CEN24LA269

NTSB accident investigation · Piper PA-36-375 · Avoca, NE · July 16, 2024

Accident · No injuriesClass 3 · LimitedFinal report
Date
July 16, 2024, 14:30 local (19:30 UTC)
Place
Avoca, NE
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N2386XPiper PA-36-375
Defining event
Maneuvering-low-alt flying: Powerplant sys/comp malf/fail
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
Lycoming Engines, FAA FSDO
FAA report
20240716009599A
Case key
194710

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

A partial loss of engine power due to the loose left magneto which resulted in erratic engine timing.

Findings · 1

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.

Ignition system: magneto/distributorAircraft › Aircraft power plant · MalfunctionPiper PA-36-375: 1 caseAll aircraft: 101 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 pilot reported that, during an aerial application flight, the engine lost power and the airplane began to descend. He added full power and pushed the propeller control full forward, but did not feel the engine respond and the airplane continued to descend. After he dumped the hopper tank, he still was not able to stop the airplane’s descent, and the airplane touched down in the field and continued through a cattle fence, resulting in substantial damage to the fuselage and left wing. The airplane was recovered to a secure facility for further examination. There was a crack observed between the Nos. 1, 2, and 3 cylinders that was most likely the result of impact damage. Examination of the magnetos revealed that, while still attached to the engine, the left magneto could be rotated at its flange. Both magnetos were removed and spun by hand and both magnetos produced spark at their terminal leads. The right magneto made a “clunking” sound when rotated and rattled when shaken. Further examination revealed that the right magneto coil wedges were loose in the housing. The coil wedges appeared to have been initially wedged in place, but only exhibited minimal marring, and may not have been secured sufficiently. That the left magneto was found loose and could be rotated at its flange, it’s likely it was out of time. Although the right magneto coil wedges were loose in the housing, it is more likely the left magneto firing at the wrong time would have had the most significant impact on the engine only being able to produce partial power.

Factual narrative

On July 16, 2024, about 1430 central daylight time, a Piper PA-36-375 airplane, N2386X, was substantially damaged when it was involved in an accident near Avoca, Nebraska. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 137 aerial application flight. The pilot reported that he maneuvered the airplane for his fourth spray pass and had rolled the airplane level at an altitude of about 300 ft above ground level when the airplane “lost all power” and began to descend. He added full power and pushed the propeller control full forward, but did not feel the engine respond and the airplane continued to descend. After he dumped the hopper tank load, he still was not able to stop the airplane’s descent. The airplane touched down in the field and continued through a cattle fence before coming to rest, resulting in substantial damage to the fuselage and left wing. The airplane was recovered to a secure facility for further examination. There was a crack observed between the Nos. 1, 2, and 3 cylinders; however, no thermal distress was found within the engine. Internal continuity was confirmed throughout the engine and borescope examination of the cylinders revealed no anomalies. Examination of the fuel divider, injectors, servo, and pump revealed no anomalies. The oil filter was removed and contained no contamination. The air inlet and filter were free of debris. While still attached to the engine, the left magneto flange could be rotated slightly. Both magnetos were removed and rotated by hand. The right magneto made a “clunking” sound when rotated and rattled when shaken. Both magnetos produced spark at their terminal leads. Further examination of the magnetos found the right magneto distributor gear was timed correctly. Both coil wedges were loose in the housing. The coil wedges appeared to have been initially wedged in place, but only had minimal marring, which may not have provided enough tension to retain the wedges properly. A review of maintenance records found that the magneto was overhauled on November 27, 2023, and was installed on the airplane on April 12, 2024. The airplane had flown about 40 hours since the magneto installation. The left magneto was in good condition and subsequently bench tested. The magneto operated as expected.

Aircraft

Registration
N2386X
Reported as
Piper PA-36-375
Category
Airplane
Serial number
36-8202018
Built
1982
Airframe hours
5,252.9
Engine
Lycoming IO-720-D1C, 400 horsepower, reciprocating
Damage
Substantial damage
Flight
Aerial application · Part 137
Registered owner
Stove Creek Air LLC
Airworthiness certificate
Special, Restricted (Special)
Last inspection
Annual · April 12, 2024 · 40 hours before
Departed
Elmwood, NE
Equipment
Stall warning system, Satellite tracking device

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
41
Injuries
None
Certificates
Commercial, Private
Airplane ratings
Single-engine sea, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
January 11, 2024
Seat
Single
Restraint
4-point
Flight hours
2,577 total · 64 in this make and model · 1,912 as pilot in command · 124 in the last 90 days · 66 in the last 30 days · 7 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
30° at 6 knots
Visibility
10 statute miles
Lowest ceiling
11,000 ft broken
Temperature
77 °F, dew point 61 °F
Altimeter
29.97 inHg
Observed at
KPMV, 11 nm away
METAR
KPMV 161935Z AUTO 03006KT 10SM BKN110 25/16 A2997 RMK AO2 T02490163

FAA reports on this event · 1

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