# NTSB ERA10LA475: Cessna 150, N7922E, Fayetteville, WV, September 10, 2010 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: September 10, 2010, 13:15 local (17:15 UTC) - Place: Fayetteville, WV - Coordinates: 38.022777, -81.118614 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=38.0228&lon=-81.1186&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) - Highest injury: Serious injuries - Injuries: 2 serious - Status: Completed, report August 3, 2011 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - ADs cited in the narratives: [AD 78-09-07 R3](https://openairdocs.org/ad/78-09-07-R3), [AD 96-12-07](https://openairdocs.org/ad/96-12-07), [AD 2005-12-06](https://openairdocs.org/ad/2005-12-06) (OpenAirDocs) - NTSB case key (mKey): 77257 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA10LA475 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/77257/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=77257 - Page: https://openairdocs.org/ntsb/ERA10LA475 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Ignition system: magneto/distributor](https://openairdocs.org/ntsb-findings/01057414): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [Cessna 150, 1 case](https://openairdocs.org/ntsb-findings/01057414/cases.md?model=2071802), [All aircraft, 101 cases](https://openairdocs.org/ntsb-findings/01057414/cases.md) - [Ignition system: magneto/distributor](https://openairdocs.org/ntsb-findings/01057414): Aircraft › Aircraft power plant · Incorrect service/maintenance (probable cause); cases with it: [Cessna 150, 1 case](https://openairdocs.org/ntsb-findings/01057414/cases.md?model=2071802), [All aircraft, 101 cases](https://openairdocs.org/ntsb-findings/01057414/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) (defining event); cases with it: [Cessna 150, 2 cases](https://openairdocs.org/ntsb-events/342/sequence.md?model=2071802), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Cessna 150, 4 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=2071802), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Emergency descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cessna 150, 7 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2071802), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/deregistered/N7922E-2011-08-30), registration cancelled 2011-08-30, S/N 17722, built 1959 (OpenAirDocs) - Reported make and model: CESSNA 150 - Registry model: [Cessna 150](https://openairdocs.org/model/cessna-150) (registry code 2071802) (OpenAirDocs) - Registry engine: [Continental 0-200 series](https://openairdocs.org/engine/continental-0-200-series) (registry code 17020, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 17722 - Airframe hours: 2587 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 66; injuries: serious; 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 ## 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 20100910046219A](https://openairdocs.org/incident/20100910046219A), Sep 10, 2010: Cessna 150, Fayetteville, WV, Substantial damage. Fayetteville, WV (WV59): N7922E, a C150, while departing from the Fayette Airport, lost power and crashed into trees. The local authorities responded and the 2… ## Docket (13 files) The files NTSB released with the investigation on June 13, 2011, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=77257. 3.7 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 411 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40342895&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Miscellaneous: Pilot's Statement. (item 2, .PDF, 41 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40342814&FileExtension=.PDF&FileName=Miscellaneous%3A%20Pilot%27s%20Statement.-Redacted.PDF - Miscellaneous: Magneto Examination Field Notes. (item 3, .PDF, 102 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40342815&FileExtension=.PDF&FileName=Miscellaneous%3A%20Magneto%20Examination%20Field%20Notes.-Master.PDF - Miscellaneous:Excerpts from the Airplane's Maintenance Records. (item 4, .PDF, 344 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40342817&FileExtension=.PDF&FileName=Miscellaneous%3AExcerpts%20from%20the%20Airplane%27s%20Maintenance%20Records.-Redacted.PDF - Miscellaneous:Excerpts from the Service Bulletin. (item 5, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40342819&FileExtension=.PDF&FileName=Miscellaneous%3AExcerpts%20from%20the%20Service%20Bulletin.-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 6, .PDF, 171 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40342820&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Photo 1)View of the Wreckage. Photo Provided by Federal Aviation Administration. (item 7, .PDF, 284 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40342825&FileExtension=.PDF&FileName=Photo%201)View%20of%20the%20Wreckage.%20Photo%20Provided%20by%20Federal%20Aviation%20Administration.-Master.PDF - Photo 2) View of the Left Magneto's Data Plate. Photo Provide by Federal Aviation Administration. (item 8, .PDF, 254 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40342824&FileExtension=.PDF&FileName=Photo%202)%20View%20of%20the%20Left%20Magneto%27s%20Data%20Plate.%20Photo%20Provide%20by%20Federal%20Aviation%20Administration.-Master.PDF - Photo 3) View of the Left Magneto Opened. (item 9, .PDF, 189 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40342833&FileExtension=.PDF&FileName=Photo%203)%20View%20of%20the%20Left%20Magneto%20Opened.-Master.PDF - Photo 4)View of the Distributor Gear. (item 10, .PDF, 162 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40342828&FileExtension=.PDF&FileName=Photo%204)View%20of%20the%20Distributor%20Gear.-Master.PDF - Photo 5) Close View of the Distributor Gear Missing Teeth. (item 11, .PDF, 199 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40342829&FileExtension=.PDF&FileName=Photo%205)%20Close%20View%20of%20the%20Distributor%20Gear%20Missing%20Teeth.-Master.PDF - Photo 6) View of Old (Left) and New (Right) Style Distributor Gear Assembly. (item 12, .PDF, 128 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40342830&FileExtension=.PDF&FileName=Photo%206)%20View%20of%20Old%20(Left)%20and%20New%20(Right)%20Style%20Distributor%20Gear%20Assembly.-Master.PDF - Photo 7) View of the Distributer Block's. Underside. (item 13, .PDF, 142 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40342831&FileExtension=.PDF&FileName=Photo%207)%20View%20of%20the%20Distributer%20Block%27s.%20Underside.-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.