# NTSB LAX04FA042: Cessna 177RG, N431DL, Blk Canyon City, AZ, November 13, 2003 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: November 13, 2003, 09:25 local (16:25 UTC) - Place: Blk Canyon City, AZ - Coordinates: 34.130916, -112.129875 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=34.1309&lon=-112.1299&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report December 28, 2006 - Report: Approved by Office Director - Parties: Teledyne Continental Motors, Cessna Aircraft Company, Textron Lycoming, Federal Aviation Administration - ADs cited in the narratives: [AD 78-18-04](https://openairdocs.org/ad/78-18-04), [AD 79-12-07](https://openairdocs.org/ad/79-12-07), [AD 79-18-06](https://openairdocs.org/ad/79-18-06), [AD 80-17-14](https://openairdocs.org/ad/80-17-14), [AD 82-11-05](https://openairdocs.org/ad/82-11-05), [AD 82-20-01](https://openairdocs.org/ad/82-20-01), [AD 96-12-07](https://openairdocs.org/ad/96-12-07) (OpenAirDocs) - NTSB case key (mKey): 58339 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX04FA042 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/58339/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=58339 - Page: https://openairdocs.org/ntsb/LAX04FA042 ## Probable cause a loss of engine power due to the failure of the single-drive dual magneto that resulted from inadequate lubrication of the breaker cam. Also causal was the improper maintenance by other maintenance personnel during a recent inspection, which should have detected the lubrication deficiency. A contributing factor in the accident that likely exacerbated the pilot's injuries was his decision not to wear the installed shoulder harness. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(total) - mech failure/malf, cruise - normal - ignition system,magneto - improperly serviced (cause) - ignition system,ignition points - not operating (cause) - maintenance,lubrication - inadequate, other maintenance personnel (cause) - maintenance,inspection - improper, other maintenance personnel (cause) - Forced landing, emergency descent/landing - terrain condition - none suitable - In flight collision with object, emergency descent/landing - terrain condition - mountainous/hilly - object - tree(s) - shoulder harness - not used, pilot in command (contributing factor) ## Analysis During cruise flight over mountainous terrain, a loss of engine power occurred and the airplane impacted trees during the subsequent forced landing attempt. The pilot radioed air traffic control personnel that the engine was losing power and would not sustain flight. He was attempting to make it to an airport when the airplane impacted trees in mountainous terrain. An airframe inspection was conducted with no discrepancies noted that would have precluded normal operation. The engine was equipped with a single-drive dual magneto that remained secure at its mounting pad. During manual rotation of the crankshaft, investigators could hear the "snapping" of the coupling, but no spark was observed at any of the leads. Magneto-to-engine timing could not be established because the contacts were not breaking electrical continuity. A functional check by the magneto manufacturer revealed that both magneto primary circuits had short-circuited to ground in all magnet positions, which was consistent with the breaker points not opening. Disassembly revealed that the plastic cam followers were melted and smeared in the direction of normal cam rotation. The breaker cams, made of sintered iron material, are supposed to be impregnated with oil per the service manual or production instructions for lubrication purposes at each overhaul. The oil lubricates the surface of the breaker cams over the cams service life. Four months prior to the accident the single-drive dual magneto had been removed, and the mechanic at a local fixed based operator had internally timed the magneto, then had completed a ground run and full operational check. The accident flight occurred 38.2 hours after this maintenance operation. According to the manufacturer, to internally time the magneto, maintenance personnel have to partially disassemble the magneto and physically touch the cam and breaker points. In accordance with the Service Support Manual instructions for the magneto, during this process the breaker cams and contact points should be inspected for lubrication, wear, burning, or melting. The on-scene examination revealed that the pilot was not wearing his shoulder harness, which remained stowed in the stowage sheath above the pilot's cabin door. The airframe manufacturer indicated that the airplane had been delivered new in 1975 with shoulder harnesses as standard equipment for the pilot and co-pilot. The coroner listed the cause of death as blunt force craniocerebral trauma due to an airplane crash. ## Factual narrative HISTORY OF FLIGHT On November 13, 2003, about 0925 mountain standard time, a Cessna 177RG, N431DL, collided with mountainous terrain after the pilot reported experiencing engine problems 12 miles east of Black Canyon City, Arizona. The airline transport pilot/owner operated the airplane under the provisions of 14 CFR Part 91. The airplane was destroyed. The pilot, the sole occupant, sustained fatal injuries. The charity cross-country flight departed Flagstaff Pulliam Airport (FLG), Flagstaff, Arizona, about 0840, en route to the Phoenix Deer Valley Airport (DVT), Phoenix, Arizona, with an ultimate destination to the Bob Hope Airport (BUR), Burbank, California. Day visual meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan had been filed. The primary wreckage was at 34-degrees 06.330 minutes north latitude and 111-degrees 57.675 minutes west longitude. At 2128 (November 12, 2003), the pilot contacted Prescott Automated Flight Service Station (AFSS) and requested an outlook weather briefing for the following areas: FLG, DVT, BUR, with a return to FLG. The pilot then filed three separate flight plans: FLG to DVT, DVT to BUR, and BUR to FLG. The pilot did not obtain an updated weather briefing on the morning of the accident. During the flight from FLG, on the morning of the 13th, the accident airplane climbed to an altitude of 10,000 feet above ground level (agl). At 0922, the flight was transferred from Albuquerque, New Mexico, Air Route Traffic Control Center (ZAB ARTCC), to PHX TRACON. At that time, the pilot reported a partial loss of engine power and that he was attempting to reach the Pleasant Valley Airport (P48), Peoria, Arizona. The controller asked if the pilot wanted to continue to Carefree, Arizona, or return to Prescott, Arizona. The pilot reported that he wanted the closest airport. The controller advised that Carefree Airport was 23 nautical miles on a 160-degree heading. The pilot advised that he was descending 600 feet per minute (fpm) and would head towards Carefree. The controller instructed him to fly a heading of 160 degrees if able, and to descend at the pilot's discretion, and maintain 7,000 feet agl. At 0924, the controller asked the pilot if his carburetor heat was on, to which the pilot replied negatively as the airplane was fuel-injected. The pilot indicated the airplane had slowed to 75 knots, descending at 800 fpm, and the propeller was "windmilling." The controller reported that Carefree was still 21 nautical miles away on a 155-degree heading. A minute later the controller advised the accident pilot that radar contact was lost 45 miles north of PHX. The pilot replied, "Okay, understand." Between 0926 and 0932, the controller attempted to make contact with the accident pilot, but received no response. During this time the PHX TRACON controller was in contact with ZAB. The ZAB controller reported they still had radar contact with the accident airplane. One sweep at 0926:08 depicted the airplane at 6,400 feet, and the last sweep at 0927:35, the airplane was at 5,400 feet. At 0928:04, there were no more radar returns recorded on ZAB's radarscope for the accident airplane. PERSONNEL INFORMATION A review of Federal Aviation Administration (FAA) airman records revealed the pilot held an airline transport pilot certificate with a rating for airplane multiengine land, and commercial privileges for airplane single engine land. The pilot held a third-class medical certificate issued on August 27, 2002. It had the limitations that the pilot must have glasses available for near vision, and that the certificate was not valid for any class after August 31, 2004. No personal flight records were located for the pilot and the aeronautical experience listed in this report was obtained from a review of the airmen FAA records on file in the Airman and Medical Records Center located in Oklahoma City, Oklahoma. These records indicated the pilot reported accumulating a total time of 28,360 hours. AIRCRAFT INFORMATION The airplane was a Cessna 177RG, serial number 177RG-0762. The pilot/owner purchased the airplane in June 2000. The following information was obtained through e-mails submitted to the National Transportation Safety Board after the accident by the moderator for the Cessna Cardinal group that the accident pilot belonged to. Separate e-mails dated October 4, 2001, June 25, 2002, July 13, 2002, August 30, 2003, and September 1, 2003, indicated that the newly overhauled engine was experiencing oil temperature overheating problems during climb out, with very little reduction in temperature during cruise. On September 1, 2003, the pilot/owner reported that the engine had gone through a major field overhaul about 150 hours ago, and posed the question as to whether or not incorrect magneto timing could cause the high oil temperature readings. At the accident scene the tachometer read 4,220.9 and the Hobbs hour meter read 2,697.3. A review of the airplane's logbooks revealed a total airframe time of 3,958.0 hours at the last annual inspection, which was completed on August 6, 2002. An entry dated August 11, 2003, reported that an unspecified inspection had been conducted and the airframe total time was 4,151.0 hours. Recorded in the airplane's logbook, was the annual inspection for June 20, 2000, which contained the following information pertaining to the magneto: "(MAGNETO) AD 78-18-04 PCW per entry dated 10/29/81, AD (Airworthiness Directive) 79-12-07 DNA per model [number] of magneto, AD 79-18-06R(1) DNA per "K" stamped following s/n, AD 80-17-14 PCW per entry dated 10/29/81, AD 82-11-05 DNA per color of tag, AD 82-20-01 PCW per entry dated 10/19/82, AD 96-12-07 PCW at [overhaul] dated 08/27/98." The airplane had a Textron Lycoming IO-360-A1B6D engine, serial number L-14190-51A. Total time on the engine at the last annual inspection was recorded as 3,958.0 hours. On September 9, 2003, the dual magneto was removed to set the internal timing, at a total time of 4,182.7 hours. On October 7, 2003, routine maintenance was performed and the engine's total time was reported as 4,201.0 hours. Maintenance records regarding work completed on the airplane obtained from Wiseman Aviation, Flagstaff, revealed that on July 10, 2003, the magneto was internally timed, and a ground run and operational check were conducted with no mechanical malfunctions encountered. On May 6, 2002, Professional Aircraft Accessories, Inc., Amelia, Ohio, submitted a FAA Form 8130-3 titled Airworthiness Approval Tag for an overhauled and tested magneto, part number 10-382555-11. On May 14, 2002, Signature Engines, Inc., Cincinnati, Ohio, submitted FAA form 8130-3, which indicated that the engine had been overhauled, and one of the parts/accessories replaced was "2 ea magnetos." The overhauled engine was then shipped to Wiseman Aviation for installation on the airplane. According to the Bendix-Teledyne Continental Motors (TCM) overhaul manual, the following applicable AD's pertained to the magneto: 96-12-07 - titled Inspection of riveted impulse couplings and stop pins - Inspect Impulse, recurring inspection with a required compliance every 500-hours 78-18-04 - titled Teledyne Continental Motors Ignition System-Coil Retention - Inspect Shimming of Rotor, recurring inspection with a required compliance at every overhaul 82-20-01 - titled Teledyne Continental Motors Ignition System-Impulse Coupling - Inspect Impulse, one time inspection 80-17-14 - titled Teledyne Continental Motors Ignition System-Housing Distortion - Inspect Housing, one time inspection 82-11-05 - titled Teledyne Continental Motors Ignition System-Distributor Gear - Inspect Gears, one time inspection According to the manufacturer, the above AD's do not pertain to the lubrication of the cam follower. However, TCM Service Bulletin 643A titled Maintenance Intervals for ## Aircraft - Registration: [N431DL](https://openairdocs.org/deregistered/N431DL-2004-02-11), registration cancelled 2004-02-11, S/N 177RG0762, built 1975 (OpenAirDocs) - Reported make and model: Cessna 177RG - Registry model: [Cessna 177RG](https://openairdocs.org/model/cessna-177rg) (registry code 2073709) (OpenAirDocs) - Registry engine: [Lycoming IO-360-A1B6D](https://openairdocs.org/engine/lycoming-io-360-a1b6d) (registry code 41593, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 177RG0762 - Airframe hours: 4220.9 - Engines: Lycoming IO-360-A1B6D 200 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Registered owner: Robert E. Fried - Airworthiness certificate: Standard, Normal - Last inspection: Annual, August 1, 2002, 69.9 hours before - Departed: FLG, Flagstaff, AZ - Destination: DVT, Phoenix, AZ - Flight plan: IFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 72; injuries: fatal; commercial, airline transport; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 3; seat: left; toxicology performed; flight hours: 28,360 total ## Weather - Conditions: Visual (VMC), Day - Wind: 210° at 4 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 59 °F, dew point 55 °F - Altimeter: 30.11 inHg - Observed at: DVT, 33 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 20031113031139A](https://openairdocs.org/incident/20031113031139A), Nov 13, 2003: Cessna 177RG, Black Canyon, AZ, Destroyed, 1 fatal. (-23) On November 13, 2003, at approximately 0828 MST, during an IFR flight from flagstaff, AZ to deer valley airport phoenix, AZ. Mr. Robert fried,… ## Docket (15 files) The files NTSB released with the investigation on October 16, 2006, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=58339. 14.9 MB in all. - Toxicological Report (item 1, .PDF, 104 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478145&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - Excerpt Cessna Report- Wreckage Diagram and Accident Site (item 2, .PDF, 107 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40261179&FileExtension=.PDF&FileName=Excerpt%20Cessna%20Report-%20Wreckage%20Diagram%20and%20Accident%20Site-Master.PDF - Excerpt FAA ATC Package (item 3, .PDF, 382 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40261180&FileExtension=.PDF&FileName=Excerpt%20FAA%20ATC%20Package-Redacted.PDF - Excerpt TCM Report (item 4, .PDF, 14 photos, 3.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40261182&FileExtension=.PDF&FileName=Excerpt%20TCM%20Report-Master.PDF - Excerpt TCM Service Support Manual- Magneto (item 5, .PDF, 352 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40261183&FileExtension=.PDF&FileName=Excerpt%20TCM%20Service%20Support%20Manual-%20Magneto-Redacted.PDF - Engine Logbook (item 6, .PDF, 190 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40261185&FileExtension=.PDF&FileName=Engine%20Logbook-Redacted.PDF - Excerpt Aircraft Logbook (item 7, .PDF, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40261235&FileExtension=.PDF&FileName=Excerpt%20Aircraft%20Logbook-Redacted.PDF - Records from Wiseman Aircraft (item 8, .PDF, 505 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40261236&FileExtension=.PDF&FileName=Records%20from%20Wiseman%20Aircraft-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 9, .PDF, 111 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40261238&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 10, .PDF, 72 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478146&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Master.PDF - Photo 1 - Aerial View (Lycoming) (item 11, .PDF, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40261240&FileExtension=.PDF&FileName=Photo%201%20-%20Aerial%20View%20(Lycoming)-Master.PDF - Photo 2 - Overview of Accident Site (Lycoming) (item 12, .PDF, 136 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40261241&FileExtension=.PDF&FileName=Photo%202%20-%20Overview%20of%20Accident%20Site%20(Lycoming)-Master.PDF - Photo 3 - Left Side View of Airplane (NTSB) (item 13, .PDF, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40261242&FileExtension=.PDF&FileName=Photo%203%20-%20Left%20Side%20View%20of%20Airplane%20(NTSB)-Master.PDF - Photo 4 - Right Side View of Airplane (NTSB) (item 14, .PDF, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40261243&FileExtension=.PDF&FileName=Photo%204%20-%20Right%20Side%20View%20of%20Airplane%20(NTSB)-Master.PDF - Photo 5 - Pictures of Magneto (Lycoming) (item 15, .PDF, 3 photos, 3.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40261244&FileExtension=.PDF&FileName=Photo%205%20-%20Pictures%20of%20Magneto%20(Lycoming)-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.