# NTSB ERA19LA021: Piper PA28, N3631K, Plant City, FL, October 18, 2018 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Class 3 · Limited · Final report - Date: October 18, 2018, 14:05 local (18:05 UTC) - Place: Plant City, FL - Coordinates: 28.000278, -82.16333 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=28.0003&lon=-82.1633&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Fuel related](https://openairdocs.org/ntsb-events/190) - Highest injury: Minor injuries - Injuries: 1 minor - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - 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): 98519 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA19LA021 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/98519/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=98519 - Page: https://openairdocs.org/ntsb/ERA19LA021 ## Probable cause The pilot’s failure to utilize carburetor heat in conditions conducive to the formation of carburetor icing, which resulted in a total loss of engine power. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Temp/humidity/pressure: conducive to carburetor icing](https://openairdocs.org/ntsb-findings/03031030): Environmental issues › Conditions/weather/phenomena · Effect on equipment (probable cause); cases with it: [Piper PA-28-140, 10 cases](https://openairdocs.org/ntsb-findings/03031030/cases.md?model=7102802), [All aircraft, 435 cases](https://openairdocs.org/ntsb-findings/03031030/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA-28-140, 43 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=7102802), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Fuel related](https://openairdocs.org/ntsb-events/190) (defining event); cases with it: [Piper PA-28-140, 8 cases](https://openairdocs.org/ntsb-events/190/sequence.md?model=7102802), [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-28-140, 56 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=7102802), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-28-140, 137 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102802), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot reported that he was practicing flight maneuvers before returning to the departure airport. As he approached the airport, he entered on the downwind leg of the traffic pattern for a touch-and-go landing. After the touch-and-go landing, while the airplane was climbing out and accelerating, the engine began to “sputtering” several times and then lost power completely. The pilot performed a forced landing to trees below and the airplane’s wings and fuselage were substantially damaged. Postaccident examination of the engine did not reveal evidence of any mechanical malfunctions or failures that would have precluded normal operation. Based on the pilot’s description of the fuel onboard at the time he departed, and the duration of the flight, sufficient fuel should have been available when the loss of engine power occurred. The pilot also reported that at the time of the loss of engine power, the carburetor heat was off. He did not report activating it prior to or following the time the engine began losing power. The temperature and dew point at the time of the accident was conducive to the formation of carburetor icing. Given this information, it is likely that the loss of engine power was due to the formation of carburetor ice during the approach to landing and subsequent takeoff. ## Factual narrative On October 18, 2018, about 1405 eastern daylight time, a Piper PA-28-140, N3631K, sustained substantial damage when it was involved in an accident near Plant City, Florida. The commercial pilot sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. Before departure, the pilot conducted a preflight inspection, and no anomalies were noted. The pilot also recalled that all pre-takeoff checks were normal, and there were 6 quarts of oil in the engine. He confirmed that both fuel tanks were full, which amounted to 18 gallons in each tank. The pilot was practicing flight maneuvers that consisted of visual approaches, pattern work and landings at Plant City Airport (PCM), Plant City, Florida. After takeoff from PCM, and about 45 minutes into the flight, the pilot switched fuel tanks from the right tank to the left tank. After finishing his flight maneuvers, he proceeded back to PCM and entered on the downwind leg of the traffic pattern for runway 10 for a touch-and-go landing. After the touch-and-go landing, while climbing out and accelerating to 85 mph, the engine “sputtered” several times. The pilot leveled off the airplane about 400 ft mean sea level and checked the engine indications and controls, with all appearing normal. The carburetor heat was off, and the pilot did not activate it before or during the loss of engine power. The engine then lost power completely. The pilot was unable to turn the airplane due to the low airspeed and performed a forced landing into the trees below. The pilot exited the airplane and waited for emergency services to arrive. Pictures taken at the accident site showed that the airplane sustained substantial damage to the wings and fuselage. The left wing was broken away from the fuselage, and the right wing and cabin section buckled. Postaccident examination of the engine revealed that while the engine could not be test run due to damage sustained during the accident, no mechanical anomalies were discovered that would have prevented normal operation. The weather conditions at PCM about the time of the accident included a temperature of 33° C, and a dew point of 20° C. Review of the icing probability chart contained within Federal Aviation Administration Special Airworthiness Information Bulletin CE-09-35 revealed the atmospheric conditions at the time of the accident were conducive to the formation of carburetor icing at cruise and serious icing at glide power settings. ## Aircraft - Registration: [N3631K](https://openairdocs.org/deregistered/N3631K-2020-02-21), registration cancelled 2020-02-21, S/N 28-23661, built 1967 (OpenAirDocs) - Reported make and model: Piper PA28 (140) - Registry model: [Piper PA-28-140](https://openairdocs.org/model/piper-pa-28-140) (registry code 7102802) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-23661 - Year built: 1967 - Airframe hours: 5312 - Engines: Lycoming 320-E2A 160 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, June 15, 2018, 19 hours before - Departed: PCM, Plant City, FL - Destination: PCM, Plant City, FL - Airport: PCM, Plant City, runway 10, 3,950 × 75 ft, asphalt - Equipment: Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 76; injuries: minor; commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; last flight review June 18, 2018; seat: left; restraint: lap only; flight hours: 4,839 total, 538 in this make and model, 3,000 as pilot in command, 14 in the last 90 days, 5 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 60° at 9 knots - Visibility: 10 statute miles - Lowest ceiling: 4,700 ft broken - Temperature: 91 °F, dew point 68 °F - Altimeter: 30.15 inHg - Observed at: KPCM ## 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 20181018020309A](https://openairdocs.org/incident/20181018020309A), Oct 18, 2018: Piper PA-28-140, Plant City, FL, Substantial damage. The pilot experience loss of power on climb out and the engine shut down. Aircraft landed in a wooded area on the airport. ## Docket (6 files) The files NTSB released with the investigation on July 15, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=98519. 11.3 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 6.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9411335&FileExtension=pdf&FileName=NTSB%20Report%206120_Redacted-Rel.pdf - Pilot's statement (item 2, PDF, 3 pages, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9411839&FileExtension=pdf&FileName=Pilot%20Statement%20LA021_Redacted-Rel.pdf - Maintenance records (item 3, PDF, 8 pages, 3.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9414171&FileExtension=pdf&FileName=Logbook%20pages_Redacted-Rel.pdf - Memorandum of record engine examination (item 4, PDF, 1 page, 105 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9413340&FileExtension=pdf&FileName=Memorandum%20Of%20Record%20engine%20examiantion%20review%20LA021-Rel.pdf - Memorandum of weather (item 5, PDF, 1 page, 95 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9411775&FileExtension=pdf&FileName=Memorandum%20of%20weather%20LA021-Rel.pdf - Photos (item 6, PDF, 1 page, 119 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9411879&FileExtension=pdf&FileName=Photo%20Array%20LA021-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.