# NTSB LAX96FA097: Piper PA-28-236, N2476Y, Seal Beach, CA, January 20, 1996 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Field investigation · Final report - Date: January 19, 1996, 17:20 local (Jan 20, 1996, 01:20 UTC) - Place: Seal Beach, CA - Location: 33.6801° N, 118.0247° W: Placed by OpenAirDocs from NTSB’s distance and direction from JOHN WAYNE/ORANGE COUNTY (SNA), within about 3 miles (OpenAirDocs) - Nearby events: https://openairdocs.org/map.md?lat=33.6801&lon=-118.0247&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Minor injuries - Injuries: 2 minor, 1 uninjured - Status: Completed, report December 16, 1996 - Report: Approved by Office Director - NTSB case key (mKey): 29253 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX96FA097 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/29253/pdf - Page: https://openairdocs.org/ntsb/LAX96FA097 ## Probable cause a total loss of engine power from an improperly installed magneto that separated from the engine housing due to fatigue from vibration. ## 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 - ignition system,magneto - separation (contributing factor) - maintenance,installation - improper, other maintenance personnel (cause) - lack of certification, unqualified person (cause) - ignition system,magneto - fatigue (contributing factor) - ignition system,magneto - vibration (contributing factor) - Ditching, emergency descent/landing - Wheels down landing in water, emergency descent/landing - terrain condition - water,glassy ## Analysis The engine suddenly quit during cruise flight and, unable to reach land, the pilot ditched in the ocean. After recovery, oil streaks were observed inside the engine cowling that proceeded back along the underside of the aircraft to the empennage. Also noted was a separation of the magneto housing from the accessory case and an oil residue. Examination of the housing revealed the presence of wear on the contact surfaces of the hold down lugs that suggests both lugs were loose prior to the accident. The looseness of the lugs would allow the magneto to vibrate, resulting in fatigue cracking through the mounting flange. The magneto was recently installed on the aircraft at the last inspection and the mechanic who performed the work did not have an inspection authorization. ## Factual narrative HISTORY OF FLIGHT On January 19, 1996, at 1720 hours Pacific standard time, the pilot of a Piper PA-28-236, N2476Y, experienced a loss of engine power during a cruise flight near Seal Beach, California. Visual meteorological conditions existed at the time. The aircraft sustained substantial damage. The pilot was not injured and his two passengers received minor injuries. The aircraft departed John Wayne Airport in Santa Ana, California, at 1700 for a local pleasure flight. The pilot stated that he was cruising at 2,000 feet above the water at an indicated airspeed of 125 knots when the engine suddenly stopped with no warning. The engine gauges were indicating normal prior to the power loss. The pilot attempted to restart the engine twice with no success. When he realized he wasn't going to make landfall, he ditched the aircraft in the water about 200 yards offshore at Seal Beach. The occupants got out of the aircraft and swam to the shore after it sank. AIRCRAFT INFORMATION The aircraft was operated and maintained by a local flying club at the John Wayne Airport. The last inspection was completed in June, 1996. During this time, the magneto was overhauled and reinstalled on the aircraft by a local mechanic. According to the FAA, the mechanic did not have an inspection authorization certificate. WRECKAGE The aircraft sank in 27 feet of water as measured by a pneumofathometer. The aircraft was found intact lying on the bottom in an inverted position and was partially submerged in the ocean silt. The aircraft was recovered intact on January 22, 1996, washed with fresh water, and brought to shore at San Pedro, CA. An examination of the aircraft revealed an oil stain on the inside of the engine cowling that proceeded back along the underside of the aircraft to the empennage. Afterwards, the aircraft was taken to a facility in Compton, California, for a more detailed examination. Examination of the engine revealed that the magneto housing had separated from the accessory case at the mounting flange with oil residue present in the area. The magneto and the mounting flange were sent to the Board's metallurgical laboratory in Washington, D.C., for examination. TESTS AND RESEARCH The separated pieces of the magneto housing were cleaned ultrasonically in acetone and examined with a scanning electron microscope (SEM). According to the metallurgist, the SEM examination disclosed no discernible fracture features on the upper surface. However, the SEM examination of the lower piece revealed fatigue striations in fracture areas with lesser amounts of corrosion. Due to extensive corrosion, the exact extent of the fatigue cracking was not determined. Examination of the lower lug with the aid of a low power binocular microscope revealed evidence of wear on the contact surface. The amount of wear on the contact surface of the upper lug was significantly less. ADDITIONAL DATA The aircraft was verbally released 1/23/96 to Mr. Daniel Heersema of Associated Aviation Underwriters of Universal City, California. The magneto was returned to Mr. Heersema on September 30, 1996. ## Aircraft - Registration: [N2476Y](https://openairdocs.org/deregistered/N2476Y-1997-09-11), registration cancelled 1997-09-11, S/N 288511016 (OpenAirDocs) - Reported make and model: Piper PA-28-236 - Registry model: [Piper PA-28-236](https://openairdocs.org/model/piper-pa-28-236) (registry code 7102815) (OpenAirDocs) - Category: Airplane - Serial number: 28-8511016 - Airframe hours: 3576 - Engines: Lycoming IO-540 235 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Orange Co. Flight Center - Registered owner: Yates Robert W - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, September 26, 1995, 64 hours before - Departed: SNA, SANTA ANA, CA - Airport: SNA, John Wayne/Orange County ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 37; private; airplane ratings: single-engine land; medical: class 3, valid medical--no waivers/lim.; seat: left; flight hours: 305 total, 4 in this make and model, 203 as pilot in command, 12 in the last 90 days, 6 in the last 30 days, 2 in the last 24 hours ## Weather - Conditions: Visual (VMC), Dusk - Wind: 240° at 8 knots - Visibility: 15 statute miles - Lowest ceiling: none - Temperature: 63 °F, dew point 52 °F - Altimeter: 30.00 inHg - Observed at: SLI, 9 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 19960119000769A](https://openairdocs.org/incident/19960119000769A), Jan 19, 1996: Piper PA28236, Long Beach, CA, Substantial damage. En route to VFR practice area, lost radar and radio contact, crashed. 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.