NTSB CAROL · Event
Event WPR19LA065
Aircraft involved
Probable cause & findings
A partial loss of engine power due to the mechanic’s failure to properly secure the throttle lever locking nut and cotter pin.
Factual narrative
On January 15, 2019, about 1050 mountain standard time, a Piper PA28-140 airplane, N1697J, was substantially damaged when it was involved in an accident near Salt Lake City, Utah. The commercial pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that he was practicing touch-and-go landings. While on landing approach, he reduced the throttle control to decrease engine rpm; however, the engine remained at 2,200 rpm. He then pushed the throttle back in and the power increased to 2,500 rpm. He attempted to reduce throttle again, but the engine remained at 2,500 rpm. The pilot initiated a go-around, and, shortly thereafter, engine power decreased from 2,500 to 1,500 rpm. With no usable runway remaining, the pilot performed a forced landing to a road, during which the propeller struck the road and the landing gear sheared off the airplane. The service manual for the Marvel-Schebler Model MA4 series carburetor lists a castellated nut and cotter pin to secure the serrated throttle arm to the throttle shaft of the carburetor (see figure 1). Examination of the engine revealed that the carburetor serrated throttle lever locking nut was finger-tight and the cotter pin was absent. When the throttle lever was retracted and extended, the loosely attached throttle shaft did not move, as shown in figures 2 and 3. Figure 1. Excerpt from the Marvel-Schebler Carburetor Service Manual. A review of the engine maintenance records revealed that, on December 14, 2018, as part of the annual inspection, the mechanic wrote, "Verified control movement and lubricated." In an interview with a Federal Aviation Administration (FAA) representative, the mechanic confirmed that he took the throttle cable off to do this work. Postaccident examination of the carburetor at Precision Air Power, Woods Cross, Utah revealed no anomalies that would have precluded normal operation. Figure 2. Note the serrated throttle lever and idle stop at the idle position. Figure 3. Photo showing the serrated throttle lever at full power setting while the idle stop lever remained at idle. The pilot was practicing takeoffs and landings when the engine became unresponsive to throttle inputs. He performed a forced landing onto a highway, during which the airplane was substantially damaged. Examination of the engine revealed that the carburetor throttle lever lock nut was finger-tight, and its cotter pin was absent, which likely resulted in the throttle lever intermittently disengaging from the serrated throttle shaft when the pilot manipulated the throttle. A review of the maintenance log books and an interview with the mechanic revealed that the throttle cable had been removed and subsequently reinstalled onto the carburetor as part of the most recent annual inspection, which was completed about 1 month before the accident. It is likely that, at this time, the mechanic did not install or inadequately installed the cotter pin through the locking nut and bolt. Source: NTSB Aviation Accident Database Retrieved: 2026-02-12
NTSB Findings
Hierarchical cause / factor breakdown from the FAA bulk avdata database. Each finding tagged C (Cause) or F (Factor).
- C Aircraft-Aircraft power plant-Engine fuel and control-Fuel control/carburetor-Incorrect service/maintenance
- — Aircraft-Fluids/misc hardware-Misc hardware-Fasteners-Incorrect service/maintenance
Verbatim from NTSB's published report. Source file
NTSB_2019_WPR19LA065.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, stall, go-around, 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
Reconfigurable Guidance and Control Systems for Emerging On-Orbit Servicing, Assembly, and Manufacturing (OSAM) Space Vehicles
Dynamic response to emergent situations is a necessity in the on-orbit servicing, assembly, and manufacturing (OSAM) field, because traditional on-orbit guidance and control (G&C) cannot respond effic…
- arXiv 2023 · arXiv preprint
Variation of Critical Crystallization Pressure for the Formation of Square Ice in Graphene Nanocapillaries
Two-dimensional square ice in graphene nanocapillaries at room temperature is a fascinating phenomenon and has been confirmed experimentally.
- Embry-Riddle Scholarly Commons 2023 · Conference paper
The Value of Strong Partnerships to Build a Successful Aviation Maintenance Career Pathway Program for Transitioning Military Service Members
The aerospace industry is competing with other industries for a qualified workforce, and many of those competing industries are investing heavily in creating workforce development pipelines.
- arXiv 2022 · arXiv preprint
Enhanced Prediction of Three-dimensional Finite Iced Wing Separated Flow Near Stall
Icing on three-dimensional wings causes severe flow separation near stall. Standard improved delayed detached eddy simulation (IDDES) is unable to correctly predict the separating reattaching flow due…
- NASA NTRS 2019 · Contractor Report (CR)
An Evaluation of an Analytical Simulation of an Airplane with Tailplane Icing by Comparison to Flight Data
This report presents the assessment of an analytical tool developed as part of the NASA/FAA Tailplane Icing Program. The analytical tool is a specialized simulation program called TAILSM4 which was de…
- NASA NTRS 2019 · Technical Publication (TP)
NASA/FAA Tailplane Icing Program: Flight Test Report
This report presents results from research flights that explored the characteristics of an ice-contaminated tailplane using various simulated ice shapes attached to the leading edge of the horizontal …
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