# NTSB ERA17LA325: Beech C23, N2120W, Machias, ME, September 14, 2017 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: September 14, 2017, 11:30 local (15:30 UTC) - Place: Machias, ME - Coordinates: 44.703056, -67.478614 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=44.7031&lon=-67.4786&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-VFR pattern base: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report April 8, 2019 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 96015 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA17LA325 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/96015/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=96015 - Page: https://openairdocs.org/ntsb/ERA17LA325 ## Probable cause The pilot's delay in applying carburetor heat, which resulted in a total loss of engine power due to carburetor icing. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Action: delayed action](https://openairdocs.org/ntsb-findings/02041025): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Beech C23, 4 cases](https://openairdocs.org/ntsb-findings/02041025/cases.md?model=1151242), [All aircraft, 894 cases](https://openairdocs.org/ntsb-findings/02041025/cases.md) - [Temp/humidity/pressure: conducive to carburetor icing](https://openairdocs.org/ntsb-findings/03031030): Environmental issues › Conditions/weather/phenomena · Effect on equipment; cases with it: [Beech C23, 3 cases](https://openairdocs.org/ntsb-findings/03031030/cases.md?model=1151242), [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 base: Fuel related](https://openairdocs.org/ntsb-events/190); cases with it: [Beech C23, 3 cases](https://openairdocs.org/ntsb-events/190/sequence.md?model=1151242), [All aircraft, 361 cases](https://openairdocs.org/ntsb-events/190/sequence.md) - [Approach-VFR pattern base: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Beech C23, 10 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=1151242), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Beech C23, 5 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=1151242), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing: Landing gear collapse](https://openairdocs.org/ntsb-events/094); cases with it: [Beech C23, 6 cases](https://openairdocs.org/ntsb-events/094/sequence.md?model=1151242), [All aircraft, 1,787 cases](https://openairdocs.org/ntsb-events/094/sequence.md) - [Landing: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Beech C23, 25 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=1151242), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/deregistered/N2120W-2018-03-08), registration cancelled 2018-03-08, S/N M-1492, built 1973 (OpenAirDocs) - Reported make and model: BEECH C23 (NO SERIES) - Registry model: [Beech C23](https://openairdocs.org/model/beech-c23) (registry code 1151242) (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: M-1492 - Year built: 1973 - Airframe hours: 2550 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 21; injuries: none; 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 ## 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 20170914019369A](https://openairdocs.org/incident/20170914019369A), Sep 14, 2017: Beech C23, Machias, ME, Substantial damage. Thursday morning , September 14, 2017, pilot prepared a cross country flight departing kaug to Kmvm, klrg and back to kaug. Pilot had gone over his flight plan… ## Other investigations on N2120W (1) 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. - [NTSB IAD75AI011](https://openairdocs.org/ntsb/IAD75AI011), Sep 8, 1974: Beech C23 (N2120W), Norfolk, VA, no damage ## Docket (6 files) The files NTSB released with the investigation on November 28, 2018, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=96015. 2.0 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 647 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468624&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Interview Summaries (item 2, .PDF, 67 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468625&FileExtension=.PDF&FileName=Interview%20Summaries-Master.PDF - Excerpt from Pilot Operating Handbook (item 3, .PDF, 116 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468626&FileExtension=.PDF&FileName=Excerpt%20from%20Pilot%20Operating%20Handbook-Master.PDF - Weather Report (item 4, .PDF, 126 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468627&FileExtension=.PDF&FileName=Weather%20Report-Master.PDF - FAA Carburetor Icing Chart (item 5, .PDF, 66 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468628&FileExtension=.PDF&FileName=FAA%20Carburetor%20Icing%20Chart-Master.PDF - Photo Array (item 6, .PDF, 3 photos, 939 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468629&FileExtension=.PDF&FileName=Photo%20Array-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.