# NTSB ERA20LA126: Piper PA28, N656ST, Beverly, MA, March 12, 2020

- Type: NTSB accident investigation
- Classification: Accident · Minor injuries · Class 3 · Limited · Final report
- Date: March 12, 2020, 16:22 local (20:22 UTC)
- Place: Beverly, MA
- Coordinates: 42.579723, -70.926666 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=42.5797&lon=-70.9267&mi=10
- Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping)
- Defining event: [Takeoff: 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): 101071
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA20LA126
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/101071/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=101071
- Page: https://openairdocs.org/ntsb/ERA20LA126

## 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

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-28-181, 6 cases](https://openairdocs.org/ntsb-findings/03031030/cases.md?model=7102807), [All aircraft, 435 cases](https://openairdocs.org/ntsb-findings/03031030/cases.md)
- [Engine (reciprocating)](https://openairdocs.org/ntsb-findings/01058500): Aircraft › Aircraft power plant · Not specified; cases with it: [Piper PA-28-181, 3 cases](https://openairdocs.org/ntsb-findings/01058500/cases.md?model=7102807), [All aircraft, 497 cases](https://openairdocs.org/ntsb-findings/01058500/cases.md)
- [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · Student/instructed pilot (probable cause); cases with it: [Piper PA-28-181, 11 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md?model=7102807), [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-28-181, 2 cases](https://openairdocs.org/ntsb-findings/01023020/cases.md?model=7102807), [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.

- [Takeoff: Fuel related](https://openairdocs.org/ntsb-events/190) (defining event); cases with it: [Piper PA-28-181, 6 cases](https://openairdocs.org/ntsb-events/190/sequence.md?model=7102807), [All aircraft, 361 cases](https://openairdocs.org/ntsb-events/190/sequence.md)
- [Landing: Collision during takeoff/land](https://openairdocs.org/ntsb-events/490); cases with it: [Piper PA-28-181, 9 cases](https://openairdocs.org/ntsb-events/490/sequence.md?model=7102807), [All aircraft, 1,309 cases](https://openairdocs.org/ntsb-events/490/sequence.md)

## 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](https://openairdocs.org/deregistered/N656ST-2022-10-12), registration cancelled 2022-10-12, S/N 2843656, built 2007 (OpenAirDocs)
- Reported make and model: Piper PA28 (181)
- Registry model: [Piper PA-28-181](https://openairdocs.org/model/piper-pa-28-181) (registry code 7102832) (OpenAirDocs)
- Registry engine: [Lycoming O-360-A4M](https://openairdocs.org/engine/lycoming-o-360-a4m) (registry code 42276, 4 cycle) (OpenAirDocs)
- Category: Airplane
- Serial number: 2843656
- Year built: 2007
- Airframe hours: 4114
- Engines: 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

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Student pilot; age 23; injuries: minor; 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

## 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 20200312000699A](https://openairdocs.org/incident/20200312000699A), Mar 12, 2020: Piper Aircraft Inc PA-28-181, Danvers, MA, Destroyed. N656ST was conducting touch-and-go landings on runway 16. During the 5th takeoff, the pilot heard and felt a reduction of power from the engine at…

## Docket (10 files)

The files NTSB released with the investigation on March 17, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=101071. 19.0 MB in all.

- Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 5.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12903600&FileExtension=pdf&FileName=6120%20N656ST%20Signed_Redacted-Rel.pdf
- Student pilot statement (item 2, PDF, 1 page, 48 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13123601&FileExtension=pdf&FileName=N656ST%20Pilot%20Statement-Rel.pdf
- Pilot operating handbook (excerpt) (item 3, PDF, 2 pages, 4.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13124153&FileExtension=pdf&FileName=N656ST%20POH%20Carb%20Ice%20Detection_Redacted-Rel.pdf
- Logbook excerpts (item 4, PDF, 3 pages, 3.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12902856&FileExtension=pdf&FileName=Memorandum%20for%20Record-N656ST%20Logbook%20Excerpts_Redacted-Rel.pdf
- Engine examination (item 5, PDF, 2 pages, 290 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12902479&FileExtension=pdf&FileName=Memorandum%20for%20Record-N656ST%20Engine%20Exam_Redacted-Rel.pdf
- Meteorology factual (item 6, PDF, 7 pages, 517 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11639253&FileExtension=pdf&FileName=ERA20LA126%20-%20Beverly,%20MA%20Wx%20Factual-Rel.pdf
- Investigative photographs (item 7, PDF, 4 pages, 829 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13127813&FileExtension=pdf&FileName=Investigative%20Photographs%20-%20ERA20LA126-Rel.pdf
- Cockpit display - specialist's factual report (item 8, PDF, 12 pages, 2.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11990034&FileExtension=pdf&FileName=Cockpit%20Display%20-%20Specialist%27s%20Factual%20Report-Rel.pdf
- Attachment 1 to cockpit display - specialist's factual report -- tabular data (item 9, CSV, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11991400&FileExtension=csv&FileName=Attachment%201%20to%20Cockpit%20Display%20-%20Specialist%27s%20Factual%20Report%20--%20Tabular%20Data-Rel.csv
- Attachment 2 to cockpit display - specialist's factual report -- tabular data (item 10, CSV, 49 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11991083&FileExtension=csv&FileName=Attachment%202%20to%20Cockpit%20Display%20-%20Specialist%27s%20Factual%20Report%20--%20Tabular%20Data-Rel.csv

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.

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