# NTSB SEA89FA040: Piper PA-23-160, N4391P, Carson City, NV, January 27, 1989

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Field investigation · Final report
- Date: January 27, 1989, 12:52 local (20:52 UTC)
- Place: Carson City, NV
- Coordinates: 39.139579, -119.709365 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=39.1396&lon=-119.7094&mi=10
- Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping)
- Highest injury: Fatal
- Injuries: 1 fatal
- Status: Completed, report May 22, 1990
- Report: Approved by Office Director
- NTSB case key (mKey): 40911
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=SEA89FA040
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/40911/pdf
- Page: https://openairdocs.org/ntsb/SEA89FA040

## Probable cause

LOSS OF POWER ON THE LEFT ENGINE DUE TO A FOREIGN OBJECT WHICH OBSTRUCTED THE FUEL FLOW, AND THE PILOT'S FAILURE TO MAINTAIN AIRSPEED ABOVE VMC DURING HIS ATTEMPTED RETURN TO THE AIRFIELD. CONTRIBUTING TO THE ACCIDENT WAS THE LACK OF RECENT FLIGHT TIME BY THE PILOT.

## Analysis

WHILE ON CROSSWIND LEG AFTER T/O, THE PILOT ANNOUNCED HE HAD LOST AN ENGINE AND WAS RETURNING TO LAND. DURING A LEFT TURN BACK TOWARD THE ARPT, THE ACFT ROLLED INVERTED TO THE LEFT AND DESCENDED IN A NOSE DOWN ATTITUDE UNTIL IMPACT. EXAM REVEALED AN EXTRA NEEDLE VALVE LOOSE IN THE LEFT ENG CARBURETOR FLOAT BOWL. ANOTHER NEEDLE VALVE AND SEAT ASSEMBLY WAS CORRECTLY INSTALLED IN THE CARBURETOR. NUMEROUS SMOOTH BRIGHT SPOTS OF WEAR WERE FOUND ON THE BOTTOM SURFACE OF THE GRAINY TEXTURED INTERIOR OF THE FLOAT BOWL. THE AREA AROUND THE FUEL MIXTURE METERING ASSEMBLY PORT WAS POLISHED AND THE NEEDLE VALVE COULD BE INSERTED IN THE PORT. MAINTENANCE RECORDS REVEALED NEW ENGINES HAD BEEN INSTALLED ON 10/30/79. ALTHOUGH RECORDS AND WITNESSES INDICATED POWER PROBLEMS WITH THE LEFT ENGINE, NO RECORDS INDICATED THE CARBURETOR FLOAT BOWL HAD EVER BEEN REMOVED AFTER THE ENGINE HAD INITIALLY BEEN INSTALLED ON THE AIRCRAFT.

## Sequence of events

In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf).

- Loss of engine power(total) - mech failure/malf, takeoff - initial climb
  - 1 engine
  - fuel system,carburetor - foreign object (cause)
  - fuel system - improper, manufacturer (cause)
  - fluid,fuel - starvation (cause)
  - propeller feathering - performed, pilot in command
- Loss of control - in flight, maneuvering - turn to landing area (emergency)
  - emergency procedure - improper, pilot in command
  - airspeed(vmc) - not maintained, pilot in command (cause)
  - lack of recent experience, pilot in command (contributing factor)
- In flight collision with terrain/water, descent - uncontrolled

## Aircraft

- Registration: [N4391P](https://openairdocs.org/deregistered/N4391P-2014-10-09), registration cancelled 2014-10-09, S/N 23-1902, built 1960 (OpenAirDocs)
- Reported make and model: PIPER PA-23-160
- Registry model: [Piper PA-23-160](https://openairdocs.org/model/piper-pa-23-160) (registry code 7102304) (OpenAirDocs)
- Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: 23-1902
- Airframe hours: 2976
- Engines: LYCOMING O-360-A1D 180 horsepower reciprocating
- Damage: Destroyed
- Fire: On-Ground
- Flight: Personal, Part 91
- Registered owner: Viking Air
- Airworthiness certificate: Standard, Normal
- Last inspection: Annual, July 7, 1988, 34 hours before
- Departed: O04, CARSON CITY, NV
- Airport: 004, Carson City, runway 27, 5,900 × 75 ft, asphalt

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 65; private; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 3, valid medical--w/ waivers/lim; seat: left; toxicology performed; flight hours: 538 total, 104 in this make and model, 519 as pilot in command

## Weather

- Conditions: Visual (VMC), Day
- Wind: calm
- Visibility: 20 statute miles
- Lowest ceiling: none
- Temperature: 37 °F, dew point 19 °F
- Altimeter: 30.00 inHg
- Observed at: RNO, 19 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 19890127001419A](https://openairdocs.org/incident/19890127001419A), Jan 27, 1989: Piper STCPA23, Carson City, NV, Destroyed, 1 fatal. Lost left engine on climbout. Tried to turn back,stalled,rolled,spun in. Found loose extra needle valve in carb bowl

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.

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