Pilot Debrief

PIPER PA28 near Vero Beach, FL — 2019-02-08

Final reportERA19LA097
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Date
2019-02-08
Location
Vero Beach, FL, USA
Airport
VRB
Aircraft
PIPER PA28
Registration
N9219J
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Approach

Probable cause

The pilot's failure to use carburetor heat while operating the airplane in weather conditions and at engine power settings conducive to the formation of carburetor ice, which resulted in a loss of engine power due to carburetor icing and the subsequent forced landing.

NTSB narrative

The pilot was flying in the airport traffic pattern practicing touch-and-go landing maneuvers. On his third approach, the air traffic controller directed him to extend the downwind leg of the traffic pattern. On final approach, the engine rpm dropped, and the pilot felt the airplane "sinking." The pilot did not perform any checklists but advised air traffic control that he would be making an emergency landing and advanced the throttle lever. The engine momentarily produced more power but then lost total power when the airplane was about 500-600 ft above ground level; the propeller windmilled. The pilot did not attempt to perform any other remedial actions, such as applying carburetor heat, to restore power and executed a forced landing on a nearby gravel road. During the landing, the airplane impacted a utility pole and trees and sustained substantial damage to the wings and stabilator. Postaccident examination of the engine, which included a successful engine test run, revealed no evidence of any preimpact malfunctions or failures that would have precluded normal operation. The weather conditions at the time of the accident were conducive to serious carburetor icing at descent engine power settings. Because postaccident examination of the engine revealed no anomalies, it is likely that the loss of engine power was a result of carburetor ice accumulation. When asked, the pilot stated that carburetor heat was only appropriate for simulated engine-out procedures. However, according to the pilot's operating handbook for the airplane make/model, carburetor heat should be used, if required, during a normal descent. The pilot failed to properly assess that conditions were conducive to carburetor icing and apply carburetor heat before the reduction in engine power.

Analysis

Primary failure mode
Fuel management
First missed decision gate
Pilot did not apply carburetor heat when conditions were conducive to icing.

NTSB coding

Evidence available

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

Docket documents10

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