# NTSB GAA16CA377: Piper PA 44, N190ND, Keene, NH, July 7, 2016 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: July 7, 2016, 12:00 local (16:00 UTC) - Place: Keene, NH - Coordinates: 42.898334, -72.270835 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=42.8983&lon=-72.2708&mi=10 - Phase of flight: [Emergency descent](https://openairdocs.org/ntsb-phases/600) (OpenAirDocs' grouping) - Defining event: [Emergency descent: Landing area undershoot](https://openairdocs.org/ntsb-events/370) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report April 4, 2017 - Report: Approved by Office Director - NTSB office: General Aviation Accidents - Parties: FAA - NTSB case key (mKey): 93614 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA16CA377 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/93614/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=93614 - Page: https://openairdocs.org/ntsb/GAA16CA377 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Info processing/decision: identification/recognition](https://openairdocs.org/ntsb-findings/02041510): Personnel issues › Action/decision · Instructor/check pilot (probable cause); cases with it: [Piper PA-44-180, 3 cases](https://openairdocs.org/ntsb-findings/02041510/cases.md?model=7104402), [All aircraft, 559 cases](https://openairdocs.org/ntsb-findings/02041510/cases.md) - [Temp/humidity/pressure: conducive to carburetor icing](https://openairdocs.org/ntsb-findings/03031030): Environmental issues › Conditions/weather/phenomena · Effect on operation (probable cause); cases with it: [Piper PA-44-180, 2 cases](https://openairdocs.org/ntsb-findings/03031030/cases.md?model=7104402), [All aircraft, 435 cases](https://openairdocs.org/ntsb-findings/03031030/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-44-180, 2 cases](https://openairdocs.org/ntsb-findings/01023020/cases.md?model=7104402), [All aircraft, 108 cases](https://openairdocs.org/ntsb-findings/01023020/cases.md) - [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · Instructor/check pilot (probable cause); cases with it: [Piper PA-44-180, 5 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md?model=7104402), [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md) - [Object/animal/substance: airport structure](https://openairdocs.org/ntsb-findings/03022042): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Piper PA-44-180, 1 case](https://openairdocs.org/ntsb-findings/03022042/cases.md?model=7104402), [All aircraft, 50 cases](https://openairdocs.org/ntsb-findings/03022042/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach-IFR missed approach: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340); cases with it: [Piper PA-44-180, 2 cases](https://openairdocs.org/ntsb-events/340/sequence.md?model=7104402), [All aircraft, 820 cases](https://openairdocs.org/ntsb-events/340/sequence.md) - [Approach-IFR missed approach: Attempted remediation/recovery](https://openairdocs.org/ntsb-events/060); cases with it: [Piper PA-44-180, 1 case](https://openairdocs.org/ntsb-events/060/sequence.md?model=7104402), [All aircraft, 1,422 cases](https://openairdocs.org/ntsb-events/060/sequence.md) - [Emergency descent: Landing area undershoot](https://openairdocs.org/ntsb-events/370) (defining event); cases with it: [Piper PA-44-180, 1 case](https://openairdocs.org/ntsb-events/370/sequence.md?model=7104402), [All aircraft, 201 cases](https://openairdocs.org/ntsb-events/370/sequence.md) - [Landing-landing roll: Loss of control on ground](https://openairdocs.org/ntsb-events/230); cases with it: [Piper PA-44-180, 5 cases](https://openairdocs.org/ntsb-events/230/sequence.md?model=7104402), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) ## 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](https://openairdocs.org/deregistered/N190ND-2019-11-01), registration cancelled 2019-11-01, S/N 4495002, built 1989 (OpenAirDocs) - Reported make and model: PIPER PA 44 (180) - Registry model: [Piper PA-44-180](https://openairdocs.org/model/piper-pa-44-180) (registry code 7104402) (OpenAirDocs) - Registry engine: [Lycoming O&VO-360 series](https://openairdocs.org/engine/lycoming-o-vo-360-series) (registry code 41514, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 4495002 - Year built: 1989 - Airframe hours: 9927 - Engines: LYCOMING LO-360-A1H6 180 horsepower reciprocating; LYCOMING 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 48; injuries: none; 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 - Pilot; age 54; injuries: none; 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 ## 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 20160707016519A](https://openairdocs.org/incident/20160707016519A), Jul 7, 2016: Piper PA-44-180, Keene, NH, Substantial damage. An unintentional landing occurred in Piper seminole N190ND on July 7, 2016 at approximately 11:50 am at the Dillant-Hopkins Airport. This was an instructional… ## Other investigations on N190ND (1) 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. - [NTSB CHI94LA087](https://openairdocs.org/ntsb/CHI94LA087), Feb 13, 1994: Piper PA-44-180 (N190ND), Grand Forks, ND, substantial damage. Probable cause: the improper maintenance installation (cotter pin) by other maintenance personnel. Factors were main landing gear scissors not safetied properly and extension of landing gear not possible by… ## Docket (6 files) The files NTSB released with the investigation on February 28, 2017, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=93614. 3.1 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449603&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Memorandum for Record - Telephone Interview, Flight Instructor (item 2, .PDF, 112 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449604&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20-%20Telephone%20Interview,%20Flight%20Instructor-Master.PDF - Density and Pressure Altitude (item 3, .PDF, 56 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449605&FileExtension=.PDF&FileName=Density%20and%20Pressure%20Altitude-Master.PDF - Carburetor Icing Probability Chart (item 4, .PDF, 84 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449606&FileExtension=.PDF&FileName=Carburetor%20Icing%20Probability%20Chart-Master.PDF - Airport Diagram (item 5, .PDF, 70 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449607&FileExtension=.PDF&FileName=Airport%20Diagram-Master.PDF - Photos (Courtesy of FAA) (item 6, .PDF, 3 photos, 547 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449608&FileExtension=.PDF&FileName=Photos%20(Courtesy%20of%20FAA)-Master.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.