ERA20LA126

NTSB accident investigation · Piper PA28 · Beverly, MA · March 12, 2020

Accident · Minor injuriesClass 3 · LimitedFinal report
Date
March 12, 2020, 16:22 local (20:22 UTC)
Place
Beverly, MA
Injuries
1 minor
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N656STPiper PA28
Defining event
Takeoff: Fuel related
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Eastern Region Aviation
Parties
FAA FSDO
FAA report
20200312000699A
Case key
101071

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

A loss of engine power due to carburetor icing, and the student pilot’s failure to utilize carburetor heat in conditions conducive to carburetor icing.

Findings · 4

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Temp/humidity/pressure: conducive to carburetor icingEnvironmental issues › Conditions/weather/phenomena · Effect on equipmentPiper PA-28-181: 6 casesAll aircraft: 435 casesProbable cause
Engine (reciprocating)Aircraft › Aircraft power plant · Not specifiedPiper PA-28-181: 3 casesAll aircraft: 497 cases
Action: lack of actionPersonnel issues › Action/decision · Student/instructed pilotPiper PA-28-181: 11 casesAll aircraft: 792 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The student pilot performed a power-off approach and touch-and-go landing, and during the initial climb, the engine lost partial power. He made a left turn to land on another runway at the airport; however, the airplane did not touch down until it was about ¾ down the runway. The airplane continued off the runway and came to rest in trees past the airport perimeter fence, resulting in substantial damage to the wings, horizontal stabilizer, and engine mounts. An examination of the wreckage revealed no evidence of pre-impact mechanical anomalies. The airplane was equipped with a carburetor ice detection system and both the control box and carburetor heat control lever were found in the off position. The pilot did not report using the carburetor heat during the flight. The atmospheric conditions at the time of the accident were conducive to serious icing at cruise power. Since no anomalies were noted during the engine examination, it is likely that the loss of engine power was a result of carburetor icing.

Factual narrative

On March 12, 2020, about 1622 eastern daylight time, a Piper PA28-181, N656ST, was substantially damaged when it was involved in an accident near Beverly, Massachusetts. The student pilot sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. According to the student pilot, he was practicing traffic pattern work on runway 16. He performed 5 or 6 touch-and-go landings before the accident. The approach before the accident takeoff was a power off-approach and landing, and the pilot subsequently applied power to takeoff. During the initial climb, when the airplane was about 500 ft above ground level, the engine lost power and the airplane would not climb. The pilot noted a drop in engine rpm from 2,500 to around 2,350, declared an emergency, and made a 270° left turn to attempt an emergency landing on runway 27. The airplane touched down on the last 1/4 of the runway, continuing across the grass and over a ditch before impacting trees near the airport property line. Data collected from the primary flight display (PFD) indicated an engine power setting of 2,430 rpm at 1618. At 1619, the rpm decreased to 2,350 and continued to decrease until impact. Calculated relative humidity at the time of the accident was 65%. Review of the icing probability chart contained within Federal Aviation Administration Special Airworthiness Information Bulletin CE-09-35 revealed that the atmospheric conditions were "conducive to serious icing at cruise power." A carburetor ice detection system was installed on the airplane, which comprised a control box mounted on the instrument panel, a probe sensor mounted to the carburetor, and red warning light to indicate the presence of ice in the carburetor. An examination of the system by a mechanic revealed that both the carburetor control lever and the detection system were in the off position. Additionally, the student pilot did not report using the carburetor heat or ice detection system. The airplane sustained substantial damage to both wings, the right aileron, horizontal stabilizers, and engine mounts. Postaccident examinations of the airframe and engine did not reveal any preimpact anomalies that would have contributed to a loss of engine power.

Aircraft

Registration
N656ST
Reported as
Piper PA28 (181)
Category
Airplane
Serial number
2843656
Built
2007
Airframe hours
4,114
Engine
Lycoming O-360-A4M, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
Beverly Flight Center Inc
Registered owner
Beverly Flight Center Inc
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · March 4, 2020 · 15.4 hours before
Airport
BVY · Beverly Rgnl, runway 27, 4,755 × 100 ft, asphalt
Equipment
Stall warning system, ADS-B, Auto-pilot, Electronic multifunction display, Electronic primary flight display

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Student pilot
Age
23
Injuries
Minor
Certificate
Student
Medical
Class 1, Without waivers/limitations
Seat
Left
Restraint
3-point
Flight hours
38 total · 38 in this make and model · 6 as pilot in command · 16 in the last 90 days · 5 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
100° at 6 knots
Visibility
10 statute miles
Lowest ceiling
6,000 ft overcast
Temperature
45 °F, dew point 34 °F
Altimeter
30.22 inHg
Observed at
BVY

Docket · 10

The files NTSB released with the investigation on March 17, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 19.0 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.