WPR19FA178

NTSB accident investigation · Maule M7-235B · Sunriver, OR · June 22, 2019

Accident · FatalClass 2 · FieldFinal report
Date
June 22, 2019, 10:40 local (17:40 UTC)
Place
Sunriver, OR
Injuries
1 fatal, 1 minor
Damage
Substantial damage
Phase of flight
Emergency descent
Aircraft
N118GMaule M7-235B
Defining event
Emergency descent: Landing gear not configured
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 2
NTSB office
Western Pacific Region
Parties
FAA Flight Standards District Office, Lycoming
FAA report
20190622007809A
Case key
99690

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

A partial loss of engine power due to the separation of baffling in both mufflers. Contributing to the accident was the pilot's failure to retract the landing gear on the float-equipped airplane before performing a forced landing to the river.

Findings · 4

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Engine exhaustAircraft › Aircraft power plant · Damaged/degradedMaule M-7-235B: 1 caseAll aircraft: 56 casesProbable cause
Action: forgotten action/omissionPersonnel issues › Action/decision · PilotMaule M-7-235B: 1 caseAll aircraft: 440 casesProbable cause
Landing gear system: wheel/ski/floatAircraft › Aircraft systems · Incorrect use/operationMaule M-7-235B: 1 caseAll aircraft: 48 casesProbable cause
Terrain: waterEnvironmental issues › Physical environment · Contributed to outcomeMaule M-7-235B: 1 caseAll aircraft: 97 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The pilot and passenger departed on a local flight in the amphibious airplane from a paved runway. The passenger described the airplane's rate of climb after takeoff as "slow" and stated that it was apparent that the airplane would not clear the 50-ft-tall trees ahead. A witness described the airplane as "struggling to gain altitude" and noticed a "definite power loss." The pilot performed a forced landing to a river, where the airplane immediately nosed over and began filling with water. The landing gear was found in the extended position and the water rudders were retracted. The landing gear position indicators were operational and also indicated that the landing gear was extended. The position of the landing gear likely resulted in the airplane nosing over upon impact with the water. Examination of the engine revealed that the muffler baffles had broken at the weld point. The left muffler baffling moved freely inside of the muffler. The right muffler baffling was turned 180° and was obstructing the exhaust outlet. A test run of the engine with the mufflers installed was unsuccessful; however, upon removal of the mufflers, the engine performed with no anomalies. There is no requirement to check the inside of a muffler during annual or 100-hour inspections to ensure that the baffling is intact. It could not be determined as to how long these mufflers had been in this condition. It is likely that the airflow restriction of the separated baffling resulted in a partial loss of engine power and the airplane's subsequent inability to climb after takeoff.

Factual narrative

The last maintenance performed was dated June 4, 2019, at a tachometer time of 967.7 hours. The exhaust system was sent for repairs during an annual inspection on June 22, 2011, at an airframe total time of 794.7 hours. On June 22, 2019, about 1040 Pacific daylight time, an amphibious Maule M-7-235B airplane, N118G, was substantially damaged when it was involved in an accident near Sunriver, Oregon. The pilot was fatally injured, and the pilot-rated passenger sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the passenger, the purpose of the flight was to see how the airplane performed with two people onboard. The pilot taxied the airplane to the runway, performed an engine run-up with no anomalies noted, and began the takeoff roll. The passenger stated that the throttle was full forward and the engine did not sound abnormal. He stated that the pilot rotated the airplane about 65 knots with about 1,000 ft of the 5,461-ft-long runway remaining, and the airplane lifted off the runway into ground effect. He recalled that once the airplane climbed out of ground effect, the rate of climb was slow, and it was apparent that they would not clear the 50-ft-tall trees across the river. The pilot maneuvered the airplane to the left, and the airplane touched down on the Deschutes River, nosed over, and began to fill with water. The passenger said that he was unaware that the river was the intended forced landing site until seconds before touchdown. Two witnesses who saw the takeoff described the airplane as low and struggling to gain altitude. One witness stated that the engine "sounded like the pilot had not throttled up enough or the engine was bogging for some reason." He stated that there was a "definite power loss" but no "engine sputter or misfire." The airplane turned slowly to the left, continued losing altitude, and cleared large trees lining the Deschutes River. The witness then heard a loud pop, saw the splash, and the tail "flip over." Another witness said that the airplane impacted the tops of the trees. An autopsy was performed by the Deschutes County Medical Examiner's Office. According to its report, the cause of death was drowning. A toxicology screen performed by FAA's Forensic Sciences laboratory detected no carboxyhemoglobin or ethanol in blood. Rosuvastatin was detected in blood and liver tissue; rosuvastatin is not impairing. The landing gear was found in the extended position. The water rudders were found in the retracted position. The pontoons (floats) were equipped with four visual landing gear position indicators. Each indicator was operational and indicated that the wheels were extended. Supplement 2 of the Maule Airplane Flight Manual stated, "Do not land on water unless the landing gear is fully retracted." The engine was examined following recovery from the river. During the first attempt to run the engine, the engine started but would notmaintain power. Examination of the mufflers revealed that the baffles had broken off at the weld point. The left muffler baffling moved freely inside of the muffler. The right muffler baffling was turned 180° and obstructed the outlet port. Both mufflers were removed, and the engine was restarted; the throttle was advanced to about 1,500 rpm. A magneto drop was conducted. A loss of about 100 rpm was noted when the magnetos were isolated. Power was then advanced to 2,400 rpm with no anomalies noted. Per the maintenance manual TLC-M-7-235A/B, rev. C, dated April 13, 2016, and Part 43, Appendix D, there is no requirement to check the inside of a muffler during annual or 100-hour inspections to ensure that the baffling is intact. How long the mufflers had been in this condition on the accident engine could not be determined.

Aircraft

Registration
N118G
Reported as
Maule M7-235B
Category
Airplane
Serial number
23025C
Built
1996
Airframe hours
953.7
Engine
Lycoming IO-540-W1A5, 235 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · December 7, 2018
Departed
S21 · Sunriver, OR
Destination
S21 · Sunriver, OR
Airport
S21 · Sunriver, runway 18, 5,461 × 75 ft, asphalt

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
Pilot
Age
63
Injuries
Fatal
Certificates
Airline transport, Commercial, Flight instructor
Airplane ratings
Single-engine sea, Multi-engine land, Single-engine land
Instrument ratings
Airplane, Helicopter
Medical
Class 3, With waivers/limitations
Last flight review
June 8, 2008
Seat
Left
Restraint
3-point
Toxicology
Performed
Flight hours
7,080 total · 73 in this make and model · 15 in the last 90 days · 10 in the last 30 days
Role
Pilot-rated passenger
Age
69
Injuries
Minor
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Without waivers/limitations
Last flight review
March 15, 2019
Seat
Right
Restraint
3-point
Flight hours
1,600 total · 155 in this make and model · 25 in the last 90 days

Weather

Conditions
Visual (VMC) · Day
Wind
360° at 6 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
61 °F, dew point 37 °F
Altimeter
30.12 inHg
Observed at
KBDN, 18 nm away

Docket · 10

The files NTSB released with the investigation on September 24, 2020, on NTSB’s docket system: statements, records, photos and specialists’ reports. 4.6 MB 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.