# NTSB CEN12LA551: Piper PA-24-260, N8546P, Holton, KS, August 17, 2012 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: August 16, 2012, 21:54 local (Aug 17, 2012, 02:54 UTC) - Place: Holton, KS - Coordinates: 39.453887, -95.788887 - Nearby events: https://openairdocs.org/map.md?lat=39.4539&lon=-95.7889&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Fire/smoke (non-impact)](https://openairdocs.org/ntsb-events/150) - Highest injury: Serious injuries - Injuries: 2 serious, 1 minor - Status: Completed, report January 31, 2013 - Report: Approved by Office Director - NTSB office: Central Region - Parties: FAA Flight Standards District Office - NTSB case key (mKey): 84703 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN12LA551 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/84703/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=84703 - Page: https://openairdocs.org/ntsb/CEN12LA551 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Maintenance: replacement](https://openairdocs.org/ntsb-findings/02062020): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Piper PA-24-260, 1 case](https://openairdocs.org/ntsb-findings/02062020/cases.md?model=7102406), [All aircraft, 70 cases](https://openairdocs.org/ntsb-findings/02062020/cases.md) - [Accessory gear-boxes](https://openairdocs.org/ntsb-findings/01058300): Aircraft › Aircraft power plant · Incorrect service/maintenance (probable cause); cases with it: [Piper PA-24-260, 1 case](https://openairdocs.org/ntsb-findings/01058300/cases.md?model=7102406), [All aircraft, 19 cases](https://openairdocs.org/ntsb-findings/01058300/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: Fire/smoke (non-impact)](https://openairdocs.org/ntsb-events/150) (defining event); cases with it: [Piper PA-24-260, 1 case](https://openairdocs.org/ntsb-events/150/sequence.md?model=7102406), [All aircraft, 504 cases](https://openairdocs.org/ntsb-events/150/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Piper PA-24-260, 7 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=7102406), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) ## 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](https://openairdocs.org/deregistered/N8546P-2018-02-07), registration cancelled 2018-02-07, S/N 24-4003, built 1964 (OpenAirDocs) - Reported make and model: PIPER PA-24-260 - Registry model: [Piper PA-24-260](https://openairdocs.org/model/piper-pa-24-260) (registry code 7102406) (OpenAirDocs) - Registry engine: [Lycoming TI0-540 series](https://openairdocs.org/engine/lycoming-ti0-540-series) (registry code 41533, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: 24-4003 - Airframe hours: 8545 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 58; injuries: serious; 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 - Pilot; age 52; injuries: serious; 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 ## 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 20120816024529A](https://openairdocs.org/incident/20120816024529A), Aug 16, 2012: Piper PA-24-260, Holton, KS, Destroyed. Aircraft N8546P was enroute to phillip billiard municipal airport from mitchell south dakota flying VFR. At 2148 local time contacted Kansas city center and… ## Other investigations on N8546P (3) 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. - [NTSB CEN11CA277](https://openairdocs.org/ntsb/CEN11CA277), Mar 29, 2011: Piper PA-24-260 (N8546P), Kansas City, MO, substantial damage. Probable cause: The pilot's failure to extend the landing gear for a landing. - [NTSB CHI07CA008](https://openairdocs.org/ntsb/CHI07CA008), Oct 12, 2006: Piper PA-24-260 (N8546P), Osage Beach, MO, substantial damage. Probable cause: The pilot's inadequate compensation for wind conditions which resulted in the hard landing. The gusting crosswind was a factor. - [NTSB MKC66F0069](https://openairdocs.org/ntsb/MKC66F0069), Jun 20, 1965: Piper PA-24 (N8546P), Wichita, KS, substantial damage ## Docket (8 files) The files NTSB released with the investigation on November 29, 2012, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=84703. 24.6 MB in all. - NTSB Form 6120.1-2, Pilot-Operator Aircraft Accident Report (item 1, .PDF, 166 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40376446&FileExtension=.PDF&FileName=NTSB%20Form%206120.1-2,%20Pilot-Operator%20Aircraft%20Accident%20Report-Redacted.PDF - FAA Inspector's Report (item 2, .PDF, 334 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40378955&FileExtension=.PDF&FileName=FAA%20Inspector%27s%20Report-Redacted.PDF - Excerpts from Maintenance Logs (item 3, .PDF, 374 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40378957&FileExtension=.PDF&FileName=Excerpts%20from%20Maintenance%20Logs-Redacted.PDF - Weather Reports and Records (item 4, .PDF, 49 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40376452&FileExtension=.PDF&FileName=Weather%20Reports%20and%20Records-Master.PDF - Photo 1 - The left side of N8546P at the accident site. (item 5, .PDF, 6.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40380981&FileExtension=.PDF&FileName=Photo%201%20-%20The%20left%20side%20of%20N8546P%20at%20the%20accident%20site.-Master.PDF - Photo 2 - Severed right wing (foreground) and N8546P (background). (item 6, .PDF, 5.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40380982&FileExtension=.PDF&FileName=Photo%202%20-%20Severed%20right%20wing%20(foreground)%20and%20N8546P%20(background).-Master.PDF - Photo 3 - Close-up view of right rear of airplane. (item 7, .PDF, 8.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40380983&FileExtension=.PDF&FileName=Photo%203%20-%20Close-up%20view%20of%20right%20rear%20of%20airplane.-Master.PDF - Photo 4 - The right magneto hangs at bottom of photo. Note mounting pad and gasket have backed off the mounting pad. (item 8, .PDF, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40380984&FileExtension=.PDF&FileName=Photo%204%20-%20The%20right%20magneto%20hangs%20at%20bottom%20of%20photo.%20Note%20mounting%20pad%20and%20gasket%20have%20backed%20off%20the%20mounting%20pad.-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.