# NTSB ERA19LA162: Piper PA28, N3031W, Melbourne, FL, April 29, 2019 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: April 29, 2019, 13:05 local (17:05 UTC) - Place: Melbourne, FL - Coordinates: 27.844392, -80.756156 - Nearby events: https://openairdocs.org/map.md?lat=27.8444&lon=-80.7562&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering: Fuel related](https://openairdocs.org/ntsb-events/190) - Highest injury: No injuries - Injuries: 2 uninjured - 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): 99351 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA19LA162 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99351/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99351 - Page: https://openairdocs.org/ntsb/ERA19LA162 ## Probable cause A partial loss of engine power due to carburetor icing, and the flight instructor’s failure to effectively use carburetor heat while operating at an idle engine power setting in conditions conducive to carburetor icing. ## 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-28-161, 6 cases](https://openairdocs.org/ntsb-findings/03031030/cases.md?model=7102803), [All aircraft, 435 cases](https://openairdocs.org/ntsb-findings/03031030/cases.md) - [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · Instructor/check pilot (probable cause); cases with it: [Piper PA-28-161, 8 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md?model=7102803), [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md) - [Ice/rain protection system: intake anti-ice, deice](https://openairdocs.org/ntsb-findings/01023020): Aircraft › Aircraft systems · Not used/operated (probable cause); cases with it: [Piper PA-28-161, 2 cases](https://openairdocs.org/ntsb-findings/01023020/cases.md?model=7102803), [All aircraft, 108 cases](https://openairdocs.org/ntsb-findings/01023020/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering: Fuel related](https://openairdocs.org/ntsb-events/190) (defining event); cases with it: [Piper PA-28-161, 4 cases](https://openairdocs.org/ntsb-events/190/sequence.md?model=7102803), [All aircraft, 361 cases](https://openairdocs.org/ntsb-events/190/sequence.md) - [Maneuvering: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342); cases with it: [Piper PA-28-161, 13 cases](https://openairdocs.org/ntsb-events/342/sequence.md?model=7102803), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) - [Maneuvering: 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 flight instructor and student pilot were practicing a simulated engine failure. After completing the emergency checklist, the student added engine power to recover from the maneuver about 500 ft above the ground, but the engine did not respond. The flight instructor took control of the airplane, verified the fuel selector position, and landed. The atmospheric conditions at the time of the accident were conducive to the development of carburetor icing at glide (idle) power settings, and the instructor reported that he did not apply carburetor heat during the simulated engine-out or attempted recovery. Based on the available information, it is likely that the loss of engine power was the result of the accumulation of carburetor ice during the idle-power descent and that the use of carburetor heat would likely have prevented the loss of engine power. ## Factual narrative On April 29, 2019, about 1305 eastern daylight time, a Piper PA-28-161, N3031W, was substantially damaged when it was involved in an accident near Melbourne, Florida. The student pilot and flight instructor were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The flight instructor stated that he and the student pilot departed to a nearby practice area to train emergency procedures. At 2,500 ft, they performed a simulated loss of engine power. The student pilot established best glide speed, identified a landing spot, and completed the checklist. At 500 ft, when the student added power to recover from the maneuver, the engine did not respond. The instructor took control of the airplane and verified the correct fuel selector position. The airplane continued to descend, and he landed on a brush-covered island surrounded by swamp. A Federal Aviation Administration (FAA) inspector traveled to the site and examined the airplane. The right wing was partially separated from the fuselage and there was leading edge damage to the right wing. The inspector noted fuel in both wing tanks. The flight instructor later reported to the FAA that he had overlooked the carburetor heat and did not apply it during the simulated loss of engine power or attempted recovery. Review of the icing probability chart contained within Federal Aviation Administration Special Airworthiness Information Bulletin CE-09-35 revealed that the atmospheric conditions at the time of the accident were "conducive to serious icing at glide [idle] power." ## Aircraft - Registration: [N3031W](https://openairdocs.org/aircraft/N3031W), registered now, S/N 28-7916348, built 1979 (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: 28-7916348 - Year built: 1979 - Airframe hours: 7933.6 - Engines: Lycoming O-320-D3G 160 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Operator: Paris Air Inc - Registered owner: Paris Air Inc - Airworthiness certificate: Special, Experimental (Special); Standard, Normal - Last inspection: 100 hour, March 6, 2019 - Departed: VRB, Vero Beach, FL - Destination: VRB, Vero Beach, FL - Equipment: Unknown ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 38; injuries: none; private, commercial, flight instructor; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; seat: right; flight hours: 560 total - Student pilot; injuries: none; student; medical: unknown, unknown; seat: left ## Weather - Conditions: Visual (VMC), Day - Wind: 70° at 13 knots - Visibility: 10 statute miles - Temperature: 82 °F, dew point 66 °F - Altimeter: 30.14 inHg - Observed at: VRB, 21 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 20190429003609A](https://openairdocs.org/incident/20190429003609A), Apr 29, 2019: Piper PA-28-161, Sebastian, FL, Substantial damage. Instructing student to perform a emergency decent, student recovered, proceeded to 2500 feet. Instructed student to perform emergency landing and approach, as… ## Docket (4 files) The files NTSB released with the investigation on May 18, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99351. 2.1 MB in all. - Pilot/operator aircraft accident report, memo for record (item 1, PDF, 1 page, 94 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11764066&FileExtension=pdf&FileName=MOR%20-%20Request%20for%206120-Rel.pdf - Pilot's statement (item 2, PDF, 2 pages, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11759462&FileExtension=pdf&FileName=Pilot%20Statements_Redacted-Rel.pdf - FAA inspector's statement (item 3, PDF, 1 page, 96 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11760137&FileExtension=pdf&FileName=ROC-%20FAA%20Inspector-Rel.pdf - Photos (item 4, PDF, 3 pages, 392 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11759220&FileExtension=pdf&FileName=Photos-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.