ERA17LA325

NTSB accident investigation · Beech C23 · Machias, ME · September 14, 2017

Accident · No injuriesLimited investigationFinal report
Date
September 14, 2017, 11:30 local (15:30 UTC)
Place
Machias, ME
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N2120WBeech C23
Defining event
Approach-VFR pattern base: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report April 8, 2019
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20170914019369A
Case key
96015

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The pilot's delay in applying carburetor heat, which resulted in a total loss of engine power due to carburetor icing.

Findings · 2

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Action: delayed actionPersonnel issues › Action/decision · PilotBeech C23: 4 casesAll aircraft: 894 casesProbable cause
Temp/humidity/pressure: conducive to carburetor icingEnvironmental issues › Conditions/weather/phenomena · Effect on equipmentBeech C23: 3 casesAll aircraft: 435 cases

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The private pilot descended the airplane to the destination airport but did not apply carburetor heat. While in the traffic pattern, as the airplane was turning onto a left base leg for the runway, the engine began to run roughly. The pilot then applied carburetor heat, but the engine lost total power. After realizing that the airplane was not going to glide to the runway threshold, the pilot performed a forced landing in a grassy area just short of the runway. During the landing, the nose gear collapsed and the airplane spun 180° before it came to rest, which resulted in substantial damage to the right wing. Examination of the wreckage did not reveal any evidence of preimpact mechanical malfunctions or failures of the ignition system, fuel system, or engine that would have precluded normal operation. The weather conditions at the time of the accident were conducive to the formation of serious carburetor icing at glide power. Although the Descent checklist in the pilot operating handbook for the airplane make and model instructed the pilot to use carburetor heat as required, the pilot did not apply carburetor heat before initiating the descent; rather, he waited until the engine began to run roughly. It is likely that the engine initially lost partial power after developing carburetor ice and that the pilot's delayed application of carburetor heat was ineffective at melting any accumulated ice.

Factual narrative

On September 14, 2017, about 1130 eastern daylight time, a Beech C23, N2120W, operated by Maine Instrument Flight, was substantially damaged during a forced landing, following a total loss of engine power while on approach to Machias Valley Airport (MVM), Machias, Maine. The private pilot was not injured. The instructional flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and a visual flight rules flight plan was filed for the flight that departed Augusta State Airport (AUG), Augusta, Maine, about 1015.The pilot was accruing cross-country flight experience for his commercial license. The pilot reported that he and his flight instructor reviewed his flight planning for a three-leg cross-country flight and he departed with full fuel. During the first leg, about 10 miles from MVM, the pilot descended the airplane to the airport traffic pattern altitude. While in the traffic pattern, as the airplane was turning on to a left base leg for the runway, the engine began to run rough. The pilot verified that the mixture was full rich and the fuel boost pump was on. He also applied carburetor heat, but the engine lost all power about 15 to 20 seconds later. The pilot then turned the airplane directly toward the runway, which resulted in a 45°-angle to the runway threshold. The pilot realized that the airplane was not going to glide all the way to the runway threshold and prepared to land in a grass area just prior to the runway. During the landing, the landing gear sank into soft ground and the nosewheel touched down hard, which collapsed the nose gear. The airplane spun 180° and came to rest upright in the grass area. Examination of the airplane by a Federal Aviation Administration (FAA) inspector revealed damage to the right wing spar. The inspector noted that 20 gallons of fuel per wing were removed from the airplane. The magnetos, fuel boost pump and engine driven fuel pump tested satisfactorily. The carburetor was intact and its screens were absent of debris. The fuel bowl was also absent of debris. The inspector rotated the propeller by hand and noted camshaft, crankshaft, and valve train continuity to the rear accessory section of the engine. Due to damage to the engine mounts and exhaust system, an engine test-run was not attempted. The inspector added that the engine had accumulated about 359 hours since major overhaul. Hancock County-Bar Harbor Airport (BHB), Bar Harbor, Maine was located about 40 miles west of the accident site. The recorded weather at BHB, at 1156, was: wind from 180° at 5 knots; visibility 10 miles; sky clear; temperature 24° C; dew point 17° C; altimeter 29.83 inches of mercury. Review of an FAA Carburetor Icing Probability Chart for the given weather conditions revealed, "Serious icing (glide power)." Review of a descent checklist from a pilot operating handbook for the make and model airplane revealed, "2. Carburetor Heat - FULL ON or FULLOFF, AS REQUIRED."

Aircraft

Registration
N2120W
Reported as
Beech C23 (NO SERIES)
Category
Airplane
Serial number
M-1492
Built
1973
Airframe hours
2,550
Engine
Lycoming O-360, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
Maine Instrument Flight
Registered owner
Maine Instrument Flight
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · July 13, 2017 · 11 hours before
Departed
AUG · Augusta, ME
Destination
MVM · Machias, ME
Flight plan
VFR
Airport
MVM · Machias Valley Airport, runway 36, 2,909 × 60 ft, asphalt
Equipment
Stall warning system

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
21
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Without waivers/limitations
Last flight review
August 1, 2017
Seat
Left
Restraint
4-point
Flight hours
155 total · 91 in this make and model · 87 as pilot in command · 8 in the last 90 days · 1 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
180° at 5 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
75 °F, dew point 63 °F
Altimeter
29.82 inHg
Observed at
BHB, 40 nm away

Docket · 6

The files NTSB released with the investigation on November 28, 2018, on NTSB’s docket system: statements, records, photos and specialists’ reports. 2.0 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.

Other investigations on N2120W · 1

Matched to the same aircraft by N-number and date.