Pilot Debrief

PIPER PA-38-112 near Ojai, CA — 2009-12-10

Final reportWPR10FA078
Sign in to save
Date
2009-12-10
Location
Ojai, CA, USA
Aircraft
PIPER PA-38-112
Registration
N2463K
Category
Airplane
Highest injury
Fatal
Fatalities
2
Phase of flight
Maneuvering

Probable cause

Airspeed was not maintained, which resulted in a loss of control and the airplane entering into a stall/spin to the ground. Contributing to the accident was a loss of engine power due to carburetor icing.

Contributing factors

Contributing to the accident was a loss of engine power due to carburetor icing.

NTSB narrative

The purpose of the flight was for the flight instructor to evaluate the student for a pre-solo training flight. Radar data indicated that the airplane maneuvered in the vicinity of the accident site for 22 to 24 minutes. It then descended from 3,500 feet, at approximately 660 feet per minute, until 2,000 feet was reached and radar coverage was no longer possible. A witness, located at an adjacent school playground, reported that the airplane approached her position at a very low altitude. At the time she thought it was a sailplane, because she did not hear any engine noise. As the airplane approached within 0.5 miles of her position, she heard noises she thought sounded like the pilot was trying to start the engine. She then heard the engine running and the airplane turned toward rising terrain. The engine noise once again stopped and she lost sight of the airplane shortly before it crashed. Documentation of the wreckage indicated that the airplane collided with the terrain in a nearly vertical attitude. A postimpact examination did not reveal any anomalies with the airframe or engine that would have precluded normal operation. The temperature and dew point weather conditions were plotted on a carburetor icing chart, which indicated serious icing at glide power conditions. The loss of engine power, as reported by the witness, was likely due to carburetor icing.

Analysis

Primary failure mode
Loss of control
First missed decision gate
Instructor did not use carburetor heat during emergency maneuvers as required.

NTSB coding

Evidence available

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

Docket documents27

Related mishaps