ERA13LA025

NTSB accident investigation · Piper PA-28-140 · Allentown, PA · October 12, 2012

Accident · No injuriesLimited investigationFinal report
Date
October 12, 2012, 18:35 local (22:35 UTC)
Place
Allentown, PA
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N15037Piper PA-28-140
Defining event
Initial climb: Loss of engine power (partial)
Weather
Visual (VMC) · Day
Status
Completed · report June 19, 2013
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
Lycoming Engines, FAA/FSDO
FAA report
20121012026649A
Case key
85337

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

The operator's failure to perform magneto inspections per the manufacturer's recommendations and failure to comply with the engine manufacturer's recommended time interval for engine overhaul, which resulted in defects in the magnetos going undetected and the failure of the right magneto during initial climb.

Findings · 4

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.

Inspection: scheduled/routine inspectionPersonnel issues › Task performance · Maintenance personnelPiper PA-28-140: 5 casesAll aircraft: 167 casesProbable cause
Ignition system: magneto/distributorAircraft › Aircraft power plant · Fatigue/wear/corrosionPiper PA-28-140: 2 casesAll aircraft: 101 casesProbable cause
Ignition system: magneto/distributorAircraft › Aircraft power plant · FailurePiper PA-28-140: 2 casesAll aircraft: 101 casesProbable cause
Maintenance: scheduled/routine maintenancePersonnel issues › Task performance · Maintenance personnelPiper PA-28-140: 9 casesAll aircraft: 320 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

During the initial climb, the engine lost partial power, and the flight instructor performed a forced landing into a cornfield. During a subsequent test-run of the engine, the engine would lose all power if only the right magneto was selected. Laboratory examination of the right magneto revealed that seven teeth from its drive gear were fractured and exhibited single-sided bending fatigue, consistent with applied force in one direction over a period of time. At the time of the accident, the engine had accumulated about 2,300 hours since overhaul, which had been completed about 7 years prior. The accident magnetos had not been replaced or serviced since they were installed during engine overhaul. The engine manufacturer recommended overhauling the engine every 2,000 hours or 12 years, which would have included replacing the magnetos with new or overhauled units. Additionally, a service bulletin issued by the magneto manufacturer recommended inspecting the magnetos every 500 hours; however, there was no evidence that an inspection was ever performed during the 2,300-hour life of the failed magneto.

Factual narrative

On October 12, 2012, about 1835 eastern daylight time, a Piper PA-28-140, N15037, operated by Ace Pilot Training Inc., was substantially damaged during a forced landing to a corn field, following a partial loss of engine power during initial climb from Lehigh Valley International Airport (ABE), Allentown, Pennsylvania. The certified flight instructor (CFI) and private pilot were not injured. The instructional flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and no flight plan was filed for the planned local flight. The CFI stated that the airplane was fueled to 36 gallons prior to the flight. The engine start-up, taxi, and run-up were normal. While departing from runway 31, about 200 feet above ground level, the CFI noticed that the throttle lever did not appear to be completely forward. He and the private pilot pushed the throttle lever full forward with resistance, which was followed by engine sputtering. The CFI then applied carburetor heat; however, the engine continued to sputter. He then elected to land in a corn field. During the landing, the engine firewall and right aileron were substantially damaged. Examination of the wreckage by a Federal Aviation Administration (FAA) inspector revealed that the No. 2 top sparkplug, No. 3 bottom sparkplug, and No. 3 top sparkplug were "fouled." During a subsequent test-run of the engine, the engine lost all power whenever the right magneto was selected. Both magnetos were retained and forwarded to the NTSB Materials Laboratory, Washington, DC. Laboratory examination of the right magneto revealed that seven teeth from its drive gear were fractured and exhibited single-sided bending fatigue, consistent with applied force in one direction over a period of time. Examination of the left magneto revealed a loose drive gear with teeth worn along the top corner. The drive gear had not been fully seated on the drive shaft and was removed by hand. Additionally, the point cam was not fully installed and seated in the bottom of its slot and exhibited a wear scar where the cam contacted the points. The mis-installed cam prevented full seating of the drive gear onto the drive shaft. When the distributor cap was installed, the top corner of the drive gear contacted the distributor housing. When in operation, the wobbling action of the drive gear resulted in wear of the drive gear teeth; however, the mis-installation did not appear to prevent the left magneto from operating in its current condition (for more information, see Materials Laboratory Factual Report in the public docket). The airplane was manufactured in 1972 and equipped with a Lycoming O-320-E3D, 150-horsepower engine. According to maintenance records and an FAA inspector, the airplane's most recent annual inspection was completed on August 22, 2012. The engine's most recent overhaul was completed on June 27, 2005. At the time of the accident, the engine had accumulatedapproximately 72 hours since the annual inspection and 2,300 hours since overhaul. The FAA inspector further reviewed the maintenance records and noted that the accident magnetos (Unison [Slick] model 4370 right, and model 4371 left) were installed at overhaul and had not been replaced or serviced during the time since overhaul. Additionally, when the inspector attempted to disassemble the magnetos for examination, he had to remove inspector's lacquer (yellow paint) from screw holes, which was also consistent with the magnetos never having been disassembled for inspection since overhaul. The engine manufacturer recommended overhauling the engine every 2,000 hours or 12 years, which would have included replacing the magnetos with new or overhauled units. Additionally, Slick service bulletin (SB-308A) recommended inspecting the magnetos every 500 hours.

Aircraft

Registration
N15037
Reported as
Piper PA-28-140
Category
Airplane
Serial number
28-7225560
Airframe hours
8,946
Engine
Lycoming O-320, 150 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
Ace Pilot Training Inc
Registered owner
Yialamas Constantine G
Airworthiness certificate
Standard, Normal
Last inspection
Annual · August 22, 2012 · 72 hours before
Departed
ABE · Allentown, PA
Destination
ABE · Allentown, PA
Airport
ABE · Lehigh Valley International, runway 31, 5,797 × 150 ft, asphalt

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Flight instructor
Age
24
Injuries
None
Certificates
Flight instructor, Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
March 5, 2012
Seat
Right
Flight hours
1,103 total · 500 in this make and model · 1,000 as pilot in command · 200 in the last 90 days · 40 in the last 30 days · 2 in the last 24 hours
Role
Student pilot
Age
26
Injuries
None
Certificate
Private
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1
Last flight review
November 5, 2005
Seat
Left
Flight hours
262 total · 108 in this make and model · 153 as pilot in command · 0 in the last 90 days · 0 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
330° at 7 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
46 °F, dew point 27 °F
Altimeter
30.32 inHg
Observed at
ABE, 1 nm away

Docket · 13

The files NTSB released with the investigation on April 26, 2013, on NTSB’s docket system: statements, records, photos and specialists’ reports. 4.5 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.

Other investigations on N15037 · 1

Matched to the same aircraft by N-number and date.