CEN12LA551

NTSB accident investigation · Piper PA-24-260 · Holton, KS · August 17, 2012

Accident · Serious injuriesLimited investigationFinal report
Date
August 16, 2012, 21:54 local (Aug 17, 2012, 02:54 UTC)
Place
Holton, KS
Injuries
2 serious, 1 minor
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N8546PPiper PA-24-260
Defining event
Enroute-cruise: Fire/smoke (non-impact)
Weather
Visual (VMC) · Night/dark
Status
Completed · report January 31, 2013
Report
Approved by Office Director
NTSB office
Central Region
Parties
FAA Flight Standards District Office
FAA report
20120816024529A
Case key
84703

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

On this page

Probable cause

The mechanic's failure to adequately torque the right magneto attachment nuts, allowing the right magneto to come loose, which allowed engine oil to escape, causing the engine to seize.

Findings · 2

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.

Maintenance: replacementPersonnel issues › Task performance · Maintenance personnelPiper PA-24-260: 1 caseAll aircraft: 70 casesProbable cause
Accessory gear-boxesAircraft › Aircraft power plant · Incorrect service/maintenancePiper PA-24-260: 1 caseAll aircraft: 19 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

During a cross-country flight, the pilot and passengers smelled something burning; smoke began to fill the cockpit, and the oil pressure dropped. The propeller then oversped, and the engine seized. In the ensuing forced landing in the dark, the airplane struck trees and impacted a ditch. The engine was covered with oil, and the right magneto was found hanging by spark plug wires. The separation of the right magneto from the engine allowed the engine oil to escape, causing the engine to seize. The magneto had been installed in the airplane about 7 hours before the accident. The mechanic who had replaced the magneto could not recall if he had torqued the magneto attachment nuts. It is likely that the right magneto attachment nuts were not torqued properly and came loose.

Factual narrative

On August 16, 2012, about 2154 central daylight time, the pilot of a Piper PA-24-260, N8546P, made a forced landing on a rural road 3 miles southwest of Holton, Kansas. The pilot and a pilot-rated passenger were seriously injured. Another passenger sustained minor injuries. The airplane was substantially damaged. The airplane was registered to N8546 PAPA, LLC, Tecumseh, Kansas, and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a business flight. Visual meteorological conditions prevailed at the time of the accident, and no flight plan had been filed. The cross country flight originated in Mitchell, South Dakota about 2030 and was en route to Topeka, Kansas. According to the pilot's accident report, after cruising at 7,500 feet mean sea level (msl), he began a 700 foot per minute descent about 37 miles form Topeka. About 6,500 feet msl, he and his passengers smelled something burning and smoke began to fill the cockpit. There was a loss of oil pressure, engine sounds changed, and the propeller oversped to high rpm. Shortly thereafter, the engine seized. The pilot declared an emergency with the Kansas City air route traffic control center. The pilot said the sky was overcast, there was no moon, and the ground was indistinguishable. The pilot then saw automobile headlights, and he aligned the airplane with the lights. The pilot saw telephone poles and trees. He attempted to skim the tree tops, but one of the trees tore the right wing off mid-span and the left wing broke off when the airplane impacted the road and nosed down into a ditch. Two Federal Aviation Administration inspectors examined the airplane. The airworthiness inspector said oil covered the engine components in the aft section of the engine compartment, and the oil-soaked right magneto was hanging by spark plug wires. The inside radius of the magneto spacer bore nicks and scratches around the entire circumference. There was also a hole and crack in the engine case above the number 3 cylinder. The engine, a Lycoming TI0-540-D4A5 (serial no. RL-6852-48), was installed on the airplane on May 5, 2005, after undergoing a major overhaul. The most recent annual inspection was accomplished on July 2, 2012, at a tachometer time of 8545 hours, about 32 hours before the accident. On August 10, 2012, the right magneto was removed and a new magneto was installed, which was about 7 hours before the accident occurred. The FAA inspectors interviewed the mechanic who had replaced the magneto. He told the inspectors he could not recall if he had torqued the magneto attachment nuts.

Aircraft

Registration
N8546P
Reported as
Piper PA-24-260
Category
Airplane
Serial number
24-4003
Airframe hours
8,545
Engine
Lycoming TIO-540-D4A5, 260 horsepower, reciprocating
Damage
Substantial damage
Flight
Business · Part 91
Operator
David F. Osborne
Registered owner
N8546 Papa LLC
Airworthiness certificate
Standard, Normal
Last inspection
Annual · July 2, 2012 · 32 hours before
Departed
KMHE · Mitchell, SD
Destination
KTOP · Topeka, KS

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
58
Injuries
Serious
Certificate
Private
Airplane ratings
Single-engine land, Single-engine sea
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
February 9, 2011
Seat
Left
Flight hours
1,751 total · 456 in this make and model · 1,441 as pilot in command · 18 in the last 90 days · 18 in the last 30 days · 4 in the last 24 hours
Role
Pilot
Age
52
Injuries
Serious
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 2, With waivers/limitations
Seat
Right
Flight hours
120 total

Weather

Conditions
Visual (VMC) · Night/dark
Wind
0° at 0 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
66 °F, dew point 52 °F
Altimeter
30.07 inHg
Observed at
KTOP, 40 nm away

Docket · 8

The files NTSB released with the investigation on November 29, 2012, on NTSB’s docket system: statements, records, photos and specialists’ reports. 24.6 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 N8546P · 3

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