WPR24LA064

NTSB accident investigation · Diamond Aircraft Ind DA 40 · Spanish Fork, UT · December 21, 2023

Accident · No injuriesClass 3 · LimitedFinal report
Date
December 21, 2023, 16:53 local (23:53 UTC)
Place
Spanish Fork, UT · Airport
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N453DSDiamond Aircraft Ind DA 40
Defining event
Enroute: Powerplant sys/comp malf/fail
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
Lycoming Engines, Federal Aviation Administration
FAA report
20231221019699A
Case key
193572

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

Maintenance personnel’s improper installation of the left magneto, which resulted in oil starvation to the engine and a subsequent total loss of engine power.

Findings · 3

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.

Maintenance: installationPersonnel issues › Task performance · Maintenance personnelDiamond Aircraft Ind DA 40: 1 caseAll aircraft: 371 casesProbable cause
Fluids: oilAircraft › Fluids/misc hardware · Fluid levelDiamond Aircraft Ind DA 40: 1 caseAll aircraft: 174 casesProbable cause
Ignition system: magneto/distributorAircraft › Aircraft power plant · Incorrect service/maintenanceDiamond Aircraft Ind DA 40: 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 conducting a local flight when he heard a loud noise and saw objects eject from the engine area followed by a total loss of power. The pilot saw that the oil pressure had dropped to zero and the oil pressure alarm was sounding. He performed an emergency engine shutdown and made a forced landing at a nearby airport. During the descent smoke entered the cockpit, likely due to an inflight fire. During the landing roll, the nose gear collapsed as the airplane came to a stop on the runway. The two occupants egressed the airplane unassisted. The inflight fire thermally damaged the airframe from the engine back to the aft end of the cockpit. Postaccident examination revealed the left magneto mounting hardware had backed out on the studs, which allowed the magneto to separate from the mounting pad on the accessory case. The open magneto mounting pad allowed the engine oil to escape until the oil sump was depleted of oil. The engine damage that consisted of multiple large fractures to the engine cases, and extensive damage to the valvetrain and the rotating and reciprocating group, was consistent with lubrication deprivation. The magneto was installed on the engine the day before the accident and had accumulated about 5.6 hours of flight time between the installation and the accident. The pilot reported the oil level at preflight inspection to be just above the 6-quart line and did not observe the oil pressure out of the normal range during the flight before hearing the loud noise.

Factual narrative

On December 21, 2023, about 1653 mountain standard time, a Diamond Aircraft Industries DA 40, N453DS, was substantially damaged when it was involved in an accident near Spanish Fork, Utah. The pilot and passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, he and his brother departed Spanish Fork Municipal Airport (SPK) for a local flight that lasted about 36 minutes. While about 5 miles west of SPK, at an altitude of about 10,500 ft mean sea level (msl), they heard a loud sound and saw something depart through the top of the engine cowling. The engine began to run rough along with smoke emanating from the engine area. The pilot noticed that the oil pressure had dropped to zero and the audible oil pressure alarm had activated. The pilot turned the fuel selector valve to OFF, pulled the mixture to idle cutoff, and opened the window to remove thick smoke as they made an emergency descent. He stated that during the descent, sparks and pieces of metal were coming out of the engine cowling. The pilot configured the airplane for landing, and upon touchdown on runway 12, the nosewheel collapsed. The pilot and passenger exited the airplane unassisted. The pilot saw flames emanating from the airplane but elected not to try to put the fire out himself. A postaccident photo provided by the operator showed the entire engine and cabin area engulfed in flames, as shown in figure 1. Figure 1. N453DS on the runway at SPK. Source: operator. Examination of the engine revealed the engine case was fractured into multiple large sections, which exposed the internal components of the engine. The left magneto was not secured and had fallen from the magneto mounting pad (figure 2). The left magneto mounting hardware and hold-down clamps remained on the mounting studs but were near the ends of the studs with no stud threads exposed beyond the nuts. The magneto mounting flange and the magneto mounting pad for the left magneto did not exhibit damage that would have allowed the magneto to separate. Figure 2. Rear view of the engine showing the left magneto separated from the mounting pad. Further examination of the engine revealed damage to the valvetrain, including a fractured cam shaft. Damage to the rotating and reciprocating group included fractured connecting rods, scored and fractured pistons, and damage to all but one bearing journal, consistent with frictional forces from bearing surfaces in excessive, inadequately lubricated contact. Examination of the oil filter revealed metallic debris within the pleats of the filter that consisted of phosphor bronze material, which was consistent with the material used in bearings. Figure 3 shows the damage to the engine, as seen from the right side, after removal of the cylinders. Figure 3. Right-side view of the engine after cylinders were removed. According to the pilot, the oil level was just above the 6-quart line when he checked itduring the preflight inspection. The postaccident examination of the airframe revealed that the fire thermally damaged the airplane from the engine nacelle to the aft section of the cockpit and from the root of both wings outboard about 6 ft. Examination of the remaining airframe revealed no evidence of a mechanical malfunction or failure that would have precluded normal operation. Review of the maintenance logbooks revealed the left magneto was replaced on December 20, 2023; however, the writeup was incorrectly dated December 21, 2023. According to the Director of Maintenance, he replaced the left magneto on the day before the accident. He used new hardware and secured the hardware to the required torques. According to the operator, the airplane had flown about 4.9 hours with the new magneto. The pilot reported that the accident flight was about 36 minutes in duration.

Aircraft

Registration
N453DS
Reported as
Diamond Aircraft Ind DA 40
Category
Airplane
Serial number
40.1123
Built
2011
Airframe hours
1,866.8
Engine
Lycoming IO-360-M1A, 180 horsepower, reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Personal · Part 91
Operator
453ds Aircraft Leasing LLC
Registered owner
453ds Aircraft Leasing LLC
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · December 28, 2023 · 50 hours before
Destination
Same as departure
Airport
SPK · Spanish Fork Municipal Airport/Woodhouse Field, runway 12, 6,500 × 100 ft, asphalt
Equipment
Electronic primary flight display, Satellite tracking device, Stall warning system, ADS-B, Auto-pilot, Electronic multifunction display

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
24
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 1, Without waivers/limitations
Last flight review
September 14, 2023
Seat
Left
Restraint
3-point
Flight hours
147 total · 41 in this make and model · 92 as pilot in command · 73 in the last 90 days · 36 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
None
Temperature
46 °F, dew point 34 °F
Altimeter
30.19 inHg
Observed at
SPK

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.