# NTSB NYC02FA025: Piper PA-28-180, N3672R, Mansfield, OH, November 12, 2001 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: November 11, 2001, 19:25 local (Nov 12, 2001, 00:25 UTC) - Place: Mansfield, OH - Coordinates: 40.801109, -82.488334 - Nearby events: https://openairdocs.org/map.md?lat=40.8011&lon=-82.4883&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal, 1 serious - Status: Completed, report August 28, 2002 - Report: Approved by Office Director - Parties: Piper Aircraft Co., Federal Aviation Administration, Textron Lycoming - NTSB case key (mKey): 53744 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC02FA025 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/53744/pdf - Page: https://openairdocs.org/ntsb/NYC02FA025 ## Probable cause the pilot's improper use of carburetor heat, and subsequent forced landing. Factors were the carburetor icing condition, night conditions, trees, and the pilot's impairment from ingestion of an over-the-counter antihistamine. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(partial) - nonmechanical, cruise - normal - impairment(drugs), pilot in command (contributing factor) - carburetor heat - improper use of, pilot in command (cause) - weather condition - carburetor icing conditions (contributing factor) - light condition - dark night (contributing factor) - Forced landing, emergency descent/landing - In flight collision with object, descent - emergency - object - tree(s) (contributing factor) ## Analysis The pilot and passenger were en route on a night cross-country flight when the engine experienced a partial power loss. The pilot pulled on carburetor heat for about 10 seconds and then with no change in engine operation, returned the carburetor heat to cold and told the passenger he thought the engine was experiencing vapor lock. The pilot was unable to restore full power and struck trees during the execution of an off airport, forced landing. Examination revealed evidence of a fuel spill at the accident site. The engine was run and no problems were noted. A check of weather along the route of flight revealed the temperature and dewpoint spreads were getting closer together as the flight continued towards its destination. The spread at the accident site was 3 degrees C. According to FAA publications a temperature spread of 11 degrees C corresponds to a relative humidity of about 50 percent, and there is an increased likelihood of carburetor icing. Further, the FAA stated, "If detected, full carburetor heat should be applied immediately, and it should be left in the on position until the pilot is certain that all the ice has been removed." The FAA carburetor icing chart revealed the airplane nearing conditions of serious icing at cruise power. The toxicological examination found an over-the-counter antihistamine in the pilot's blood. Adverse affects for the antihistamine included, drowsiness. ## Factual narrative HISTORY OF FLIGHT On November 11, 2001, about 1925 eastern standard time, a Piper PA-28-180, N3672R, was destroyed during a forced landing and collision with trees in Mansfield, Ohio. The certificated commercial pilot was fatally injured, and the passenger received serious injuries. Night visual meteorological conditions prevailed for the personal flight. No flight plan had been filed for the flight that was conducted under 14 CFR Part 91. On November 9, 2001, the pilot and passenger flew from Custer Airport, Monroe, Michigan, to Raleigh-Durham International Airport, Raleigh/Durham, North Carolina. The return flight departed Raleigh/Durham at 1619, on November 11, 2001, destined for the Custer Airport. The pilot was receiving visual flight rules (VFR) traffic advisories while en route. According to air traffic control transcripts, he was handed off to Mansfield Approach Control at 1915. When the pilot established radio contact with Mansfield Approach Control, he reported that he was at 4,500 feet. At 1921, the pilot reported that he was experiencing engine problems and requested to land at Mansfield. He was told that runway 32 was 4 miles straight ahead, and to proceed straight toward it. He was asked if he needed assistance, and told the approach controller that he did not. At 1922:32, the pilot was given winds from 360 degrees at 5 knots, and cleared to land on runway 32. At 1922:54, the pilot reported that it didn't look like he was going to make the runway. The local controller asked if the engine had quit and the pilot confirmed that it had. At 1923:05, the pilot reported that he was going to try to land on a road, which the local controller acknowledged. No further transmissions were received from the airplane. The accident occurred during the hours of darkness at 40 degrees, 48.061 minutes north latitude, and 82 degrees, 29.307 minutes west longitude. PERSONNEL INFORMATION The pilot's logbook was not recovered. According to Federal Aviation Administration (FAA) records, the pilot held a commercial pilot certificate with airplane single and multi-engine land and instrument airplane ratings. He held a flight instructor certificate for single engine airplanes. According to his last FAA second class airman medical application dated December 12, 2000, his total flight experience was 2,500 hours. According to the pilot's last insurance application dated April 26, 2001, his total flight experience was 2,500 hours, with 250 hours in multiengine airplanes. His total pilot-in-command experience was 2,400 hours. The pilot's last flight review was a 14 CFR Part 135 pilot-in-command and instrument proficiency check ride on February 23, 2001. The pilot's recent flight experience was not determined. METEOROLOGICAL INFORMATION A check of temperature dewpoint spreads was made with stations along the route of flight. Location Time Temperature Dewpoint Raleigh-Durham, NC 1551 19 C 02 C Danville, VA 1656 16 C -02 C Roanoke, VA 1654 13 C -04 C Parkersburg, WV 1853 07 C -02 C Zanesville, OH 1853 06 C -03 C Mansfield, OH 1905 01 C -04 C Mansfield, OH 1915 -01 C -04 C A check of the FAA carburetor icing probability chart revealed the temperature and dewpoint at Mansfield placed the airplane adjacent to the line for serious icing at cruise power. According to FAA Advisory Circular 20-113, PILOT PRECAUTIONS AND PROCEDURES TO BE TAKEN IN PREVENTING AIRCRAFT RECIPROCATING ENGINE INDUCTION SYSTEM AND FUEL SYSTEM ICING PROBLEMS, dated October 22, 1981. "..Fuel Vaporization Ice....It is most prevalent with conventional float type carburetors, and to a lesser degree with pressure carburetors when the air/fuel mixture reaches a freezing temperature as a result of the cooling of the mixture during the expansion process that takes place between the carburetor and engine manifold...Vaporization icing may occur at temperatures from 32 degrees F[0 C]. to as high as 100 degrees F [38 C]. with a relative humidity of 50 percent or above...it is possible to relate the temperature dewpoint spread to relative humidity. As the spread becomes less, relative humidity increases and becomes 100% when temperature and dewpoint are the same. In general, when the temperature/dewpoint spread reaches 20 degrees F [11 C]. or less, you have a relative humidity of 50% or higher and are in potential icing conditions." The FAA inspector who assisted in the accident, drove to the accident site from near Cleveland. He reported that when he left his residence, his vehicle was wet with dew, and there was frost on the grass of his yard. WRECKAGE AND IMPACT INFORMATION The airplane came to rest in the front yard of a residence, 1.16 nautical miles from the approach end of runway 32, on extended runway centerline. The airplane was inverted and both wings had separated from the fuselage. The right wing was found about 30 feet from the fuselage, laying inverted, at the base of trees that were fractured at a height of 20 feet. The left wing separated at its attach fitting, and was found laying against the left side of the fuselage. Both wings had rounded depressions similar to impact with trees, and were ruptured. There was a localized area of wilted vegetation, similar to being sprayed with gasoline. Flight control continuity was confirmed for the rudder and elevator. The control cables to the ailerons were separated with puffed ends consistent with tension overloads. All breaks at control cables occurred at other than attach points. No evidence of blockage was found in the fuel system. All fuel filters were absent of debris. Fuel was found in the line leading to the carburetor and in the carburetor bowl. All fuel samples were bright and clear, with a blue tint. Engine valve train continuity was confirmed. Thumb compression was obtained in all cylinders. All sparkplug leads produced spark when the engine crankshaft was rotated. The engine was shipped to Lycoming in Williamsport, Pennsylvania, for additional testing. The engine was run under the supervision of an inspector from the FAA. According to the engine test log, the engine achieved 2,720 rpm at full throttle. MEDICAL AND PATHOLOGICAL INFORMATION Toxicological testing was conducted by the FAA Toxicology Accident Research Laboratory, Oklahoma City, Oklahoma. The following was found: DIPHENHYDRAMINE in blood 0.021 ug/ml, ug/g DIPHENHYDRAMINE in urine EPHEDRINE in urine PHENYLPROPANOLAMINE in urine PSEUDOEPHEDRINE in urine ACETAMINOPHEN in urine 18.063 ug/ml, ug/g According to the web site www.mentalhealth.com, the brand name of diphenhydramine was Benadryl, and the following adverse effects were listed, "Drowsiness, dizziness, dryness of mouth, nausea and nervousness...." A web search on the name Benadryl revealed it was an over-the-counter antihistamine. An autopsy was conducted on November 13, 2001, by Cynthia S. Beisser, M.D., Deputy Coroner for Lucas County, State of Ohio. ADDITIONAL INFORMATION GPS Data A hand held global position navigation system (GPS) was recovered from the airplane. The unit was sent to Garmin and examined under the supervision of an FAA inspector from the Kansas City, Kansas, Flight Standards District Office. No altitude data was recorded. However, time, latitude, longitude, and ground speed in mph were recorded. The time used in the report was Central Standard Time (UTC-6). The entire flight took place in Eastern Standard Time (UTC-5). The GPS started recording at 1617, and an increase in ground speed, consistent with flight was recorded at 1620. The distance to the accident site was 344 nautical miles. The average ground speed was about 128 mph (110 knots), although excursions were observed between 100 and 150 mph. ## Aircraft - Registration: [N3672R](https://openairdocs.org/deregistered/N3672R-2013-08-22), registration cancelled 2013-08-22, S/N 28-5775, built 1969 (OpenAirDocs) - Reported make and model: Piper PA-28-180 - Registry model: [Piper PA-28-180](https://openairdocs.org/model/piper-pa-28-180) (registry code 7102808) (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: 28-5775 - Airframe hours: 3519 - Engines: Lycoming O-360-A4A 180 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Operator: Monroe Aviation - Registered owner: John Klyder Inc. - Airworthiness certificate: Standard, Utility; Standard, Normal - Last inspection: 100 hour, November 2, 2001, 8 hours before - Departed: RDU, Raleigh, NC - Destination: MFD, Mansfield, OH - Airport: MFD, Mansfield Lahm Regional Arpt, runway 32, 9,001 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 42; injuries: fatal; flight instructor, commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, valid medical--w/ waivers/lim; seat: left; toxicology performed; flight hours: 2,500 total, 2,400 as pilot in command ## Weather - Conditions: Visual (VMC), Night/dark - Wind: 360° at 5 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 32 °F, dew point 25 °F - Altimeter: 30.38 inHg - Observed at: MFD, 1 nm away ## 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 20011111032359A](https://openairdocs.org/incident/20011111032359A), Nov 11, 2001: Piper PA28180, Mansfield, OH, No damage, 1 fatal. (-23) PA-28-180 aircraft was enroute to monroe mi (ttf) from raleigh durham NC (rdu) and indicated to ATC that he was having an engine problem and ask for… 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.