GAA16CA377

NTSB accident investigation · Piper PA 44 · Keene, NH · July 7, 2016

Accident · No injuriesData collectionFinal report
Date
July 7, 2016, 12:00 local (16:00 UTC)
Place
Keene, NH
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Emergency descent
Aircraft
N190NDPiper PA 44
Defining event
Emergency descent: Landing area undershoot
Weather
Visual (VMC) · Day
Status
Completed · report April 4, 2017
Report
Approved by Office Director
NTSB office
General Aviation Accidents
Parties
FAA
FAA report
20160707016519A
Case key
93614

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

The flight instructor’s failure to use carburetor heat during the approach while operating in atmospheric conditions that were conducive to carburetor icing, which resulted in a loss of engine power due to carburetor icing.

Findings · 5

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.

Info processing/decision: identification/recognitionPersonnel issues › Action/decision · Instructor/check pilotPiper PA-44-180: 3 casesAll aircraft: 559 casesProbable cause
Temp/humidity/pressure: conducive to carburetor icingEnvironmental issues › Conditions/weather/phenomena · Effect on operationPiper PA-44-180: 2 casesAll aircraft: 435 casesProbable cause
Action: lack of actionPersonnel issues › Action/decision · Instructor/check pilotPiper PA-44-180: 5 casesAll aircraft: 792 casesProbable cause
Object/animal/substance: airport structureEnvironmental issues › Physical environment · Contributed to outcomePiper PA-44-180: 1 caseAll aircraft: 50 cases

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 flight instructor in the multiengine airplane reported that, during a simulated single-engine instrument approach to runway 2, the right engine was configured for the simulated failure. The instructor added that the goal was to perform a missed approach on one engine and note the airplane's performance. The pilot under instruction descended to the decision height and executed the missed approach procedure, but the airplane would not climb. The flight instructor told the pilot to go to full power on both engines. According to the flight instructor, "mixtures, props and throttles were all full forward and the fuel flow levers were both at the ON position," and he took control of the airplane. The flight instructor reported that there were trees and buildings to the north and that he made a left turn about 400 ft above ground level with the intent to land on runway 14. He extended the landing gear but realized that he would not reach the runway. He executed a forced landing to the southwest on taxiway Sierra, the airplane crossed over runway 32/14, and although heavy braking was applied, the airplane exited the taxiway and impacted a drainage culvert. The airplane sustained substantial damage to the aft fuselage stringers and longerons. The airport elevation was 488 ft, the density altitude was 2,120 ft, the temperature was 81°, the dew point was 66° F, and the wind was calm, and the flight instructor stated that carburetor heat was not used during the approach on either engine. The relative humidity was about 60 percent, and the weather conditions were conducive to serious icing probability when operating in a gliding flight profile.

Factual narrative

The flight instructor in the multi-engine airplane reported that during a simulated single-engine instrument approach to runway 2, the right engine was configured for the simulated failure. The instructor reported that the goal was to perform a missed approach on one engine and note the airplane's performance. The pilot under instruction descended to the decision height and executed the missed approach procedure, but the airplane would not climb. The flight instructor told the pilot to go to full power on both engines. "Mixtures, props and throttles were all full forward and the fuel flow levers were both at the ON position," according to the flight instructor, and he took control of the airplane. The flight instructor reported that there were trees and buildings to the north and he made a left turn about 400 feet above ground level with the intent to land on runway 14. He extended the landing gear; but realized that he would not make the runway. He executed a forced landing to the southwest on taxiway Sierra, the airplane crossed over runway 32-14, and although heavy braking was applied, the airplane exited the taxiway and impacted a drainage culvert. The airplane sustained substantial damage to the aft fuselage stringers and longerons. The airport elevation was 488 feet, the density altitude was 2,120 feet, the temperature was 81° and the dew point was 66° F, the wind was calm, and the flight instructor stated that carburetor heat was not used during the approach on either engine. Per the AOPA Carburetor Ice Probability Chart, the relative humidity was about 60 percent and there was serious icing probability when operating in a gliding flight profile.

Aircraft

Registration
N190ND
Reported as
Piper PA 44 (180)
Category
Airplane
Serial number
4495002
Built
1989
Airframe hours
9,927
Engines
Lycoming LO-360-A1H6, 180 horsepower, reciprocatingLycoming O-360-A1H6, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
Plane Nonsense Inc
Registered owner
Plane Nonsense Inc
Airworthiness certificate
Standard, Normal
Last inspection
June 28, 2016
Departed
BED · Bedford, MA
Destination
EEN · Keene, NH
Flight plan
IFR
Airport
EEN · Dillant-Hopkins, runway 02, 6,201 × 100 ft, asphalt
Equipment
Stall warning system, Auto-pilot

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
48
Injuries
None
Certificates
Flight instructor, Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
September 3, 2014
Seat
Right
Restraint
3-point
Flight hours
5,516 total · 300 in this make and model · 5,433 as pilot in command · 127 in the last 90 days · 41 in the last 30 days · 4.1 in the last 24 hours
Role
Pilot
Age
54
Injuries
None
Certificates
Flight instructor, Commercial
Airplane ratings
Single-engine land, Multi-engine land, Single-engine sea
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
February 16, 2016
Seat
Left
Restraint
3-point
Flight hours
1,265 total · 6.5 in this make and model · 1,175 as pilot in command · 138 in the last 90 days · 54 in the last 30 days · 4 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Temperature
81 °F, dew point 66 °F
Altimeter
29.81 inHg
Observed at
KEEN

Docket · 6

The files NTSB released with the investigation on February 28, 2017, on NTSB’s docket system: statements, records, photos and specialists’ reports. 3.1 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.

Other investigations on N190ND · 1

Matched to the same aircraft by N-number and date.