WPR17LA208

NTSB accident investigation · Piper PA 28-161 · El Cajon, CA · September 17, 2017

Accident · Minor injuriesLimited investigationFinal report
Date
September 17, 2017, 13:47 local (20:47 UTC)
Place
El Cajon, CA
Injuries
1 minor, 1 uninjured
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N2587XPiper PA 28-161
Defining event
Approach-VFR pattern base: Loss of engine power (partial)
Weather
Visual (VMC) · Day
Status
Completed · report March 18, 2019
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration
FAA report
20170917022419A
Case key
96032

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

A partial loss of engine power due to the formation of carburetor ice during descent for landing. Contributing to the accident was the pilot’s failure to apply carburetor heat.

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 operationPiper PA-28-161: 6 casesAll aircraft: 435 cases
Use of equip/info: use of equip/systemPersonnel issues › Task performance · PilotPiper PA-28-161: 12 casesAll aircraft: 1,391 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 commercial pilot reported that he and the pilot-rated passenger returned to the airport to practice touch-and-go landings after a local flight. The first two landings were uneventful. While on the downwind leg of the traffic pattern for the third landing, the pilot reduced engine power and started to descend the airplane. After turning base, the pilot increased power, but the engine did not respond and remained at idle. There was no change in engine noise and the engine was not running rough. The pilot manipulated the throttle and primer several times, but the engine did not respond, and the pilot elected to land the airplane on a nearby road. During the descent, the airplane struck powerlines and a tree before it impacted the road and slid to a stop. A postaccident engine examination did not reveal any anomalies that would have precluded normal operation. A review of the carburetor icing probability chart revealed that the airplane was operating in conditions favorable to the formation of serious carburetor icing at glide power. In addition, on-scene photographs revealed that the carburetor heat lever was in the off position; therefore, it is likely that carburetor ice accumulated during the descent, which resulted in a partial loss of engine power.

Factual narrative

On September 17, 2017, about 1347 Pacific daylight time, a Piper 28-161 airplane, N2587X, experienced a loss of engine power while on downwind for runway 27L at Gillespie Field Airport (SEE), El Cajon, California. The certified flight instructor (CFI) sustained minor injuries and pilot rated passenger was not injured. The airplane sustained substantial damage to the left wing. The airplane was registered to and operated by the pilot as a Title 14 Code of Federal Regulations Part 91 personal flight. Visual meteorological conditions prevailed, and no flight plan was filed. The flight originated from SEE at about 1250. The pilot reported that after flying around the area they returned to the airport to practice a few touch-and-go landings. The first two left traffic touch-and-goes were uneventful; after the third takeoff, the tower informed them to make right traffic. While on downwind they were cleared to land; the pilot reduced power and started to descend. After turning base, the pilot increased power, but the engine did not respond and remained at idle. There was no change in engine noise and the engine was not running rough. Both pilots manipulated the throttle several times, but the engine did not respond; they also manipulated the primer, but to no avail. The pilot elected to land the airplane onto a nearby road. During the descent the airplane struck powerlines and a tree, before it impacted the roadway and slid to a stop. A postaccident engine examination revealed no anomalies that would have precluded normal operations. The throttle and mixture controls moved freely from stop to stop. The gascolator bowl was removed and the screen was clear of debris. The oil filter was removed and opened; oil was present and no contaminates or debris were noted. The spark plugs were removed from the engine and exhibited wear consistent with normal operations per the Champion check-a-plug chart. The rocker covers were removed and the propeller was rotated by hand. Spark was obtained in proper firing order and the rockers moved at the appropriate time. Thumb compression was obtained on all cylinders, except for the number 2 cylinder. Further examination revealed the intake valve was unseated due to impact damage. The engine was boroscoped and all cylinders exhibited normal operating signatures. The carburetor bowl was removed from the engine. The fuel screen was clear of debris; the carburetor bowl was removed and no fuel was present in the bowl or the accelerator pump well. The floats were intact and undamaged. Air was blown from the gascolator to the wing root, as well as from the electric driven fuel pump to the carburetor inlet; all lines were clear of blockages and debris. At the time of the accident, weather at SEE reported a temperature of 25°C and a dewpoint of 15°C. A review of the carburetor icing probability chart, located in the Federal Aviation Administration's (FAA) Special Airworthiness Information Bulletin CE-09-35, dated June 30, 2009,revealed that the airplane was operating in an area favorable for the formation of serious carburetor icing at glide power. On scene photographs provided by the FAA inspector revealed the carburetor heat lever was in the off position.

Aircraft

Registration
N2587X
Reported as
Piper PA 28-161
Category
Airplane
Serial number
28-8516083
Built
1985
Airframe hours
11,906
Engine
Lycoming O-320 SERIES, 160 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · August 25, 2017 · 16 hours before
Departed
SEE · El Cajon, CA
Destination
SEE · El Cajon, CA
Airport
SEE · Gillespie Field Airport, runway 27L, 2,738 × 60 ft, asphalt
Equipment
None

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
49
Injuries
Minor
Certificates
Flight instructor, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Without waivers/limitations
Last flight review
July 4, 2016
Seat
Right
Flight hours
2,475 total · 1,854 in this make and model · 2,374 as pilot in command · 112 in the last 90 days · 12 in the last 30 days · 2 in the last 24 hours
Role
Pilot-rated passenger
Age
49
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Last flight review
December 11, 2016
Seat
Left
Restraint
3-point
Flight hours
112 total · 112 in this make and model · 14 as pilot in command · 1 in the last 90 days

Weather

Conditions
Visual (VMC) · Day
Wind
260° at 9 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
77 °F, dew point 59 °F
Altimeter
29.93 inHg
Observed at
SEE, 2 nm away

Docket · 4

The files NTSB released with the investigation on October 2, 2018, on NTSB’s docket system: statements, records, photos and specialists’ reports. 2.9 MB 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.