# NTSB ERA13LA025: Piper PA-28-140, N15037, Allentown, PA, October 12, 2012 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: October 12, 2012, 18:35 local (22:35 UTC) - Place: Allentown, PA - Coordinates: 40.502223, -75.440551 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=40.5022&lon=-75.4406&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: No injuries - Injuries: 2 uninjured - Status: Completed, report June 19, 2013 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: Lycoming Engines, FAA/FSDO - NTSB case key (mKey): 85337 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA13LA025 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/85337/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=85337 - Page: https://openairdocs.org/ntsb/ERA13LA025 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Inspection: scheduled/routine inspection](https://openairdocs.org/ntsb-findings/02061520): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Piper PA-28-140, 5 cases](https://openairdocs.org/ntsb-findings/02061520/cases.md?model=7102802), [All aircraft, 167 cases](https://openairdocs.org/ntsb-findings/02061520/cases.md) - [Ignition system: magneto/distributor](https://openairdocs.org/ntsb-findings/01057414): Aircraft › Aircraft power plant · Fatigue/wear/corrosion (probable cause); cases with it: [Piper PA-28-140, 2 cases](https://openairdocs.org/ntsb-findings/01057414/cases.md?model=7102802), [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 · Failure (probable cause); cases with it: [Piper PA-28-140, 2 cases](https://openairdocs.org/ntsb-findings/01057414/cases.md?model=7102802), [All aircraft, 101 cases](https://openairdocs.org/ntsb-findings/01057414/cases.md) - [Maintenance: scheduled/routine maintenance](https://openairdocs.org/ntsb-findings/02062010): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Piper PA-28-140, 9 cases](https://openairdocs.org/ntsb-findings/02062010/cases.md?model=7102802), [All aircraft, 320 cases](https://openairdocs.org/ntsb-findings/02062010/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: [Piper PA-28-140, 47 cases](https://openairdocs.org/ntsb-events/342/sequence.md?model=7102802), [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: [Piper PA-28-140, 56 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=7102802), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing-flare/touchdown: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-28-140, 137 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102802), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/aircraft/N15037), registered now, S/N 28-7225560, built 1972 (OpenAirDocs) - Reported make and model: PIPER PA-28-140 - Registry model: [Piper PA-28-140](https://openairdocs.org/model/piper-pa-28-140) (registry code 7102802) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-7225560 - Airframe hours: 8946 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 24; injuries: none; 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 - Student pilot; age 26; injuries: none; 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 ## 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 20121012026649A](https://openairdocs.org/incident/20121012026649A), Oct 12, 2012: Piper PA-28-140, Allentown, PA, Substantial damage. 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… ## Other investigations on N15037 (1) 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. - [NTSB IAD05LA021](https://openairdocs.org/ntsb/IAD05LA021), Nov 29, 2004: Piper PA-28-140 (N15037), Allentown, PA, substantial damage. Probable cause: The pilot's improper decision to continue the flight with known deficiencies in equipment. Also causal was the failure of the right main landing gear due to overstress cracking. ## Docket (13 files) The files NTSB released with the investigation on April 26, 2013, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=85337. 4.5 MB in all. - Materials Laboratory Factual Report 12-138 (11 embedded images) (item 1, .PDF, 11 photos, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40389336&FileExtension=.PDF&FileName=Materials%20Laboratory%20Factual%20Report%2012-138%20(11%20embedded%20images)-Master.PDF - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 2, .PDF, 925 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40386143&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Interview Summaries (item 3, .PDF, 78 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40386144&FileExtension=.PDF&FileName=Interview%20Summaries-Master.PDF - Statement From FAA Inspector (item 4, .PDF, 41 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40389383&FileExtension=.PDF&FileName=Statement%20From%20FAA%20Inspector-Redacted.PDF - Excerpt From Engine Logbook (item 5, .PDF, 274 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40386145&FileExtension=.PDF&FileName=Excerpt%20From%20Engine%20Logbook-Redacted.PDF - Weather Report (item 6, .PDF, 15 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40386147&FileExtension=.PDF&FileName=Weather%20Report-Master.PDF - Slick Service Bulletin (SB3-08A) (item 7, .PDF, 55 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40389381&FileExtension=.PDF&FileName=Slick%20Service%20Bulletin%20(SB3-08A)-Master.PDF - Statement of Parties to NTSB Investigation (item 8, .PDF, 384 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40389386&FileExtension=.PDF&FileName=Statement%20of%20Parties%20to%20NTSB%20Investigation-Redacted.PDF - Evidence Control Form (item 9, .PDF, 68 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40391084&FileExtension=.PDF&FileName=Evidence%20Control%20Form-Master.PDF - Photograph # 1: Main Wreckage (Photo Courtesy of FAA) (item 10, .PDF, 110 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40386148&FileExtension=.PDF&FileName=Photograph%20%23%201%3A%20%20Main%20Wreckage%20(Photo%20Courtesy%20of%20FAA)-Master.PDF - Photograph # 2: Number Two Top Sparkplug (Photo Courtesy of FAA) (item 11, .PDF, 67 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40386149&FileExtension=.PDF&FileName=Photograph%20%23%202%3A%20%20Number%20Two%20Top%20Sparkplug%20(Photo%20Courtesy%20of%20FAA)-Master.PDF - Photograph # 3: Number Three Bottom Sparkplug (Photo Courtesy of FAA) (item 12, .PDF, 58 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40386150&FileExtension=.PDF&FileName=Photograph%20%23%203%3A%20%20Number%20Three%20Bottom%20Sparkplug%20(Photo%20Courtesy%20of%20FAA)-Master.PDF - Photograph # 4: Number Three Top Sparkplug (Photo Courtesy of FAA) (item 13, .PDF, 76 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40386151&FileExtension=.PDF&FileName=Photograph%20%23%204%3A%20%20Number%20Three%20Top%20Sparkplug%20(Photo%20Courtesy%20of%20FAA)-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.