NTSB Identification: CHI05LA226.
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Accident occurred Wednesday, August 10, 2005 in Culver, IN
Probable Cause Approval Date: 07/25/2007
Aircraft: Piper PA-28-161, registration: N4512Q
Injuries: 2 Fatal.
NTSB investigators may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.
The airplane was being operated as part of a school's aviation program with a flight instructor and student pilot. Shortly after takeoff, the airplane lost engine power and impacted a lake. Witnesses reported that the engine was sputtering, a momentary restart was performed, and a loss of engine power ensued while the airplane was maneuvering at an altitude of approximately 150-200 feet above ground level. Both wings had leading edge crushing and vertical separation from the fuselage consistent with a low-speed shallow pitch impact attitude. The propeller did not display signs of bending or twisting. The flaps were in a retracted position, and cockpit switches were in positions contrary to that called for in the emergency landing procedures checklist for the airplane. Examination of the engine ignition system revealed that the left magneto timing was approximately 30-35 degrees before top dead center, and the impulse coupling was unwound. An annual inspection of the airplane was completed on the day of the accident. Engine logbook records for the airplane shows an entry dated August 9, 2004, that states, "changed left magneto with new magneto model number 4371." There was no annotation as to the serial number of the left magneto, and no further entries within the engine logbook for overhaul of either magneto. There was no serviceable tag for the left magneto associated with its replacement. At the time of the annual inspection, the left magneto had accumulated a total time of 406 hours, and the right magneto had accumulated a total time of 1,429 hours since last overhaul based on logbook entries. According to the magneto manufacturer’s service bulletin, these magnetos are to be overhauled every 500 hours. Inspection of the remaining airplanes used in the school's aviation program revealed numerous maintenance related discrepancies, including the use of unairworthy parts. Upon recovery of the airplane, it was noted that the entry door was in the latched closed position.
The National Transportation Safety Board determines the probable cause(s) of this accident to be: The loss of engine power while maneuvering due to partial failure of the left magneto, and the flight instructor's failure to maintain sufficient airspeed to avoid a stall. An additional cause was improper maintenance by company maintenance personnel, resulting in the failure of the left magneto. Factors associated with the accident are the instructor's inadvertent stall, his failure to follow established emergency procedures, and the inadequate surveillance of the operation by company management. Full narrative available
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