ERA25LA217

NTSB accident investigation · Piper PA-23 · Palm Bay, FL · June 4, 2025

Accident · Minor injuriesClass 3 · LimitedFinal report
Date
June 4, 2025, 13:41 local (17:41 UTC)
Place
Palm Bay, FL · Located in the Indian River
Injuries
1 minor, 1 uninjured
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N2109PPiper PA-23
Defining event
Maneuvering: Fuel exhaustion
Weather
Visual (VMC) · Day
Status
Completed · report October 16, 2026
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Eastern Region Aviation
Parties
Piper Aircraft, FAA/FSDO
FAA report
20250604007829A
Case key
200265

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

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Probable cause

A loss of engine power to both of the airplane’s engines due to fuel exhaustion and fuel starvation.

Findings · 2

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.

Planning/preparation: fuel planningPersonnel issues › Task performance · PilotPiper PA-23: 2 casesAll aircraft: 719 casesProbable cause
Fluids: fuelAircraft › Fluids/misc hardware · Fluid levelPiper PA-23: 3 casesAll aircraft: 1,695 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 pilot of the multi-engine airplane reported that he was completing a cross-country flight and was nearing the next fuel stop at the time of the accident. The pilot reported that only the main fuel tanks were used for the flight due to a fuel leak in the auxiliary fuel tanks. While nearing the airport, the pilot encountered unexpected weather and had to divert several times around the weather. After he diverted around the patches of weather and on approach to the airport, he reported entering a rainstorm with heavy precipitation. He then began a climbing turn to exit the weather; during the climb, the left engine lost power. As he attempted to regain engine power of the left engine, which included turning on the carburetor heat, the right engine began to lose power, after which the airplane could no longer maintain altitude. The pilot then determined that a forced landing was required, and he ditched the airplane in a river. Postaccident examination of the airplane revealed that it had sustained substantial damage to the fuselage and empennage. The examination of the wreckage revealed several maintenance problems, such as the right engine’s carburetor leaking from the gasket, the right engine’s carburetor float valve missing the attach bracket, and the left engine’s fuel strainer housing having severe corrosion. Any of these items could have contributed to a loss of power in a particular engine; however, since the loss of power from both engines occurred within a short period of time, it is unlikely that these maintenance issues would have resulted in a near simultaneous loss of engine power. Postaccident examination of the airframe’s fuel system revealed that there was no fuel remaining in the left main fuel tank and approximately 4 gallons remained in the right main fuel tank. No documentation could be found in the airplane’s operator’s handbook or type certificate data sheet that indicated how much fuel was unusable in each fuel tank. An airplane of similar design on the same type certificate data sheet indicated that its unusable fuel was 1.7 gallons per fuel tank. If the accident airplane’s fuel system had a similar unusable amount of fuel, that would indicate the airplane only had about 2.3 gallons of usable fuel remaining. A review of the weather conditions at the time of the accident revealed that it was conducive to serious carburetor icing at glide engine power settings. At the time of the loss of power, the pilot had was approaching his next fuel stop and would have likely been at a low power setting, during that approach. Additionally, the pilot entered a rainstorm, which would increase the amount of moisture that was in the air, increasing the chances of carburetor ice formation. The pilot stated that after the left engine power loss, he engaged the carburetor heat; indicating that the pilot had not been utilizing the carburetor heat prior to the loss of engine power. While it is possible that the loss of engine power to bothengines was the result of carburetor icing, given the postaccident examination findings it is most likely that the left engine lost power after its fuel supply was exhausted. While the fuel tank feeding the right engine’s fuel supply had not yet been completely exhausted, it is likely that while maneuvering after the left engine loss of power, the right engine’s fuel tank pickup partially unported due to its low fuel level, resulting in its inconsistent delivery of fuel to that engine, a partial loss of power, and the airplane’s inability to maintain altitude.

Factual narrative

The airplane was equipped with four fuel tanks, one main fuel tank for each engine and one auxiliary fuel tank for each engine. According to the PA-23 Operator’s Handbook, each main fuel tank had a capacity of 36 gallons, and each auxiliary fuel tank had a capacity of 18 gallons. A review of the Operator’s Handbook and the airplane’s Type Certificate Data Sheet (TCDS), revealed no indication of what the airplane’s unusable amount of fuel was. However, the TCDS indicated a similar airframe, the PA-23-250, had 1.7 gallons of fuel that were unusable. According to the pilot, he did not use the auxiliary fuel tanks due to fuel leaks. On June 4, 2025, at 1341 eastern daylight time, a Piper PA-23, N2109P, was substantially damaged when it was involved in an accident near Palm Bay, Florida. The commercial pilot was uninjured and the passenger received minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the owner/operator, the flight departed from Front Royal-Warren County Airport (FRR), Front Royal, Virginia, in the morning and was enroute to Boca Raton, Florida. According to the pilot, prior to departing FRR, he had filled both main fuel tanks with a total of 72 gallons of fuel. The pilot also reported that due to a fuel leak, the auxiliary fuel tanks were not used. The pilot reported making a fuel stop at the Orangeburg Municipal Airport (OGB), Orangeburg, South Carolina, where 60.3 gallons of fuel was added to top off the main fuel tanks. After departing OGB, the flight continued south. When the flight approached Savannah, Georgia, the pilot reported encountering a patch of weather and diverted to the west to go around it. After passing the weather, the pilot began to follow the coastline, and as the airplane approached the Daytona Beach area, the pilot diverted to the east to avoid another patch of weather. Shortly afterward, the pilot began an approach to their next fuel stop at Valkaria Airport (X59), Valkaria, Florida. While on approach to X59, the pilot reported entering a “massive rain shower,” and the pilot lost sight of the runway. The pilot aborted the approach and initiated a climb toward the east to exit the weather. After reaching about 1,500 ft mean sea level (msl), the pilot reported that the left engine began to sputter and lost power. The pilot applied carburetor heat and attempted to restart the left engine; however, engine power did not return. The pilot then reported that the right engine began to sputter. Unable to reach an airport, he elected to perform a forced ditching into the Indian River near Palm Bay, Florida. During the ditching, the airplane sustained substantial damage to the fuselage and empennage. The pilot and passenger exited the airplane and swam to shore. When asked how this accident could have been prevented, the pilot wrote that the “accident could have been prevented by landing sooner and filling up sooner” and noted that there were nomechanical malfunctions or failures that would have precluded normal operation. The weather at the time of the accident was conducive to serious carburetor icing at glide power. According to the FAA Special Airworthiness Information Bulletin CE-09-35, pilots “should be aware that carburetor icing doesn’t just occur in freezing conditions, it can occur at temperatures well above freezing temperatures when there is visible moisture or high humidity. Icing can occur in the carburetor at temperatures above freezing because vaporization of fuel, combined with the expansion of air as it flows through the carburetor, (Venturi Effect) causes sudden cooling, sometimes by a significant amount within a fraction of a second.” The bulletin also stated that pilots should be able to recognize the signs of carburetor icing, such as a drop in manifold pressure with constant speed airplanes and roughness in engine operation. The airplane was recovered the same day as the accident from the river and taken to shore where it was examined the following day. Both fuel selectors were found in the “MAIN” fuel tank position. The left main and auxiliary fuel tank caps were found to be secure, and there were no signs of a fuel leak around the fuel tanks. The left main fuel tank was drained at the left fuel strainer bowl, where approximately 7 gallons of water were drained from the fuel tank. There were no signs of fuel in the left main fuel tank. The left auxiliary fuel tank was drained at the strainer, and the tank contained approximately 4 gallons of fuel that had the odor and color consistent with 100LL Avgas; there was no water found in the left auxiliary fuel tank. The left fuel strainer bowl was removed and visually inspected; the strainer bowl cap was found to be severely corroded and displayed corrosion consistent with exfoliation corrosion. There was no fuel screen installed in the left fuel strainer, and the bowl contained several large pieces of corroded debris. The right main fuel tank cap was found to be secured to the fuel tank filler and was able to seal properly. The right auxiliary fuel tank cap was found installed in the right auxiliary tank filler; however, the right auxiliary tank filler neck was missing the metal ring insert that would allow the cap to seal properly. A lighted borescope was inserted into the right auxiliary fuel tank, and the filler port insert was found near the right auxiliary tank pickup screen. The right main fuel tank was drained at the fuel strainer, where approximately 1 gallon of water and 4 gallons of fuel with the odor and color consistent with 100LL Avgas were drained from the fuel tank. The right auxiliary fuel tank was found to be completely devoid of fluid. The left engine remained attached to the airframe through the engine mounts, hoses, wires, and cables. The bottom spark plugs were removed from all four cylinders, and the cylinders were drained of water. Continuity was established between the crankshaft, camshaft,connecting rods, and associated components by rotating the crankshaft manually. All four cylinders displayed thumb compression and suction. The overhead components (valves, springs, and rocker arms) displayed normal operating and lubrication signatures and operated normally during crankshaft rotation. The cylinders were inspected using a lighted borescope; the piston faces, cylinder walls, and valve heads displayed normal operating and combustion signatures as well as some minor corrosion consistent with saltwater exposure. The fuel pump remained attached to its installation point, and the fuel lines remained secure. The fuel pump was removed, manually actuated, and found to be capable of pumping fluid. The fuel line going from the fuel pump to the carburetor remained secure, and there were no signs of fuel leaks. Engine control continuity was established by moving the cockpit controls and observing throttle and mixture control movement at the carburetor. The carburetor mixture and throttle control arms were capable of normal movement. The carburetor heat control was found in the “OFF” position. The carburetor was removed and examined. The throttle valve moved normally, and during full throttle movement, the accelerator pump and jet operated normally. The fuel inlet screen was removed, and there was a small amount of debris within the screen; however, the screen was not obstructed. The carburetor was disassembled and the internal components were visually examined. The carburetor bowl was full of fluid consistent with water. After draining the water, the bowl displayed corrosion consistent with saltwater exposure. The carburetor floats, and float valve displayed normal operating signatures as well as some corrosion of the valve. Both magnetos remained attached to their respective installation points and were undamaged. The ignition harness remained secure to both magnetos and to each individual spark plug. The magneto drives were spun manually and both magnetos were capable of producing a spark on all four of their respective posts. The top spark plugs were removed and their electrodes were visually inspected. The electrodes displayed corrosion consistent with saltwater exposure. The electrodes also displayed normal operating and were in a normal worn out condition when compared with Champion Aviation Service Manual AV6-R. The induction system remained intact and displayed impact damage at the carburetor airbox. The left air filter box cover was found not fully secured to the rest of the airbox. The inlet air filter was visually inspected and found to contain a significant amount of material consistent with sand. There were no signs of induction leaks observed. The exhaust system remained intact and displayed impact damage signatures. There were no signs of exhaust leaks. The right engine remained attached to the airframe through the engine mounts, hoses, wires, and cables. The bottom spark plugs were removed from all four cylinders, and thecylinders were drained of water. After draining the water, the bottom spark plugs were reinstalled. Continuity was established between the crankshaft, camshaft, connecting rods, and associated components by rotating the crankshaft manually. All four cylinders displayed thumb compression and suction. The overhead components (valves, springs, and rocker arms) displayed normal operating and lubrication signatures and operated normally during crankshaft rotation. The piston faces, cylinder walls, and valve heads displayed normal operating and combustion signatures as well as some minor corrosion consistent with saltwater exposure. The fuel pump remained attached to its installation point and the fuel lines remained secure. The fuel pump was removed, and the fuel pump was incapable of pumping residual fluid. The fuel pump was disassembled, and the internal components displayed corrosion consistent with water exposure. The rest of the fuel pump displayed normal operating signatures. The fuel line going from the fuel pump to the carburetor remained secure, and there were no signs of fuel leaks. After removing the fuel line from the carburetor, it was noted that the threads of the AN fitting were damaged, consistent with improper installation of the fuel line. Engine control continuity was established by moving the cockpit controls and observing throttle and mixture control movement at the carburetor. The carburetor mixture and throttle control arms were capable of normal movement. The carburetor heat control was found partially engaged to the “ON” position. The carburetor remained intact and displayed blue staining around the fuel bowl, consistent with a small fuel leak from the fuel bowl gasket. The carburetor fuel inlet screen was removed and was found to have debris within the screen; however, the screen was not obstructed. The carburetor was removed and disassembled for examination. The carburetor bowl had a mixture of fluid consistent with 100LL Avgas as well as water. The fluid was drained from the bowl, there were no signs of corrosion within the bowl. The float valve retaining clip was found at the bottom of the fuel bowl, resulting in the float valve no longer being directly attached to the floats; however, the float valve remained within the float valve boss and was capable of movement within the boss. Both magnetos remained attached to their respective installation points and the ignition harness was secure to the magnetos and to each spark plug. The magnetos were removed for examination. The right magneto drive gear nut was improperly saftied; however, the nut remained tight. Both magneto drives were spun, and neither magneto were capable of producing a spark. The magnetos were partially disassembled and the internal components displayed significant corrosion and saltwater contamination. The spark plugs' electrodes displayed corrosion, normal combustion signatures, and were in a normally worn-out condition when compared with ChampionAviation Service Manual AV6-R. The induction system displayed impact damage signatures to the carburetor airbox. The air filter box remained secured and was undamaged. The exhaust system remained attached to the engine and displayed impact damage. There were no signs of an exhaust leak observed.

Aircraft

Registration
N2109P
Reported as
Piper PA-23
Category
Airplane
Serial number
23-699
Built
1956
Airframe hours
4,807
Engines
Lycoming O-360-A1D, 180 horsepower, reciprocatingLycoming O-360-A1D, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · February 1, 2025 · 35 hours before
Departed
OGB · Orangeburg, SC
Destination
X59 · Valkaria, FL
Equipment
ADS-B, Handheld GPS

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
Pilot
Age
27
Injuries
None
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Seat
Left
Restraint
Lap only
Flight hours
1,940 total · 170 in this make and model · 1,875 as pilot in command · 150 in the last 90 days · 60 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
180° at 12 knots, gusting 41
Visibility
2.5 statute miles
Lowest ceiling
3,100 ft broken
Temperature
73 °F, dew point 70 °F
Altimeter
30.08 inHg
Observed at
MLB, 6 nm away
METAR
KMLB 041749Z 18012G41KT 2 1/2SM +RA BR FEW016 BKN031 BKN044 23/21 A3008 RMK AO2 PK WND 17041/1740 WSHFT 1732 LTG DSNT SW AND W RAB44 P0006

Docket · 8

The files NTSB released with the investigation on October 16, 2026, on NTSB’s docket system: statements, records, photos and specialists’ reports. 16.6 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.