NTSB Factual Report

HISTORY OF FLIGHT

On November 11, 2001, about 1925 eastern standard time, a Piper PA-28-180, N3672R, was destroyed during a forced landing and collision with trees in Mansfield, Ohio. The certificated commercial pilot was fatally injured, and the passenger received serious injuries. Night visual meteorological conditions prevailed for the personal flight. No flight plan had been filed for the flight that was conducted under 14 CFR Part 91.

On November 9, 2001, the pilot and passenger flew from Custer Airport, Monroe, Michigan, to Raleigh-Durham International Airport, Raleigh/Durham, North Carolina. The return flight departed Raleigh/Durham at 1619, on November 11, 2001, destined for the Custer Airport.

The pilot was receiving visual flight rules (VFR) traffic advisories while en route. According to air traffic control transcripts, he was handed off to Mansfield Approach Control at 1915. When the pilot established radio contact with Mansfield Approach Control, he reported that he was at 4,500 feet. At 1921, the pilot reported that he was experiencing engine problems and requested to land at Mansfield. He was told that runway 32 was 4 miles straight ahead, and to proceed straight toward it. He was asked if he needed assistance, and told the approach controller that he did not.

At 1922:32, the pilot was given winds from 360 degrees at 5 knots, and cleared to land on runway 32.

At 1922:54, the pilot reported that it didn't look like he was going to make the runway. The local controller asked if the engine had quit and the pilot confirmed that it had.

At 1923:05, the pilot reported that he was going to try to land on a road, which the local controller acknowledged. No further transmissions were received from the airplane.

The accident occurred during the hours of darkness at 40 degrees, 48.061 minutes north latitude, and 82 degrees, 29.307 minutes west longitude.

PERSONNEL INFORMATION

The pilot's logbook was not recovered. According to Federal Aviation Administration (FAA) records, the pilot held a commercial pilot certificate with airplane single and multi-engine land and instrument airplane ratings. He held a flight instructor certificate for single engine airplanes. According to his last FAA second class airman medical application dated December 12, 2000, his total flight experience was 2,500 hours.

According to the pilot's last insurance application dated April 26, 2001, his total flight experience was 2,500 hours, with 250 hours in multiengine airplanes. His total pilot-in-command experience was 2,400 hours. The pilot's last flight review was a 14 CFR Part 135 pilot-in-command and instrument proficiency check ride on February 23, 2001.

The pilot's recent flight experience was not determined.

METEOROLOGICAL INFORMATION

A check of temperature dewpoint spreads was made with stations along the route of flight.

Location Time Temperature Dewpoint

Raleigh-Durham, NC 1551 19 C 02 C

Danville, VA 1656 16 C -02 C

Roanoke, VA 1654 13 C -04 C

Parkersburg, WV 1853 07 C -02 C

Zanesville, OH 1853 06 C -03 C

Mansfield, OH 1905 01 C -04 C

Mansfield, OH 1915 -01 C -04 C

A check of the FAA carburetor icing probability chart revealed the temperature and dewpoint at Mansfield placed the airplane adjacent to the line for serious icing at cruise power.

According to FAA Advisory Circular 20-113, PILOT PRECAUTIONS AND PROCEDURES TO BE TAKEN IN PREVENTING AIRCRAFT RECIPROCATING ENGINE INDUCTION SYSTEM AND FUEL SYSTEM ICING PROBLEMS, dated October 22, 1981.

"..Fuel Vaporization Ice....It is most prevalent with conventional float type carburetors, and to a lesser degree with pressure carburetors when the air/fuel mixture reaches a freezing temperature as a result of the cooling of the mixture during the expansion process that takes place between the carburetor and engine manifold...Vaporization icing may occur at temperatures from 32 degrees F[0 C]. to as high as 100 degrees F [38 C]. with a relative humidity of 50 percent or above...it is possible to relate the temperature dewpoint spread to relative humidity. As the spread becomes less, relative humidity increases and becomes 100% when temperature and dewpoint are the same. In general, when the temperature/dewpoint spread reaches 20 degrees F [11 C]. or less, you have a relative humidity of 50% or higher and are in potential icing conditions."

The FAA inspector who assisted in the accident, drove to the accident site from near Cleveland. He reported that when he left his residence, his vehicle was wet with dew, and there was frost on the grass of his yard.

WRECKAGE AND IMPACT INFORMATION

The airplane came to rest in the front yard of a residence, 1.16 nautical miles from the approach end of runway 32, on extended runway centerline.

The airplane was inverted and both wings had separated from the fuselage. The right wing was found about 30 feet from the fuselage, laying inverted, at the base of trees that were fractured at a height of 20 feet. The left wing separated at its attach fitting, and was found laying against the left side of the fuselage. Both wings had rounded depressions similar to impact with trees, and were ruptured. There was a localized area of wilted vegetation, similar to being sprayed with gasoline.

Flight control continuity was confirmed for the rudder and elevator. The control cables to the ailerons were separated with puffed ends consistent with tension overloads. All breaks at control cables occurred at other than attach points.

No evidence of blockage was found in the fuel system. All fuel filters were absent of debris. Fuel was found in the line leading to the carburetor and in the carburetor bowl. All fuel samples were bright and clear, with a blue tint.

Engine valve train continuity was confirmed. Thumb compression was obtained in all cylinders. All sparkplug leads produced spark when the engine crankshaft was rotated.

The engine was shipped to Lycoming in Williamsport, Pennsylvania, for additional testing. The engine was run under the supervision of an inspector from the FAA. According to the engine test log, the engine achieved 2,720 rpm at full throttle.

MEDICAL AND PATHOLOGICAL INFORMATION

Toxicological testing was conducted by the FAA Toxicology Accident Research Laboratory, Oklahoma City, Oklahoma. The following was found:

DIPHENHYDRAMINE in blood 0.021 ug/ml, ug/g

DIPHENHYDRAMINE in urine

EPHEDRINE in urine

PHENYLPROPANOLAMINE in urine

PSEUDOEPHEDRINE in urine

ACETAMINOPHEN in urine 18.063 ug/ml, ug/g

According to the web site www.mentalhealth.com, the brand name of diphenhydramine was Benadryl, and the following adverse effects were listed, "Drowsiness, dizziness, dryness of mouth, nausea and nervousness...."

A web search on the name Benadryl revealed it was an over-the-counter antihistamine.

An autopsy was conducted on November 13, 2001, by Cynthia S. Beisser, M.D., Deputy Coroner for Lucas County, State of Ohio.

ADDITIONAL INFORMATION

GPS Data

A hand held global position navigation system (GPS) was recovered from the airplane. The unit was sent to Garmin and examined under the supervision of an FAA inspector from the Kansas City, Kansas, Flight Standards District Office. No altitude data was recorded. However, time, latitude, longitude, and ground speed in mph were recorded. The time used in the report was Central Standard Time (UTC-6). The entire flight took place in Eastern Standard Time (UTC-5).

The GPS started recording at 1617, and an increase in ground speed, consistent with flight was recorded at 1620. The distance to the accident site was 344 nautical miles. The average ground speed was about 128 mph (110 knots), although excursions were observed between 100 and 150 mph.

At 1820:52, the ground speed which had been recently averaging around 138 to 140 mph started to decrease. The ground speed decreased to 94.6 mph, and then increased back to 103 mph at 1921:52, after which the ground speed steadily decreased until 1824:26, the last recorded data, when the ground speed was 5.6 mph, and the position of the airplane was 40 degrees, 48.078 minutes north latitude, and 82 degrees, 29.317 minutes west longitude.

FAA Approved Flight Manual and Piper PA-28 Owners Manual

Carburetor icing, and use of carburetor heat was not addressed in the Piper PA-28-180, FAA approved flight manual. However, in The Piper Cherokee Owner's Handbook, Section III, Approach and Landing, the following information was found.

"Carburetor heat should not be applied unless there is an indication of carburetor icing, since the use of carburetor heat causes a reduction in power which may be critical in case of a go-around. Full throttle operation with heat on is likely to cause detonation."

The following was extracted from Advisory Circular 61-23C PILOT'S HANDBOOK OF AERONAUTICAL KNOWLEDGE, Chapter 2 - AIRPLANES AND ENGINES, ENGINE OPERATION:

"Indications of Carburetor Icing

For airplanes with fixed-pitch propellers, the first indication of carburetor icing is loss of RPM. For airplanes with controllable-pitch (constant-speed) propellers, the first indication is usually a drop in manifold pressure. In both cases, a roughness in engine operation may develop later. There will be no reduction in RPM in airplanes with constant-speed propellers, since propeller pitch is automatically adjusted to compensate for the loss of power, thus maintaining constant RPM."

"Use of Carburetor Heat"

"When conditions are conducive to carburetor icing during flight, periodic checks should be made to detect its presence. If detected, full carburetor heat should be applied immediately, and it should be left in the 'on' position until the pilot is certain that all the ice has been removed. If ice is present, applying partial heat or leaving heat on for an insufficient time might aggravate the situation."

Passenger Interview

In an interview, the surviving passenger reported that the flight had been uneventful until it neared Mansfield. The airplane was at 4,500 feet in normal cruise when he heard a "pop", and the engine lost partial power. He reported that the pilot pulled on carburetor heat for about 10 seconds and then with no change in engine operation, turned the carburetor heat off. He then stated, "the engine must be vaporlocked." The pilot did not pull on carburetor heat again, was unable to restore full power, and the airplane continued toward the ground. The airplane struck trees and came to rest upside down.

Wreckage Release

The aircraft wreckage was released on November 13, 2001, to the insurance adjustor.

NTSB Probable Cause

the pilot's improper use of carburetor heat, and subsequent forced landing. Factors were the carburetor icing condition, night conditions, trees, and the pilot's impairment from ingestion of an over-the-counter antihistamine.