Pilot Debrief

BEECH C23 near Machias, ME — 2017-09-14

Final reportERA17LA325
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Date
2017-09-14
Location
Machias, ME, USA
Airport
MVM
Aircraft
BEECH C23
Registration
N2120W
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Approach

Probable cause

The pilot's delay in applying carburetor heat, which resulted in a total loss of engine power due to carburetor icing.

NTSB narrative

The private pilot descended the airplane to the destination airport but did not apply carburetor heat. While in the traffic pattern, as the airplane was turning onto a left base leg for the runway, the engine began to run roughly. The pilot then applied carburetor heat, but the engine lost total power. After realizing that the airplane was not going to glide to the runway threshold, the pilot performed a forced landing in a grassy area just short of the runway. During the landing, the nose gear collapsed and the airplane spun 180° before it came to rest, which resulted in substantial damage to the right wing. Examination of the wreckage did not reveal any evidence of preimpact mechanical malfunctions or failures of the ignition system, fuel system, or engine 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 power. Although the Descent checklist in the pilot operating handbook for the airplane make and model instructed the pilot to use carburetor heat as required, the pilot did not apply carburetor heat before initiating the descent; rather, he waited until the engine began to run roughly. It is likely that the engine initially lost partial power after developing carburetor ice and that the pilot's delayed application of carburetor heat was ineffective at melting any accumulated ice.

Analysis

Primary failure mode
Engine power loss
First missed decision gate
Pilot could have checked carburetor heat earlier to prevent engine power loss.

NTSB coding

Evidence available

  • Photos
  • 6 docket documents
View NTSB final reportView NTSB docket

Docket documents6

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