 Code of Federal Regulations Part 91 personal flight. Marginal visual meteorological conditions prevailed near the airport about the time of the accident, and no flight plan was filed. The flight originated from JYO about 0845 and was destined for the Blue Ridge Airport (MTV), Martinsville, Virginia.The pilot stated that he purchased the airplane three months before the accident but had to wait for the weather to improve before he could fly the airplane back to his home in Washington state. On the day of the accident, he topped off the airplane's 16-gallon fuel tank and reviewed weather conditions along his intended route of flight. He said it was "drizzly" but the ceiling was "good." The pilot conducted a preflight inspection of the airplane and performed an engine run-up before he departed. The pilot said when he got about 20 miles south of the airport, weather conditions deteriorated, and he elected to turn back to Leesburg. When he was on final approach to runway 35 at an altitude of 700 ft, the engine "just stopped." The pilot attempted to re-start the engine, but to no avail, and he made a forced landing just short of the runway. The pilot said he "ran out of airspeed" when the airplane was about 100 ft above the ground, and that it then "pancaked" onto the ground and slid for about 100 ft before coming to a stop. The pilot said that the weather conditions (high humidity and visible moisture) were conducive to carburetor icing, but he did not apply carburetor heat until he tried to re-start the engine. Even then, he did not use full carburetor heat. When the airplane was recovered, the pilot said he drained 13 gallons of fuel from the fuel tank and it was absent of debris and water. A postaccident examination of the engine revealed that it rotated freely, and compression and valve train continuity was established for each cylinder. A borescope was used to examine the inside of each cylinder and no anomalies were noted. No oil leaks were observed, and oil was present in the sump. The magnetic drain plug was removed, and it was absent of debris. External and internal examination of the distributor, rotor, and points revealed no evidence of anomalies that would have precluded normal operation. Neither of the two ignition coils displayed any evidence of damage. Examination of the sparkplugs revealed the electrodes were gray in color and exhibited normal signatures. The carburetor heat linkage and air door were functional. External and internal examination of the carburetor revealed no evidence of malfunction, the accelerator pump was functional, the floats showed no sign of leakage, and the float bowl containedfluid consistent with 100LL Aviation Gasoline. The fuel was then tested with water finding paste and no water was detected. The weather conditions reported at JYO, at 0915, included wind 010° at 8 knots, visibility 10 miles, light drizzle, scattered clouds 1,600 ft, broken clouds at 2,400 ft, overcast clouds at 3,600 ft, temperature 55° C, dewpoint 54° C, and a barometric altimeter setting of 29.94 in Hg. The carburetor icing probability chart from Federal Aviation Administration (FAA) Special Airworthiness Information Bulletin (SAIB): CE-09-35 Carburetor Icing Prevention, June 30, 2009, shows a probability of serious icing at cruise power at the temperature and dew point reported at the time of the accident. The pilot held a private pilot certificate with a rating for airplane single-engine land, and instrument airplane. His last FAA third class medical was issued on January 4, 2015. The pilot reported a total of 932 hours, of which, 2 hours were in the accident airplane. ## Aircraft - Registration: N212AG (not matched to a registry record) - Reported make and model: GANJOO AMIT SONEX (NO SERIES) - Category: Airplane, amateur-built - Serial number: 1470 - Year built: 2017 - Airframe hours: 72 - Engines: Ganjoo Convair 120 hp reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Special, Experimental (Special) - Last inspection: Annual, August 3, 2016, 3 hours before - Departed: JYO, Leesburg, VA - Destination: MTV, Martinsville, VA - Airport: JYO, Leesburg - Equipment: Handheld GPS, Electronic primary flight display, Electronic multifunction display, Data recorder ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 53; injuries: none; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; last flight review March 11, 2017; seat: left; restraint: 3-point; flight hours: 932 total, 2 in this make and model, 854 as pilot in command, 7 in the last 90 days, 5 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 10° at 8 knots - Visibility: 10 statute miles - Lowest ceiling: 2,400 ft broken - Temperature: 55 °F, dew point 54 °F - Altimeter: 29.94 inHg - Observed at: JYO, 1 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 20170422008499A](https://openairdocs.org/incident/20170422008499A), Apr 22, 2017: Sonex, Leesburg, VA, Substantial damage. Accident pilot [privacy data omitted] legally changed his name to [privacy data omitted]. He has not notified the FAA of this change however this narrative,… ## Docket (6 files) The files NTSB released with the investigation on December 11, 2018, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=95042. 796 KB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 318 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469212&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Record of Conversation - Pilot (item 2, .PDF, 70 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469247&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20Pilot-Master.PDF - Maintenance Records (item 3, .PDF, 64 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469248&FileExtension=.PDF&FileName=Maintenance%20Records-Master.PDF - Carburetor Icing Probability Chart (item 4, .PDF, 67 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469249&FileExtension=.PDF&FileName=Carburetor%20Icing%20Probability%20Chart-Master.PDF - Photos (item 5, .PDF, 242 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469250&FileExtension=.PDF&FileName=Photos-Master.PDF - Memorandum for Record- Engine Examination (NTSB) (item 6, .PDF, 35 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469251&FileExtension=.PDF&FileName=Memorandum%20for%20Record-%20Engine%20Examination%20(NTSB)-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.