ERA19LA109

NTSB accident investigation · Piper PA28 · Louisville, KY · February 26, 2019

Accident · No injuriesClass 3 · LimitedFinal report
Date
February 26, 2019, 18:35 local (23:35 UTC)
Place
Louisville, KY
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N2184XPiper PA28
Defining event
Takeoff-rejected takeoff: Loss of engine power (partial)
Weather
Visual (VMC) · Night
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Eastern Region Aviation
Parties
FAA
FAA report
20190226022839A
Case key
99028

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 failure of the magnetos due to a known deficiency, which resulted in a partial loss of engine power. Contributing to the accident was maintenance personnel’s failure to comply with the applicable service bulletin.

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 · FailurePiper PA-28-181: 1 caseAll aircraft: 101 casesProbable cause
Maintenance: replacementPersonnel issues › Task performance · Maintenance personnelPiper PA-28-181: 2 casesAll aircraft: 70 cases

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

According to the pilot, the airplane accelerated normally during the takeoff roll, became airborne, and the engine started to run "rough." He elected to land straight ahead on the remaining runway. The airplane subsequently overran the runway and collided with the perimeter fence. Examination of the airplane revealed it sustained substantial damage to the airframe. During an examination of the left magneto, two ignition wires in the distributor cap revealed evidence of arcing, and one ignition lead was found detached from the insulator and spring. The right magneto was removed, rotated, and produced spark at each spark lead. The metal copper electrode on the right magneto distributor gear was found loose. To address a potential decreased service life of Slick 4-cylinder magneto distributor gear assemblies, Slick/Champion Aerospace Service Bulletin SB1-15A calls for replacing distributor gear assemblies that have a copper electrode with assemblies that have a Monel electrode. A rough running engine was a symptom of the condition that the SB was intended to address. A review of the accident airplane’s maintenance logbooks revealed no entries for the repair of the magnetos or compliance with the applicable SB and that the airplane received three annual inspections since the release and the revision of the SB.

Factual narrative

On February 26, 2019, about 1835 eastern standard time, a Piper PA-28-181, N2184X, was substantially damaged when it was involved in an accident near Louisville, Kentucky. The private pilot and passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 flight. According to the pilot, after performing a preflight inspection, he taxied to the active runway for departure. He conducted an engine run-up; pretakeoff checklist and no anomalies were noted. Once he was cleared for takeoff, he advanced the throttle and began the takeoff roll. As the airplane accelerated through 60 knots and became airborne, the engine started to run "rough." He elected to land straight ahead on the remaining runway. The airplane over-ran the runway and collided with the perimeter fence. An examination of the airplane by a Federal Aviation Administration inspector revealed that the left wing was broken away from the fuselage. The outboard section of the right wing, which included the aileron, was broken away from the wing assembly. The vertical stabilizer was also separated from the empennage. While examining the engine, the propeller was rotated through 360° of motion and spark was noted at each of the spark leads. The left magneto was removed and two ignition wires in the distributor cap revealed evidence of arcing. One ignition lead was found detached from the insulator and the spring. The right magneto was removed and rotated and produced spark at each lead. The metal copper electrode on the right magneto distributor gear was found loose. Slick/Champion Aerospace Service Bulletin (SB)1-15A (issued July 2, 2015, and revised November 12, 2018) indicated a potential decreased service life of Slick 4-cylinder magneto distributor gear assemblies and was based on a limited number of field reports and product returns. Typical symptoms are unusual rpm drops during magneto check, difficulty starting the engine, or rough running engines. The anomaly was observed in magnetos with a varying number of service hours. The SB called for replacing affected distributor gear assemblies that have a copper electrode with assemblies that incorporate a Monel distributor gear electrode. The accident airplane’s engine was equipped with serial numbers 4370 and 4371 magnetos, which are in the range of affected magnetos indicated in the SB. A review of the maintenance logbooks revealed an entry dated February 29, 2016, for an "excessive rpm drop of the right magneto" during run-up. No logbook entries were noted for the repair of the magnetos or compliance with SB1-15A. The airplane received three annual inspections since the release and the revision of the SB.

Aircraft

Registration
N2184X
Reported as
Piper PA28 (181)
Category
Airplane
Serial number
28-7990365
Built
1979
Airframe hours
9,638
Engine
Lycoming O&VO-360 SER, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · August 10, 2018 · 506 hours before
Departed
LOU · Louisville, KY
Destination
LEX · Lexington, KY
Flight plan
VFR
Airport
LOU · Bowman Field Airport, runway 24, 4,358 × 75 ft, asphalt
Equipment
Stall warning system, Auto-pilot

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
35
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
October 18, 2018
Seat
Left
Restraint
3-point
Flight hours
252 total · 35 in this make and model · 215 as pilot in command · 8 in the last 90 days · 1 in the last 30 days

Weather

Conditions
Visual (VMC) · Night
Wind
120° at 5 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
54 °F, dew point 43 °F
Altimeter
30.25 inHg
Observed at
LOU

Docket · 7

The files NTSB released with the investigation on February 24, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 22.7 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.