Pilot Debrief

BEECH C23 near Waianae, HI — 2016-05-23

Final reportWPR16LA119
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Date
2016-05-23
Location
Waianae, HI, USA
Aircraft
BEECH C23
Registration
N6697Y
Category
Airplane
Highest injury
Minor
Fatalities
0
Phase of flight
Climb

Probable cause

The total loss of engine power during cruise flight due to carburetor icing. Contributing to the accident was the pilot’s delay in applying carburetor heat during flight while operating in an area conducive to carburetor icing.

NTSB narrative

The private pilot reported that, during the climb-to-cruise portion of the cross-country interisland flight over open ocean water, the engine began to run roughly. The pilot applied carburetor heat, which resolved the engine roughness. The pilot decided to continue his flight. As the flight approached his destination, the engine began running roughly again, accompanied by a significant loss of engine rpm. The pilot applied carburetor heat and adjusted the mixture, but the engine power was not restored. He then ditched the airplane into the water just offshore of the island. The airplane wreckage was recovered from the water 3 days after the accident, and it had sustained significant damage from tidal forces. Postaccident examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. Weather conditions in the area at the time of the accident were conducive to the formation of carburetor icing at glide and cruise power and serious carburetor icing at glide power. If the pilot had either kept the carburetor heat on or applied it earlier, the loss of engine power and subsequent ditching could have been avoided.

Analysis

Primary failure mode
Engine power loss
First missed decision gate
Pilot could have diverted earlier when engine began running rough.

NTSB coding

Evidence available

  • 5 docket documents
View NTSB final reportView NTSB docket

Docket documents5

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