# NTSB ERA19LA097: Piper PA28, N9219J, Vero Beach, FL, February 8, 2019 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: February 8, 2019, 17:06 local (22:06 UTC) - Place: Vero Beach, FL - Coordinates: 27.664167, -80.42472 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=27.6642&lon=-80.4247&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 August 10, 2020 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 98968 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA19LA097 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/98968/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=98968 - Page: https://openairdocs.org/ntsb/ERA19LA097 ## Probable cause The pilot's failure to use carburetor heat while operating the airplane in weather conditions and at engine power settings conducive to the formation of carburetor ice, which resulted in a loss of engine power due to carburetor icing and the subsequent forced landing. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-28-161, 12 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=7102803), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) - [Temp/humidity/pressure: conducive to carburetor icing](https://openairdocs.org/ntsb-findings/03031030): Environmental issues › Conditions/weather/phenomena · Contributed to outcome (probable cause); cases with it: [Piper PA-28-161, 6 cases](https://openairdocs.org/ntsb-findings/03031030/cases.md?model=7102803), [All aircraft, 435 cases](https://openairdocs.org/ntsb-findings/03031030/cases.md) - [Object/animal/substance: pole](https://openairdocs.org/ntsb-findings/03022010): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Piper PA-28-161, 4 cases](https://openairdocs.org/ntsb-findings/03022010/cases.md?model=7102803), [All aircraft, 142 cases](https://openairdocs.org/ntsb-findings/03022010/cases.md) - [Object/animal/substance: tree(s)](https://openairdocs.org/ntsb-findings/03022020): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Piper PA-28-161, 9 cases](https://openairdocs.org/ntsb-findings/03022020/cases.md?model=7102803), [All aircraft, 933 cases](https://openairdocs.org/ntsb-findings/03022020/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: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Piper PA-28-161, 22 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=7102803), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Landing: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Piper PA-28-161, 19 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=7102803), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) ## Analysis The pilot was flying in the airport traffic pattern practicing touch-and-go landing maneuvers. On his third approach, the air traffic controller directed him to extend the downwind leg of the traffic pattern. On final approach, the engine rpm dropped, and the pilot felt the airplane "sinking." The pilot did not perform any checklists but advised air traffic control that he would be making an emergency landing and advanced the throttle lever. The engine momentarily produced more power but then lost total power when the airplane was about 500-600 ft above ground level; the propeller windmilled. The pilot did not attempt to perform any other remedial actions, such as applying carburetor heat, to restore power and executed a forced landing on a nearby gravel road. During the landing, the airplane impacted a utility pole and trees and sustained substantial damage to the wings and stabilator. Postaccident examination of the engine, which included a successful engine test run, revealed no evidence of any preimpact malfunctions or failures that would have precluded normal operation. The weather conditions at the time of the accident were conducive to serious carburetor icing at descent engine power settings. Because postaccident examination of the engine revealed no anomalies, it is likely that the loss of engine power was a result of carburetor ice accumulation. When asked, the pilot stated that carburetor heat was only appropriate for simulated engine-out procedures. However, according to the pilot's operating handbook for the airplane make/model, carburetor heat should be used, if required, during a normal descent. The pilot failed to properly assess that conditions were conducive to carburetor icing and apply carburetor heat before the reduction in engine power. ## Factual narrative According to the normal procedures section of the airplane's Pilot's Operating Handbook (POH), the fourth step that should be performed as part of the normal descent is: Carburetor Heat . . . . . . ON if required. Review of the POH amplified emergency procedures for engine roughness revealed, "Engine roughness is usually due to carburetor icing which is indicated by a drop in RPM and may be accompanied by a slight loss of airspeed or altitude. If too much ice is allowed to accumulate, restoration of full power may not be possible; therefore, prompt action is required. Turn carburetor heat on. RPM will decrease slightly and roughness will increase. Wait for a decrease in engine roughness or an increased in RPM, indicating ice removal. If there is no change in approximately one minutes, return the carburetor heat to OFF." According to the emergency procedures section of the POH, the following are the first three steps that should be performed in the event of engine roughness in flight: Carburetor Heat . . . . . . . ON If roughness continues after one minute: Carburetor Heat . . . . . . . OFF According to the emergency procedures section of the POH, the fourth action that should be performed in the event of an engine power loss in flight was: Carburetor Heat . . . . . . . ON. On February 8, 2019, at 1706 eastern standard time, a Piper PA-28-161, N9219J, was substantially damaged when it impacted a utility pole and trees during a forced landing near Vero Beach, Florida. The private pilot was uninjured. The airplane was registered to FlightSafety International and operated as a Title 14 Code of Federal Regulations Part 91 personal flight. Visual meteorological conditions prevailed at the time of the accident and no flight plan was filed for local flight that originated from the Vero Beach Regional Airport (VRB), Vero Beach, Florida. According to the pilot, he was flying in the airport traffic pattern to practice touch-and-go landing maneuvers. On his third approach, the air traffic controller directed him to extend the downwind leg of the traffic pattern. On final approach, the engine power output decreased, and the pilot noted a "sinking" feeling. He stated that he did not perform any checklists but advised air traffic control that he would be making an emergency landing. He advanced the throttle lever, and the engine momentarily produced more power before losing total power about 500-600 ft above ground level (agl) while the propeller continued to windmill. The pilot stated that he was not using Carburetor Heat at the time and that there was no time to perform remedial actions such as switching fuel tanks, applying carburetor heat, or using the emergency checklist, but that he did retract the fully-extended flaps. When he determined that he would not reach the runway, he executed a forced landing on a nearby gravel road. During the landing, the airplane impacted a utility pole, trees, and shrubs, coming to rest in the grass after rotating 180°. Ina post-accident interview, when asked when he typically applied carburetor heat, the pilot responded that the it was appropriate to apply carburetor heat when practicing a simulated engine out procedure. When asked if there were other instances when it might be appropriate to use carburetor heat, he reiterated that it was only appropriate for simulated engine out procedures. At 1653, the reported weather at VRB included overcast clouds at 5,500 ft agl, 10 miles visibility, and wind from 050° at 9 knots. The temperature was 23° C, the dew point was 17° C, and the altimeter setting was 30.20 inches of mercury. The calculated relative humidity at this temperature and dewpoint was 71%. A High Resolution Rapid Refresh numerical model for the time of the accident was obtained from archive data at the NOAA Air Resource Laboratory over the accident site coordinates. The sounding depicted a temperature inversion due to subsidence at 6,724 ft with drying conditions immediately above the inversion. The Rawinsonde Observation algorithm indicated a high probability of carburetor icing from the surface to the inversion or through 5,000 ft. According to a Carburetor Icing-Probability Chart recommended by the Australian Transport Safety Bureau, the atmospheric conditions at the time of the accident were "conducive to moderate icing at cruise power and serious icing at descent power." FAA Advisory Circular 20-113 explains, "To prevent accidents due to induction system icing, the pilot should regularly use [carburetor] heat under conditions known to be conducive to atmospheric icing and be alert at all times for indications of icing in the fuel system." According to Federal Aviation Administration (FAA) records, the pilot held a private pilot certificate with a rating for airplane single-engine land. He was issued an FAA first-class medical certificate with no limitations on November 18, 2017. A review of the pilot's logbook revealed 128 total hours of flight experience, all of which were in the accident airplane make and model. The four-seat, single-engine, low-wing, fixed landing gear-equipped airplane was manufactured in 1988 and powered by a Lycoming O-320-D3 engine, rated to produce 160 horsepower. Its most recent Approved Airworthiness Inspection Program inspection was completed on February 7, 2019, at 14,682 aircraft hours. The engine had accrued 9,211 total hours of operation; of which, 431 hours were since the last major overhaul. The operator's records indicated the airplane had been flown 10.3 hours since the last inspection. The left-wing leading edge showed inward crushing. The left flap was impact damaged in an upward direction. The left outer 18-inches of the stabilator was bent upward about 15°. The right wingtip was crushed and the right-wing leading edge, inboard of the right fuel tank, was fractured back to the main spar as a result of utility pole impact. The landing gear was fractured off and one propeller blade was bent aft. The propellersexhibited no rotational scoring. The external engine exam revealed no impact damage. The spark plugs were removed and visually examined with no anomalies noted. Rotation of the engine's crankshaft produced compression on all four cylinders. Valvetrain movement was observed when the crankshaft was rotated, and the impulse couplings could be heard from the magnetos. Examination of the cylinders with a lighted borescope revealed no damage to the cylinder walls or pistons. Fuel was present throughout the fuel system, carburetor, and fuel filter. The fuel was blue, clear, and consistent with 100-low-lead aviation fuel. Mechanics employed by the operator installed a loaner propeller on the engine in order to perform an engine test run under the supervision of an NTSB investigator. The engine started after the first rotation of the propeller and no anomalies were noted in the engine operation. The magnetos, primer, and carburetor heat were tested, and no anomalies were noted. The test run was accomplished utilizing fuel plumbed from the left fuel tank. Air was blown through the fuel lines from the right fuel tank indicating that no obstructions were present in those lines. In addition, the gascolator fuel screen was removed, examined and found to be clean and free of debris. ## Aircraft - Registration: [N9219J](https://openairdocs.org/deregistered/N9219J-2019-09-16), registration cancelled 2019-09-16, S/N 2841028, built 1988 (OpenAirDocs) - Reported make and model: PIPER PA28 (161) - Registry model: [Piper PA-28-161](https://openairdocs.org/model/piper-pa-28-161) (registry code 7102803) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 2841028 - Year built: 1988 - Airframe hours: 14682.5 - Engines: Lycoming O-320-D3G 160 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: FlightSafety International - Registered owner: FlightSafety International - Airworthiness certificate: Standard, Normal; Standard, Utility - Last inspection: AAIP, February 7, 2019, 10 hours before - Departed: VRB, Vero Beach, FL - Destination: VRB, Vero Beach, FL - Airport: VRB, Vero Beach Rgnl - 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; medical: class 1, without waivers/limitations; last flight review November 19, 2018; seat: left; restraint: 3-point; flight hours: 128 total, 128 in this make and model, 62 as pilot in command, 55 in the last 90 days, 28 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 50° at 9 knots - Visibility: 10 statute miles - Lowest ceiling: 5,500 ft overcast - Temperature: 73 °F, dew point 63 °F - Altimeter: 30.20 inHg - Observed at: VRB, 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 20190208010019A](https://openairdocs.org/incident/20190208010019A), Feb 8, 2019: Piper PA-28-161, Vero Beach, FL, Substantial damage. A private rated airplane pilot on a solo flight for commercial airplane training experienced engine roughness on final approach for runway 12 left while flying… ## Docket (10 files) The files NTSB released with the investigation on April 11, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=98968. 6.2 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 682 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471827&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Pilot Interviews and Statement (item 2, .PDF, 589 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471828&FileExtension=.PDF&FileName=Pilot%20Interviews%20and%20Statement-Master.PDF - Memorandum of Record Pilot Interview Correction (item 3, .PDF, 51 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40485432&FileExtension=.PDF&FileName=Memorandum%20of%20Record%20Pilot%20Interview%20Correction-Master.PDF - FAA Inspector's Statement (item 4, .PDF, 62 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471829&FileExtension=.PDF&FileName=FAA%20Inspector%27s%20Statement-Master.PDF - Meteorology Specialist Report (item 5, .PDF, 584 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471830&FileExtension=.PDF&FileName=Meteorology%20Specialist%20Report-Master.PDF - Weather Reports and Records (item 6, .PDF, 172 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471831&FileExtension=.PDF&FileName=Weather%20Reports%20and%20Records-Master.PDF - Investigative Photographs (item 7, .PDF, 8 photos, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471832&FileExtension=.PDF&FileName=Investigative%20Photographs-Master.PDF - Airframe and Engine Examination Notes (item 8, .PDF, 10 photos, 679 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471833&FileExtension=.PDF&FileName=Airframe%20and%20Engine%20Examination%20Notes-Master.PDF - PA28 Pilot Operating Handbook Excerpts (item 9, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471834&FileExtension=.PDF&FileName=PA28%20Pilot%20Operating%20Handbook%20Excerpts-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 10, .PDF, 76 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471835&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-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.