# NTSB MIA04FA076: Cessna 177RG, N1910Q, Tampa, FL, April 20, 2004 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: April 20, 2004, 11:34 local (15:34 UTC) - Place: Tampa, FL - Coordinates: 27.909999, -82.441665 - Nearby events: https://openairdocs.org/map.md?lat=27.9100&lon=-82.4417&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report January 31, 2006 - Report: Approved by Office Director - Parties: Cessna Aircraft Company, FAA FSDO, Textron Lycoming Engines, Teledyne Continental Motors, Inc. - NTSB case key (mKey): 59101 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=MIA04FA076 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/59101/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=59101 - Page: https://openairdocs.org/ntsb/MIA04FA076 ## Probable cause Improper maintenance by other maintenance personnel, and the reinstallation of an unserviced magneto during an engine overhaul, which resulted in the magneto malfunctioning, a loss of engine power, and the airplane being ditched into the water. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(partial) - mech failure/malf, approach - maintenance,overhaul - inadequate, other maintenance personnel (cause) - ignition system,magneto - improperly serviced - ignition system,magneto - malfunction - Forced landing, descent - emergency - Ditching, descent - emergency - terrain condition - water ## Analysis An attendant at the Peter O. Knight Airport, Tampa, Florida, stated that she heard a radio communications transmission during which the voice stated that his airplane engine was experiencing roughness and backfiring. Shortly after the initial call, the attendant said she heard the pilot say "we're not going to make it." The accident airplane subsequently ditched in Tampa Bay, about a third of a mile short of the airport, in about 16 feet of water. Postaccident examination of the airplane revealed no anomalies with the airframe and flight controls or engine. During a detailed examination of the Teledyne Continental Motors dual-drive magneto, the magneto's cam was shown to have lost all lubrication, and the points were seized. Airplane records showed that the last known magneto overhaul was conducted by Electrosystems, Inc in October 1997. The records also showed that the magneto had been reinstalled on July 21, 2003, when the engine was overhauled, but a magneto overhaul had not been performed. Teledyne Continental Motors SB643B Service Bulletin pertinent to subject magneto, specifies that the magneto be overhauled when the engine is overhauled. In addition, Textron Lycoming's Mandatory Service Bulletin specifies mandatory parts replacement at overhaul and during repair and normal maintenance. Examination of the Bendix Fuel Flow Divider which was installed on the accident airplane revealed that the subject fuel flow divider did not have the latest diaphragm installation, as specified in Bendix Fuel Systems Service Bulletin RS-86, dated December 23, 1983. ## Factual narrative HISTORY OF FLIGHT On April 20, 2004, about 1134 eastern daylight time, a Cessna 177RG, N1910Q, registered to and operated by a private individual, as a Title 14 CFR Part 91 personal flight, ditched into Tampa Bay, Tampa, Florida. Visual meteorological conditions prevailed and no flight plan was filed. The private-rated pilot and one passenger received fatal injuries, and the airplane incurred substantial damage. The flight originated in Pompano Beach, Florida, the same day, about 0930. An attendant at the fixed-based operator's facility at Peter O. Knight Airport, Tampa, Florida, stated that she heard a radio communications transmission from a pilot stating that he was 6 miles from the airport, and his airplane's engine was experiencing roughness and backfiring. She said that she acknowledged the call, told the pilot to use the runway of his choice, and instructed the other aircraft to clear the traffic pattern. She further stated that shortly after the initial call, she heard the pilot say "we're not going to make it." According to a nearby fisherman, the accident aircraft was heading in a westerly direction at an altitude of about 200 to 300 feet, about a mile to the west of where he was fishing. The witness further stated that he heard erratic changes in the sound of the airplane's engine, which was continually backfiring. He said that the airplane's engine then became silent, and at that point he noticed the airplane make a controlled turn towards the airport. A second witness working in the vicinity of the Port of Tampa Bay stated that the airplane appeared to hit the water hard and it remained afloat for about 3 to 5 minutes. A third witness that was in a boat at the time, about a mile from the accident site stated that he became aware of the airplane when he heard a loud smacking noise as the airplane hit the water. He said that he proceeded to the place where the airplane impacted the water, arriving about 3 to 5 minutes later, but at that time the airplane had sunk. PERSONNEL INFORMATION Records obtained from the FAA showed that the pilot held an FAA private pilot certificate with an airplane single engine land rating, issued on December 24, 2003. He also held an FAA third class medical certificate, issued on January 9, 2003, with the stated limitation "must wear corrective lenses". According to the pilot's logbook, the pilot commenced flight training on April 22, 2003, and had accumulated a total of about 96 flight hours, 16 of which were in the accident aircraft. AIRCRAFT INFORMATION N1910Q is a 1972 Cessna 177RG, serial number 177RG0310. According to the airplane's maintenance logbook it had been given an annual inspection on July 21, 2003, and had accumulated 4,094 flight hours on the airframe at the time of the accident. It was also equipped with a 200 horsepower Lycoming IO 360 A1B6D engine, serial number L-9866-51A. Records showed that the engine was overhauled on July 21, 2003 and had accumulated about 175 flight hours at the time of the accident. The accident airplane was also equipped with a McCauley 2-bladed controllable pitch propeller, serial number 754887. METEOROLOGICAL INFORMATION Visual meteorological conditions prevailed at the time of the accident. The Tampa International Airport, Tampa, Florida, 1153, surface weather observation was, wind from 260 degrees at 7 knots, visibility 10 statute miles, scattered clouds at 4,000 feet, a broken cloud layer at 25,000 feet, temperature 75 degrees F, dew point temperature 51 degrees F, altimeter setting 30.17 inHg. The Tampa International Airport is located 6 NM northwest of the accident site. WRECKAGE AND IMPACT INFORMATION According to officials at the Tampa Police Department, the accident airplane was found submerged, in a shipping channel about one third of a mile east of the Peter O'Knight Airport, having sunk in Seddon Channel. The airplane was upright, in position 27 degrees, 54.543 North latitude, 082 degrees, 26.520 West longitude, in about 14 feet of water, oriented on about a northwest heading. The airplane was recovered about 4 hours after the accident, and after recovery from Tampa Bay, the NTSB examined the airplane on April 21 and 22, 2004, along with NTSB party representatives to the investigation, which included an FAA inspector, as well as persons from Lycoming Engines, and Cessna Aircraft Company. The airplane was intact and there was minimal structural damage. The Tampa Police Department divers reported that they had found the left door in the open position, and the right door was closed. Post-recovery examination showed no distortions to the cabin, and when both doors were tested, the interior right-side door handle was found to be loose, with that door disengaged intermittently when the handle was rotated. The handles were removed and the splines in the handle appeared to be worn. The pilot and passenger lap belts and shoulder harnesses were found intact, unlatched, and had remained connected to their attachment points. The seats were also intact and attached to the seat rails. During the cockpit examination, the landing gear lever was set to "Up", the flap indicator read 0, and the selector showed about 25 degrees, with both flaps being visibly up. The fuel selector valve was set to "Both", and the fuel boost pump was "Off." The cockpit flight control positions included the throttle being extended about 1 inch, the mixture and propeller controls being full in, and the cowl flaps being open. Gauge reading were as follows. The airspeed indicator showed 0 knots, the altimeter 240 feet, and the setting in the Kollsman window being 30.12 inches. The heading indicator read 300 degrees, the vertical speed indicator read plus 2,050; the turn coordinator was level and the ball in the center. No. 1 VOR's Omni Bearing Selector was set on 322 and No. 2's was 357. The communications/navigation radios were of a digital design, and No. 1 had been selected. The ADF was off and its frequency was 740. The transponder was set at 1200. The "Master" switch was set to "On", and the magneto switch was set to "Both." The Hobbs hour meter read 1,505.2, the tachometer read 0, the tachometer hour meter read 1016.82. The cylinder head temperature needle was pegged to the right of the gauge, and the oil temperature and pressure gauges, as well as EGT, suction and fuel flow gauges read 0. The main and nose landing gear were in the retracted position. The lower cowling exhibited some aft crushing, and the leading edge of the left stabilator was torn and the undersurface exhibited buckling. There was a diagonal crease that extended from about the mid section of the stabilator to the outboard aft tip. The right hand section of the right stabilator and the corresponding section of the trim tab exhibited signs of wrinkling. The stabilator structure was loose in the area of the tailcone, and the tailcone fairing was wrinkled. There was minimal damage associated with the ailerons, flaps, and rudder, and flight control surfaces had remained attached to the airframe. Control cable continuity was established to each of the flight control surfaces. The flap's jackscrew was extended 3.3 inches, consistent with the flaps being extended less than 10 degrees. When battery power was momentarily applied to test the flaps, they started to extend. Examination of the left and right wing fuel tanks revealed blue liquid about 1.25 inches from the tabs. Approximately four gallons of saltwater and 15 gallons of blue fuel were drained from the right wing, and no fuel was drained from the left fuel tank. An officer with the Tampa Police department stated that the fuel selector switch had been moved from "both" to "off" during recovery. When examined, fuel was observed to flow from the line from the fuel tanks to the fuel strainer when the fuel switch was in all positions other than the "Off" position. Water and some debris were found in the fuel ## Aircraft - Registration: [N1910Q](https://openairdocs.org/deregistered/N1910Q-2012-08-10), registration cancelled 2012-08-10, S/N 177RG0310, built 1972 (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: 177RG0310 - Airframe hours: 4269.12 - Engines: Lycoming IO-360-A1B6D 200 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Registered owner: Lawrence Soojin Koh - Airworthiness certificate: Standard, Normal - Last inspection: Annual, July 21, 2003, 174.77 hours before - Departed: PMP, Pompano Beach, FL - Destination: TPF, Tampa, FL - Airport: TPF, Peter O'Knight ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 44; injuries: fatal; private; airplane ratings: single-engine land; medical: class 3, valid medical--w/ waivers/lim; seat: left; toxicology performed; flight hours: 97 total, 15 in this make and model, 42 as pilot in command, 22 in the last 90 days, 3 in the last 30 days, 0 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 260° at 7 knots - Visibility: 10 statute miles - Lowest ceiling: 25,000 ft broken - Temperature: 75 °F, dew point 52 °F - Altimeter: 30.17 inHg - Observed at: TPA, 6 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 20040420007729A](https://openairdocs.org/incident/20040420007729A), Apr 20, 2004: Cessna 177RG, Tampa, FL, Substantial damage, 2 fatal. (-23) Pilot departed pompano beach airpark (pmp) pompano beach, FL at approximately 9:30 am enroute to Peter o'Knight airport (tpf) Tampa, FL. The pilot… ## Docket (26 files) The files NTSB released with the investigation on October 18, 2005, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=59101. 9.8 MB in all. - Witness Statements (item 1, .PDF, 272 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40410124&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - Map of Accident Site (item 2, .PDF, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40230615&FileExtension=.PDF&FileName=Map%20of%20Accident%20Site-Master.PDF - Excerpts of Lycoming Report (item 3, .PDF, 248 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40239574&FileExtension=.PDF&FileName=Excerpts%20of%20Lycoming%20Report-Redacted.PDF - Excerpts of Police Report (item 4, .PDF, 132 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40239581&FileExtension=.PDF&FileName=Excerpts%20of%20Police%20Report-Redacted.PDF - Excerpt of Cessna Report (item 5, .PDF, 295 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40239582&FileExtension=.PDF&FileName=Excerpt%20of%20Cessna%20Report-Master.PDF - Excerpts of TCM Recommended Maintenance for D-3000 Magnetos (item 6, .PDF, 104 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40239583&FileExtension=.PDF&FileName=Excerpts%20of%20TCM%20Recommended%20Maintenance%20for%20D-3000%20Magnetos-Master.PDF - TCM Report on Magneto Examination (item 7, .PDF, 133 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40239584&FileExtension=.PDF&FileName=TCM%20Report%20on%20Magneto%20Examination-Master.PDF - TCM Service Bulletin for Maintenance of Magnetos (item 8, .PDF, 87 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40239585&FileExtension=.PDF&FileName=TCM%20Service%20Bulletin%20for%20Maintenance%20of%20Magnetos-Master.PDF - Textron Lycoming Service Bulletin (item 9, .PDF, 57 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40239586&FileExtension=.PDF&FileName=Textron%20Lycoming%20Service%20Bulletin-Master.PDF - Bendix Service Bulletin for Maintenance of Fuel Injector System (item 10, .PDF, 29 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40239587&FileExtension=.PDF&FileName=Bendix%20Service%20Bulletin%20for%20Maintenance%20of%20Fuel%20Injector%20System-Master.PDF - Airframe Logbook photo 1 (item 11, .PDF, 186 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40239588&FileExtension=.PDF&FileName=Airframe%20Logbook%20photo%201-Master.PDF - Airframe Logbook photo 2 (item 12, .PDF, 229 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40239589&FileExtension=.PDF&FileName=Airframe%20Logbook%20photo%202-Master.PDF - Airframe Logbook photo 3 (item 13, .PDF, 238 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40239590&FileExtension=.PDF&FileName=Airframe%20Logbook%20photo%203-Master.PDF - Airframe Logbook photo 4 (item 14, .PDF, 230 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40239591&FileExtension=.PDF&FileName=Airframe%20Logbook%20photo%204-Master.PDF - Airframe Logbook photo 5 (item 15, .PDF, 221 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40239592&FileExtension=.PDF&FileName=Airframe%20Logbook%20photo%205-Master.PDF - Engine Logbook photo (item 16, .PDF, 241 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40239593&FileExtension=.PDF&FileName=Engine%20Logbook%20photo-Master.PDF - Propeller Logbook photo (item 17, .PDF, 182 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40239594&FileExtension=.PDF&FileName=Propeller%20Logbook%20photo-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 18, .PDF, 344 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40410121&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 19, .PDF, 94 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40410122&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Toxicological Report (item 20, .PDF, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40410120&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF - Photo 1: Recovery of N1910Q (item 21, .PDF, 478 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40239595&FileExtension=.PDF&FileName=Photo%201%3A%20Recovery%20of%20N1910Q-Master.PDF - Photo 2: Removal from water of N1910Q (item 22, .PDF, 472 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40239596&FileExtension=.PDF&FileName=Photo%202%3A%20Removal%20from%20water%20of%20N1910Q-Master.PDF - Photo 3: Right front of N1910Q (item 23, .PDF, 777 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40239597&FileExtension=.PDF&FileName=Photo%203%3A%20Right%20front%20of%20N1910Q-Master.PDF - Photo 4: Left side of N1910Q (item 24, .PDF, 761 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40239598&FileExtension=.PDF&FileName=Photo%204%3A%20Left%20side%20of%20N1910Q-Master.PDF - Photo 5: Engine Exam N1910Q (item 25, .PDF, 803 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40239599&FileExtension=.PDF&FileName=Photo%205%3A%20Engine%20Exam%20N1910Q-Master.PDF - Photo 6: Magneto Exam of N1910Q (item 26, .PDF, 415 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40239600&FileExtension=.PDF&FileName=Photo%206%3A%20Magneto%20Exam%20of%20N1910Q-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.