WPR16LA119

NTSB accident investigation · Beech C23 · Waianae, HI · May 23, 2016

Accident · Minor injuriesLimited investigationFinal report
Date
May 23, 2016, 11:37 local (21:37 UTC)
Place
Waianae, HI
Injuries
2 minor
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N6697YBeech C23
Defining event
Enroute-cruise: Loss of engine power (partial)
Weather
Visual (VMC) · Day
Status
Completed · report May 25, 2017
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration
Case key
93269

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 total loss of engine power during cruise flight due to carburetor icing. Contributing to the accident was the pilot’s delay in applying carburetor heat during flight while operating in an area conducive to carburetor icing.

Findings · 3

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.

Temp/humidity/pressure: conducive to carburetor icingEnvironmental issues › Conditions/weather/phenomena · Effect on equipmentBeech C23: 3 casesAll aircraft: 435 casesProbable cause
Use of equip/info: use of equip/systemPersonnel issues › Task performance · PilotBeech C23: 5 casesAll aircraft: 1,391 casesProbable cause
Action: delayed actionPersonnel issues › Action/decision · PilotBeech C23: 4 casesAll aircraft: 894 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 private pilot reported that, during the climb-to-cruise portion of the cross-country interisland flight over open ocean water, the engine began to run roughly. The pilot applied carburetor heat, which resolved the engine roughness. The pilot decided to continue his flight. As the flight approached his destination, the engine began running roughly again, accompanied by a significant loss of engine rpm. The pilot applied carburetor heat and adjusted the mixture, but the engine power was not restored. He then ditched the airplane into the water just offshore of the island. The airplane wreckage was recovered from the water 3 days after the accident, and it had sustained significant damage from tidal forces. Postaccident examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. Weather conditions in the area at the time of the accident were conducive to the formation of carburetor icing at glide and cruise power and serious carburetor icing at glide power. If the pilot had either kept the carburetor heat on or applied it earlier, the loss of engine power and subsequent ditching could have been avoided.

Factual narrative

On May 23, 2016, about 1137 Hawaiian standard time, A Beech C23, N6697Y, sustained substantial damage following a loss of engine power and subsequent ditching within the open waters of the Pacific Ocean near Waianae, Hawaii. The airplane was registered to and operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91. The private pilot and his passenger sustained minor injuries. Visual meteorological conditions prevailed and no flight plan was filed for the personal flight. The cross-country flight originated from the Lihue Airport, Lihue, Hawaii, about 20 minutes prior to the accident, with an intended destination of Kalaeloa Airport, Kapolei, Hawaii.The pilot reported that during the climb to cruise portion of the flight, the engine began to run rough. The pilot applied carburetor heat, which resolved the roughness, and he continued his climb to 5,500 feet mean sea level. As the flight was approaching the shores of Oahu Island, the engine began running rough in addition to a reduction of engine rpm to about 1,700. The pilot applied carburetor heat and adjusted the mixture, however, was unsuccessful at restoring engine power. The pilot initiated a forced landing into the ocean waters just off shore of the island of Oahu. The airplane came to rest nose low partially submerged within about 20 feet of water, about 50 to 75 feet from the shoreline. Initial examination of the wreckage revealed that the forward portion of the fuselage was damaged. The wreckage was recovered from the water three days after the accident. Following removal from the water, the engine was rinsed with fresh water and subsequently filled with diesel fuel in an attempt to preserve the engine. Examination of the recovered airplane on June 30, 2016, revealed that it was mostly fragmented into multiple pieces from the ocean tidal action. The engine remained attached to the firewall structure. Corrosion was observed throughout the engine and firewall. The carburetor was separated from its mounts. The magnetos and fuel pump remained secured to their mounting pads. The bottom spark plugs were removed and exhibited corrosion and debris consistent with ocean water and salt. The magnetos were removed. Partial rotational continuity was obtained when the propeller was rotated about ¼ of a turn and mechanical continuity was obtained at the rear of the engine. The right magneto drive shaft rotated however did not produce spark at the lead terminals. Disassembly of the magneto was not performed due to the corrosion on the cap bolts. The left magneto drive shaft would not rotate by hand. Disassembly of the magneto was not performed due to the corrosion on the cap bolts. The carburetor was removed and disassembled for inspection. The internal float was intact and the needle valve was intact. A significant amount of salt and other ocean vegetation debris was observed throughout the float bowl and screen. The right side exhaust remained partially attached tocylinders one and three. No nuts were observed on the cylinder number one exhaust mount and only one nut remained attached to the cylinder number three cylinder exhaust mount. It could not be determined if the missing nuts were displaced prior to the accident or during salvage and subsequent engine preservation methods. No evidence of any preexisting anomalies that would have precluded normal operation and production of power was observed. The Federal Aviation Administration (FAA) published Special Airworthiness Information Bulletin (SAIB) CE-09-35 on June 30, 2009, regarding carburetor ice prevention. The conditions encountered in this accident (ambient temperature 84 degrees F, dew point 63 degrees F) were in the area of icing at glide and cruise power, and in the area of serious icing at glide power.

Aircraft

Registration
N6697Y
Reported as
Beech C23 (NO SERIES)
Category
Airplane
Serial number
M-2224
Built
1979
Airframe hours
648.7
Engine
Lycoming O&VO-360 SER, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · April 24, 2016
Departed
Lihue, HI
Destination
JRF · Kapolei, HI
Equipment
Stall warning system

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
56
Injuries
Minor
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Last flight review
March 15, 2016
Seat
Left
Restraint
3-point
Flight hours
224 total · 92 in this make and model · 161 as pilot in command · 3 in the last 90 days · 3 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
Variable at 3 knots
Visibility
10 statute miles
Lowest ceiling
4,500 ft broken
Temperature
84 °F, dew point 63 °F
Altimeter
30.12 inHg
Observed at
PHJR, 12 nm away

Docket · 5

The files NTSB released with the investigation on April 6, 2017, on NTSB’s docket system: statements, records, photos and specialists’ reports. 2.1 MB in all.