WPR24LA117

NTSB accident investigation · Piper PA-28-140 · Acton, CA · March 23, 2024

Accident · No injuriesClass 3 · LimitedFinal report
Date
March 22, 2024, 18:04 local (Mar 23, 2024, 01:04 UTC)
Place
Acton, CA · Angeles National Forest
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N1695HPiper PA-28-140
Defining event
Maneuvering: Loss of engine power (partial)
Weather
Visual (VMC) · Day
Status
Completed · report January 14, 2026
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration
FAA report
20240322003469A
Case key
193985

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

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Probable cause

The pilots inability to fully turn off the carburetor heat which resulted in a reduction of engine power and reduced climb performance. Contributing to the accident was the pilots delayed recovery from the simulated emergency landing.

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.

Engine controlsAircraft › Aircraft power plant · MalfunctionPiper PA-28-140: 2 casesAll aircraft: 51 casesProbable cause
Action: delayed actionPersonnel issues › Action/decision · PilotPiper PA-28-140: 17 casesAll 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 private pilot applicant and designated pilot examiner (DPE) were conducting a simulated engine failure exercise as part of the flight portion of a private pilot practical test. Once satisfied that the applicant would successfully complete an emergency landing, the DPE announced the end of the exercise and asked the applicant to initiate a go-around. The applicant advanced the throttle to full forward, turned the carburetor heat off, and pitched the airplane for 66 kts. A few seconds later, the applicant informed the DPE that the airplane didn’t seem to be climbing, and the DPE checked the airplane’s climb configuration, confirming full throttle, full rich mixture, carburetor heat cold, and flaps up. Both pilots noted that the tachometer was displaying about 2000 rpm. During the simulated emergency descent and subsequent go-around, the airplane was flying toward rising terrain. The DPE attempted several shallow turns toward lower terrain; however, he could not turn without losing altitude, so did not turn away from the rising terrain. He identified a flat area on top of a ridge and executed an emergency landing on the ridgeline in heavy brush, about one mile from the go around initiation point. Postaccident examination of the wreckage revealed that the carburetor heat control cable was improperly attached to the carburetor heat control arm, which restricted travel of the airbox heat door and the cabin-mounted carburetor heat control knob. The improper attachment restricted the heat door from closing fully in the carburetor heat OFF position but did not restrict the heat door from closing fully in the ON position. The inability to fully close the carburetor heat into the OFF position could have resulted in a reduction in engine power; however, an exact amount of engine rpm reduction could not be determined. Postaccident test run of the engine revealed that it produced full power and showed no evidence of mechanical malfunctions or failures that would have precluded normal operation. The reason for the partial loss of engine power could not be determined. Both pilots reported that they initiated the go-around while about 800 ft above ground level (agl); however, recorded flight data from the airplane’s avionics indicated that the airplane had descended to about 90 ft agl when the go-around was initiated. The airplane then attained an average climb rate of 310 ft per minute between the initiation of the go-around and the accident site. The elevation at the accident site was 381 ft higher than the elevation where the go-around was initiated. While flying into rising terrain, the airplane could have appeared to the pilots that it was not climbing, despite the documented climb rate. However, the partial loss of engine power likely prevented the airplane from outclimbing the rising terrain.

Factual narrative

On March 22, 2024, about 1804 Pacific daylight time, a Piper PA-28-140, N1695H, was substantially damaged when it was involved in an accident near Acton, California. The private pilot applicant and designated pilot examiner were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 flight test. According to statements from the DPE and private pilot applicant, they were conducting the flight portion of a private pilot practical test. The DPE announced a simulated engine failure and reduced the engine power to idle. The private pilot applicant turned on the carburetor heat and performed the simulated emergency procedures for an engine failure. At approximately 800 ft agl the DPE instructed the applicant to go around, ending the simulated emergency. The applicant increased the engine power by advancing the throttle full forward, turning the carburetor heat off, and pitching the airplane for an indicated airspeed of 66 knots. After about 10 seconds, the applicant stated to the DPE that the airplane would not climb. The DPE confirmed that the throttle control was set to full power, mixture control was set to full rich, carburetor heat control was set to off, and that the flaps were up. He noticed that the tachometer indicated about 2000 rpm. The DPE took control of the airplane and attempted to turn away from rising terrain; however, the airplane would not maintain altitude in a turn. The DPE continued straight ahead and determined that the airplane would not outclimb the surrounding terrain, then prepared to make an emergency landing. The DPE initiated a landing along a ridgeline about 1 mile south of the go around initiation point. During the landing, the airplane impacted vegetation and came to rest upright. It sustained substantial damage to both wings, the fuselage, and the stabilator. Postaccident examination of the airframe revealed limited function of the heat door within the airbox. The carburetor heat control arm traveled from stop to stop; however, the heat door only exhibited about half its designed travel. It traveled from the carburetor heat ON position to halfway between carburetor heat OFF and ON. The carburetor heat control cable was looped around the attachment bolt and found to be loose; it was not threaded through the attachment bolt, and no safety wire was observed. The carburetor heat control knob inside the cabin traveled without binding but exhibited limited travel and was found to travel between the “Carburetor Heat OFF” position and about halfway to the “Carburetor Heat ON” position. A postaccident test run of the engine was conducted and revealed that it produced full power and showed no anomalies that would have precluded normal operation. Accident flight data from the airplane’s Garmin G5 was downloaded and indicated that the simulated emergency descent was flown toward agricultural fields, and rising terrain. Recovery from the simulated engine failure began at approximately 90 ft agl,and the airplane achieved an average rate of climb of 310 fpm from the exercise’s go-around point to the accident site. The geographical change in elevation from the go-around point to the accident site was +381 ft and the lateral distance was about one mile. According to maintenance records, the most recent annual inspection was completed on April 14, 2023, and the most recent maintenance logbook entry related to the travel of carburetor heat controls, was March 11, 2024.

Aircraft

Registration
N1695H
Reported as
Piper PA-28-140
Category
Airplane
Serial number
28-7725155
Built
1977
Airframe hours
2,602.7
Engine
Lycoming O-320-E3D, 150 horsepower, reciprocating
Damage
Substantial damage
Flight
Flight test · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · January 24, 2024 · 73.8 hours before
Departed
KWHP · Pacoima, CA
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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Student pilot
Age
19
Injuries
None
Certificate
Student
Airplane ratings
Single-engine land
Medical
Class 1, With waivers/limitations
Seat
Left
Restraint
3-point
Flight hours
85 total · 83 in this make and model · 10 as pilot in command · 69 in the last 90 days · 0 in the last 24 hours
Role
Check pilot
Age
65
Injuries
None
Certificates
Commercial, Flight instructor, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Seat
Right
Restraint
3-point
Flight hours
15,000 total

Weather

Conditions
Visual (VMC) · Day
Wind
150° at 8 knots
Visibility
8 statute miles
Lowest ceiling
None
Temperature
68 °F, dew point 52 °F
Altimeter
29.99 inHg
Observed at
KWHP, 14 nm away
METAR
METAR KWHP 230050Z 15008KT 8SM HZ SKC 20/11 A2999

Docket · 12

The files NTSB released with the investigation on January 14, 2026, on NTSB’s docket system: statements, records, photos and specialists’ reports. 158 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.