# NTSB WPR19FA178: Maule M7-235B, N118G, Sunriver, OR, June 22, 2019 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 2 · Field · Final report - Date: June 22, 2019, 10:40 local (17:40 UTC) - Place: Sunriver, OR - Coordinates: 43.864444, -121.455001 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=43.8644&lon=-121.4550&mi=10 - Phase of flight: [Emergency descent](https://openairdocs.org/ntsb-phases/600) (OpenAirDocs' grouping) - Defining event: [Emergency descent: Landing gear not configured](https://openairdocs.org/ntsb-events/095) - Highest injury: Fatal - Injuries: 1 fatal, 1 minor - Status: Completed - Report: Approved by Office Director - Investigation class: Class 2 - NTSB office: Western Pacific Region - Parties: FAA Flight Standards District Office, Lycoming - NTSB case key (mKey): 99690 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR19FA178 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99690/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99690 - Page: https://openairdocs.org/ntsb/WPR19FA178 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Engine exhaust](https://openairdocs.org/ntsb-findings/01057800): Aircraft › Aircraft power plant · Damaged/degraded (probable cause); cases with it: [Maule M-7-235B, 1 case](https://openairdocs.org/ntsb-findings/01057800/cases.md?model=5460109), [All aircraft, 56 cases](https://openairdocs.org/ntsb-findings/01057800/cases.md) - [Action: forgotten action/omission](https://openairdocs.org/ntsb-findings/02041035): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Maule M-7-235B, 1 case](https://openairdocs.org/ntsb-findings/02041035/cases.md?model=5460109), [All aircraft, 440 cases](https://openairdocs.org/ntsb-findings/02041035/cases.md) - [Landing gear system: wheel/ski/float](https://openairdocs.org/ntsb-findings/01023246): Aircraft › Aircraft systems · Incorrect use/operation (probable cause); cases with it: [Maule M-7-235B, 1 case](https://openairdocs.org/ntsb-findings/01023246/cases.md?model=5460109), [All aircraft, 48 cases](https://openairdocs.org/ntsb-findings/01023246/cases.md) - [Terrain: water](https://openairdocs.org/ntsb-findings/03021020): Environmental issues › Physical environment · Contributed to outcome (probable cause); cases with it: [Maule M-7-235B, 1 case](https://openairdocs.org/ntsb-findings/03021020/cases.md?model=5460109), [All aircraft, 97 cases](https://openairdocs.org/ntsb-findings/03021020/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); cases with it: [Maule M-7-235B, 1 case](https://openairdocs.org/ntsb-events/342/sequence.md?model=5460109), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) - [Emergency descent: Landing gear not configured](https://openairdocs.org/ntsb-events/095) (defining event); cases with it: [Maule M-7-235B, 1 case](https://openairdocs.org/ntsb-events/095/sequence.md?model=5460109), [All aircraft, 584 cases](https://openairdocs.org/ntsb-events/095/sequence.md) - [Landing: Nose over/nose down](https://openairdocs.org/ntsb-events/096); cases with it: [Maule M-7-235B, 5 cases](https://openairdocs.org/ntsb-events/096/sequence.md?model=5460109), [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md) ## 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](https://openairdocs.org/aircraft/N118G), registered now, S/N 23025C, built 1996 (OpenAirDocs) - Reported make and model: Maule M7-235B - Registry model: [Maule M-7-235B](https://openairdocs.org/model/maule-m-7-235b) (registry code 5460109) (OpenAirDocs) - Registry engine: [Lycoming IO-540 series](https://openairdocs.org/engine/lycoming-io-540-series) (registry code 41530, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 23025C - Year built: 1996 - Airframe hours: 953.7 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 63; injuries: fatal; 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 - Pilot-rated passenger; age 69; injuries: minor; 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 ## 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 20190622007809A](https://openairdocs.org/incident/20190622007809A), Jun 22, 2019: Maule M-7-235B, Sunriver, OR, Substantial damage, 1 fatal. Arrived on scene approx. 1930 local. Located deputy who was securing scene. Observed aircraft in the river floats up with amphibious wheels extended. Aircraft… ## Docket (10 files) The files NTSB released with the investigation on September 24, 2020, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99690. 4.6 MB in all. - Passenger's Statement (item 1, .PDF, 190 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40487210&FileExtension=.PDF&FileName=Passenger%27s%20Statement-Master.PDF - Witness' Statements (item 2, .PDF, 135 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40487211&FileExtension=.PDF&FileName=Witness%27%20Statements-Master.PDF - FAA Inspector's Statement (item 3, .PDF, 160 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40487212&FileExtension=.PDF&FileName=FAA%20Inspector%27s%20Statement-Master.PDF - Engine Examination (item 4, .PDF, 668 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40487213&FileExtension=.PDF&FileName=Engine%20Examination-Master.PDF - Maule AFM Supplement 2 (item 5, .PDF, 96 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40487214&FileExtension=.PDF&FileName=Maule%20AFM%20Supplement%202-Master.PDF - Letter from Viper Aviation (item 6, .PDF, 102 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40487215&FileExtension=.PDF&FileName=Letter%20from%20Viper%20Aviation-Master.PDF - Certification of Party Representative (item 7, .PDF, 107 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40487216&FileExtension=.PDF&FileName=Certification%20of%20Party%20Representative-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 8, .PDF, 258 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40487217&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Master.PDF - Toxicology Report (item 9, .PDF, 297 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40487218&FileExtension=.PDF&FileName=Toxicology%20Report-Master.PDF - Accident Report Photographs (item 10, .PDF, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40487219&FileExtension=.PDF&FileName=Accident%20Report%20Photographs-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.