Pilot Debrief

Piper J3C near Elyria, OH — 2019-06-30

Final reportCEN19FA191
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Date
2019-06-30
Location
Elyria, OH, USA
Airport
1G1
Aircraft
Piper J3C
Registration
N98527
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Initial climb

Probable cause

A loss of engine power due to carburetor icing, and the pilot’s subsequent exceedance of the airplane’s critical angle of attack, which resulted in an aerodynamic stall and impact with terrain.

NTSB narrative

Witnesses reported that the airplane performed a touch-and-go landing. Upon reaching an altitude of 75 to 100 ft above the ground, the engine power “seemed to drop off” and the airplane entered a descending left turn. The airplane then made a right turn and descended vertically into an open field. The weather conditions at the time of the accident were conducive to the development of serious carburetor icing at glide power. Impact damage prevented determination of the carburetor heat controls position at the time of the accident. No anomalies were noted with the airframe or engine that would have precluded normal operation. Toxicology testing of the pilot detected the non-impairing high blood pressure medication hydrochlorothiazide. Flecainide, used to treat irregular heartbeat, was detected in heart blood and urine; while it is unknown when the pilot received the diagnosis or treatment of arrhythmia, given the circumstances of the accident, it is unlikely that sudden incapacitation from arrythmia was a factor in this accident. Laudanosine, which is a metabolite of drugs used for general anesthesia, was detected in the pilot’s urine; while it is also unknown what procedure the pilot had that required anesthesia, the laudanosine in urine would not be impairing. The opioid pain medication codeine was detected in the pilot’s blood (8.5 and 10 ng/mL) and codeine and its metabolites, morphine and hydrocodone, were detected in the pilot’s urine. It is unknown why the pilot was using this mild pain medication. While these drugs are generally impairing, the level of codeine in the blood was one-tenth of the lowest therapeutic level and would not be impairing. Given the circumstances of this accident, it is unlikely that the pilot’s medical conditions or the effects from the pilot’s use of codeine and other detected medications were factors in this accident. The accident is consistent with the pilot’s exceedance of the airplane’s critical angle of attack following a loss of engine power due to carburetor icing, which resulted in an aerodynamic stall and impact with terrain.

Analysis

Primary failure mode
Fuel management
First missed decision gate
Pilot could have used carburetor heat during initial climb to prevent icing.

NTSB coding

Evidence available

  • ADS-B / radar
  • Photos
  • 9 docket documents
View NTSB final reportView NTSB docket

Docket documents9

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