# NTSB WPR09LA196: Cessna 152, N6285M, Glendale, AZ, April 15, 2009 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: April 15, 2009, 10:00 local (17:00 UTC) - Place: Glendale, AZ - Coordinates: 33.506942, -112.288055 - Nearby events: https://openairdocs.org/map.md?lat=33.5069&lon=-112.2881&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340) - Highest injury: Minor injuries - Injuries: 2 minor - Status: Completed, report September 10, 2009 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 73667 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR09LA196 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/73667/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=73667 - Page: https://openairdocs.org/ntsb/WPR09LA196 ## Probable cause A loss of engine power due to the failure of both magnetos resulting from an improper maintenance repair by maintenance personnel. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Ignition system: magneto/distributor](https://openairdocs.org/ntsb-findings/01057414): Aircraft › Aircraft power plant · Malfunction (probable cause); cases with it: [Cessna 152, 4 cases](https://openairdocs.org/ntsb-findings/01057414/cases.md?model=2071835), [All aircraft, 101 cases](https://openairdocs.org/ntsb-findings/01057414/cases.md) - [Maintenance: repair](https://openairdocs.org/ntsb-findings/02062015): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Cessna 152, 4 cases](https://openairdocs.org/ntsb-findings/02062015/cases.md?model=2071835), [All aircraft, 99 cases](https://openairdocs.org/ntsb-findings/02062015/cases.md) - [Ignition system: magneto/distributor](https://openairdocs.org/ntsb-findings/01057414): Aircraft › Aircraft power plant · Incorrect service/maintenance (probable cause); cases with it: [Cessna 152, 4 cases](https://openairdocs.org/ntsb-findings/01057414/cases.md?model=2071835), [All aircraft, 101 cases](https://openairdocs.org/ntsb-findings/01057414/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Aircraft maintenance event](https://openairdocs.org/ntsb-events/040); cases with it: [Cessna 152, 4 cases](https://openairdocs.org/ntsb-events/040/sequence.md?model=2071835), [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md) - [Approach: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340) (defining event); cases with it: [Cessna 152, 6 cases](https://openairdocs.org/ntsb-events/340/sequence.md?model=2071835), [All aircraft, 820 cases](https://openairdocs.org/ntsb-events/340/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Cessna 152, 35 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=2071835), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) ## 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 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. ## Aircraft - Registration: [N6285M](https://openairdocs.org/deregistered/N6285M-2009-05-15), registration cancelled 2009-05-15, S/N 15284653, built 1980 (OpenAirDocs) - Reported make and model: CESSNA 152 - Registry model: [Cessna 152](https://openairdocs.org/model/cessna-152) (registry code 2071835) (OpenAirDocs) - Registry engine: [Lycoming 0-235 series](https://openairdocs.org/engine/lycoming-0-235-series) (registry code 41505, 4 cycle) (OpenAirDocs) - Category: Airplane - Serial number: 15284653 - Airframe hours: 13841 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 28; injuries: minor; 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 - Student pilot; age 24; injuries: minor; 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 ## 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 20090415004629A](https://openairdocs.org/incident/20090415004629A), Apr 15, 2009: Cessna 152, Phoenix, AZ, Substantial damage. (-23) While enroute to geu the aircraft experienced a complete loss of engine power. The instructor on board was unable to restart the engine and made an… ## Docket (3 files) The files NTSB released with the investigation on July 21, 2009, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=73667. 852 KB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 617 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40315897&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - FAA Inspector Statement (item 2, .PDF, 125 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40315899&FileExtension=.PDF&FileName=FAA%20Inspector%20Statement-Master.PDF - Excerpts from Aircraft Maintenance Records (item 3, .PDF, 110 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40315903&FileExtension=.PDF&FileName=Excerpts%20from%20Aircraft%20Maintenance%20Records-Redacted.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.