ERA10LA475

NTSB accident investigation · Cessna 150 · Fayetteville, WV · September 10, 2010

Accident · Serious injuriesLimited investigationFinal report
Date
September 10, 2010, 13:15 local (17:15 UTC)
Place
Fayetteville, WV
Injuries
2 serious
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N7922ECessna 150
Defining event
Initial climb: Loss of engine power (partial)
Weather
Visual (VMC) · Day
Status
Completed · report August 3, 2011
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20100910046219A
Case key
77257

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 loss of engine power due to the failure of the left magneto system’s distributor gear as a result of the improper maintenance of the magnetos by maintenance personnel.

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.

Ignition system: magneto/distributorAircraft › Aircraft power plant · FailureCessna 150: 1 caseAll aircraft: 101 casesProbable cause
Ignition system: magneto/distributorAircraft › Aircraft power plant · Incorrect service/maintenanceCessna 150: 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 stated that during the initial climb the airplane engine's rpm gauge indicated 1900 and the airplane would not gain altitude which resulted in a forced landing. Postaccident examination of the airplane revealed fuel in the fuel tanks and carburetor system. All cylinders had compression when checked. The right magneto developed sparks to all corresponding plugs. The left magneto produced spark to one plug only. A teardown examination of the left magneto revealed the distributor gear had 12 gear teeth sheared from the disk. Review of the engine's maintenance records showed that the ignition system had several inspections as required by airworthiness directives and service bulletins (SB) throughout its time in service. The distributor gear was required to be replaced with a redesigned gear as outlined in SB658; however, both magnetos had the old-style distributor gear, dating to before 1978. Additionally, the gear tooth separation was noted starting and ending at the magneto timing block location marker. The manufacturer of the magneto warned not to use a gear holding tool during installation, which may cause hidden damage to the distributor gear and subsequent engine failure.

Factual narrative

On September 10, 2010, at about 1315 eastern daylight time, a Cessna 150, N7922E, owned and operated by a private individual, incurred substantial damaged during a forced landing following a partial loss of engine power shortly after takeoff from the Fayette Airport (WV59), Fayetteville, West Virginia. The airline transport rated pilot and the private pilot passenger received serious injuries. Visual meteorological conditions prevailed for the Title 14 Code of Federal Regulations Part 91, personal flight. The pilot stated that the preflight and ground run prior to flight were unremarkable. During the initial climb the airplane engine's rpm gage indicated 1900 and the airplane would not gain altitude. He elected to land in a field and the airplane collided with trees before impacting the ground. The pilot was able to call for assistance and both pilots were taken to the hospital due to their injuries. The responding Federal Aviation Administration inspector stated that post recovery examination of the airplane revealed fuel in the fuel tanks and observed up to the carburetor system. All cylinders had compression when checked. The right magneto developed sparks to all corresponding plugs. The left magneto produced spark to one plug only. The magnetos, carburetor, and spark plugs were retained for further testing. A review of the airplane maintenance records revealed that the last annual inspection was on April 27, 2010 ,at 2,512 total hours. The magnetos were inspected on August 11, 1994 at 2418 total hours, March 6, 1996 at total 2422, and October 14, 2002 at 2,459 total hours. Examination of the left magneto with National Transportation Safety Board oversight revealed that the exterior appearance of the magneto was consistent with the unit having been in service for a length of time. No exterior damage was observed and the magneto rotated when done so by hand with internal discrepancies noted. When it was disassembled the distributor gear was observed with 12 each gear teeth sheared from the disk, which the sheared gears were recovered within the magneto assembly. The separation was noted starting/ending at the magneto timing block location marker. The distributor cap was observed with indications of arching in-between the housing area. The coil and condenser were tested and found unremarkable. It was noted that the magnetos were required to have the riveted style impulse coupling checked every 100 hours in service as per Airworthiness Directive (AD) 78-09-07, AD 96-12-07, and AD 2005-12-06 and it's identifiable by the missing mark "A" in the lower right corner of the magneto's data plate. Any time after the year 1978, when the magneto was opened, in the case of a riveted impulse coupling examination, the distributor gear was required to be replaced with the updated distributor gear, if not done so as per Teledyne Continental Ignition Systems, Service Bulletin 658. Both magnetos had the old style distributor gear, dating prior to 1978. TeledyneContinental Ignition Systems, Service Bulletin 658 makes warning reference not to use any gear holding tool for this may cause hidden damage to the distributor gear and subsequent engine failure.

Aircraft

Registration
N7922E
Reported as
Cessna 150
Category
Airplane
Serial number
17722
Airframe hours
2,587
Engine
Cont Motor 0-200 SERIES, 100 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · April 27, 2010 · 75 hours before
Departed
WV59 · Fayetteville, WV
Destination
0A4 · Johson City, TN

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
66
Injuries
Serious
Certificates
Flight instructor, Commercial, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
August 5, 2010
Seat
Left
Flight hours
21,645 total · 500 in this make and model · 46 in the last 90 days · 18 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
Variable at 4 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
66 °F, dew point 46 °F
Altimeter
30.04 inHg
Observed at
KBKW, 14 nm away

Docket · 13

The files NTSB released with the investigation on June 13, 2011, on NTSB’s docket system: statements, records, photos and specialists’ reports. 3.7 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.