WPR21LA329

NTSB accident investigation · Cessna 150D · Chino, CA · August 25, 2021

Accident · Minor injuriesClass 3 · LimitedFinal report
Date
August 25, 2021, 09:45 local (16:45 UTC)
Place
Chino, CA
Injuries
1 minor
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N4375UCessna 150D
Defining event
Enroute: Fuel related
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration
FAA report
20210825014759A
Case key
103761

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

The pilot’s delayed use of carburetor heat, which resulted in a loss of engine power due to carburetor icing.

Findings · 2

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 · Contributed to outcomeCessna 150D: 1 caseAll aircraft: 435 casesProbable cause
Action: delayed actionPersonnel issues › Action/decision · PilotCessna 150D: 1 caseAll 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 pilot flew in the local area for about 2 hours 45 minutes and then began to return to the departure airport. While the airplane was descending to 2,500 ft mean sea level, the engine surged, prompting the pilot to use carburetor heat. After a brief period of normal engine operation, the engine surging resumed, resulting in a partial power loss as the airplane approached the airport. Despite the pilot’s attempts to troubleshoot the issue, the airplane was unable to maintain altitude. The pilot performed an off-airport landing, during which the airplane collided with a fence. During the recovery of the airplane, about 3.5 to 4 gallons of fuel from the left wing and about 0.5 gallons of fuel from the right wing were drained, and both the carburetor bowl and gascolator contained fuel. The fuel tanks in the wing were intact, but fuel was dripping from the left fuel vent due to the angle at which the airplane came to rest (left wing down). Because fuel was dripping from the vent, the investigation could not determine if the airplane had a sufficient amount of fuel aboard at the time of the engine failure; the amount of fuel found in the tanks did not represent the amount of fuel aboard before impact. The Federal Aviation Administration (FAA) Carburetor Icing Probability Chart revealed that the outside air temperature and dew point temperature were within the "serious icing at glide power" portion of the chart, and the pilot reported haze in the area. An FAA Special Airworthiness Information Bulletin emphasized the risk of carburetor icing, even in above-freezing conditions with visible moisture, due to fuel vaporization and air expansion. Thus, it is likely that carburetor icing during the accident flight resulted in the loss of engine power, which might have been mitigated if the pilot had applied carburetor heat earlier in the descent.

Factual narrative

On August 25, 2021 about 0945 Pacific daylight time, a Cessna 150D, N4375U, was substantially damaged when it was involved in an accident near Ontario, California. The pilot sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot stated that, before departure, she added 16 gallons of fuel to the fuel tank, which brought the total fuel aboard to 28 gallons. The pilot maneuvered in the local area for about 2 hours 45 minutes before returning to the airport. During the descent to 2,500 ft mean sea level (msl), the engine began to surge; in response, the pilot added carburetor heat. The engine sounded normal for about 3 to 4 minutes and then began to surge again. As the airplane approached the airport, the pilot noticed that a partial loss of engine power had occurred, and that the engine was running between 1,000 and 1,200 rpm, equivalent to a near-idle setting. The pilot attempted to troubleshoot the partial loss of power by verifying that the mixture was rich, the fuel selector was positioned to “BOTH,” and the magnetos were both selected. The pilot further stated that, despite these attempts, the airplane could not maintain level altitude, so she selected an area for an off-airport landing. About 20 seconds before touchdown, the engine lost total power, and the airplane collided with a fence, causing damage to the airplane wings. The pilot noted that, after the accident, fuel was draining from the airplane, and moisture (haze) was visible. Postaccident examination at the accident site found that the fuel tanks were intact, and only a small drip from the left fuel vent was observed. The airplane owner stated that he recovered the airplane and that about 3.5 to 4 gallons of fuel from the left wing and about 0.5 gallons from the right wing were drained. The owner added that both the carburetor bowl and gascolator contained fuel. A representative from Cessna Aircraft stated that the airplane was equipped with long range fuel tanks that held a total of 38 gallons of fuel. The representative estimated that the airplane had a range of 800 miles (or 7.1 hours) at 5,000 ft msl, with the engine at 2,500 rpm, and at a cruise speed of 113 mph. The airplane was equipped with an on/off fuel selector valve, and the two fuel tanks were interconnected before the valve. A check valve in the left fuel tank vent line was designed to prevent fuel from leaking out, but the valve contained a small (0.04 inch) hole so that pressure in a full tank could bleed out. The Cessna representative stated that this hole would allow a small drip of fuel to leak out of the tank when the airplane was in a left wing low position. The amount of fuel that leaked out would be based on the amount of fuel that was in the tank (head pressure) and the length of time that the airplane was in that position. Fuel could escape from the system if damage had occurred forward of the fuel valve. The Cessna representativeestimated that, on the basis of the accident flight track, the airplane should have had more than 10 gallons of fuel when the engine failure occurred. In a postaccident statement, the pilot indicated that, given the haze outside, she should have applied carburetor heat as soon as she began descending the airplane. The pilot further stated that she should have had a greater reserve of fuel and had planned for a 20% discrepancy in the airplane’s fuel performance numbers. The meteorological aerodrome report for Chino, California, that was issued at 0953 stated that the temperature was 79°F and the dew point was 61°F. The temperatures were applied to the FAA Carburetor Icing Probability Chart, which revealed that both recorded temperatures were within the "serious icing at glide power" portion of the chart. The FAA published Special Airworthiness Information Bulletin (SAIB) CE-09-35 in June 2009, which discussed carburetor ice prevention. The SAIB noted that carburetor icing does not only occur in freezing conditions; it can occur at temperatures well above freezing when visible moisture or high humidity is present. Vaporization of fuel combined with the expansion of air as it flows through the carburetor (the Venturi effect) causes sudden cooling, and a significant amount of ice can build up within a fraction of a second.

Aircraft

Registration
N4375U
Reported as
Cessna 150D
Category
Airplane
Serial number
15060375
Built
1964
Airframe hours
4,878
Engine
Continental O-200, 100 hp, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · October 2, 2020 · 67.95 hours before
Departed
KCNO · Chino, CA
Airport
CNO · Chino
Equipment
Electronic flight bag or handheld device, ADS-B, 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
25
Injuries
Minor
Certificates
Commercial, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
June 10, 2021
Seat
Left
Restraint
Lap only
Flight hours
735 total · 111 in this make and model · 535 as pilot in command · 122 in the last 90 days · 36 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
5 statute miles
Lowest ceiling
None
Temperature
79 °F, dew point 61 °F
Altimeter
29.98 inHg
Observed at
KCNO, 3 nm away
METAR
SPECI 00000KT 5SM HZ FEW200 26/16 A2998

Docket · 3

The files NTSB released with the investigation on September 20, 2023, on NTSB’s docket system: statements, records, photos and specialists’ reports. 2.2 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.