# NTSB WPR23LA156: Piper PA-28-180, N8376W, Riverside, CA, April 16, 2023 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Class 3 · Limited · Final report - Date: April 16, 2023, 10:10 local (17:10 UTC) - Place: Riverside, CA · field 2 mi west of KRAL - Coordinates: 33.955456, -117.48377 - Nearby events: https://openairdocs.org/map.md?lat=33.9555&lon=-117.4838&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Fuel related](https://openairdocs.org/ntsb-events/190) - Highest injury: Minor injuries - Injuries: 1 minor, 2 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - 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): 107070 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR23LA156 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/107070/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=107070 - Page: https://openairdocs.org/ntsb/WPR23LA156 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Engine (reciprocating)](https://openairdocs.org/ntsb-findings/01058500): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [Piper PA-28-180, 4 cases](https://openairdocs.org/ntsb-findings/01058500/cases.md?model=7102808), [All aircraft, 497 cases](https://openairdocs.org/ntsb-findings/01058500/cases.md) - [Attention/monitoring: monitoring equip/instruments](https://openairdocs.org/ntsb-findings/02021525): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Piper PA-28-180, 2 cases](https://openairdocs.org/ntsb-findings/02021525/cases.md?model=7102808), [All aircraft, 142 cases](https://openairdocs.org/ntsb-findings/02021525/cases.md) - [Temp/humidity/pressure: conducive to carburetor icing](https://openairdocs.org/ntsb-findings/03031030): Environmental issues › Conditions/weather/phenomena · Effect on equipment (probable cause); cases with it: [Piper PA-28-180, 5 cases](https://openairdocs.org/ntsb-findings/03031030/cases.md?model=7102808), [All aircraft, 435 cases](https://openairdocs.org/ntsb-findings/03031030/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Fuel related](https://openairdocs.org/ntsb-events/190) (defining event); cases with it: [Piper PA-28-180, 3 cases](https://openairdocs.org/ntsb-events/190/sequence.md?model=7102808), [All aircraft, 361 cases](https://openairdocs.org/ntsb-events/190/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Piper PA-28-180, 40 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=7102808), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) ## 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](https://openairdocs.org/aircraft/N8376W), registered now, S/N 28-2576 (OpenAirDocs) - Reported make and model: PIPER PA-28-180 - Registry model: [Piper PA-28-180](https://openairdocs.org/model/piper-pa-28-180) (registry code 7102808) (OpenAirDocs) - Registry engine: [Lycoming O&VO-360 series](https://openairdocs.org/engine/lycoming-o-vo-360-series) (registry code 41514, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-2576 - Year built: 1965 - Airframe hours: 4221.83 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 58; injuries: none; 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 ## 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 20230416004049A](https://openairdocs.org/incident/20230416004049A), Apr 16, 2023: Piper PA-28-180, Riverside, CA, Substantial damage. The pilot took off from chino. Before take off everything was uneventful... The run up was uneventful. Magnetos checked out good. Flight controls were good.… ## Docket (5 files) The files NTSB released with the investigation on November 7, 2024, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=107070. 4.1 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16344384&FileExtension=pdf&FileName=WPR23LA156_6120_flat_Redacted-Rel.pdf - Weather summary (item 2, PDF, 2 pages, 351 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16431920&FileExtension=pdf&FileName=WPR23LA156%20WX%20Summary-Rel.pdf - Engine and airframe exam summary (item 3, PDF, 5 pages, 374 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16444790&FileExtension=pdf&FileName=Engine%20and%20Airframe%20Exam%20Summary-WPR23LA156-Rel.pdf - Statement of party representatives to NTSB investigation (item 4, PDF, 1 page, 226 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16444677&FileExtension=pdf&FileName=1.%20Piper%20Party%20Form%20N8376W_Redacted-Rel.pdf - Photo array (item 5, PDF, 2 pages, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16438887&FileExtension=pdf&FileName=WPR23LA156_photos_508-Rel.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.