# NTSB ERA20LA163: Piper PA28, N33005, East Hampton, NY, April 25, 2020 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: April 25, 2020, 13:40 local (17:40 UTC) - Place: East Hampton, NY · Field off departure end off runway 10 - Coordinates: 40.959445, -72.251663 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=40.9594&lon=-72.2517&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-VFR pattern downwind: Fuel related](https://openairdocs.org/ntsb-events/190) - Highest injury: No injuries - Injuries: 3 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): 101210 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA20LA163 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/101210/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=101210 - Page: https://openairdocs.org/ntsb/ERA20LA163 ## Probable cause The partial loss of engine power after takeoff due to the formation of carburetor ice while on the ground. Contributing to the accident was the pilot’s failure to apply 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 · Effect on equipment (probable cause); cases with it: [Piper PA-28-151, 4 cases](https://openairdocs.org/ntsb-findings/03031030/cases.md?model=7102805), [All aircraft, 435 cases](https://openairdocs.org/ntsb-findings/03031030/cases.md) - [Action: forgotten action/omission](https://openairdocs.org/ntsb-findings/02041035): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA-28-151, 1 case](https://openairdocs.org/ntsb-findings/02041035/cases.md?model=7102805), [All aircraft, 440 cases](https://openairdocs.org/ntsb-findings/02041035/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 downwind: Fuel related](https://openairdocs.org/ntsb-events/190) (defining event); cases with it: [Piper PA-28-151, 3 cases](https://openairdocs.org/ntsb-events/190/sequence.md?model=7102805), [All aircraft, 361 cases](https://openairdocs.org/ntsb-events/190/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Piper PA-28-151, 10 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=7102805), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing-landing roll: Runway excursion](https://openairdocs.org/ntsb-events/300); cases with it: [Piper PA-28-151, 12 cases](https://openairdocs.org/ntsb-events/300/sequence.md?model=7102805), [All aircraft, 3,643 cases](https://openairdocs.org/ntsb-events/300/sequence.md) - [Landing-landing roll: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-28-151, 22 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102805), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis During the climb after takeoff and with the throttle in the full throttle position, the pilot noticed a vibration and diminished engine power. At 400 or 500 ft mean seal level (msl), the engine began sputtering. The pilot maneuvered the airplane to return to the airport. When the airplane was at an altitude of 300 to 400 ft msl, the engine continued to sputter then experienced a total loss of power. The airplane descended, and the pilot made a right turn toward a runway. The airplane touched down about 3/4 down the runway, went off the end through a fence, and came to rest in a field. The airplane sustained substantial damage. Postaccident examination found no evidence of any preimpact mechanical failures or malfunctions of the airframe or engine that would preclude normal operation. After the examination, the engine was started and test run normally. Review of the meteorological conditions that existed around the time of the accident and a carburetor icing chart indicated that conditions were conducive to the formation of carburetor icing at glide (idle) and cruise power. Per the pilot’s operating handbook (POH), the pilot had turned off the carburetor heat after the pre-takeoff engine runup. Afterward, during the climb and despite experiencing a partial loss of power and engine roughness, the pilot did not turn on carburetor heat as directed in the POH emergency procedures. Therefore, it is likely that carburetor ice accumulated while the airplane was on the ground, which resulted in a partial loss of power once airborne. ## Factual narrative On April 25, 2020, about 1340 eastern daylight time, a Piper PA-28-151, N33005 was substantially damaged when it was involved in an accident near East Hampton, New York. The pilot and two passengers were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, they departed Igor I. Sikorsky Memorial Airport (BDR), Bridgeport, Connecticut about 1045. She landed at East Hampton Airport (HTO) about 1115 and parked the airplane. She subsequently returned to the airplane with the passengers about 1315. The pilot then reviewed the weather and performed a preflight inspection of the airplane with no anomalies noted. The pilot started the engine and taxied to the delta intersection of runway 28, where she performed an engine run-up procedure and configured the airplane for takeoff. The takeoff roll was normal, but after rotation during the climb, the pilot noticed a vibration and diminished engine power, though the throttle was in the full throttle position. At 400 or 500 feet mean seal level (msl), the engine began sputtering. The pilot made a successful right turn back to the airport before the engine lost power completely. The pilot was able to return to the airport and land about 3/4 down an available runway. The airplane went off the end of the runway through a deer fence and came to rest in a field. Examination of the airplane by a Federal Aviation Administration (FAA) inspector revealed substantial damage to both wings and the fuselage. The propeller displayed scratches on the leading edges of both blades with no curling of the blade tips. No visible damage was present in the engine compartment. No oil or fuel leaks were noted. Engine oil on the dipstick showed the correct level and appeared clean. Examination of the throttle, mixture, and carburetor heat controls revealed that they were intact, displayed correct movement, with no evidence of binding. The fuel in the left- and right-wing fuel tanks was sampled, and no debris or water contamination was visible. Examination of the fuel strainer showed no debris or water, and fuel was present in both wing tanks with the fuel quantities at a level just below the tabs. The drive train was rotated by turning the propeller and compression was evident on all four cylinders. After the examination, the fuel selector was turned on, the engine was primed using the electric fuel pump and started. The engine was first idled at 1,200 rpm, and then power was increased to 1,500 rpm. The engine ran normally, and no vibrations or sputtering was noted. After 8 minutes, the engine was shut down. Review of the meteorological conditions that existed around the time of the accident and the carburetor icing chart from FAA Special Airworthiness Information Bulletin CE-09-35 “Carburetor Icing Prevention” indicated a potential for icing at glide (idle) power and cruise power at the temperature and dew point that existed around the time of the accident.Review of the pilot’s NTSB Form 6120.1 Pilot/Operator Aircraft Accident/Incident Report revealed that after the runup, the pilot had turned the “Carb heat off”, and examination of a post-accident photo of the instrument panel also indicated that the carburetor heat control was in the off or nearly off position. The Emergency Procedures section under Engine Roughness in the Cherokee Warrior pilot operating handbook (POH) described engine roughness as 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. It went on to advise that if too much ice is allowed to accumulate, restoration of full power may not be possible; therefore, prompt action is required. It further advised, in part, that once the carburetor heat is selected on, the rpm will decrease slightly, and roughness will increase. Pilot should wait for a decrease in engine roughness or an increase in rpm, indicating ice removal. Further review of the POH revealed that the Engine Power Loss During Takeoff and Engine Power Loss in Flight sections also advised to turn on the carburetor heat. ## Aircraft - Registration: [N33005](https://openairdocs.org/deregistered/N33005-2023-12-11), registration cancelled 2023-12-11, S/N 28-7515288, built 1975 (OpenAirDocs) - Reported make and model: Piper PA28 (151) - Registry model: [Piper PA-28-151](https://openairdocs.org/model/piper-pa-28-151) (registry code 7102805) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-7515288 - Year built: 1975 - Airframe hours: 8390.5 - Engines: Lycoming O-320-D3G 160 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal; Standard, Utility - Last inspection: Annual, June 14, 2019, 38 hours before - Departed: HTO, East Hampton, NY - Destination: BDR, Bridgeport, CT - Airport: HTO, East Hampton, runway 10, 4,255 × 100 ft, asphalt - Equipment: Onboard weather, Handheld GPS, ADS-B, Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 58; injuries: none; private; airplane ratings: single-engine land; medical: basicmed, with waivers/limitations; last flight review August 30, 2018; seat: left; restraint: 3-point; flight hours: 772 total, 743 in this make and model, 11 in the last 90 days, 3 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 160° at 9 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 57 °F, dew point 27 °F - Altimeter: 30.08 inHg - Observed at: HTO ## 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 20200425006109A](https://openairdocs.org/incident/20200425006109A), Apr 25, 2020: Piper PA-28-151, East Hampton, NY, Substantial damage. On April 25, at approximately 1315L, 1715Z, a single engine aircraft, PA-28-151, N33005 departed rwy 28 at East Hampton, new york (hto). VFR conditions were… ## Docket (10 files) The files NTSB released with the investigation on April 29, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=101210. 3.6 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13390941&FileExtension=pdf&FileName=NTSB%20Form%206120%20(Signed)_Redacted-Rel.pdf - Pilot/operator aircraft accident report, NTSB form 6120.1 - attachment 1 (narrative of flight) (item 2, PDF, 7 pages, 60 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13390931&FileExtension=pdf&FileName=Attachment%201%20to%20NTSB%20Form%206120%20-%20Narrative%20History%20of%20Flight-Rel.pdf - Pilot/operator aircraft accident report, NTSB form 6120.1 - attachment 2 (flight path drawing) (item 3, PDF, 1 page, 85 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13389581&FileExtension=pdf&FileName=Attachment%202%20to%20NTSB%20Form%206120-Rel.pdf - Witness statements and interview summaries (item 4, PDF, 5 pages, 176 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13391227&FileExtension=pdf&FileName=Witness%20Statements%20and%20Interview%20Summaries-Rel.pdf - Excerpts from Piper warrior information manual (item 5, PDF, 4 pages, 135 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13391237&FileExtension=pdf&FileName=Excerpts%20from%20Cherokee%20Warrior%20Information%20Manual-Rel.pdf - Weather reports and records - khto metars (item 6, PDF, 2 pages, 55 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13391247&FileExtension=pdf&FileName=KHTO%20METARs-Rel.pdf - Weather reports and records - carburetor icing chart (item 7, PDF, 1 page, 57 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13391111&FileExtension=pdf&FileName=Carburetor%20Icing%20Chart-Rel.pdf - Photo array (item 8, PDF, 6 pages, 587 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13779132&FileExtension=pdf&FileName=Photo%20Array-Rel.pdf - N33005 a�� post accident carburetor heat control position (item 9, PDF, 1 page, 82 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13390677&FileExtension=pdf&FileName=Post%20Accident%20Image%20-%20Carburetor%20Heat%20Control-Rel.pdf - Memorandum for record - wreckage examination (item 10, PDF, 1 page, 119 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13391430&FileExtension=pdf&FileName=Memorandum%20For%20Record%20-%20Wreckage%20Examination-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.