Culver, IN, USA
N4512Q
Piper PA-28-161
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.
HISTORY OF FLIGHT On August 10, 2005, at 1420 eastern standard time, a Piper PA-28-161, N4512Q, operated by Culver Educational Foundation, received substantial damage on impact with Lake Maxinkuckee after takeoff from runway 26 (2,500 feet by 200 feet, grass) at Fleet Field Airport (IN73), Culver, Indiana. The airplane was reported to have experienced a loss of engine power. Visual meteorological conditions prevailed at the time of the accident. The 14 CFR Part 91 instructional flight was not operating on a flight plan. The certified flight instructor (CFI) and student pilot were fatally injured. The local flight was originating at the time of the accident. A witness, the pilot of N767PP stated that he was preparing to takeoff on runway 26 when saw N4512Q begin and perform a takeoff roll on runway 26. He then "looked again" and saw N4512Q pitch up and bank left. He then lost sight of the airplane when he positioned N767PP for takeoff. A second witness who was the fourth airplane in sequence to takeoff stated he watched N4512Q takeoff from runway 26 but from his viewpoint he was unable to see the climbout due to trees that were obstructing his view. He stated that he did not hear or see anything during the runup or takeoff roll of N4512Q that indicated "distress." A third witness stated that he observed the airplane flying very low over a bluff located on the east side of the lake. He stated that he heard the airplane sputtering and it landed belly first into the water and then barrel rolled over. A fourth witness stated that he heard the engine sputter as it came over the bluff. He stated the airplane "cut back" as it came over a tree line along the bluff and then began flying over water. He stated that the airplane was heading in a southerly direction when it came nose down into the water. A fifth witness stated she did not hear engine noise from the airplane and it glided in at "low level". According to the Marshall County Police Report, the witness stated that the airplane was heading towards what she believed was towards the south or a southerly direction when it crashed. The airplane was afloat for approximately 2 minutes before it sank nose first. A sixth witness stated the he heard a "loud" crash when he had just started a lawn mower to mow his front lawn, about 25 feet from the lake. He looked up and saw an airplane about 150-200 feet out in the lake directly in front of his pier. The airplane was nose down in the water and sank within 2-3 minutes. A fishing boat and a Culver Education Foundation boat were at the site within 5 minutes, but they could not get into the airplane. According to Federal Aviation Administration (FAA) inspectors, a seventh witness located on a golf course stated that he heard attempted restarts from the airplane. The airplane momentarily restarted when it was over the tree line heading south along the shore line. PERSONNEL INFORMATION The CFI accumulated a total flight time of 493 hours of which 127 hours were in the accident airplane make and model and 130 hours in the last 90 days. He held a commercial pilot certificate with airplane single-engine land, airplane multiengine land, and instrument airplane ratings. The student pilot was issued a medical certificate on August 29, 2002. AIRCRAFT INFORMATION The 1979 Piper PA-28-161, serial number (S/N) 28-8016019, was registered to Culver Educational Foundation on June 14, 1999, and operated as an instructional airplane in Culver Educational Foundation's aviation program. A logbook entry dated August 10, 2005, states that an annual inspection of the airplane was competed on this date at a total time of 5,432 hours and a tachometer time of 1,061 hours. The airplane was powered by Lycoming O-320-D3G, S/N L-12152-39A, engine that received a major overhaul on March 13, 2001, and was installed in the airplane on March 20, 2001, at a tachometer time of 1,699.0 hours. On July 4, 2002, the tachometer was removed at 2,040 hours and replaced with a new tachometer indicating 0.0 hours. 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 within maintenance records that were requested by and presented to FAA inspectors for the left magneto referenced in the August 9, 2004, entry. At the time of the annual inspection, the left magneto accumulated a total time of 406 hours and the right magneto accumulated a total time of 1,429 hours since last overhaul based on logbook entries. A CFI who had flown N4512Q the day before the accident and prior to closing the airport stated that the airplane was in "good" flying condition with "no problems or concerns." METEOROLOGICAL INFORMATION The Warsaw, Indiana, Automated Weather Observing System (AWOS), located approximately 25 nautical miles east of IN73, recorded at 1345: wind 290 degrees at 10 knots, visibility 10 statute miles, sky conditions broken 7,000 feet above ground level; temperature 31 degrees Celsius (C), dew point 19 degrees C. The witness that departed after N4512Q's departure, stated they were using runway 26 in "light" winds, temperature was in the mid 80s and the clouds were scattered "several" thousand feet AGL. The second witness stated that the wind was less the 10 knots down the runway, and the temperature was probably in the upper 80s. WRECKAGE AND IMPACT INFORMATION The airplane impacted Lake Maxinkuckee in 6.2 feet of water at Global Positioning System coordinates: 41 degrees 12.960 seconds North and 86 degrees 23.829 seconds West. The airplane was resting upside down with its landing gear wheels extending above the water surface. Both wings exhibited separation near the wing root in the vertical or upwards direction with both wings displaying leading edge crushing. The left wing exhibited greater relative damage than the right wing. The left fuel tank was broken open and the fuel cap was intact. The right wing displayed inward leading edge crushing about 6 feet from the wing root and its landing gear was folded into the wing. The right fuel tank was not broken open and did not contain fuel. The right fuel tank cap was intact. Examination of the flight control system revealed that all control surfaces were attached to their respective wings and stabilizers. Flight control continuity was confirmed from all control surfaces to their respective cockpit controls. The tabulator trim drum inner shaft exhibited 8 treads of upper extension, which equates to approximately 3 degrees of nose-up trim. The fuel selector control handle and valve were positioned to the right tank with no noted obstruction within the selector valve upon its disassembly. The master switch was in the on position. The auxiliary electric fuel pump switch was in the on position and a sound consistent with the pump's operation was heard when the wreckage was recovered. The magneto/starter switch was in the on position and no anomalies were noted with the switch. The carburetor heat control was in the off position. The throttle and mixture controls were in the full forward position. The elevator and rudder trim cockpit indicators were in the near neutral position. The gascolator displayed impact damage and contained vegetation consistent with aquatic vegetation. The filer element within the bowl did not contain blockage. The electric boost pump filter element contained a substance consistent with that of the lake bottom. The left magneto, Slick model 4371, S/N 03070194, timing was approximately 30-35 degrees before top dead center (the engine data tag indicated that the spark advance is 25 degrees). The left magneto impulse coupling could not be operated. The right magneto, Slick model 4370, S/N 01010500, was within ignition timing specifications. The propeller blades did not display damage resulting from the accident. The tachometer indicated 1,063.3 hours. The Hobbs meter indicated 3,400.9 hours. MEDICAL AND PATHOLOGICAL INFORMATION FAA toxicological test results for the CFI and student pilot were negative for all substances tested. Autopsies of the CFI and student were conducted by the Marshal County Coroner on August 10, 2005. The cause of death for the student pilot and CFI was listed as "drowning, blunt force injuries; chemical burns." FIRE There was no evidence of smoke or fire. SURVIVAL ASPECTS The water temperature was recorded by a Conservation officer as 85.5 degrees Farenheight. Upon recovery of the airplane, the cabin and baggage doors were in the latched closed position. The airplane was equipped with seat belts and shoulder harnesses and were attached to the airframe and were buckled. Both front seats were attached to the seat tracks and were not deformed. The student pilot and CFI were in the rear cabin area. TEST AND RESEARCH The FAA had four of the airplanes used in Culver Educational Foundation's aviation program examined under Title 49 United States Code 44.709(a), Reinspection and Reexamination. Each airplane was inspected and discrepancies noted by a maintenance facility under the supervision of the FAA. The airplanes were: Piper PA-28-140, N673FL, S/N 28-7125601, Piper PA-28-140, N700FL, S/N 28-7225206, and PA-28-151, N767PP, S/N 76-15197. The discrepancies for N673FL listed 80 items which included a "non approved" air filter, "non-aircraft" alternator belt, two broken bolts for the right hand main landing gear with "some hardware non-airworthy," and the battery box drain tube "incorrect." Discrepancies for N700FL listed 67 discrepancies which included the right main landing gear brake, emergency locator transmitter (ELT) antenna not connected to the ELT, NAPA air intake filter installed "non-approved parts," shoulder harness has no tag and frayed, right wing aft outboard rib cracked, left wing top skin cracked aft of fuel filter two places at rib, throttle rod end at carburetor worn, throttle and mixture worn at quadrant, carburetor worn at control center fuselage stinger broken at crack in skin, center bottom of fuselage near registration number had a 2 inch ling crack, compass 30 degrees off - "non airworthy." Discrepancies for N767PP listed 52 discrepancies which included a missing alternator bracket, a cracked number 3 cylinder, carburetor heat box and control wire connector "beyond repair," and components relating to the right main landing gear needed to be replaced. The airplane’s used in the aviation program were refueled from an underground fuel storage tank with a "Amoco Ultimate Lead Free Premium" fuel pump equipped with a Petro Clear 40830PA-DV fuel filter. The fuel filter was a 30 micron fuel filter that was not intended for use with aviation fuel. The fuel hose leading to the fuel pump nozzle was covered with tape. Fuel samples taken by the FAA from the fuel filter showed a brown liquid contaminant at the bottom of the sample jar and below a layer of a blue liquid consistent with 100 LL aviation fuel. The fuel filter did not possess a date indicating when it was last changed or when it should be changed. There were no records to indicate how much fuel was pumped during each refueling nor where there fuel facility records annotating when and what was inspected. The FAA inspector stated that testing for the presence of water was not being performed. Fuel distributor records from July 2, 2004, to July 7, 2005, showed that the only supplies purchased was "AVGAS 100LL." Inspection of the remaining airplanes and revealed no contamination consistent with water or debris in their fuel filters or carburetors. The engine, S/N L-12152-39A, was removed and shipped to Textron Lycoming were it underwent an engine run within test specifications. Both magnetos were removed and replaced for the engine run with "slave" magnetos due to internal corrosion consistent with rust. The magnetos were timed to that which was noted during the on-scene portion of the investigation for the test and the engine was then run. Following the engine run, the carburetor was removed and tested at Precision Airmotive LLC. The carburetor test results were within the test specifications. The left magneto, Slick model 4371, S/N 03070194, drive gear was removed in order to mount it into a test apparatus for functional testing. Removal of the magneto cap revealed corrosion consistent with rust. The plastic gears were intact. During rotation of the magneto it was noted that the points were not opening even after they were cleaned with emery cloth. The magneto produced a spark when a test cell cap and ignition lead were attached; however, the magneto was out of time. The magneto was removed from the test apparatus and the impulse coupling spring was noted to be unwound. The spring was rewound and the magneto was remounted in the test apparatus. The magneto then produced a spark and was in time. The right magneto, Slick model 4370, S/N 01010500, was mounted in a test apparatus. Removal of the magneto cap revealed corrosion consistent with rust. The plastic gears were intact. During rotation of the magneto it was noted that the points were not opening even after they were cleaned with emery cloth. The points were replaced and the magneto produced a spark at all leads in order and timing specifications. Lycoming Service Letter No. L173C, dated March 10, 2006, references Slick Aircraft Products Service Bulletin (SB) No. SB2-80C, which was revised on April 1, 1991, covers, in part, magneto maintenance and overhaul schedules for Slick 4300 series magnetos. The SB states, "These magnetos should be inspected externally every 100 hours and internally every 500 hours." The SB states in a later paragraph, "These magnetos should be completely overhauled as required by the inspection noted above." The PA-28-161 Emergency Procedures Check List for Power Off Landing states, in part: Touchdowns should normally be made at lowest possible airspeed with full flaps. When committed to landing: Ignition - OFF Master switch - OFF Fuel selector - OFF Mixture - idle cut-off Seat belt and harness - tight The Director of Aviation stated that the CFIs at Culver Educational Foundation were from Purdue University. He said that all the CFIs received a pamphlet discussing procedures to be followed in the conduct of providing flight instruction. The CFIs received a checkout when they were hired following the completion of flight training provided by other Culver Educational Foundation CFIs that included the performance of stalls, steep turns, and takeoffs and landings. The Director of Aviation stated that he was the one to "sign off" the CFIs following completion of training. He also said that they held safety meetings. A CFI who worked in Culver Educational Foundation's aviation program beginning in June 2005, stated that he heard about employment at the aviation program through a friend of his that previously worked there. The CFI then applied for a flight instructor position by submitting a resume and calling the Director of Aviation who later invited him for an interview. This CFI stated that he did not recall whether the Director of Aviation reviewed his pilot logbook that he brought with to the interview. Upon his hiring, he received approximately 15 hours of flight training that involved flying with CFIs who had taught in the aviation program. He said that there was no training syllabus used for the training and that the flight training could be described more like orientation flights. He stated that he did not receive any training relating to ditching procedures while at Culver Educational Foundation. A second CFI stated that he attended high school at Culver Educational Foundation and then attended Embry Riddle in Daytona, Florida. He was a certified flight instructor (CFI) at Culver Educational Foundation since 2002. He said that CFIs at Culver Educational Foundation would arrive a week before school began each season in order to receiv
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.
Source: NTSB Aviation Accident Database
Aviation Accidents App
In-Depth Access to Aviation Accident Reports
