WPR11LA025

NTSB accident investigation · Piper PA-28-236 · Dorrington, CA · October 23, 2010

Accident · Minor injuriesLimited investigationFinal report
Date
October 23, 2010, 14:27 local (21:27 UTC)
Place
Dorrington, CA
Injuries
1 minor
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N228KKPiper PA-28-236
Defining event
Enroute-cruise: Loss of engine power (partial)
Weather
Instrument (IMC) · Day
Status
Completed · report December 27, 2011
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration
FAA report
20101023048709A
Case key
77660

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

The pilot’s failure to use carburetor heat while cruising in carburetor icing conditions, which resulted in a loss of engine power.

Findings · 4

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.

Action: forgotten action/omissionPersonnel issues › Action/decision · PilotPiper PA-28-236: 1 caseAll aircraft: 440 casesProbable cause
Temp/humidity/pressure: conducive to carburetor icingEnvironmental issues › Conditions/weather/phenomena · Effect on operationPiper PA-28-236: 2 casesAll aircraft: 435 casesProbable cause
Object/animal/substance: tree(s)Environmental issues › Physical environment · Not specifiedPiper PA-28-236: 2 casesAll aircraft: 933 cases
Ice/rain protection system: intake anti-ice, deiceAircraft › Aircraft systems · Not used/operatedPiper PA-28-236: 1 caseAll aircraft: 108 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 reported that, while the airplane was level at 15,000 feet in instrument meteorological conditions, he failed to apply carburetor heat to the engine. After several minutes, the engine began losing power, and the airplane was not able to sustain flight. During the descent for a forced landing in mountainous terrain, the airplane descended below the cloud base about 2,000 feet above the ground, and the pilot observed a road and a clearing. During the landing rollout, the airplane impacted trees, which severed its wings. Icing probability charts indicated that carburetor ice was probable under the atmospheric conditions in which the airplane had been flying. The pilot reported that if he had applied the carburetor heat during flight, the accident likely would not have occurred.

Factual narrative

On October 23, 2010, about 1427 Pacific daylight time, a Piper PA-28-236, N228KK, experienced a partial loss of engine power during cruise flight. Unable to sustain flight, the pilot made a forced landing in mountainous terrain, about 4 miles east of Dorrington, California. The airplane was owned and operated by the pilot, and it was substantially damaged. The instrument rated private pilot received minor injuries. Instrument meteorological conditions prevailed at the time of the personal flight that was performed under the provisions of 14 Code of Federal Regulations Part 91. An instrument flight rules (IFR) flight plan was filed. The flight originated from Truckee, California, about 1330. The pilot reported to the National Transportation Safety Board investigator that he was cruising at 15,000 feet and was en route to Borrego Valley Airport, Borrego Springs, California. The engine became rough, and then most of the power was lost. The pilot notified the Oakland Air Route Traffic Control Center of his emergency, and they tracked the airplane's descending flight path until it disappeared from radar about 1418. The pilot stated that he broke out of the clouds about 2,000 feet above the ground and observed a road and a clearing. During landing rollout, the airplane collided with trees, which severed the airplane's wings and bent the stabilator. From the crash site, the pilot used his cell phone to telephone the Federal Aviation Administration (FAA). He provided the FAA and local rescue authorities with his precise global positioning system's coordinates in the Stanislaus National Forest. The pilot was rescued from his 5,400-foot mean sea level (msl) crash site location before sunset. The closest airport to the accident site was located about 44 miles from the crash site at South Lake Tahoe, California (TVL). This airport’s elevation is 6,264 feet msl. At 1353, TVL reported an overcast sky condition at 2,900 feet above ground level and light rain. Its temperature and dewpoint were 8 and 5 degrees, respectively. The pilot reported to the Safety Board investigator that the airplane climbed to about 15,000 feet msl approximately 10 minutes before the accident. He was cruising in actual instrument meteorological conditions. The outside air temperature was about -10 degrees Celsius. No ice was observed on the windshield or wings. The carburetor heat was off. Although the engine slowly lost manifold pressure, it never quit running. The pilot additionally stated that he did not initially think of turning on the carburetor heat. Eventually, the engine lost so much power that he could not sustain flight. Published icing probability charts indicate that at -10 degrees Celsius (14 degrees Fahrenheit) with 100 percent humidity, icing is likely when operating at cruise engine power. In the pilot’s completed aircraft accident report, he opined that the cause of the loss of engine power was due to carburetor ice. He stated that had he used the carburetor heat,the accident likely would have been avoided.

Aircraft

Registration
N228KK
Reported as
Piper PA-28-236
Category
Airplane
Serial number
28-7911056
Airframe hours
3,688
Engine
Lycoming O-540-J3A5D, 235 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Departed
TRK · Truckee, CA
Destination
L08 · Borrego Valley, CA
Flight plan
IFR

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
63
Injuries
Minor
Certificate
Private
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
August 22, 2009
Seat
Left
Flight hours
1,195 total · 1,033 in this make and model · 1,130 as pilot in command · 17 in the last 90 days · 3 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Day
Wind
190° at 11 knots
Visibility
8 statute miles
Lowest ceiling
2,900 ft overcast
Temperature
46 °F, dew point 41 °F
Altimeter
30.06 inHg
Observed at
TVL, 38 nm away

Docket · 2

The files NTSB released with the investigation on November 18, 2011, on NTSB’s docket system: statements, records, photos and specialists’ reports. 246 KB 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.