# NTSB ERA23LA127: Piper PA-28-181, N103AV, Atlanta, GA, February 16, 2023 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Class 3 · Limited · Final report - Date: February 16, 2023, 14:31 local (19:31 UTC) - Place: Atlanta, GA - Coordinates: 33.870301, -84.30246 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=33.8703&lon=-84.3025&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Fuel related](https://openairdocs.org/ntsb-events/190) - Highest injury: Serious injuries - Injuries: 1 serious, 1 minor - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: Lycoming Engines, FAA/FSDO - SAIBs cited in the narratives: [SAIB CE-09-35](https://openairdocs.org/saib/CE-09-35) (OpenAirDocs) - NTSB case key (mKey): 106743 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA23LA127 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106743/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=106743 - Page: https://openairdocs.org/ntsb/ERA23LA127 ## Probable cause The flight instructor’s failure to effectively utilize carburetor heat, which resulted in a total loss of engine power during initial climb due to carburetor ice that formed during the engine run-up and taxi. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · Instructor/check pilot (probable cause); cases with it: [Piper PA-28-181, 11 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md?model=7102807), [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md) - [Temp/humidity/pressure: conducive to carburetor icing](https://openairdocs.org/ntsb-findings/03031030): Environmental issues › Conditions/weather/phenomena · Decision related to condition (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) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: 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) - [Emergency descent: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120); cases with it: [Piper PA-28-181, 11 cases](https://openairdocs.org/ntsb-events/120/sequence.md?model=7102807), [All aircraft, 1,074 cases](https://openairdocs.org/ntsb-events/120/sequence.md) ## Analysis Before takeoff, the student pilot and flight instructor performed a preflight inspection and an engine run-up that included checking the carburetor heat before taxiing the airplane into position; they noted no anomalies. After takeoff, about 200 ft above ground level, the engine lost total power. The flight instructor initiated a left turn and the airplane impacted the ground near a parallel runway, resulting in substantial damage to the wings and fuselage. Postaccident examination of the engine revealed no evidence of preimpact mechanical malfunctions or failures that would have precluded normal operation. The weather conditions at the time of the accident were conducive to the formation of serious carburetor icing at glide (idle) engine power settings. Furthermore, the engine data monitor indicated that the carburetor temperature decreased to 38°F just before the loss of engine power. Thus, it is likely that during the taxi and engine run-up, a period during which the engine would typically be operating at low power, carburetor ice formed and subsequently resulted in a total loss of engine power during the initial climb. ## Factual narrative On February 16, 2023, about 1431 eastern standard time, a Piper PA-28-181, N103AV, was substantially damaged when it was involved in an accident at Dekalb-Peachtree Airport (PDK), Atlanta, Georgia. The flight instructor sustained serious injuries and 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 and the flight instructor conducted a preflight inspection, start up, taxi, and engine run-up, which included two checks of the carburetor heat system. Then, once they received their takeoff clearance, they began the takeoff roll on runway 21R and, after rotation while around 200 ft above ground level, the engine started to “sputter.” The flight instructor took over control of the airplane as the engine lost total power. The flight instructor stated that after the engine lost total power, he initiated a left turn to avoid colliding with structures. The airplane impacted the ground on the right side of runway 3R, resulting in substantial damage to the fuselage and wings. Postaccident examination of the engine revealed that internal and valvetrain continuity was established when the crankshaft was rotated by hand. Examination of the cylinders with a lighted borescope revealed no anomalies. The fuel inlet screen and fuel filter were examined and no debris was noted. The carburetor was disassembled, residual fuel was in the carburetor bowl, and no anomalies were noted with the system. The engine-driven fuel pump was actuated by hand and functioned normally. The engine oil, engine oil filter, and engine oil pickup screen were all absent of debris. Both magnetos produced spark at all towers. Data downloaded from an Electronics International MVP-50P engine data monitor began at 1419 and ended at 1434. The data indicated that carburetor temperature decreased to 40°F and then increased twice before the takeoff. Then, during the takeoff, the rpm increased to 2,600 rpm and the carburetor temperature decreased to 38°F for about a minute. The fuel flow at the same time increased, surged three times, and then decreased to 0. Furthermore, the engine rpm remained around or below 1,500 rpm for the majority of the accident flight except two times, when the rpm increased to 2,000 rpm and 2,600 rpm respectively. At 1444, the weather reported at PDK included a temperature of 23°C and a dew point 14°C. The calculated relative humidity at this temperature and dewpoint was 57%. Review of the icing probability chart contained within Federal Aviation Administration (FAA) Special Airworthiness Information Bulletin CE-09-35 revealed the atmospheric conditions at the time of the accident were "conducive to serious icing at glide [idle] power." According to FAA Advisory Circular (AC) 20-113, "To prevent accidents due to induction system icing, the pilot should regularly use [carburetor] heat under conditions known to be conducive to atmospheric icing andbe alert at all times for indications of icing in the fuel system." The AC recommended that when operating in conditions where the relative humidity is greater than 50%, "…apply carburetor heat briefly immediately before takeoff, particularly with float type carburetors, to remove any ice which may have been accumulated during taxi and runup." It also stated, "Remain alert for indications of induction system icing during takeoff and climbout, especially when the relative humidity is above 50%, or when visible moisture is present in the atmosphere." ## Aircraft - Registration: [N103AV](https://openairdocs.org/aircraft/N103AV), registered now, S/N 28-8390084, built 1983 (OpenAirDocs) - Reported make and model: PIPER PA-28-181 - Registry model: [Piper PA-28-181](https://openairdocs.org/model/piper-pa-28-181) (registry code 7102807) (OpenAirDocs) - Registry engine: [Lycoming 0-360-A1D](https://openairdocs.org/engine/lycoming-0-360-a1d) (registry code 41504, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-8390084 - Year built: 1983 - Airframe hours: 13761.8 - Engines: Lycoming O-360-A4M 180 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Operator: Centennial Aviation Academy INC - Registered owner: Flying To Infinity And Beyond LLC - Airworthiness certificate: Standard, Normal - Last inspection: Annual, March 31, 2022 - Airport: PDK, Dekalb-Peachtree, runway 3R, 6,001 × 100 ft, asphalt - Equipment: Onboard weather, Stall warning system, ADS-B, Electronic flight bag or handheld device, Electronic multifunction display, Electronic primary flight display ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 22; injuries: serious; flight instructor, commercial; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 1, with waivers/limitations; last flight review November 22, 2022; seat: right; restraint: 3-point; flight hours: 557.7 total, 113 in this make and model, 496.5 as pilot in command, 115.6 in the last 90 days, 42.4 in the last 30 days, 3.7 in the last 24 hours - Student pilot; age 14; injuries: minor; seat: left; restraint: 3-point ## Weather - Conditions: Visual (VMC), Day - Wind: 190° at 8 knots - Visibility: 10 statute miles - Lowest ceiling: 4,500 ft broken - Temperature: 73 °F, dew point 57 °F - Altimeter: 30.00 inHg - Observed at: PDK, 1 nm away - METAR: KPDK 161944Z 19008KT 10SM BKN045 OVC060 23/14 A3000 RMK AO2 T02280144 ## 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 20230216015739A](https://openairdocs.org/incident/20230216015739A), Feb 16, 2023: Piper PA-28-181, Atlanta, GA, Destroyed. On February 16, 2023, about 1431 eastern standard time, a Piper PA-28-181, [privacy data omitted] was substantially damaged when it was involved in an accident… ## Docket (15 files) The files NTSB released with the investigation on May 2, 2024, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=106743. 16.6 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=15840786&FileExtension=pdf&FileName=6120-p_Redacted-Rel.pdf - Wreckage examination summary (item 2, PDF, 26 pages, 4.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15839751&FileExtension=pdf&FileName=Wreckage%20Examination%20Summary%20ERA23LA127-Rel.pdf - Pilots statements - memorandum for record (item 3, PDF, 3 pages, 327 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15840472&FileExtension=pdf&FileName=Pilots%20Statements_Redacted-Rel.pdf - Carburetor icing probability chart for accident day/time (item 4, PDF, 1 page, 325 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15457110&FileExtension=pdf&FileName=Carburetor%20Icing%20Probability%20Chart%20-%20ERA23LA127-Rel.pdf - FAA special airworthiness information bulletin CE-09-35 - carburetor icing prevention (item 5, PDF, 3 pages, 106 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15457303&FileExtension=pdf&FileName=r_CE-09-35-Rel-Rel.pdf - Airplane checklist for N103AV (item 6, PDF, 5 pages, 940 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15457818&FileExtension=pdf&FileName=PA28-181%20Operating%20Checklist%20Rev.%2023_Redacted-Rel.pdf - Maintenance log excerpts (item 7, PDF, 11 pages, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15841090&FileExtension=pdf&FileName=Mx%20Record%20Excerpts%20LA127_Redacted-Rel.pdf - Engine data monitor - specialist's factual report (item 8, PDF, 8 pages, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15370431&FileExtension=pdf&FileName=Engine%20Data%20Monitor%20-%20Specialist%27s%20Factual%20Report_ERA23LA127-Rel.pdf - Attachment 1 to engine data monitor - specialist's factual report_tabular data (item 9, CSV, 365 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15370884&FileExtension=csv&FileName=Attachment%201%20to%20Engine%20Data%20Monitor%20-%20Specialist%27s%20Factual%20Report_ERA23LA127_Tabular%20Data-Rel.csv - Attachment 2 to engine data monitor - specialist's factual report_tabular data (item 10, CSV, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15371055&FileExtension=csv&FileName=Attachment%202%20to%20Engine%20Data%20Monitor%20-%20Specialist%27s%20Factual%20Report_ERA23LA127_Tabular%20Data-Rel.csv - Attachment 3 to engine data monitor - specialist's factual report_tabular data (item 11, CSV, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15371365&FileExtension=csv&FileName=Attachment%203%20to%20Engine%20Data%20Monitor%20-%20Specialist%27s%20Factual%20Report_ERA23LA127_Tabular%20Data-Rel.csv - Certification of party representative - Lycoming (item 12, PDF, 14 pages, 764 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15456641&FileExtension=pdf&FileName=N103AV%20Lycoming%20Party%20Form%20-p_Redacted-Rel.pdf - Investigative photographs (item 13, PDF, 5 pages, 4 photos, 618 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15840937&FileExtension=pdf&FileName=Photo%20Array%20Template%20LA127-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 14, PDF, 1 page, 614 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15840684&FileExtension=pdf&FileName=Wreckage%20Release%20-%20Signed%20-%20LA127_Redacted-Rel.pdf - Evidence control form (item 15, PDF, 2 pages, 141 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15940516&FileExtension=pdf&FileName=Evidence-Control-Form%20LA127-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.