Aviation Accident Summaries

Aviation Accident Summary ERA13LA025

Allentown, PA, USA

Aircraft #1

N15037

PIPER PA-28-140

Analysis

During the initial climb, the engine lost partial power, and the flight instructor performed a forced landing into a cornfield. During a subsequent test-run of the engine, the engine would lose all power if only the right magneto was selected. Laboratory examination of the right magneto revealed that seven teeth from its drive gear were fractured and exhibited single-sided bending fatigue, consistent with applied force in one direction over a period of time. At the time of the accident, the engine had accumulated about 2,300 hours since overhaul, which had been completed about 7 years prior. The accident magnetos had not been replaced or serviced since they were installed during engine overhaul. The engine manufacturer recommended overhauling the engine every 2,000 hours or 12 years, which would have included replacing the magnetos with new or overhauled units. Additionally, a service bulletin issued by the magneto manufacturer recommended inspecting the magnetos every 500 hours; however, there was no evidence that an inspection was ever performed during the 2,300-hour life of the failed magneto.

Factual Information

On October 12, 2012, about 1835 eastern daylight time, a Piper PA-28-140, N15037, operated by Ace Pilot Training Inc., was substantially damaged during a forced landing to a corn field, following a partial loss of engine power during initial climb from Lehigh Valley International Airport (ABE), Allentown, Pennsylvania. The certified flight instructor (CFI) and private pilot were not injured. The instructional flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and no flight plan was filed for the planned local flight. The CFI stated that the airplane was fueled to 36 gallons prior to the flight. The engine start-up, taxi, and run-up were normal. While departing from runway 31, about 200 feet above ground level, the CFI noticed that the throttle lever did not appear to be completely forward. He and the private pilot pushed the throttle lever full forward with resistance, which was followed by engine sputtering. The CFI then applied carburetor heat; however, the engine continued to sputter. He then elected to land in a corn field. During the landing, the engine firewall and right aileron were substantially damaged. Examination of the wreckage by a Federal Aviation Administration (FAA) inspector revealed that the No. 2 top sparkplug, No. 3 bottom sparkplug, and No. 3 top sparkplug were "fouled." During a subsequent test-run of the engine, the engine lost all power whenever the right magneto was selected. Both magnetos were retained and forwarded to the NTSB Materials Laboratory, Washington, DC. Laboratory examination of the right magneto revealed that seven teeth from its drive gear were fractured and exhibited single-sided bending fatigue, consistent with applied force in one direction over a period of time. Examination of the left magneto revealed a loose drive gear with teeth worn along the top corner. The drive gear had not been fully seated on the drive shaft and was removed by hand. Additionally, the point cam was not fully installed and seated in the bottom of its slot and exhibited a wear scar where the cam contacted the points. The mis-installed cam prevented full seating of the drive gear onto the drive shaft. When the distributor cap was installed, the top corner of the drive gear contacted the distributor housing. When in operation, the wobbling action of the drive gear resulted in wear of the drive gear teeth; however, the mis-installation did not appear to prevent the left magneto from operating in its current condition (for more information, see Materials Laboratory Factual Report in the public docket). The airplane was manufactured in 1972 and equipped with a Lycoming O-320-E3D, 150-horsepower engine. According to maintenance records and an FAA inspector, the airplane's most recent annual inspection was completed on August 22, 2012. The engine's most recent overhaul was completed on June 27, 2005. At the time of the accident, the engine had accumulated approximately 72 hours since the annual inspection and 2,300 hours since overhaul. The FAA inspector further reviewed the maintenance records and noted that the accident magnetos (Unison [Slick] model 4370 right, and model 4371 left) were installed at overhaul and had not been replaced or serviced during the time since overhaul. Additionally, when the inspector attempted to disassemble the magnetos for examination, he had to remove inspector's lacquer (yellow paint) from screw holes, which was also consistent with the magnetos never having been disassembled for inspection since overhaul. The engine manufacturer recommended overhauling the engine every 2,000 hours or 12 years, which would have included replacing the magnetos with new or overhauled units. Additionally, Slick service bulletin (SB-308A) recommended inspecting the magnetos every 500 hours.

Probable Cause and Findings

The operator's failure to perform magneto inspections per the manufacturer's recommendations and failure to comply with the engine manufacturer's recommended time interval for engine overhaul, which resulted in defects in the magnetos going undetected and the failure of the right magneto during initial climb.

 

Source: NTSB Aviation Accident Database

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