# NTSB DEN02LA028: Piper PA-32R-300, N47465, Ferron, UT, February 24, 2002 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: February 24, 2002, 13:11 local (20:11 UTC) - Place: Ferron, UT - Coordinates: 39.100303, -111.16072 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=39.1003&lon=-111.1607&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Minor injuries - Injuries: 4 minor - Status: Completed, report January 16, 2003 - Report: Approved by Office Director - Parties: Federal Aviation Adminstration - NTSB case key (mKey): 54273 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=DEN02LA028 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/54273/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=54273 - Page: https://openairdocs.org/ntsb/DEN02LA028 ## Probable cause a loss of engine power due to the ingestion of foreign object(s) into the meshing of the gears, causing a malfunction of the magneto idler gear and failure of maintenance personnel to detect the signs of imminent failure during a mandatory oil filter examination to be performed at the time of an oil change, annual inspection, or engine overhaul. Contributing factors were unsuitable terrain for the forced landing, high crosswind weather conditions, and a parked vehicle in the landing area. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(total) - mech failure/malf, cruise - normal - accessory drive assy,drive gear - foreign object damage (cause) - unsafe/hazardous condition - not detected, other maintenance personnel (cause) - ignition system,magneto - failure,total (cause) - Forced landing, descent - emergency - On ground/water collision with object, landing - weather condition - high wind (contributing factor) - weather condition - crosswind (contributing factor) - unsuitable terrain or takeoff/landing/taxi area - not available (contributing factor) - object - vehicle (contributing factor) ## Analysis Approximately 30 minutes into the flight, the engine began to "miss, backfire heavily and sputter." The number 1 cylinder temperature "shot off the gauge" with a red light warning light illuminated. The engine lost power and the airplane began to descend. The pilot made a forced landing on a highway. During the landing roll, the airplane struck a truck parked on the shoulder, shearing off its left wing. The airplane then overturned and skidded 300 feet to a halt. Engine disassembly revealed the magneto idler gear that drives the dual magneto was missing 8 teeth. Three of the teeth were displaced from the gear and exhibited signatures consistent with mechanical overload, while the remaining 5 had been ground off. The respective idler gear shaft bore(s) at the back of the crankcase and at the accessory housing were missing approximately 1/3 of their circumferential material. The fracture surface(s) exhibited signatures consistent with overload. The overload forces appeared to have been applied inboard, evidenced by the symmetrical displacement of the bore material at each end of the subject idler gear shaft. ## Factual narrative On February 24, 2002, at 1311 mountain standard time, a Piper PA-32R-300, N47465, was substantially damaged when it struck a truck parked on a highway shoulder during a forced landing near Ferron, Utah. The pilot and three passengers received minor injuries. Visual meteorological conditions prevailed, and a VFR flight plan had been filed (but not activated) for the personal flight being conducted under Title 14 CFR (Code of Federal Regulations) Part 91. The flight originated at Duchesne, Utah, approximately 1245, and was en route to Cedar City, Utah. According to the pilot's accident report, he departed Riverside, California, on February 23, and flew to Duchesne to attend a wedding. The next afternoon, he departed Duchesne and was en route to Cedar City, Utah. Approximately 30 minutes into the flight, the engine began to "miss." Ten minutes later the engine began to "backfire heavily and sputter." The number 1 cylinder temperature "shot off the gauge" with a red warning light illuminated. The engine lost power and the airplane began to descend. The pilot transmitted a "Mayday" that was heard by a passing United Air Lines flight, and relayed to authorities. He started looking for an area to land and saw a road 5 miles to the east. The pilot wrote, "I had strong x [cross] -winds blowing me off my line of approach". He landed on Utah State Route 10, at milepost 3.5, near Ferron, and attempted to stay in the right lane to avoid a pickup truck that was parked on the shoulder of the highway. During the landing roll, the airplane struck the truck, shearing off its left wing. The airplane then overturned and skidded 300 feet to a halt. On April 4, 2002, the engine was examined by a Textron-Lycoming investigator at the facilities of Air Transport in Phoenix, Arizona. After removing the single drive dual magneto from its mounting pad, extensive damage to the accessory gears was noted. Removal of the accessory case disclosed the magneto idler gear (photo 5) was missing eight (8) teeth, 3 of which were displaced from the gear and exhibited signatures consistent with mechanical overload, and the remaining five (5) had been ground off (photo 6). The magneto idler gear drives the dual magnetos. The idler gear shaft bore at the back of the crankcase (photo 7) and the accessory housing (photo 8) were missing approximately 1/3 of their circumferential material, and the inside surfaces were polished, burnished and elongated (photo 11). The fracture surface(s) exhibited signatures consistent with overload. The overload forces appeared to have been applied inboard, evidenced by the symmetrical displacement of the bore material at each end of the subject idler gear shaft. The oil sump contained the three gear teeth and a piece of aluminum debris with gear tooth impressions matching the size and shape of the missing teeth (photo 9). The oil suction screen contained similar material (photo 10). It appeared the idler gear had been misaligned for some time of the mating surfaces. The oil filter contained slivers and particles of non-ferrous material similar to aluminum (photo 12). The airplane maintenance records were reviewed. At the time of the accident, the engine had accumulated 3,856.2 hours total time-in-service, and 1,256.6 hours since its last major overhaul. The tachometer read 2152.7 hours and the Hobbs meter read 2317.4 hours. The overhaul entry did not indicate the scope and detail of the work performed, the date it occurred, nor who performed the work. Between March 31, 1997, and October 15, 2001, there were seven maintenance entries indicating the oil and oil filter had been changed, but neither entry indicated whether the filter had been inspected as outlined in Lycoming Mandatory Service Bulletin SB-480D. ## Aircraft - Registration: [N47465](https://openairdocs.org/deregistered/N47465-2002-05-23), registration cancelled 2002-05-23, S/N 32R-7880008, built 1977 (OpenAirDocs) - Reported make and model: Piper PA-32R-300 - Registry model: [Piper PA-32R-300](https://openairdocs.org/model/piper-pa-32r-300) (registry code 7103213) (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: 32R-7880008 - Airframe hours: 3850 - Engines: Lycoming IO-540-K1G5D 300 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Registered owner: David R. Powers, Trustee - Airworthiness certificate: Standard, Normal - Last inspection: Annual, October 15, 2001, 25 hours before - Departed: U69, Duchesne, UT - Destination: CDC, Cedar City, UT - Flight plan: VFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 44; injuries: minor; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, valid medical--no waivers/lim.; last flight review September 5, 2001; seat: front; flight hours: 625 total, 500 in this make and model, 550 as pilot in command, 25 in the last 90 days, 10 in the last 30 days, 4 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 290° at 14 knots - Visibility: 10 statute miles - Lowest ceiling: 6,000 ft overcast - Temperature: 45 °F, dew point 19 °F - Altimeter: 30.02 inHg - Observed at: PUC, 36 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 20020224003259A](https://openairdocs.org/incident/20020224003259A), Feb 24, 2002: Piper PA32R300, Ferron, UT, Destroyed. (-23) [privacy data omitted] ## Docket (15 files) The files NTSB released with the investigation on November 6, 2002, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=54273. 4.6 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 351 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40391064&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Supplement S (item 2, .PDF, 38 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40169920&FileExtension=.PDF&FileName=Supplement%20S-Master.PDF - Textron Lycoming Aircraft Mishap Report (item 3, .PDF, 201 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40391149&FileExtension=.PDF&FileName=Textron%20Lycoming%20Aircraft%20Mishap%20Report-Redacted.PDF - Photo 1 - View to the southwest and the forced landing approach. Note pickup truck, next to guard rail, that was struck by N47465. (item 4, .PDF, 327 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40169939&FileExtension=.PDF&FileName=Photo%201%20-%20View%20to%20the%20southwest%20and%20the%20forced%20landing%20approach.%20%20Note%20pickup%20truck,%20next%20to%20guard%20rail,%20that%20was%20struck%20by%20N47465.-Master.PDF - Photo 2 - View to the northeast. After colliding with parked pickup truck (background), airplane nosed over and skidded 300 feet. (item 5, .PDF, 334 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40170336&FileExtension=.PDF&FileName=Photo%202%20-%20View%20to%20the%20northeast.%20%20After%20colliding%20with%20parked%20pickup%20truck%20(background),%20airplane%20nosed%20over%20and%20skidded%20300%20feet.-Master.PDF - Photo 3 - Parked pickup truck that was struck by N47465. (item 6, .PDF, 377 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40170337&FileExtension=.PDF&FileName=Photo%203%20-%20Parked%20pickup%20truck%20that%20was%20struck%20by%20N47465.-Master.PDF - Photo 4 - Close-up view of damaged pickup truck. Note left wing embedded in truck. (item 7, .PDF, 444 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40170338&FileExtension=.PDF&FileName=Photo%204%20-%20Close-up%20view%20of%20damaged%20pickup%20truck.%20%20Note%20left%20wing%20embedded%20in%20truck.-Master.PDF - Photo 5 - Magneto idler gear. Note missing gear teeth. (item 8, .PDF, 296 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40170339&FileExtension=.PDF&FileName=Photo%205%20-%20Magneto%20idler%20gear.%20%20Note%20missing%20gear%20teeth.-Master.PDF - Photo 6 - Close-up view of magneto idler gear. Note three teeth displaced from mechanical overload, and five teeth ground off. (item 9, .PDF, 218 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40170340&FileExtension=.PDF&FileName=Photo%206%20-%20Close-up%20view%20of%20magneto%20idler%20gear.%20%20Note%20three%20teeth%20displaced%20from%20mechanical%20overload,%20and%20five%20teeth%20ground%20off.-Master.PDF - Photo 7 - Idler gear shaft bore. Note scoring and gouging. (item 10, .PDF, 354 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40170341&FileExtension=.PDF&FileName=Photo%207%20-%20Idler%20gear%20shaft%20bore.%20%20Note%20scoring%20and%20gouging.-Master.PDF - Photo 8 - Accessory housing. Note scoring and gouging. (item 11, .PDF, 289 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40170342&FileExtension=.PDF&FileName=Photo%208%20-%20Accessory%20housing.%20%20Note%20scoring%20and%20gouging.-Master.PDF - Photo 9 - Debris removed from oil sump. Note gear tooth impressions, similar to missing idler gear teeth. (item 12, .PDF, 456 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40170345&FileExtension=.PDF&FileName=Photo%209%20-%20Debris%20removed%20from%20oil%20sump.%20%20Note%20gear%20tooth%20impressions,%20similar%20to%20missing%20idler%20gear%20teeth.-Master.PDF - Photo 10 - Similar material recovered from oil suction screen. (item 13, .PDF, 360 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40170346&FileExtension=.PDF&FileName=Photo%2010%20-%20Similar%20material%20recovered%20from%20oil%20suction%20screen.-Master.PDF - Photo 11 - Magneto idler shaft bore at crankcase. Note bore is polished, burnished, and elongated, indicative long-term misalignment. (item 14, .PDF, 229 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40170348&FileExtension=.PDF&FileName=Photo%2011%20-%20Magneto%20idler%20shaft%20bore%20at%20crankcase.%20%20Note%20bore%20is%20polished,%20burnished,%20and%20elongated,%20indicative%20long-term%20misalignment.-Master.PDF - Photo 12 - Cutting open the full flow oil filter revealed slivers and particles of non-ferrous material consistent with aluminum. (item 15, .PDF, 357 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40170350&FileExtension=.PDF&FileName=Photo%2012%20-%20Cutting%20open%20the%20full%20flow%20oil%20filter%20revealed%20slivers%20and%20particles%20of%20non-ferrous%20material%20consistent%20with%20aluminum.-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.