- Date
- April 16, 2023, 10:10 local (17:10 UTC)
- Place
- Riverside, CA · field 2 mi west of KRAL
- Injuries
- 1 minor, 2 uninjured
- Damage
- Substantial damage
- Phase of flight
- Initial climb
- Aircraft
- N8376WPiper PA-28-180
- Defining event
- Initial climb: 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
- 20230416004049A
- Case key
- 107070
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 failure to use carburetor heat during an extended ground delay before takeoff, which resulted in a total loss of engine power during initial climb due to carburetor ice.
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.
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 completed the airplane’s engine run-up and carburetor heat function checks with no anomalies noted. He then taxied to the runway and experienced an extended ground delay with the engine running at idle engine power settings. He did not use carburetor heat during the ground delay or during takeoff. About 1,000 ft above ground level (agl), during the initial climb, the engine lost all power. The pilot initiated a forced landing to a field ahead of the airplane’s position and subsequently struck terrain. Postaccident examination of the engine revealed no evidence of mechanical malfunction or failure that would have precluded normal operation. The weather conditions at the time of the accident were conducive to the formation of serious carburetor icing at glide (idle) engine power settings. It is likely that during the post run-up taxi and ground delay, a period during which the engine would typically be operating at low or idle power settings, carburetor ice formed that resulted in a total loss of engine power during the initial climb.
Factual narrative
On April 16, 2023, about 1010 Pacific daylight time, a Piper PA-28-180, N8376W, was substantially damaged when it was involved in an accident near Riverside, California. The pilot and one passenger were not injured. The second passenger sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, after conducting engine run-up and carburetor heat function checks, he switched to the left fuel tank, then taxied for departure. After taxiing to runway 27 at the Riverside Municipal Airport (RAL), Riverside, California, he “had to wait a while” before being issued a takeoff clearance from air traffic control. After takeoff and during the initial climb, about 1,000 ft agl, the engine “sputtered and came back.” The pilot verified that the mixture was full rich, the fuel pump was on, the left fuel tank was selected, and that the magneto switch was on both. Shortly thereafter, the engine sputtered a second time, then lost total power. The pilot initiated a forced landing to a nearby field ahead of the airplane’s position. During the off-airport landing, the airplane struck terrain and came to rest upright about 2 miles west of the departure end of runway 27. Postaccident examination of the engine revealed that when the crankshaft was rotated by hand using the propeller continuity was established throughout the engine and valvetrain. Thumb compression was obtained on all cylinders. An alternate fuel source was plumbed to the right-wing fuel inlet port and the engine was run. The fuel source was removed and reattached to the left-wing fuel inlet port and the engine was run. At 0953, the weather reported at RAL, included a temperature of 16°C and a dewpoint of 9°C. The calculated relative humidity at this temperature and dewpoint is approximately 65%. Review of the icing probability chart contained in Federal Aviation Administration (FAA) Special Airworthiness Information Bulletin CE-09-35 revealed that the weather conditions at the time of the accident were “conducive to serious icing at glide [idle] power.” According to FAA Advisory Circular 20-113, “To prevent accidents due to induction system icing, the pilot should regularly use [carburetor] heat under conditions known to be conducive to atmospheric icing and be alert at all times for indications of icing in the fuel system.” The circular recommended that when operating in conditions where the relative humidity is greater than 50%, “…apply carburetor heat briefly before takeoff, particularly with float type carburetors, to remove any ice which may have been accumulated during taxi and runup.” It also stated, “Remain alert for indications of induction system icing during takeoff and climb-out, especially when the relative humidity is above 50%, or when visible moisture is present in the atmosphere.”
Aircraft
- Registration
- N8376W
- Reported as
- Piper PA-28-180
- Category
- Airplane
- Serial number
- 28-2576
- Built
- 1965
- Airframe hours
- 4,221.83
- Engine
- Lycoming O-360-A3A, 180 horsepower, reciprocating
- Damage
- Substantial damage
- Flight
- Personal · Part 91
- Airworthiness certificate
- Standard, Normal
- Last inspection
- 100 hour · November 4, 2022
- Departed
- KRAL · Riverside, CA
- Destination
- KPOC · La Verne, CA
- Airport
- KRAL · Riverside Municipal, runway 27, 5,401 × 100 ft, asphalt
- Equipment
- ADS-B
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
- 58
- Injuries
- None
- Certificate
- Private
- Airplane ratings
- Single-engine land
- Medical
- BasicMed, With waivers/limitations
- Last flight review
- June 20, 2022
- Seat
- Left
- Flight hours
- 350 total · 73 in this make and model · 300 as pilot in command · 26 in the last 90 days
Weather
- Conditions
- Visual (VMC) · Day
- Wind
- 280° at 5 knots
- Visibility
- 10 statute miles
- Lowest ceiling
- None
- Temperature
- 61 °F, dew point 48 °F
- Altimeter
- 30.12 inHg
- Observed at
- KRAL, 2 nm away
- METAR
- METAR KRAL 161653Z AUTO 28005KT 10SM CLR 16/09 A3012 RMK AO2 SLP190 T01560089
Docket · 5
The files NTSB released with the investigation on November 7, 2024, on NTSB’s docket system: statements, records, photos and specialists’ reports. 4.1 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.