# NTSB ATL02FA137: Piper PA-28RT-201, N8143B, Lebanon, TN, July 2, 2002 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: July 2, 2002, 15:00 local (20:00 UTC) - Place: Lebanon, TN - Coordinates: 36.194999, -86.31639 - Nearby events: https://openairdocs.org/map.md?lat=36.1950&lon=-86.3164&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal, 1 minor - Status: Completed, report December 30, 2003 - Report: Approved by Office Director - Parties: The New Piper Aircraft Corp, Nashville FSDO, AVCO Lycoming - NTSB case key (mKey): 55132 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ATL02FA137 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/55132/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=55132 - Page: https://openairdocs.org/ntsb/ATL02FA137 ## Probable cause The certified flight instructor attempted flight with known deficiencies in equipment, inoperative magneto, and subsequent lost engine power and collided with a transmission line while maneuvering for a forced landing. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power, takeoff - initial climb - procedure inadequate, manufacturer - ignition system,magneto - inoperative - operation with known deficiencies in equipment - attempted, pilot in command(cfi) (cause) - Forced landing, emergency descent/landing - In flight collision with terrain/water, descent - uncontrolled - object - wire,transmission ## Analysis During the engine run-up, it was discovered the engine would quit on the right magneto, and the decision was made to continue the flight. During the take-off the rear seated passenger (commercial rated pilot) recalled the climb attitude of the airplane seemed normal. When the airplane was approximately two hundred feet above the trees he heard the CFI tell the private pilot to "watch the airspeed, and keep it straight". The CFI the flight controls and banked the airplane to the right. The passenger saw a barn and remembered the airplane colliding with a power line. The airplane was examined and it was discovered that the right magneto sparked sporadically when tested. The main advantages of the dual system are: increased safety, in case one magneto system fails, the engine may be operated on the other system until a landing can be made; and improved burning and combustion of the mixture, and consequently improved performance. Review of the pilot-operating handbook did not disclose procedures for operating the airplane with the magnetos switch in the both position. ## Factual narrative HISTORY OF FLIGHT On July 2, 2002, at 1500 central daylight time, a Piper PA-28RT-201, N8143B, registered to Airhead LLC and operated by Air Tech Flight School, collided with the ground during initial climb after takeoff from Lebanon Municipal Airport, Lebanon, Tennessee. The instructional flight was operated under the provisions of Title 14 CFR Part 91 and visual flight rules. Visual meteorological conditions prevailed at the time of the accident. The airplane sustained substantial damage, the certificated flight instructor and the private pilot sustained fatal injuries, and the commercial-rated passenger received minor injuries. The flight was originating from Lebanon, Tennessee, at the time of the accident. During the engine run-up the rear seated passenger, a commercial rated pilot, noticed that the checklist was not used; however the magnetos were checked. The left magneto operated normally, but when the right magneto was selected, the engine lost power. A short discussion between the pilots and the CFI ensued, and a decision was made to continue the flight on one magneto since it had been done successfully in the same plane the previous week. The private pilot was cleared for takeoff from runway 19. When the airplane was a couple hundred feet above the trees, the passenger heard the CFI tell the private pilot to "Watch the airspeed, and keep it straight". The passenger looked out of the window and noticed the airplane was slightly nose-up, and felt the "airplane sinking. The CFI took over the flight controls and banked the airplane to the right. Witnesses at the airport observed the flight during the departure and reported that the airplane sounded normal, but it did not appear to climb normally, as if it was unable to gain altitude. One witness reported as he watched the airplane pass, he could see the top of the wings, because the nose was high. Another witness, a private pilot, stated the airplane started to climb with the tail very low, an "it never climbed much." Witnesses watched the airplane travel down the runway and fly low over the trees. They saw the right wing drop dramatically, and the airplane disappeared behind the trees. The passenger saw a barn and remembered hitting a power line PERSONNEL INFORMATION The certified flight instructor was issued a commercial pilot certificate on November 19, 1998, with airplane single and multi-engine land, and instrument ratings. His total flight time was approximately 1,675 hours, and approximate flight time in the Piper PA-28RT-201 was not determined. The certified flight instructor held a second-class medical certificate dated September 06, 2001, valid when wearing corrective lenses. The private pilots' certificate was issued on April 22, 1999, with airplane single engine land, and instrument rating. Total flight time was approximately 145 hours. The approximate time in the Piper PA-28RT-201 was not determined. The private pilot held a second-class medical certificate dated August 19, 1999, valid when wearing corrective lenses. AIRCRAFT INFORMATION A review of the maintenance records did not disclose any previous work performed on the airplanes magnetos or engine ignition system. According to the engine records, the engine was previously overhauled on December 21, 1999. A review of the logbooks showed that the airplane and the propeller annual inspection were completed on December 6, 2001. The altimeter system, static pressure system, and transponder were inspected on January 24, 2002. The last recorded maintenance entry showed that a 100-hour inspection was accomplished on April 23, 2002. METEOROLOGICAL INFORMATION The Lebanon Municipal Airport, Lebanon, Tennessee, weather observation reported visibility 10 statute miles, wind calm, altimeter 30.10, temperature 95 degrees Fahrenheit, dew point 69 degrees Fahrenheit, and a density altitude of 2800 feet. AIRPORT INFORMATION Lebanon Municipal Airport has two runways, 1/19 and 4/22. At the time of the accident runway 19 was used. WRECKAGE AND IMPACT INFORMATION Examination of the wreckage site revealed the initial point of collision was a downed power line. The wreckage was found approximately 0.6 miles south of the runway. Examination of the left wing revealed it was separated at the wing-root and located at the base of a tree approximately 25 feet from the downed power line. The wing displayed electric arching on the upper surface. The wing sustained heavy crush damage to the leading edge five feet from the wing tip. The wing and the tree displayed extensive fire damage. The aileron was attached to the wing, and the aileron bell crank separated and displayed damage. The control cables from the bell crank were frayed at separation. The aileron push pull rod was damaged and separated from the attach bracket. The flap was attached to the wing. The left main landing gear was found in the down and locked position. Examination of the right wing revealed it was attached to the main fuselage. The aileron and flap remained attached to the wing, with the flap in the retracted position. The fuel tank had crush damage and fuel was observed leaking from the leading edge of the wing. Approximately 20 gallons of blue AVGAS was removed from the right wing. Control cables continuity was established from the aileron to the control yoke in the cockpit. Examination of the right and left side of the fuselage displayed distortion inward and to the left. The left wing spar was broken at fuselage. The cabin area displayed crush damage. The instrument panel was crushed, and both front seats were collapsed to the cabin floor. Control cable continuity for the horizontal stabilizer and trim tab were established to flight controls in the cockpit. The left hand horizontal stabilizer displayed heavy crush damage, and cable marks were on the leading edge of the stabilator. A one-inch measurement was noted on the stabilator trim tab, which corresponds with the nose up trim setting. Control cable continuity from the rudder was established to the rudder controls in the cockpit. The rudder and stabilator stops were not damaged. Examination of the engine revealed it remained attached to the airframe. The propeller remained attached to the crankshaft. The propeller blades had signs of scoring, torsional twisting, tip and leading edge damage. The internal pitch change mechanism for both blades was broken, and the blade retaining rings were dislodged. Examination of the fuel system revealed fuel was found in the line from the boost pump to the engine. Fuel was also found in the fuel servo, and the fuel screen was clean. The left side of the engine revealed impact damage. The engine mounts were distorted to the right, and control cables were bent. The engine control positions in the cockpit were, throttle-idle, mixture-idle cut off, and propeller control broken. All engine accessory components remained attached to the engine. The engine was rotated and continuity of the crankshaft, camshaft, valve train, and accessory drives were established. Each cylinder produced compression while the engine was rotated. The left magneto produced a spark at all towers during engine rotation. The right magneto did not produce spark. The main landing gear control handle was found in the down and locked position. TEST AND RESEARCH The left and right magnetos were removed for further examination. Both magnetos exhibited signs of previous maintenance; the tamper proof torque seal had been disturbed on both magnetos. The left magneto was put on a test bench and run at 100-rpm increments from 0-2700 rpm. The magneto functioned normally throughout the operating range. The right magneto was put on a test bench and also run at 100-rpm increments from 0-2700 rpm. Erratic spark conditions were noted on the spark leads up to 1500 rpm. From 1600-2600 rpm the spark was consistent, and 2700 rpm the magneto sparked normally. MEDICAL AND PATHOLOGI ## Aircraft - Registration: [N8143B](https://openairdocs.org/deregistered/N8143B-2003-02-28), registration cancelled 2003-02-28, S/N 28R-8018030, built 1979 (OpenAirDocs) - Reported make and model: Piper PA-28RT-201 - Registry model: [Piper PA-28RT-201](https://openairdocs.org/model/piper-pa-28rt-201) (registry code 7102818) (OpenAirDocs) - Registry engine: [Lycoming I0360 SER A&C](https://openairdocs.org/engine/lycoming-i0360-ser-a-c) (registry code 41511, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28R-8018030 - Airframe hours: 5119 - Engines: Lycoming IO-360-C1C6 200 horsepower reciprocating - Damage: Substantial damage - Fire: On-Ground - Flight: Instructional, Part 91 - Registered owner: Airtech - Airworthiness certificate: Standard, Normal - Last inspection: Annual, December 6, 2001 - Departed: M54, LEBANON, TN - Destination: M54, LEBANON, TN - Airport: M54, Lebanon Muni, runway 19, 5,000 × 100 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 48; injuries: fatal; commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, valid medical--w/ waivers/lim; seat: right; toxicology performed; flight hours: 1,675 total - Student pilot; age 22; injuries: fatal; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 2, valid medical--w/ waivers/lim; seat: rear; toxicology performed ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: 18,000 ft broken - Temperature: 95 °F, dew point 68 °F - Altimeter: 30.10 inHg - Observed at: KBNA ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20020702015509A](https://openairdocs.org/incident/20020702015509A), Jul 2, 2002: Piper PA28RT201, Lebanon, TN, Destroyed, 2 fatal. (.19) On July 2, 2002, at 1500 central daylight time, a Piper PA-28RT-201, N8143B , registered to airhead LLC and operated by air tech, collided with a power… ## Docket (13 files) The files NTSB released with the investigation on July 23, 2003, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=55132. 4.3 MB in all. - Supplement A (item 1, .PDF, 140 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40184040&FileExtension=.PDF&FileName=Supplement%20A-Master.PDF - Supplement B (item 2, .PDF, 152 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40184041&FileExtension=.PDF&FileName=Supplement%20B-Master.PDF - Supplement S (item 3, .PDF, 27 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40184042&FileExtension=.PDF&FileName=Supplement%20S-Master.PDF - Airplane Logs (item 4, .PDF, 956 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40460451&FileExtension=.PDF&FileName=Airplane%20Logs-Master.PDF - Engine Logs (item 5, .PDF, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40460452&FileExtension=.PDF&FileName=Engine%20Logs-Master.PDF - PA-28RT-201 Gear Down Performance Chart (item 6, .PDF, 96 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40184045&FileExtension=.PDF&FileName=PA-28RT-201%20Gear%20Down%20Performance%20Chart-Master.PDF - Magneto Examination (item 7, .PDF, 138 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40460453&FileExtension=.PDF&FileName=Magneto%20Examination-Master.PDF - Aircraft Squawk Sheet (item 8, .PDF, 114 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40460454&FileExtension=.PDF&FileName=Aircraft%20Squawk%20Sheet-Master.PDF - Aircraft Hobbs Book and Weight Balance (item 9, .PDF, 270 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40184048&FileExtension=.PDF&FileName=Aircraft%20Hobbs%20Book%20and%20Weight%20Balance-Master.PDF - Witness Statements (item 10, .PDF, 524 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40460455&FileExtension=.PDF&FileName=Witness%20Statements-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 11, .PDF, 62 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40460456&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 12, .PDF, 50 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40184051&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Master.PDF - Toxicological Report (item 13, .PDF, 142 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40460457&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.