# NTSB ERA19LA109: Piper PA28, N2184X, Louisville, KY, February 26, 2019

- Type: NTSB accident investigation
- Classification: Accident · No injuries · Class 3 · Limited · Final report
- Date: February 26, 2019, 18:35 local (23:35 UTC)
- Place: Louisville, KY
- Coordinates: 38.228054, -85.663612 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=38.2281&lon=-85.6636&mi=10
- Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping)
- Defining event: [Takeoff-rejected takeoff: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342)
- Highest injury: No injuries
- Injuries: 1 uninjured
- Status: Completed
- Report: Approved by Office Director
- Investigation class: Class 3
- NTSB office: Eastern Region Aviation
- Parties: FAA
- NTSB case key (mKey): 99028
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA19LA109
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99028/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99028
- Page: https://openairdocs.org/ntsb/ERA19LA109

## 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

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: [Piper PA-28-181, 1 case](https://openairdocs.org/ntsb-findings/01057414/cases.md?model=7102807), [All aircraft, 101 cases](https://openairdocs.org/ntsb-findings/01057414/cases.md)
- [Maintenance: replacement](https://openairdocs.org/ntsb-findings/02062020): Personnel issues › Task performance · Maintenance personnel; cases with it: [Piper PA-28-181, 2 cases](https://openairdocs.org/ntsb-findings/02062020/cases.md?model=7102807), [All aircraft, 70 cases](https://openairdocs.org/ntsb-findings/02062020/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Takeoff-rejected takeoff: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) (defining event); cases with it: [Piper PA-28-181, 9 cases](https://openairdocs.org/ntsb-events/342/sequence.md?model=7102807), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md)
- [Takeoff-rejected takeoff: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-28-181, 70 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102807), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md)

## 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](https://openairdocs.org/deregistered/N2184X-2019-10-23), registration cancelled 2019-10-23, S/N 28-7990365, built 1979 (OpenAirDocs)
- Reported make and model: Piper PA28 (181)
- Registry model: [Piper PA-28-181](https://openairdocs.org/model/piper-pa-28-181) (registry code 7102807) (OpenAirDocs)
- Registry engine: [Lycoming O&VO-360 series](https://openairdocs.org/engine/lycoming-o-vo-360-series) (registry code 41514, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: 28-7990365
- Year built: 1979
- Airframe hours: 9638
- Engines: 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

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 35; injuries: none; 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

## 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 20190226022839A](https://openairdocs.org/incident/20190226022839A), Feb 26, 2019: Piper PA-28-181, Louisville, KY, Substantial damage. Pilot stated he performed a normal preflight and found no issues. Taxied to runway 24 at lou performed run up all normal. Departed on 24, rotated and climbed…

## Docket (7 files)

The files NTSB released with the investigation on February 24, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99028. 22.7 MB in all.

- Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 9 pages, 17.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9545291&FileExtension=pdf&FileName=NTSB%20Report%20PDF_Redacted-Rel.pdf
- Pilot's statement (item 2, PDF, 1 page, 98 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9543201&FileExtension=pdf&FileName=N2184X%20Accident%20Notes%20Brad%20Pabian-Rel.pdf
- Passenger statement (item 3, PDF, 2 pages, 79 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9545181&FileExtension=pdf&FileName=N2184X%20Tim%20Price%20pax%20statement_Redacted-Rel.pdf
- FAA inspector's statement (item 4, PDF, 3 pages, 30 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9545520&FileExtension=pdf&FileName=N2184X%20Accident%20Notes%20FAA%20LA109_Redacted-Rel.pdf
- Maintenance records (item 5, PDF, 6 pages, 4.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9573499&FileExtension=pdf&FileName=MX%20logbook%20excerpts%20LA109_Redacted-Rel.pdf
- Memorandum of record SB1-15A excerpts (item 6, PDF, 2 pages, 142 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9573941&FileExtension=pdf&FileName=Memorandum%20Of%20Record%20SB1-15A%20excerpts%20LA109-Rel.pdf
- Photo array (item 7, PDF, 3 pages, 249 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9545621&FileExtension=pdf&FileName=Photo%20Array%20LA109-Rel.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.

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