# NTSB WPR12LA092: Piper PA-28R-201T, N38906, Kalispell, MT, February 4, 2012 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: February 4, 2012, 13:15 local (20:15 UTC) - Place: Kalispell, MT - Coordinates: 48.178611, -114.303611 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=48.1786&lon=-114.3036&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) - Highest injury: Minor injuries - Injuries: 3 minor - Status: Completed, report October 29, 2013 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Continental Motors Inc, Federal Aviation Adminstration, Piper Aircraft - NTSB case key (mKey): 82814 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR12LA092 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/82814/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=82814 - Page: https://openairdocs.org/ntsb/WPR12LA092 ## Probable cause The partial loss of engine power due to magneto malfunction. Contributing to the accident was the lack of adherence to the manufacturer’s recommended magneto overhaul schedule. ## 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: [Piper PA-28R-201T, 1 case](https://openairdocs.org/ntsb-findings/01057414/cases.md?model=7102813), [All aircraft, 101 cases](https://openairdocs.org/ntsb-findings/01057414/cases.md) - [Ignition system: magneto/distributor](https://openairdocs.org/ntsb-findings/01057414): Aircraft › Aircraft power plant · Not serviced/maintained (probable cause); cases with it: [Piper PA-28R-201T, 1 case](https://openairdocs.org/ntsb-findings/01057414/cases.md?model=7102813), [All aircraft, 101 cases](https://openairdocs.org/ntsb-findings/01057414/cases.md) - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Pilot; cases with it: [Piper PA-28R-201T, 1 case](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=7102813), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) (defining event); cases with it: [Piper PA-28R-201T, 3 cases](https://openairdocs.org/ntsb-events/342/sequence.md?model=7102813), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) - [Landing: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-28R-201T, 11 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102813), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis After takeoff, between 300 and 500 feet above ground level over a residential area, the airplane's engine started to sputter and lose power. The pilot selected the longest street on which to make a forced landing, lowered the flaps, and slowed the airplane to a minimum controllable airspeed. The airplane collided with a number of vehicles and trees, and, in the process, the left wing separated from the fuselage. The airplane rotated inverted and embedded itself into the front of a residential house. Postaccident examination and testing of the left magneto revealed that the magneto’s distributor block bushing was worn to an extent that it provided significant radial play between the bushing and distributor block. The bushing, which holds the distributor gear axle in place, would permit the distributor gear to intermittently disengage from the drive gear. Once the distributor gear had disengaged from the drive gear, the internal timing of the magneto would be off, which could disrupt the normal ignition sequence and operation of the engine. If the pilot had switched to the right magneto, engine power would have likely been restored. The most recent magneto overhaul was performed in 1989. The engine manufacturer recommends that magnetos be overhauled or replaced 5 years after the date of manufacture or last overhaul, or 4 years after the date placed in service, whichever occurs first, without regard to accumulated operating hours since new or last overhaul. ## Factual narrative HISTORY OF FLIGHT On February 4, 2012, at 1315 mountain standard time, a Piper PA-28R-201T, N38906, experienced a partial loss of engine power shortly after takeoff, at Kalispell City Airport, Kalispell, Montana. The pilot initiated a forced landing on a residential street where during the landing, the airplane collided with parked vehicles, and a residence. The airplane was registered to the pilot and was operated under the provisions of Title 14 Code of Federal Regulations Part 91. The commercial pilot and his two passengers received minor injuries, and the airplane was substantially damaged. Visual meteorological conditions prevailed, and no flight plan had been filed. The pilot stated to the National Transportation Safety Board investigator-in-charge (IIC) that he fueled the airplane with 45 gallons of AVGAS, taxied to pick up his passengers, and performed a complete engine run-up and preflight checks. During takeoff, the airplane behaved normally and accelerated smoothly. After takeoff, between 300 and 500 feet above ground level (agl) over a residential area, the airplane's engine started to sputter and lose power. The pilot selected the longest street on which he could make a forced landing. He lowered the flaps, and slowed the airplane to a minimum controllable airspeed. The airplane collided with a number of vehicles and trees, and in the process, the left wing separated from the fuselage. The airplane rotated inverted, and embedded itself into the front of a house. The pilot egressed through the pilot's side window, and he assisted with the egress of his passengers. AIRCRAFT INFORMATION The low-wing, four-seat, retractable landing gear airplane, serial number 28R-7703283, was manufactured in 1977. It was powered by a Continental Motors Incorporated (CMI) TSIO-360-F, serial number 305278, 200-hp engine, equipped with a Hartzell model BHC-C2YF-1BF constant speed propeller. A review of the airplane's maintenance records showed that an engine overhaul was completed on July 18, 1989. An annual inspection was completed on July 29, 2011, at a recorded tachometer (tach) time of 1,770.3 hours, and time since major overhaul (SMOH) of 322.3 hours. The tach time observed at the accident site was 1,772.65. Engine Roughness Procedure The Piper PA-28R-201T Cherokee Turbo Arrow III, Pilot Operating Handbook (POH) provides the following information concerning engine roughness. Mixture – adjust for max. smoothness Alternate Air – OPEN Fuel Selector- switch tanks Engine Gauges- check Magneto Switch- L then R then both “The magneto switch should then be moved to ‘L’ then ‘R’ then back to ‘BOTH.’ If operation is satisfactory on either magneto, proceed on that magneto at reduced power with full ‘RICH’ mixture to a landing at the first available airport. WRECKAGE AND IMPACT The main wreckage consisted of the fuselage, engine, tail, and right wing, which impacted a residence at ground level. The left wing had been sheared off at the wing root by a parkedpickup truck located approximately 50 yards further up the airplane's line of travel. Light blue colored fluid was observed leaking out of the severed wing. There was no post-accident fire. The engine and cockpit area of the airplane was embedded into the building structure. The following day, Sunday February 5th, the airplane was recovered and moved to a storage location in Belgrade, Montana. During the recovery, approximately 45 gallons of AVGAS was recovered from both wing tanks combined. On February 22, 2012, technical representatives from the airframe and engine manufacturer examined the airplane under the oversight of a Federal Aviation Administration (FAA) inspector. Both ailerons were attached to their respective wing, and control cables were attached to both the aileron bell cranks. The horizontal and vertical tail surfaces remained attached to the rear empennage section; the rudder and the stabilator remained attached. The fuel selector handle was in the left tank position; the throttle and mixture control levers were full forward. The AUX fuel pump switch was in the center OFF position. The auxiliary electric fuel pump was functionally tested by applying battery power to the airplane’s electrical system. The pump was found to function normally on both the low and high switch power settings, drawing in and discharging fuel. The fuel gascolator bowl was removed and bluish fluid consistent with AVGAS was observed. Engine power-train continuity was established by rotating the engine’s crankshaft. The engine driven fuel pump was removed, tested, and found to function normally. The magnetos remained attached to the engine and both produced spark at all of their ignition leads when the engine’s crankshaft was rotated by hand. The airframe manufacturer technical representative reported that the airframe revealed no pre-impact failure to any flight control surface or flight control system component. The engine manufacturer technical representative reported that the inspection of this engine did not reveal any anomalies that would have prevented its ability to produce rated horsepower. TESTS & RESEARCH Video A surveillance video camera mounted on an airport hangar captured the airplane’s takeoff departure path. The video shows an airplane immediately after takeoff moving at a constant altitude approximately 75 feet above ground level (agl) from right to left across the screen at a constant speed. Magneto Under the direction of the NTSB IIC, an Airframe & Powerplant (A&P) mechanic removed both magnetos from the engine on April 5, 2013. Both magnetos were Bendix model S6LN-25. On April 15, 2013, under the supervision of an FAA inspector, both magnetos were placed in a test fixture, and tested at normal operating speeds. The right magneto, serial number A186072, produced spark on all posts. The left magneto, serial number A186084, produced spark on one post. The A&P mechanic and FAA inspector disassembled the magneto (SN: A186084) and found a wornbushing. This magneto was then packaged, sent to the Analytical Department of Continental Motors, Inc. (CMI), and examined under the supervision of an NTSB investigator. CMI technical experts determined that the magneto’s distributor block bushing was worn to an extent that it provided significant radial play between the bushing and distributor block. The bushing, which holds the distributor gear axle in place, was worn to such an extent that it would permit the distributor gear to intermittently disengage from the drive gear. Once the distributor gear disengaged from the drive gear, the internal timing of the magneto would be off, which could disrupt the normal ignition sequence and operation of the engine. Review of the engine maintenance records showed that the magneto was last overhauled on July 18, 1989, and had accumulated 324.65 hours since overhaul. Review of the S-20 Series Magneto Service Support Manual showed CMI recommends magnetos be inspected after the first 500 hours in service and every 500 hours thereafter. In addition, magnetos should be overhauled or replaced 5 years after the date of manufacture or last overhaul, or 4 years after the date placed in service, whichever occurs first, without regard to accumulated operating hours since new or last overhaul. ## Aircraft - Registration: [N38906](https://openairdocs.org/deregistered/N38906-2013-03-07), registration cancelled 2013-03-07, S/N 28R-7703283, built 1977 (OpenAirDocs) - Reported make and model: PIPER PA-28R-201T - Registry model: [Piper PA-28R-201T](https://openairdocs.org/model/piper-pa-28r-201t) (registry code 7102813) (OpenAirDocs) - Registry engine: [Continental TSIO-360 series](https://openairdocs.org/engine/continental-tsio-360-series) (registry code 17019, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28R-7703283 - Airframe hours: 1770 - Engines: CONT MOTOR TSIO-360 SER 200 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Seaman Michael V - Registered owner: Seaman Michael V - Airworthiness certificate: Standard, Normal - Last inspection: Annual, July 29, 2011 - Departed: KS27, Kalispell, MT - Destination: K4U4, Chinook, MT - Airport: KS27, Kalispell City Airport, runway 31 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 50; injuries: minor; commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; seat: left; flight hours: 1,860 total, 1,000 in this make and model, 1,730 as pilot in command, 1 in the last 90 days, 0 in the last 30 days, 0 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: 1,800 ft overcast - Temperature: 30 °F, dew point 21 °F - Altimeter: 30.43 inHg - Observed at: KGPI, 8 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 20120204000939A](https://openairdocs.org/incident/20120204000939A), Feb 4, 2012: Piper PA-28R-201T, Kalispell, MT, Substantial damage. On February 4, 2012 N38906, registered to the pilot, [privacy data omitted] of Kalispell, Montana, took off from Kalispell city airport (S27) runway 31 with… ## Docket (14 files) The files NTSB released with the investigation on August 7, 2013, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=82814. 5.0 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 594 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40396821&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Witness Statement (item 2, .PDF, 147 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40396135&FileExtension=.PDF&FileName=Witness%20Statement-Redacted.PDF - Photo 1 - On scene photo showing airplane and house. (item 3, .PDF, 372 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40395405&FileExtension=.PDF&FileName=Photo%201%20-%20On%20scene%20photo%20showing%20airplane%20and%20house.-Master.PDF - Evidence Control Form (item 4, .PDF, 95 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40395406&FileExtension=.PDF&FileName=Evidence%20Control%20Form-Master.PDF - Reports from Parties to the Investigation - CMI Field Inspection Report (item 5, .PDF, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40395810&FileExtension=.PDF&FileName=Reports%20from%20Parties%20to%20the%20Investigation%20-%20CMI%20Field%20Inspection%20Report-Redacted.PDF - Reports from Parties to the Investigation - CMI Magneto Analytical Report (item 6, .PDF, 253 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40395408&FileExtension=.PDF&FileName=Reports%20from%20Parties%20to%20the%20Investigation%20-%20CMI%20Magneto%20Analytical%20Report-Master.PDF - S-20 Service Manual (extract) (item 7, .PDF, 176 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40395409&FileExtension=.PDF&FileName=S-20%20Service%20Manual%20(extract)-Master.PDF - FAA Video Email (item 8, .PDF, 159 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40395410&FileExtension=.PDF&FileName=FAA%20Video%20Email-Redacted.PDF - Record of Conversation with the Pilot (item 9, .PDF, 88 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40395411&FileExtension=.PDF&FileName=Record%20of%20Conversation%20with%20the%20Pilot-Redacted.PDF - Video File (item 10, .PDF, 42 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40396822&FileExtension=.PDF&FileName=Video%20File-Master.PDF - Engine Logbook (extract) (item 11, .PDF, 420 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40395412&FileExtension=.PDF&FileName=Engine%20Logbook%20(extract)-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 12, .PDF, 99 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40395414&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 13, .PDF, 326 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40395535&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Piper PA-28R-201T Emergency Procedures (extract) (item 14, .PDF, 81 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40396818&FileExtension=.PDF&FileName=Piper%20PA-28R-201T%20Emergency%20Procedures%20(extract)-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.