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National Transportation Safety Board

FACTUAL REPORT

AVIATION

NTSB ID:  MIA04FA076

Occurrence Date: 04/20/2004

Brief narrative statement of facts, conditions and circumstances pertinent to the accident/incident:

FACTUAL REPORT - AVIATION

Nearest City/Place Tampa Florida

Type of Aircraft Cessna

Aircraft Registration Number: 177RG

HISTORY OF FLIGHT

On April 20, 2004, about 1134 eastern daylight time, a Cessna 177RG, N1910Q, registered to and

operated by a private individual, as a Title 14 CFR Part 91 personal flight, ditched into Tampa

Bay, Tampa, Florida. Visual meteorological conditions prevailed and no flight plan was filed. The

private-rated pilot and one passenger received fatal injuries, and the airplane incurred

substantial damage. The flight originated in Pompano Beach, Florida, the same day, about 0930.

An attendant at the fixed-based operator's facility at Peter O. Knight Airport, Tampa, Florida,

stated that she heard a radio communications transmission from a pilot stating that he was 6 miles

from the airport, and his airplane's engine was experiencing roughness and backfiring. She said

that she acknowledged the call, told the pilot to use the runway of his choice, and instructed the

other aircraft to clear the traffic pattern. She further stated that shortly after the initial

call, she heard the pilot say "we're not going to make it."

According to a nearby fisherman, the accident aircraft was heading in a westerly direction at an

altitude of about 200 to 300 feet, about a mile to the west of where he was fishing. The witness

further stated that he heard erratic changes in the sound of the airplane's engine, which was

continually backfiring. He said that the airplane's engine then became silent, and at that point he

noticed the airplane make a controlled turn towards the airport.

A second witness working in the vicinity of the Port of Tampa Bay stated that the airplane appeared

to hit the water hard and it remained afloat for about 3 to 5 minutes. A third witness that was in

a boat at the time, about a mile from the accident site stated that he became aware of the airplane

when he heard a loud smacking noise as the airplane hit the water. He said that he proceeded to the

place where the airplane impacted the water, arriving about 3 to 5 minutes later, but at that time

the airplane had sunk.

PERSONNEL INFORMATION

Records obtained from the FAA showed that the pilot held an FAA private pilot certificate with an

airplane single engine land rating, issued on December 24, 2003. He also held an FAA third class

medical certificate, issued on January 9, 2003, with the stated limitation "must wear corrective

lenses". According to the pilot's logbook, the pilot commenced flight training on April 22, 2003,

and had accumulated a total of about 96 flight hours, 16 of which were in the accident aircraft.

AIRCRAFT INFORMATION

N1910Q is a 1972 Cessna 177RG, serial number 177RG0310. According to the airplane's maintenance

logbook it had been given an annual inspection on July 21, 2003, and had accumulated 4,094 flight

hours on the airframe at the time of the accident. It was also equipped with a 200 horsepower

Lycoming IO 360 A1B6D engine, serial number L-9866-51A. Records showed that the engine was

overhauled on July 21, 2003 and had accumulated about 175 flight hours at the time of the accident.

The accident airplane was also equipped with a McCauley 2-bladed controllable pitch propeller,

serial number 754887.

METEOROLOGICAL INFORMATION

Visual meteorological conditions prevailed at the time of the accident. The Tampa International

Airport, Tampa, Florida, 1153, surface weather observation was, wind from 260 degrees at 7 knots,

visibility 10 statute miles, scattered clouds at 4,000 feet, a broken cloud layer at 25,000 feet,

temperature 75 degrees F, dew point temperature 51 degrees F, altimeter setting 30.17 inHg. The

Tampa International Airport is located 6 NM northwest of the accident site.

WRECKAGE AND IMPACT INFORMATION

According to officials at the Tampa Police Department, the accident airplane was found submerged,

in a shipping channel about one third of a mile east of the Peter O'Knight Airport, having sunk in

Seddon Channel. The airplane was upright, in position 27 degrees, 54.543 North latitude, 082

degrees, 26.520 West longitude, in about 14 feet of water, oriented on about a northwest heading.

The airplane was recovered about 4 hours after the accident, and after recovery from Tampa Bay, the

NTSB examined the airplane on April 21 and 22, 2004, along with NTSB party representatives to the

investigation, which included an FAA inspector, as well as persons from Lycoming Engines, and

Cessna Aircraft Company.

The airplane was intact and there was minimal structural damage. The Tampa Police Department divers

reported that they had found the left door in the open position, and the right door was closed.

Post-recovery examination showed no distortions to the cabin, and when both doors were tested, the

interior right-side door handle was found to be loose, with that door disengaged intermittently

when the handle was rotated. The handles were removed and the splines in the handle appeared to be

worn. The pilot and passenger lap belts and shoulder harnesses were found intact, unlatched, and

had remained connected to their attachment points. The seats were also intact and attached to the

seat rails.

During the cockpit examination, the landing gear lever was set to "Up", the flap indicator read 0,

and the selector showed about 25 degrees, with both flaps being visibly up. The fuel selector valve

was set to "Both", and the fuel boost pump was "Off." The cockpit flight control positions included

the throttle being extended about 1 inch, the mixture and propeller controls being full in, and the

cowl flaps being open. Gauge reading were as follows. The airspeed indicator showed 0 knots, the

altimeter 240 feet, and the setting in the Kollsman window being 30.12 inches. The heading

indicator read 300 degrees, the vertical speed indicator read plus 2,050; the turn coordinator was

level and the ball in the center. No. 1 VOR's Omni Bearing Selector was set on 322 and No. 2's was

357. The communications/navigation radios were of a digital design, and No. 1 had been selected.

The ADF was off and its frequency was 740. The transponder was set at 1200. The "Master" switch was

set to "On", and the magneto switch was set to "Both." The Hobbs hour meter read 1,505.2, the

tachometer read 0, the tachometer hour meter read 1016.82. The cylinder head temperature needle was

pegged to the right of the gauge, and the oil temperature and pressure gauges, as well as EGT,

suction and fuel flow gauges read 0.

The main and nose landing gear were in the retracted position. The lower cowling exhibited some aft

crushing, and the leading edge of the left stabilator was torn and the undersurface exhibited

buckling. There was a diagonal crease that extended from about the mid section of the stabilator to

the outboard aft tip. The right hand section of the right stabilator and the corresponding section

of the trim tab exhibited signs of wrinkling. The stabilator structure was loose in the area of the

tailcone, and the tailcone fairing was wrinkled.

There was minimal damage associated with the ailerons, flaps, and rudder, and flight control

surfaces had remained attached to the airframe. Control cable continuity was established to each of

the flight control surfaces. The flap's jackscrew was extended 3.3 inches, consistent with the

flaps being extended less than 10 degrees. When battery power was momentarily applied to test the

flaps, they started to extend.

Examination of the left and right wing fuel tanks revealed blue liquid about 1.25 inches from the

tabs. Approximately four gallons of saltwater and 15 gallons of blue fuel were drained from the

right wing, and no fuel was drained from the left fuel tank.

An officer with the Tampa Police department stated that the fuel selector switch had been moved

from "both" to "off" during recovery. When examined, fuel was observed to flow from the line from

the fuel tanks to the fuel strainer when the fuel switch was in all positions other than the "Off"

position. Water and some debris were found in the fuel strainer, however the fuel screen contained

no debris. In addition, the fuel injector inlets as well as the main fuel strainer were clean, and

there was evidence of fuel in the fuel flow divider

Water was present in the oil system, about 1 1/2 quarts of oil remained in the sump. The oil

suction screen and oil filter were clean, the oil cooler was secure, and the oil cooler hoses were

intact and secure.

The right muffler exhibited an area of chaffing that extended part way around its circumference,

and when the muffler was removed and examined and its internal passages were found to be clear. The

air box was clear, the alternate air door was secure, and the induction air filter was intact. No

induction or exhaust obstructions were found.

The propeller spinner had been dented on one side, and the propeller remained attached to the

engine and exhibited little to no damage. The propeller governor was secure on the case, and the

drive gear was intact and rotated freely

During examination of the engine and accessories, hoses were noted to have aged, and the fuel hose,

in addition to being old and brittle, was long, and had significant bending to accommodate its

length. On its route from the engine-driven pump to the fuel control unit, the fuel hose was noted

to be in contact with the No. 4 cylinder's cooling fins. When the hose was detached about a trickle

of fuel was recovered at the fuel control end of the line. When the propeller was rotated fuel was

observed to flow consistent with there having been no blockages

Control positions at the engine showed the mixture was 1/4 inch from full rich, the throttle was

1/4 inch from full open, and the propeller was at low pitch. The engine was partially disassembled

and the propeller, valve covers, and accessories were removed. Continuity of the valve system and

drive train was confirmed to all cylinders and to the back of the engine. In addition, all four

cylinders produced compression. The spark plug electrodes exhibited moderate wear, the gaps were

normal, and salt-water intrusion was noticed. The ignition harness had incurred saltwater damage,

and was in a tattered and worn condition.

All engine accessories to include the starter, alternator, and vacuum pump were found affixed to

the engine, and when they were removed and examined, they displayed no anomalies. The muffler's

internal passages were clear and exhibited a light grey color. There was some chaffing on the right

side muffler can, but no leaks were observed to exist in the system.

The engine lubrication system had suffered water intrusion, and most of the oil had been displaced,

leaving only about one and a half quarts in the system, and however system integrity was maintained

to include the oil suction screen, oil filter, and associated hoses that exhibited no anomalies.

MEDICAL AND PATHOLOGICAL INFORMATION

The District 13 Medical Examiner, Hillsborough County, Tampa, Florida performed postmortem

examination of the pilot and passenger. The causes of death were attributed to drowning. No

findings that could be considered causal were reported.

The Hillsborough County Medical Examiner conducted toxicological studies on specimens obtained from

the pilot and passenger. The specimens were tested for the presence of drugs, and results of the

tests were found to be negative for drugs in the cases of both pilot and passenger.

In addition, the FAA Toxicology Laboratory, Oklahoma City, Oklahoma, conducted toxicology studies

on specimens from the pilot. The samples were tested for carbon monoxide, cyanide, volatiles and

drugs. All results of tests were negative.

TESTS AND RESEARCH

On May 4, 2004, the NTSB examined the Bendix fuel flow divider installed on the accident airplane.

During the course of the examination the Fuel Flow Divider was noted to have not been maintained

and updated with the latest diaphragm change, as specified in Bendix Fuel Systems Service Bulletin

RS-86, dated December 23, 1983. Examination of the spider/fuel nozzles revealed a fuel flow

consistent with manufacturer specifications, and no anomalies were noted.

Under the supervision of an FAA Inspector, on August 18 and 19, 2004, a detailed examination of the

magneto installed on the accident airplane was performed at Teledyne Continental Motors, Mobile,

Alabama. The examination revealed that the magneto's cam did not have proper lubrication, and the

magnetos' points had seized.

The accident airplane was equipped with a Teledyne Continental Motors single-drive dual magneto,

part number 10-38255-1, serial number 22402. The magneto was originally manufactured in August 1978

and records indicate that Electrosystems, Inc., last overhauled it in October, 1997. The magneto

harness had visible areas of wear. The magneto cover was removed and it was noted that the points

had little or no movement. According to the aircraft's engine logbook, the magneto was reinstalled

on July 21, 2003, the time in which the engine was overhauled, however, no records were found to

indicate that a magneto overhaul had been performed.

According to the Teledyne Continental Motors Service Bulletin SB643B dated February 25, 1994,

"...magnetos must be overhauled when the engine is overhauled. ...Magnetos must be overhauled or

replaced at the expiration of five years since the date of original manufacture or last overhaul,

or four years since the date the magneto was placed in service, whichever occurs first, without

regard to accumulated operating hours." In addition, Lycoming Mandatory Service Bulletin SB240R,

dated November 10, 1999, specifies mandatory parts replacement at overhaul and during repair or

normal maintenance.

ADDITIONAL INFORMATION

On April 5, 2005, the NTSB released the airplane wreckage to Mr. David Gourgues, Regional Manager,

CTC LAD Aviation Services.

 

Probable Cause

 

An attendant at the Peter O. Knight Airport, Tampa, Florida, stated that she heard a radio communications transmission during which the

voice stated that his airplane engine was experiencing roughness and backfiring. Shortly after the initial call, the attendant said she

heard the pilot say "we're not going to make it." The accident airplane subsequently ditched in Tampa Bay, about a third of a mile

short of the airport, in about 16 feet of water. Postaccident examination of the airplane revealed no anomalies with the airframe and

flight controls or engine. During a detailed examination of the Teledyne Continental Motors dual-drive magneto, the magneto's cam was

shown to have lost all lubrication, and the points were seized. Airplane records showed that the last known magneto overhaul was

conducted by Electrosystems, Inc in October 1997. The records also showed that the magneto had been reinstalled on July 21, 2003, when

the engine was overhauled, but a magneto overhaul had not been performed. Teledyne Continental Motors SB643B Service Bulletin pertinent

to subject magneto, specifies that the magneto be overhauled when the engine is overhauled. In addition, Textron Lycoming's Mandatory

Service Bulletin specifies mandatory parts replacement at overhaul and during repair and normal maintenance. Examination of the Bendix

Fuel Flow Divider which was installed on the accident airplane revealed that the subject fuel flow divider did not have the latest

diaphragm installation, as specified in Bendix Fuel Systems Service Bulletin RS-86, dated December 23, 1983.

 

Occurrence # 1 Loss of Engine Power (Partial) - Mech Failure/Malf

Phase of Operation: Approach

Findings

1. (c) Maintenance, Overhaul - Inadequate - Other Maintenance Personnel

2. Ignition System, Magneto - Improperly Serviced

3. Ingition System, Magneto - Malfunction

-------

Occurrence # 2 Forced Landing

Phase of Operation: Descent - Emergency

-------

Occurrence # 3 Ditching

Phase of Operation: Descent - Emergency

Findings

4.  Terrain Condition - Water

Findings Legend: (c) = Cause, (F) = Factor

 

The National Transportation Safety Board determines the probable cause(s) of the accident as follows.

Improper maintenance by other maintenance personnel, and the reinstallation of an unserviced magneto during an engine overhaul, which resulted in the magneto malfunctioning, a loss of engine power, and the airplance being ditched into the water.

 

 

 


 

©2004 Adam Brice Sprague

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