# NTSB LAX93LA207: Cassutt III M, N250P, Corona, CA, May 7, 1993 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: May 7, 1993, 15:44 local (22:44 UTC) - Place: Corona, CA - Location: 33.8753° N, 117.5664° W: Placed by OpenAirDocs: center of Corona, CA, within about 6 miles (OpenAirDocs) - Nearby events: https://openairdocs.org/map.md?lat=33.8753&lon=-117.5664&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: Serious injuries - Injuries: 1 serious - Status: Completed, report June 30, 1994 - Report: Approved by Office Director - NTSB case key (mKey): 28376 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX93LA207 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/28376/pdf - Page: https://openairdocs.org/ntsb/LAX93LA207 ## Probable cause the pilot improper maintenance modification and total failure of the magneto. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power, takeoff - initial climb - ignition system,magneto - failure,total (cause) - maintenance,modification - improper, pilot in command (cause) - Forced landing, descent - emergency - In flight collision with terrain/water, descent - emergency ## Analysis THE AIRPLANE EXPERIENCED A LOSS OF ENGINE POWER ON TAKEOFF. THE PILOT EXECUTED A 180 DEGREE TURN AND LANDED ADJACENT TO THE DEPARTURE RUNWAY. THE ENGINE EXAMINATION DISCLOSED ONE MAGNETO WAS INOPERABLE. THE ENGINE VALVE SPRINGS WERE FROM A DIFFERENT MODEL ENGINE. ## Factual narrative On May 7, 1993, at 1544 hours Pacific daylight time, a Cassutt III M, N250P, lost control and collided with level terrain after takeoff from the Corona Municipal Airport, Corona, California. The pilot was conducting a local visual flight rules personal flight. The airplane was destroyed. The certificated commercial pilot received serious injuries. Visual meteorological conditions prevailed at the time. The accident was witnessed by a FAA Accident Prevention Counselor (APC). According to the APC the airplane was observed turning when it appeared to stall. The airplane descended until colliding with the ground. Friends of the pilot indicated that the pilot complained of chest pains days before the accident. According to the FAA, the pilot's doctor indicated that the pilot had suffered recent heart damage. On September 2, 1993, Safety Board investigators examined the engine at Corona Airport, Corona, California. The following are the results of the examination: EXTERNAL EXAMINATION The engine was removed from the aircraft before the examination by an unknown party and the following had been removed: the propeller, magnetos, exhaust system and parts of the fuel and electrical systems. There was no evidence of impact damage to the engine casing and there was no data plate on the engine. The valve covers and carburetor had been removed and reinstalled prior to the examination by an unknown party. Spark Plugs Six of the spark plugs were AC plugs; four of which were S-88 and the remaining two were unknown. The other two spark plugs were Champion M41E and were installed in the top position of cylinders number one and two. All spark plug electrodes showed signs of normal erosion with the center ground electrodes being about half of their original thickness. Also, wet, oily deposits were noted on the spark plugs. Valve Covers Continuity of the gear and valve train assembly was established. Compression was evident during the continuity crankshaft rotation and there was no visual sign of valve leakage. The valve covers exhibited evidence of circular marks created by the valve rocker shafts. ACCESSORIES Magnetos Two Bendix S4LN-21 magnetos, serial numbers 587045 and 562364, were given to the investigator by a friend of the pilot who said that these magnetos had come off of the engine. The magnetos engine position could not be determined due to the absence of their respective wiring harnesses. Magneto, serial number 587045, produced spark upon rotation of its drive shaft; the remaining magneto did not produce spark. DISASSEMBLY Cylinders The chrome cylinders contained a small amount of oil that was light brown in color and water contamination was noted. Safety Board investigators did not determine the origin of the contaminates. Camshaft and Valve Springs The pilot's friend reported that Continental O-200 camshaft and valve springs were installed on the engine. A representative of Teledyne Continental said that replacement of the original camshaft and valve springs by the O-200 series would not adversely effect the engine operation. However, the O-200 camshaft and valve springs are not approved by the manufacture for installation in the C-85 engine. Valve Seats The intake valve seats exhibited evidence of carbon deposits. Pistons The pistons exhibited evidence of triangular patterned carbon deposits directly opposite of the bottom plugs. ## Aircraft - Registration: [N250P](https://openairdocs.org/deregistered/N250P-1993-10-06), registration cancelled 1993-10-06, S/N 250 (OpenAirDocs) - Reported make and model: CASSUTT III M - Registry model: [Procter CASSUTT III M](https://openairdocs.org/model/procter-cassutt-iii-m) (registry code 1970836) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: 250P - Airframe hours: 353 - Engines: CONTINENTAL C85-12F 85 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Registered owner: James Proctor - Airworthiness certificate: Special, Experimental (Special) - Last inspection: Annual, November 15, 1993, 7 hours before - Airport: L66, Corona, runway 21, 3,200 × 50 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 52; commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane, helicopter; medical: class 2, valid medical--w/ waivers/lim; seat: center; flight hours: 5,000 total, 750 in this make and model, 7 in the last 90 days, 4 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 210° at 7 knots - Visibility: 25 statute miles - Lowest ceiling: none - Temperature: 70 °F ## 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 19930507012549A](https://openairdocs.org/incident/19930507012549A), May 7, 1993: Amtrsx CASSUTT3M, Corona, CA, Destroyed. Stalled on a climbing turn after takeoff. Engine discrepancies and bogus parts. Pilot had recent heart damage. 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.