ANC11FA093

NTSB accident investigation · Piper PA-18-150 · McGrath, AK · September 4, 2011

Accident · Serious injuriesField investigationFinal report
Date
September 4, 2011, 15:00 local (23:00 UTC)
Place
McGrath, AK
Injuries
1 serious
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N13973Piper PA-18-150
Defining event
Approach-VFR pattern final: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report December 19, 2012
Report
Approved by Office Director
NTSB office
Alaska Regional Office
Parties
FAA FSDO-01
FAA report
20110904021679A
Case key
81693

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The pilot inadvertently switched off the engine magnetos during short final approach, which resulted in a loss of engine power. Contributing to the accident was the manufacturer's placement of the magneto switches in the cabin.

Findings · 3

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Use of equip/infoPersonnel issues › Task performance · PilotPiper PA-18-150: 3 casesAll aircraft: 111 casesProbable cause
Ignition system: switchingAircraft › Aircraft power plant · Unintentional use/operationPiper PA-18-150: 2 casesAll aircraft: 9 casesProbable cause
Physical workspace: positioning/available spaceEnvironmental issues › Task environment · Contributed to outcomePiper PA-18-150: 2 casesAll aircraft: 11 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The airplane was on short final approach to the airport when its engine would not respond to throttle input. The airplane descended into trees and impacted terrain. The pilot reported that immediately prior to the loss of engine power, he had made an elevator trim control adjustment and was in the process of making a throttle adjustment when he heard a snap and the engine quit operating, "as if the magnetos had been shut off." Examination of the airplane established that the throttle cable was intact. The engine was run, and no anomalies were noted. During the engine run, the magneto switches were turned off while the engine was at cruise rpm. The switches made an audible click/snap when turned off. Following a similar August 29, 2011, accident also involving a Piper PA-18 airplane, the pilot reported that, during the initial climb, he inadvertently switched off the engine magnetos with his coat sleeve while using the trim handle, causing the airplane’s engine to shut down. As with this accident airplane, the magneto switches were located on the left side of the cabin, just above the trim handle. As a result of incidents involving the inadvertent shutting off of the magneto switches, the Federal Aviation Administration published a notice of proposed rulemaking announcing its intent to issue an airworthiness directive requiring the reconfiguration of the magneto switches on Piper PA-18 airplanes. Given the absence of any mechanical issues with the airplane, as well as the location of the magneto switches and the trim handle, it is likely the pilot inadvertently shut off the magnetos switches while trimming the airplane on short final approach.

Factual narrative

On September 4, 2011, about 1500 Alaska daylight time, a Piper PA-18 airplane, N13973, sustained substantial damage following a loss of engine power during final approach to McGrath Airport, McGrath, Alaska. The airplane was operated by the pilot as a visual flight rules (VFR) personal cross-country flight, under the provisions of 14 Code of Federal Regulations, Part 91, when the accident occurred. Visual meteorological conditions prevailed at the time of the accident, and the solo commercial pilot received serious injuries. The flight departed Kingston Creek, about 85 miles east of McGrath. During a telephone conversation with the National Transportation Safety Board (NTSB) investigator-in-charge (IIC) on September 4, a rescuer that responded to the accident site said that the pilot told him that while on approach to land, he advanced the throttle to apply engine power to adjust his glide path, but the engine did not respond. The pilot reported that he thought the throttle cable had broken. The airplane subsequently descended into trees at the approach end of the runway, sustaining substantial damage to the wings and fuselage. Additionally, the pilot told the rescuer that he heard an audible snap, which made him think the throttle cable had snapped, and then the engine failed to respond to throttle application. During a telephone conversation with the NTSB IIC in January 2012, the pilot reported that he had owned the airplane for many years, and that there were no mechanical anomalies with the airplane prior to the accident. He said that on the accident flight, while on short final for the airport, the airplane had been trimmed for the approach, and the engine was throttled back. He said the approach was going to be short of the runway, and he applied power, but the airplane engine remained at idle. He thought the throttle cable had broken. The airplane descended striking trees and the ground, and nosed over. During recovery of the airplane, usable amounts of fuel were found in the wing tanks. The wings were removed and the airplane was transported to a maintenance facility in Anchorage, Alaska. On November 10, the airplane was examined by the NTSB IIC, accompanied by an FAA air safety inspector. During the inspection the engine was run on the airframe. The engine was started, and run through various rpm ranges. The throttle cable was found intact and it worked as anticipated. No mechanical anomalies were found with the engine. An FAA air safety inspector, a party to the investigation, said the pilot made the following statement during a telephone interview. On September 4, 2011, the accident pilot said that immediately prior to the loss of engine power, he had made elevator trim control adjustments and was in the process of making a throttle control adjustment when he heard a snap and the engine quit operating, “as if the magnetos had been shut off.“ The elevator trim adjustment handle is situated just below the magneto toggle switches. Duringthe engine run, the magneto switches were turned off while the engine was at cruise rpm. The switches being single-pole, single-throw mechanical switches, made an audible click/snap when turned off, which could be heard above the noise of the engine. Due to the pilot's injuries, no NTSB form 6120.1 was submitted. Airplane and pilot log books were examined, and no anomalies were found. Additional Information In a similar accident also involving a Piper PA-18 airplane, which occurred on August 29, 2011, near Cape Yakataga, Alaska, (ANC11CA089) the pilot reported that, during the initial climb, he inadvertently switched off the engine magnetos with his coat sleeve while using the trim handle causing the airplane’s engine to shut down; the switches were located on the left side of the cabin. The pilot realized the problem, but, due to the airplane's low altitude, he decided to land instead of trying to restart the engine. A postaccident examination of the magneto switches on the accident airplane, and other like models, revealed that a pilot's coat sleeve can contact and move the guarded magneto switches to the off position. As a result of the previous investigation the NTSB determined that the pilot inadvertently switched off the engine magnetos during the initial climb, resulting in a loss of engine power. Contributing to the accident was the manufacturer's placement of the magneto switches. The airplane in the current accident had the same magneto switch configuration as the airplane listed in ANC11CA089, and the pilot had just trimmed the airplane for the approach. Following the investigation of ANC11CA089, the FAA looked into instances of magnetos being inadvertently shut off in similarly configured airplanes. Their investigation led to publishing a notice of proposed rulemaking (NPRM), with the intent to publish an airworthiness directive (AD) for the reconfiguration of the magneto switches.

Aircraft

Registration
N13973
Reported as
Piper PA-18-150
Category
Airplane
Serial number
18-8985
Airframe hours
1,364
Engine
Lycoming O-360 SERIES, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Richardson James K
Registered owner
Richardson James K
Airworthiness certificate
Standard, Normal
Departed
Kingston Creek, AK
Destination
PAMC · McGrath, AK
Flight plan
Unknown
Airport
PAMC · McGrath, runway 05, 2,000 × 60 ft, gravel

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
66
Injuries
Serious
Certificate
Commercial
Airplane ratings
Single-engine land, Single-engine sea, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Seat
Front
Flight hours
23,000 total · 6,000 in this make and model · 3 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
20,000 ft broken
Temperature
61 °F, dew point 48 °F
Altimeter
29.26 inHg
Observed at
PAMG, 1 nm away

Docket · 2

The files NTSB released with the investigation on October 27, 2012, on NTSB’s docket system: statements, records, photos and specialists’ reports. 2.3 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.

Other investigations on N13973 · 1

Matched to the same aircraft by N-number and date.