N4512Q

Substantial
Fatal

Piper PA-28-161S/N: 28-8016019

Accident Details

Date
Wednesday, August 10, 2005
NTSB Number
CHI05LA226
Location
Culver, IN
Event ID
20050815X01247
Coordinates
41.222221, -86.386108
Aircraft Damage
Substantial
Highest Injury
Fatal
Fatalities
2
Serious Injuries
0
Minor Injuries
0
Uninjured
0
Total Aboard
2

Probable Cause and Findings

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.

Aircraft Information

Registration
N4512Q
Make
PIPER
Serial Number
28-8016019
Engine Type
Reciprocating
Year Built
1979
Model / ICAO
PA-28-161P28A
Aircraft Type
Fixed Wing Single Engine
No. of Engines
1

Registered Owner (Historical)

Name
CULVER EDUCATIONAL FOUNDATION
Address
1300 ACADEMY RD DEPT 148
Status
Deregistered
City
CULVER
State / Zip Code
IN 46511-1234
Country
United States

Analysis

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-approve...

Data Source

Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# CHI05LA226