# NTSB ERA19LA151: Cessna 150, N3795J, Fulton, NY, April 11, 2019 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Class 3 · Limited · Final report - Date: April 11, 2019, 14:30 local (18:30 UTC) - Place: Fulton, NY - Coordinates: 43.329166, -76.413887 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=43.3292&lon=-76.4139&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: Serious injuries - Injuries: 1 serious - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO, Continental Aero Technologies, Textron Aviation Inc - SAIBs cited in the narratives: [SAIB CE-09-35](https://openairdocs.org/saib/CE-09-35) (OpenAirDocs) - NTSB case key (mKey): 99259 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA19LA151 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99259/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99259 - Page: https://openairdocs.org/ntsb/ERA19LA151 ## Probable cause A total loss of engine power due to carburetor icing. Contributing was the pilot’s failure to leave the carburetor heat on fully after his initial application of carburetor heat. ## 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 · Contributed to outcome (probable cause); cases with it: [Cessna 150G, 4 cases](https://openairdocs.org/ntsb-findings/03031030/cases.md?model=2071816), [All aircraft, 435 cases](https://openairdocs.org/ntsb-findings/03031030/cases.md) - [Action: incorrect action performance](https://openairdocs.org/ntsb-findings/02041015): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Cessna 150G, 1 case](https://openairdocs.org/ntsb-findings/02041015/cases.md?model=2071816), [All aircraft, 1,386 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md) - [Ice/rain protection system: intake anti-ice, deice](https://openairdocs.org/ntsb-findings/01023020): Aircraft › Aircraft systems · Incorrect use/operation (probable cause); cases with it: [Cessna 150G, 1 case](https://openairdocs.org/ntsb-findings/01023020/cases.md?model=2071816), [All aircraft, 108 cases](https://openairdocs.org/ntsb-findings/01023020/cases.md) - [Info processing/decision: identification/recognition](https://openairdocs.org/ntsb-findings/02041510): Personnel issues › Action/decision · Pilot; cases with it: [Cessna 150G, 1 case](https://openairdocs.org/ntsb-findings/02041510/cases.md?model=2071816), [All aircraft, 559 cases](https://openairdocs.org/ntsb-findings/02041510/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: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Cessna 150G, 14 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=2071816), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Approach-VFR pattern base: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Cessna 150G, 13 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=2071816), [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: [Cessna 150G, 23 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2071816), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis After descending with the engine power above 2,000 rpm, the pilot entered the traffic pattern for the destination airport. Just after turning onto the base leg of the pattern, the pilot applied the carburetor heat and the engine “faltered” and lost partial power. The pilot then deactivated the carburetor heat, and the engine regained some power. He reapplied the carburetor heat, and the engine stopped. He attempted to restart the engine but was unsuccessful. While performing a forced landing to a road, the right wing impacted a utility pole and the airplane rolled over and sustained substantial damage to both wings and the fuselage. The weather conditions at the time of the accident were favorable for carburetor icing at altitude and at the surface. It is likely that carburetor ice developed during the descent; when the pilot applied the carburetor heat while in the traffic pattern, the ice began to melt, which introduced water into the engine intake and resulted in the engine losing partial power. The pilot’s subsequent cycling of the carburetor heat at a relatively low power setting likely resulted in the total loss of engine power. ## Factual narrative On April 11, 2019, about 1430 eastern daylight time, a Cessna 150G, N3795J, was substantially damaged when it was involved in an accident near Fulton, New York. The private pilot received serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that the airplane was last flown on July 21, 2018. The airplane had a supplemental type certificate for the use of automotive fuel, but the pilot kept it stored with 100LL aviation fuel. Before the accident flight, he added fewer than 5 gallons of 100LL aviation fuel to top off both tanks before departure. The 2-hour flight was uneventful, and he reduced engine power for the descent, but it remained above 2,000 rpm. Just after turning onto the base leg of the traffic pattern for landing, the pilot applied the carburetor heat as he prepared to reduce the engine power below 2,000 rpm. As soon as he applied the carburetor heat, the engine “faltered” and lost partial power. The engine noise decreased but did not cease. He then pushed the carburetor heat fully off, and the engine seemed to regain some, but not all, power. He then reapplied the carburetor heat and the engine lost all power. The pilot performed a forced landing to a road in a populated area about 1.3 nautical miles from the end of the runway. During landing, the right wing impacted a utility pole, and the airplane came to rest inverted with both wings partially separated from the fuselage. Examination of the wreckage by a Federal Aviation Administration (FAA) inspector revealed substantial damage to both wings and the fuselage. First responders observed fuel on the roadway and leaking from the airplane upon their arrival. The fuel selector was found in the “on” position. Engine crankshaft, valvetrain, and accessory gear continuity were confirmed when the crankshaft was rotated by hand. The exhaust, induction, and carburetor heat exchanger components were intact and showed no indication of leaks. Due to impact damage, the carburetor heat cable could not be tested; however, the control arm on the induction airbox operated normally. Both magnetos produced spark on all towers when rotated, and the ignition harness remained intact, with some damage noted to the Nos. 1 and 3 leads at the top spark plug ends. The spark plugs on cylinder Nos. 1 and 3 were oil-soaked. There was no sooting observed on any of the spark plugs and all insulators were appeared white in color. The carburetor floats, inlet valve jets, and accelerator pump were intact. The inlet screen was clear of any contaminants. The inlet valve functioned properly when air pressure was applied to the fuel inlet while float assembly was exercised up and down. A computer model of the weather conditions in the area of the accident site around the accident time indicated conditions favorable to the development of carburetor icing from the surface to 13,000 ft mean sea level at glide and cruise power settings. According toFAA Special Airworthiness Information Bulletin CE-09-35: Pilots should be aware that carburetor icing doesn’t just occur in freezing conditions, it can occur at temperatures well above freezing temperatures when there is visible moisture or high humidity. Icing can occur in the carburetor at temperatures above freezing because vaporization of fuel, combined with the expansion of air as it flows through the carburetor, (Venturi Effect) causes sudden cooling, sometimes by a significant amount within a fraction of a second. Carburetor ice can be detected by a drop in rpm in fixed pitch propeller airplanes and a drop in manifold pressure in constant speed propeller airplanes. In both types, usually there will be a roughness in engine operation… To recognize carburetor icing, the warning signs are: • A drop in rpm in fixed pitch propeller airplanes. • A drop in manifold pressure in constant speed propeller airplanes. • In both types, usually there will be a roughness in engine operation. The pilot should respond to carburetor icing by applying full carburetor heat immediately. The engine may run rough initially for short time while ice melts. ## Aircraft - Registration: [N3795J](https://openairdocs.org/deregistered/N3795J-2019-12-30), registration cancelled 2019-12-30, S/N 15065095, built 1966 (OpenAirDocs) - Reported make and model: Cessna 150 (G) - Registry model: [Cessna 150G](https://openairdocs.org/model/cessna-150g) (registry code 2071816) (OpenAirDocs) - Registry engine: [Continental 0-200 series](https://openairdocs.org/engine/continental-0-200-series) (registry code 17020, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 15065095 - Year built: 1966 - Airframe hours: 3583 - Engines: Continental O-200-A 100 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Utility - Last inspection: Annual, October 28, 2018, 2 hours before - Departed: MAL, Malone, NY - Destination: FZY, Fulton, NY - Flight plan: VFR - Airport: FZY, Oswego County, runway 06, 3,997 × 100 ft, asphalt - Equipment: Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 49; injuries: serious; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; last flight review January 18, 2019; seat: left; restraint: 4-point; flight hours: 147 total, 33 in this make and model, 62 as pilot in command, 3 in the last 90 days, 3 in the last 30 days, 3 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 340° at 4 knots - Visibility: 10 statute miles - Lowest ceiling: 6,500 ft overcast - Temperature: 41 °F, dew point 21 °F - Altimeter: 30.22 inHg - Observed at: FZY, 2 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 20190411023629A](https://openairdocs.org/incident/20190411023629A), Apr 11, 2019: Cessna 150G, Fulton, NY, Substantial damage. On approch to kfzy pilot stated he turned on the carburator heat and the engine lost power. He then turned heat off and power restored for a few seconds, then… ## Other investigations on N3795J (2) 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 NYC71DFA10](https://openairdocs.org/ntsb/NYC71DFA10), Aug 22, 1970: Cessna 150 (N3795J), Fowler, NY, substantial damage - [NTSB NYC70DFA10](https://openairdocs.org/ntsb/NYC70DFA10), Feb 28, 1970: Cessna 150 (N3795J), Gouverneur, NY, substantial damage ## Docket (8 files) The files NTSB released with the investigation on December 9, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99259. 39.9 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12513362&FileExtension=pdf&FileName=01-01%206120_1w-Simpson-N3795J_reduced_print_Redacted-Rel.pdf - Record of conversation with pilot (item 2, PDF, 1 page, 210 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12512396&FileExtension=pdf&FileName=01-02%20Memorandum%20for%20Record%20-%20conversation%20with%20pilot_ERA19LA151-Rel.pdf - Record of conversation - FAA inspector (item 3, PDF, 1 page, 209 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12513032&FileExtension=pdf&FileName=01-03%20Memorandum%20for%20Record%20-%20conversation%20with%20FAA%20Inspector_ERA19LA151-Rel.pdf - Maintenance log excerpts (item 4, PDF, 2 pages, 8.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12512946&FileExtension=pdf&FileName=03-01%20Maintenance%20Log%20Excerpts_Redacted-Rel.pdf - Weather reports and records (item 5, PDF, 6 pages, 463 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12512592&FileExtension=pdf&FileName=04-01%20Weather%20Information_ERA19LA151-Rel.pdf - Manufacturer engine examination report (item 6, PDF, 21 pages, 28.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12513472&FileExtension=pdf&FileName=06-04%20Continental%20N3795J%20Engine%20Examination%20Report_print_Redacted-Rel.pdf - Statement of party representatives to NTSB investigation (item 7, PDF, 2 pages, 484 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12512602&FileExtension=pdf&FileName=09-01%20Statement%20of%20Party%20Representatives_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 8, PDF, 1 page, 50 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12513592&FileExtension=pdf&FileName=09-02%20Wreckage%20Release_Redacted-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.