# NTSB WPR17LA208: Piper PA 28-161, N2587X, El Cajon, CA, September 17, 2017 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: September 17, 2017, 13:47 local (20:47 UTC) - Place: El Cajon, CA - Coordinates: 32.822223, -116.970275 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=32.8222&lon=-116.9703&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-VFR pattern base: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) - Highest injury: Minor injuries - Injuries: 1 minor, 1 uninjured - Status: Completed, report March 18, 2019 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration - SAIBs cited in the narratives: [SAIB CE-09-35](https://openairdocs.org/saib/CE-09-35) (OpenAirDocs) - NTSB case key (mKey): 96032 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR17LA208 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/96032/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=96032 - Page: https://openairdocs.org/ntsb/WPR17LA208 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Temp/humidity/pressure: conducive to carburetor icing](https://openairdocs.org/ntsb-findings/03031030): Environmental issues › Conditions/weather/phenomena · Effect on operation; cases with it: [Piper PA-28-161, 6 cases](https://openairdocs.org/ntsb-findings/03031030/cases.md?model=7102803), [All aircraft, 435 cases](https://openairdocs.org/ntsb-findings/03031030/cases.md) - [Ice/rain protection system: intake anti-ice, deice](https://openairdocs.org/ntsb-findings/01023020): Aircraft › Aircraft systems · Not used/operated (probable cause); cases with it: [Piper PA-28-161, 2 cases](https://openairdocs.org/ntsb-findings/01023020/cases.md?model=7102803), [All aircraft, 108 cases](https://openairdocs.org/ntsb-findings/01023020/cases.md) - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-28-161, 12 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=7102803), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach-VFR pattern base: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) (defining event); cases with it: [Piper PA-28-161, 13 cases](https://openairdocs.org/ntsb-events/342/sequence.md?model=7102803), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) - [Approach-VFR pattern base: Other weather encounter](https://openairdocs.org/ntsb-events/400); cases with it: [Piper PA-28-161, 6 cases](https://openairdocs.org/ntsb-events/400/sequence.md?model=7102803), [All aircraft, 1,127 cases](https://openairdocs.org/ntsb-events/400/sequence.md) - [Approach-VFR pattern base: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Piper PA-28-161, 19 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=7102803), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-28-161, 58 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102803), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/deregistered/N2587X-2019-11-29), registration cancelled 2019-11-29, S/N 28-8516083, built 1985 (OpenAirDocs) - Reported make and model: PIPER PA 28-161 - Registry model: [Piper PA-28-161](https://openairdocs.org/model/piper-pa-28-161) (registry code 7102803) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-8516083 - Year built: 1985 - Airframe hours: 11906 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 49; injuries: minor; 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 - Pilot-rated passenger; age 49; injuries: none; 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 ## 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 20170917022419A](https://openairdocs.org/incident/20170917022419A), Sep 17, 2017: Piper PA-28-161, El Cajon, CA, Substantial damage. San diego ? Gillespie Field, CA (see): N2587X, P28A, performing pattern work, touch and goes on 27L, Gillespie Field. Aircraft was in the right traffic pattern… ## Docket (4 files) The files NTSB released with the investigation on October 2, 2018, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=96032. 2.9 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 235 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40467152&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Engine Examination Observations (item 2, .PDF, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40467153&FileExtension=.PDF&FileName=Engine%20Examination%20Observations-Master.PDF - FAA Special Airworthiness Information Bulletin - Carburetor Icing Prevention (item 3, .PDF, 111 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40467154&FileExtension=.PDF&FileName=FAA%20Special%20Airworthiness%20Information%20Bulletin%20-%20Carburetor%20Icing%20Prevention-Master.PDF - On Scene Photo of the Carburetor Heat Lever Position - Courtesy of the FAA (item 4, .PDF, 799 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40467155&FileExtension=.PDF&FileName=On%20Scene%20Photo%20of%20the%20Carburetor%20Heat%20Lever%20Position%20-%20Courtesy%20of%20the%20FAA-Master.PDF 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.