NTSB CAROL · Event
Event LAX01LA099
Aircraft involved
Probable cause & findings
A partial loss of engine power during initial takeoff climb due to the formation of carburetor ice. A contributing factor was the pilot's improper pretakeoff actions. A finding was that the improper rigging of the mixture control cable may have precluded establishment of the proper fuel/air combustion ratio.
Factual narrative
On February 15, 2001, about 0945 hours Pacific standard time, a Beech 77, N18152, impacted trees and terrain during initial climb seconds after taking off from the Auburn Municipal Airport, Auburn, California. Sierra Nevada Flyers, Grass Valley, California, operated the airplane. Visual meteorological conditions prevailed, and no flight plan was filed for the local area flight. The airplane sustained substantial damage. The private pilot received minor injuries. The personal flight was performed under 14 CFR Part 91. In the pilot's completed report, he indicated that his private pilot certificate was obtained in a glider, and he held a student pilot certificate for airplanes. His last 90-day "proficiency check" was accomplished on December 21, 2000. Regarding the accident flight, the pilot stated that the airplane's engine lost power after climbing between 250 and 300 feet above the runway. Immediately thereafter, he made one emergency call on the common air traffic frequency and applied the engine's carburetor heat. The airplane descended into a woody area. The pilot also reported that no mechanical malfunctions or failures were experienced with the airplane. He indicated that the accident could have been prevented had he, before initiating his takeoff and while waiting for landing traffic, applied carburetor heat to the engine. The airport manager reported that the impact site was about 1,500 feet beyond the departure end of runway 07. The manager also reported that at 1000 local time, the airport's automated surface observing system (ASOS) indicated that the temperature and dew point were 9 and 1 degree Celsius, respectively. The manager estimated that the accident had occurred about 1005. The National Transportation Safety Board investigator notes that, according to a standard reference icing probability chart, the atmospheric conditions were in the range considered favorable for carburetor ice formation. A Federal Aviation Administration (FAA) airworthiness inspector reported that a witness had reported observing the airplane near the approach end of the runway for about 10 minutes before taking off. Thereafter, full engine power was not obtained during the takeoff roll. The FAA inspector examined the engine and accessories. In summary, the FAA inspector verbally reported to the Safety Board investigator that the engine's magnetos produced spark, and the impulse coupling functioned. The spark plugs appeared in the normal wear/coloration range. Compression was detected in all cylinders except number one, which was impact damaged. The induction system was devoid of foreign object blockage. The exhaust system was clear. The carburetor heat control was functional. Fuel was observed in the carburetor bowl. Additionally, the FAA reported finding evidence that the mixture control cable had received maintenance following an earlier breakage event. The FAA indicated that the current rigging of the mixture control cable was improper due to its engine mount attachment. When the cable was repaired or replaced, it had been improperly repositioned and then reconnected. As a result, when the cockpit mixture control was set to the full rich position, the mixture control arm on the carburetor was between the midrange position and 2/3 of the way to the idle cutoff position. Due to the cable's incorrect rigging, the proper fuel/air combustion ratio may not have been established. Prior to taking off, the airplane sat for about 10 minutes near the approach end of the runway. The pilot indicated that during this time no carburetor heat was applied to the engine. Thereafter, when he commenced taking off, full engine power was not produced. The airplane climbed between 250 and 300 feet above the runway, descended and impacted trees, and then collided with terrain about 1,500 feet beyond the runway's departure end. The pilot indicated that the accident could have been prevented had he, before initiating his takeoff and while waiting for landing traffic, applied carburetor heat to the engine. At the time, the temperature and dew point were 9 and 1 degree Celsius, respectively. According to a standard reference icing probability chart, the atmospheric conditions were in the range considered favorable for carburetor ice formation. The pilot reported that no mechanical malfunctions or failures were experienced with the airplane. The engine was subsequently examined, and no evidence of any internal mechanical malfunction was noted. The mixture control cable was found improperly rigged. As a result, when the cockpit mixture control was set to the full rich position, the mixture control arm on the carburetor was between the midrange position and 2/3 of the way to the idle cutoff position. The significance of the incorrect rigging to the loss of engine power could not be established. Source: NTSB Aviation Accident Database (Pre-2008 Archive) Retrieved: 2026-02-12
Verbatim from NTSB's published report. Source file
NTSB_2001_LAX01LA099.txt.
Findings + structured fields enriched from FAA avall.mdb.
Full investigation docket on
data.ntsb.gov ↗.
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Related research
What the literature says.
Academic papers and agency reports matching this event's aircraft type or causal vocabulary (icing, maintenance). Sourced from NASA NTRS, NTSB Safety Studies, FAA CAMI, AOPA Air Safety Institute, Embry-Riddle Scholarly Commons, arXiv, and the Semantic Scholar academic graph.
- Embry-Riddle Scholarly Commons 2023 · Faculty research project
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- Embry-Riddle Scholarly Commons 2020 · Conference paper
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- Embry-Riddle Scholarly Commons 2019 · Journal article (IJAAA)
Satellite Maintenance: An Opportunity to Minimize the Kessler Effect
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- Embry-Riddle Scholarly Commons 2015 · Conference paper
The Implementation of Safety Management Systems in Maintenance Operations
Literature for Safety Management Systems (SMS) that apply to flight operations is abundant, but there is a limited supply of SMS-related literature for maintenance operations.
- Embry-Riddle Scholarly Commons 2026 · Journal article (IJAAA)
From Reactive to Predictive: A hybrid Trust-Mediated Adoption Framework for Data-Driven Maintenance in Distributed-Authority Aviation Environments
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- NASA NTRS 2026 · Contractor Report (CR)
Icing Physics Studies Using the 3D SIDRM Test Article: 2023 Icing Tests Analysis
In-flight icing is an important safety issue and is a factor that affects aircraft design and performance. Newer regulations are driving a need for improvements in airframe and engine icing simulation…
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