WPR09LA196

NTSB accident investigation · Cessna 152 · Glendale, AZ · April 15, 2009

Accident · Minor injuriesLimited investigationFinal report
Date
April 15, 2009, 10:00 local (17:00 UTC)
Place
Glendale, AZ
Injuries
2 minor
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N6285MCessna 152
Defining event
Approach: Powerplant sys/comp malf/fail
Weather
Visual (VMC) · Day
Status
Completed · report September 10, 2009
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration
FAA report
20090415004629A
Case key
73667

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The NTSB’s determination of the probable cause, and any contributing factors.

A loss of engine power due to the failure of both magnetos resulting from an improper maintenance repair by maintenance personnel.

Findings · 3

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings.

Analysis

The flight instructor and student were returning to the airport when the airplane's engine began running rough. The roughness became increasingly worse, and finally the engine "sputtered briefly" and lost power. The flight instructor was unable to restart the engine, and he initiated a forced landing onto a nearby grassy field. During the landing roll, the airplane impacted a chain link fence, resulting in structural damage to the right wing. During postaccident examination of the airplane, several attempts were made to start and run the engine; however, it would not start. The magnetos were removed from the engine and tested, and neither produced spark. Disassembly of the left magneto revealed the failure of the secondary coil. Disassembly of the right magneto revealed that the point gap was set incorrectly and that the lead connector from the magneto's coil to the points was loose. Review of maintenance records revealed that the magnetos were removed 3 tachometer hours prior to the accident; new points, capacitors, and gaskets were installed and the magnetos were reinstalled on the engine.

Factual narrative

The factual narrative490 words

On April 15, 2009, approximately 1000 mountain standard time, a Cessna 152, N6285M, sustained substantial damage when it impacted a fence during a forced landing in Glendale, Arizona. The flight instructor and his student pilot received minor injuries. Air Safety Flight Academy was operating the airplane under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed for the local instructional flight, which had originated from the Glendale Municipal Airport about 0830. A flight plan had not been filed. The flight instructor reported that he and the student pilot had completed a series of flight maneuvers. While returning to the airport, the engine began running rough. The flight instructor applied carburetor heat and slightly leaned the mixture, and the engine roughness stopped. As the airplane neared the airport, the engine again began running rough, and the roughness became "increasingly worse." The flight instructor applied carburetor heat and requested priority to land. Shortly after, the engine "sputtered briefly and died." The flight instructor was unable to restart the engine and initiated a forced landing onto a grassy field. During the landing roll, the airplane impacted a chain link fence. The right wing was bent and wrinkled, and the nose wheel was bent aft. The airplane was examined under the supervision of a Federal Aviation Administration (FAA) inspector. To facilitate an engine run, the propeller was replaced. Despite several attempts, the engine would not operate. The magnetos were removed for inspection. Both magneto impulse couplings were snapped several times and both magnetos failed to produce spark. Both magnetos were placed on a test stand and run at various speeds. Both magnetos failed to produce spark. Disassembly of the left magneto revealed that the condenser was within manufacturer limits, and the points were set correctly. The coil was inspected and tested, which revealed a complete failure of the secondary coil. The coil also displayed thermal discoloration near the rotating magnet. The right magneto was disassembled and inspected. The right magneto also displayed thermal discoloration, but to a lesser degree. The primary and secondary coils were tested and no anomalies were noted. The internal timing of the magneto was tested and revealed the "EGap" was set incorrectly. The points were off center and not opening completely. Further inspection revealed that the lead connector from the magneto's coil to the points was loose. After, the magneto was retimed to manufacturer's specifications and the lead reinstalled on the points, the magneto operated normally on the test stand. Review of the engine maintenance logbook revealed that on April 13, 2009, at a tachometer time of 3,107.5 hours, a 100-hour inspection was performed. Review of the company maintenance work order for the 100-hour inspection indicated that a 12-month magneto inspection was completed. The work orderindicated that "serviceable" magnetos with new contact points, capacitors, and gaskets were reinstalled. The FAA inspector reported that the tachometer reading at the time of the accident was 3,110.5 hours.

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident.

Aircraft

Registration
N6285M
Reported as
Cessna 152
Category
Airplane
Serial number
15284653
Airframe hours
13,841
Engine
Lycoming O-235 SERIES, 115 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
Air Safety Flight Academy
Registered owner
Christiansen Aviation Inc
Airworthiness certificate
Standard, Normal
Last inspection
Annual · April 13, 2009
Departed
GEU · Glendale, AZ
Destination
GEU · Glendale, AZ
Airport
GEU · Glendale Municipal

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Flight instructor
Age
28
Injuries
Minor
Certificates
Flight instructor, Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
February 4, 2009
Seat
Right
Flight hours
300 total · 75 in this make and model · 230 as pilot in command · 90 in the last 90 days · 40 in the last 30 days · 1 in the last 24 hours
Role
Student pilot
Age
24
Injuries
Minor
Certificate
Student
Medical
Class 1, Without waivers/limitations
Seat
Left
Flight hours
40 total · 40 in this make and model · 3 as pilot in command · 30 in the last 90 days · 15 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
200° at 9 knots
Visibility
20 statute miles
Lowest ceiling
5,000 ft broken
Temperature
59 °F, dew point 28 °F
Altimeter
29.81 inHg
Observed at
GEU, 1 nm away

Docket · 3

The files NTSB released with the investigation on July 21, 2009, on NTSB’s docket system: statements, records, photos and specialists’ reports. 852 KB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.