WPR23LA307

NTSB accident investigation · Boeing A75N1(PT17) · Red Lodge, MT · August 8, 2023

Accident · No injuriesClass 3 · LimitedFinal report
Date
August 8, 2023, 09:00 local (15:00 UTC)
Place
Red Lodge, MT · 59068
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N56907Boeing A75N1(PT17)
Defining event
Takeoff: Loss of engine power (partial)
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration
FAA report
20230808020879A
Case key
192826

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 during the initial climb out due to improper maintenance of the magneto.

Findings · 1

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.

Ignition system: magneto/distributorAircraft › Aircraft power plant · Incorrect service/maintenanceBoeing A75N1(PT17): 1 caseAll aircraft: 101 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 was departing the airport with a passenger for a local flight when the accident occurred. After takeoff, and as the airplane was crossing a steep drop off in terrain, it began to descend. The pilot verified that the throttle and mixture were full forward, and ensured the ignition switch and fuel selector were both on. He did not detect a reduction in engine speed but did not check the engine tachometer. The airplane continued to descend until it impacted trees, nosed over, and came to rest in the trees, which substantially damaged the wings and the left horizontal stabilizer. Postaccident examination revealed that one set of magneto points did not open and close when the magneto drive was rotated. Further examination revealed that there was an incorrect P-lead spring installed in the advance-side coil area. The screws that hold the advance-side coil in place were loose, but the yellow tamper indicator was still intact. When placed on a test bench the retard-side points did not begin firing until 400 to 500 rpm, when they should have begun firing at 280 rpm. The advance-side points did not fire at all, and the advance-side condenser did not function. The advance-side timing was so far off that it could not be properly measured, and the retard-side timing was about 3° off proper timing. Examination of the ignition harness revealed three of the nine leads from the left-hand harness did not pass a continuity test when the leads were attached to the distributor but passed when disconnected from the distributor. The last 100-hour inspection occurred on November 2, 2022, at an airframe time of 559.47 hours, and included checking the timing of the magneto. No anomalies were noted in the maintenance records. Given the improper maintenance to the magneto, it is likely that the engine ignition system did not provide adequate spark at the correct timing, which resulted in a partial loss of power and subsequent descent into terrain.

Factual narrative

On August 8, 2023, about 0900 mountain daylight time, a Boeing A75N1 airplane, N56907, was substantially damaged when it was involved in an accident near Red Lodge, Montana. The pilot and passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that he and a passenger departed runway 16 at the Red Lodge Airport (RED), Red Lodge, Montana. As the airplane crossed over a cliff line, described as a “steep hill about 200 ft,” it began to descend. The pilot did not detect an audible decrease in engine rpm and did not look at the engine tachometer. He checked that the throttle and mixture were full forward, the ignition switch was on both, and the fuel was on. The airplane continued to descend and subsequently impacted trees. A witness, located about 1 mile away, reported the airplane stopped climbing and descended, hit trees, then nosed over. The airplane came to rest upright in trees, positioned in a nose-low attitude, which substantially damaged the upper and lower wings and the left horizontal stabilizer. Recovery efforts resulted in additional damage to the airplane. The pilot reported that at the time of departure the temperature was about 60°F and the wind was from the south-southeast at about 4 knots. Postaccident examination of the engine revealed no spark to any of the spark plug leads. The engine was equipped with a Bendix-Scintilla magneto with dual mechanical points. When the magneto drive was rotated, only one set of points opened. The magneto was shipped to a facility that catered to radial engine magnetos for further examination. The components of the magneto were identified as belonging to the advance-side or retard-side of the magneto. Examination of the magneto revealed that the retard points had a coat of grease or oil burned onto them, but the points themselves were not burned. The screws that held the advance points in place were loose, which caused the advance-side points to back away from the cam and not open. The yellow tamper indicator was still intact but fell off when the screw was tightened before the bench test run. Figure 1o is a view of the magneto and the dual points configuration. Figure 1. Bendix-Scintilla Magneto with dual points. Upon removal of the advance-side coil cover, a P-lead spring fell out. Examination of this spring indicated that it was not the correct part and appeared to be modified to fit the magneto. A test run of the magneto revealed that the retard-side points began firing at 400 to 500 rpm. According to the maintenance manual, the points should begin firing consistently at 280 rpm. The advance-side points did not fire at all but should have fired at 180 rpm. Both coils were removed and checked to be operating within tolerance. The advance-side condenser was checked and was not functional. The retard-side condenser was checked and found to be functional. The magneto drive was placed on a timing wheel to check forinternal timing. Examination revealed the advance-side timing was so far off that it could not be properly measured. The retard-side timing was dependent on correct advance-side timing, so as a control, the advance-side was timed properly, and the retard-side timing was then checked. The retard-side timing was found to be 7.5° from the advance-side timing. The correct timing was 4.5° from the advance-side timing for this model of magneto. Examination of the distributor and spark plug wires revealed no anomalies from the right-hand side. The left-hand side exhibited three spark plug wires with no continuity from the distributor to the end of the plug wire. The spark plug wires were then removed from the distributor and continuity was subsequently verified. A review of the maintenance logbook revealed that the last 100-hour inspection occurred on November 2, 2022, at an airframe time of 559.47 hours, and included checking the timing of the magneto. No anomalies were noted in the maintenance records.

Aircraft

Registration
N56907
Reported as
Boeing A75N1(PT17)
Category
Airplane
Serial number
75-1676
Built
1941
Airframe hours
599.47
Engine
Lycoming R680-17, 225 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · November 2, 2022
Airport
RED · Red Lodge Municipal Airport, runway 16, 4,000 × 75 ft, asphalt
Equipment
None

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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
76
Injuries
None
Certificate
Private
Airplane ratings
Multi-engine land, Single-engine land
Medical
Class 3, Without waivers/limitations
Last flight review
June 30, 2022
Seat
Rear
Restraint
4-point
Flight hours
1,820 total · 665 in this make and model · 1,740 as pilot in command · 8 in the last 90 days · 2 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
150° at 5 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
66 °F, dew point 46 °F
Altimeter
30.05 inHg
Observed at
KPOY, 27 nm away
METAR
KPOY 081735Z AUTO 15005KT 10SM CLR 19/08 A3005 RMK AO2

Docket · 8

The files NTSB released with the investigation on February 20, 2025, on NTSB’s docket system: statements, records, photos and specialists’ reports. 26.7 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.