# NTSB ERA21LA356: Waco GXE, N8564, Burt, NY, September 13, 2021

- Type: NTSB accident investigation
- Classification: Accident · No injuries · Class 3 · Limited · Final report
- Date: September 13, 2021, 14:05 local (18:05 UTC)
- Place: Burt, NY
- Coordinates: 43.306684, -78.745106 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=43.3067&lon=-78.7451&mi=10
- Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping)
- Defining event: [Takeoff: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340)
- 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/FSDO
- NTSB case key (mKey): 103855
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA21LA356
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103855/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=103855
- Page: https://openairdocs.org/ntsb/ERA21LA356

## Probable cause

The improper magneto timing, which resulted in the engine’s inability to produce full power during the takeoff.

## 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 · Incorrect service/maintenance (probable cause); cases with it: [Waco GXE, 1 case](https://openairdocs.org/ntsb-findings/01057414/cases.md?model=9600702), [All aircraft, 101 cases](https://openairdocs.org/ntsb-findings/01057414/cases.md)
- [Maintenance: installation](https://openairdocs.org/ntsb-findings/02062035): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Waco GXE, 1 case](https://openairdocs.org/ntsb-findings/02062035/cases.md?model=9600702), [All aircraft, 371 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md)

## Sequence of events

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

- [Prior to flight: Aircraft maintenance event](https://openairdocs.org/ntsb-events/040); cases with it: [Waco GXE, 1 case](https://openairdocs.org/ntsb-events/040/sequence.md?model=9600702), [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md)
- [Takeoff: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340) (defining event); cases with it: [Waco GXE, 1 case](https://openairdocs.org/ntsb-events/340/sequence.md?model=9600702), [All aircraft, 820 cases](https://openairdocs.org/ntsb-events/340/sequence.md)

## Analysis

The accident flight was the vintage biplane’s first since it had been restored 2 years prior. During takeoff, once the airplane was in ground effect, the pilot described that the airplane would not climb any further even though the engine was producing power. The pilot elected to land the airplane in a nearby field and during the landing, the airplane nosed over and came to rest inverted, which resulted in substantial damage to the wings and fuselage. A postaccident examination of the engine revealed that the magnetos were set to fire about 7° away from the proper position in order to obtain full engine power. Furthermore, a historical reference handbook for the vintage engine stated that the magnetos needed to have an external lever connected to a control in the cockpit to mechanically vary the magneto to engine timing while the engine was running. The magnetos installed on the accident airplane did not have these controls installed. Based on this information, it is likely the engine could not produce full power as a result of the incorrect magneto timing.

## Factual narrative

On September 13, 2021, about 1405 eastern daylight time, a Waco GXE, N8564, was substantially damaged when it was involved in an accident near Burt, New York. The airline transport pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, the accident flight was the first flight since the airplane was restored a few years prior. The airplane’s most recent annual inspection was completed on the morning of the accident. During takeoff, the airplane departed the turf runway “normally,” and once it was in ground effect, it would not climb any further even though the “engine was producing power just fine.” The pilot elected to land the airplane in a nearby field to avoid trees in the flight path. During the landing, the airplane nosed over and came to rest inverted, which resulted in substantial damage to the wings and fuselage. According to the maintenance logs, in March 2013, the engine was reassembled and reinstalled on the airplane. The next maintenance entry, in June 2019, with 0 hours since major overhaul, indicated that the engine and propeller were inspected in accordance with a 100-hr inspection. A high-speed taxi test was performed and the engine and propeller were found to be in airworthy condition. The final entry of the engine log was dated September 9, 2021. It indicated that the engine had 38 hours SMOH, a 100-hr inspection was performed, and the engine was found to be in an airworthy condition. The airplane was equipped with a vintage Curtis Aeroplane Model OX-5 engine. The engine was designed to be equipped with a variable timing magneto that assisted with engine starting. A postaccident examination of the engine by a Federal Aviation Administration inspector revealed that the accident airplane’s magnetos were set to fire about 22° before top dead center (BTDC). The engine logbook indicated that the magnetos should be timed to 30° BTDC. To obtain a “full advanced” setting, the engine historical reference handbook stated that the magnetos needed to have an external lever connected to a control in the cockpit to mechanically vary the magneto to engine timing while the engine was running. In addition, the handbook stated that the magnetos should be timed to 28° BTDC. The magnetos installed on the accident airplane’s engine did not have external control levers and without the levers, the ignition could not be timed to 28°-30° BTDC.

## Aircraft

- Registration: [N8564](https://openairdocs.org/aircraft/N8564), registered now, S/N 1927, built 1929 (OpenAirDocs)
- Reported make and model: WACO GXE
- Registry model: [Waco GXE](https://openairdocs.org/model/waco-gxe) (registry code 9600702) (OpenAirDocs)
- Registry engine: [Wright CURTISS OX5](https://openairdocs.org/engine/wright-curtiss-ox5) (registry code 67002, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: 1927
- Year built: 1929
- Airframe hours: 1538
- Engines: Milwaukee Parts Corporation Tank V502 115 horsepower reciprocating
- Damage: Substantial damage
- Flight: Personal, Part 91
- Airworthiness certificate: Standard, Normal
- Last inspection: Annual, September 13, 2021, 0 hours before
- Airport: D80, Olcott-Newfane, runway 09/27, 2,500 × 60 ft, grass/turf
- Equipment: Unknown

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 42; injuries: none; airline transport, commercial, flight instructor; airplane ratings: single-engine sea, single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, with waivers/limitations; last flight review March 18, 2021; seat: rear; restraint: 4-point; flight hours: 12,771 total, 1 in this make and model, 9,361 as pilot in command, 48 in the last 90 days, 14 in the last 30 days, 2 in the last 24 hours

## Weather

- Conditions: Visual (VMC), Day
- Wind: 310° at 5 knots
- Visibility: 10 statute miles
- Lowest ceiling: none
- Temperature: 72 °F, dew point 55 °F
- Altimeter: 30.09 inHg
- Observed at: IAG, 15 nm away
- METAR: KIAG 131753Z 31005KT 10SM CLR 22/13 A3009 RMK AO2 SLP187 T02220133 10222 20150 56019

## 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 20210913018609A](https://openairdocs.org/incident/20210913018609A), Sep 13, 2021: Waco GXE, Burt, NY, Substantial damage. On 09/13/2021 at about 1400 hrs local time, this aircraft departed a private airfield in an easterly direction on wilson-Burt road in Burt, new york with only…

## Docket (7 files)

The files NTSB released with the investigation on July 26, 2023, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=103855. 204 MB in all.

- Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14301797&FileExtension=pdf&FileName=LA356%206120_Redacted-Rel.pdf
- Memorandum for record a�� pilot (item 2, PDF, 1 page, 231 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14301946&FileExtension=pdf&FileName=Memorandum%20Of%20Record%20Color%20Pilot%20Interview%20Summary-Rel.pdf
- Maintenance records - excerpts (item 3, PDF, 5 pages, 194 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14301320&FileExtension=pdf&FileName=LA356%20Mx%20Record%20Excerpts_Redacted-Rel.pdf
- FAA inspector's statement (item 4, PDF, 3 pages, 97 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14301398&FileExtension=pdf&FileName=FAA%20Inspector%20Statement%20LA356_Redacted-Rel.pdf
- Memorandum for record a�� FAA engine examination (item 5, PDF, 1 page, 193 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14301696&FileExtension=pdf&FileName=Memorandum%20Of%20Record%20Color%20FAA%20Engine%20Examination%20Memo-Rel.pdf
- Photos (item 6, PDF, 4 pages, 2.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14301408&FileExtension=pdf&FileName=LA356%20Photo%20Array-Rel.pdf
- Curtis engine operating manual - excerpts (item 7, PDF, 16 pages, 5.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14300791&FileExtension=pdf&FileName=Curtiss%20Engine%20Operating%20Manual%20Excerpts-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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