NTSB Factual Report

HISTORY OF FLIGHT

On November 13, 2003, about 0925 mountain standard time, a Cessna 177RG, N431DL, collided with mountainous terrain after the pilot reported experiencing engine problems 12 miles east of Black Canyon City, Arizona. The airline transport pilot/owner operated the airplane under the provisions of 14 CFR Part 91. The airplane was destroyed. The pilot, the sole occupant, sustained fatal injuries. The charity cross-country flight departed Flagstaff Pulliam Airport (FLG), Flagstaff, Arizona, about 0840, en route to the Phoenix Deer Valley Airport (DVT), Phoenix, Arizona, with an ultimate destination to the Bob Hope Airport (BUR), Burbank, California. Day visual meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan had been filed. The primary wreckage was at 34-degrees 06.330 minutes north latitude and 111-degrees 57.675 minutes west longitude.

At 2128 (November 12, 2003), the pilot contacted Prescott Automated Flight Service Station (AFSS) and requested an outlook weather briefing for the following areas: FLG, DVT, BUR, with a return to FLG. The pilot then filed three separate flight plans: FLG to DVT, DVT to BUR, and BUR to FLG. The pilot did not obtain an updated weather briefing on the morning of the accident.

During the flight from FLG, on the morning of the 13th, the accident airplane climbed to an altitude of 10,000 feet above ground level (agl).

At 0922, the flight was transferred from Albuquerque, New Mexico, Air Route Traffic Control Center (ZAB ARTCC), to PHX TRACON. At that time, the pilot reported a partial loss of engine power and that he was attempting to reach the Pleasant Valley Airport (P48), Peoria, Arizona. The controller asked if the pilot wanted to continue to Carefree, Arizona, or return to Prescott, Arizona. The pilot reported that he wanted the closest airport. The controller advised that Carefree Airport was 23 nautical miles on a 160-degree heading. The pilot advised that he was descending 600 feet per minute (fpm) and would head towards Carefree. The controller instructed him to fly a heading of 160 degrees if able, and to descend at the pilot's discretion, and maintain 7,000 feet agl.

At 0924, the controller asked the pilot if his carburetor heat was on, to which the pilot replied negatively as the airplane was fuel-injected. The pilot indicated the airplane had slowed to 75 knots, descending at 800 fpm, and the propeller was "windmilling." The controller reported that Carefree was still 21 nautical miles away on a 155-degree heading. A minute later the controller advised the accident pilot that radar contact was lost 45 miles north of PHX. The pilot replied, "Okay, understand."

Between 0926 and 0932, the controller attempted to make contact with the accident pilot, but received no response. During this time the PHX TRACON controller was in contact with ZAB. The ZAB controller reported they still had radar contact with the accident airplane. One sweep at 0926:08 depicted the airplane at 6,400 feet, and the last sweep at 0927:35, the airplane was at 5,400 feet. At 0928:04, there were no more radar returns recorded on ZAB's radarscope for the accident airplane.

PERSONNEL INFORMATION

A review of Federal Aviation Administration (FAA) airman records revealed the pilot held an airline transport pilot certificate with a rating for airplane multiengine land, and commercial privileges for airplane single engine land.

The pilot held a third-class medical certificate issued on August 27, 2002. It had the limitations that the pilot must have glasses available for near vision, and that the certificate was not valid for any class after August 31, 2004.

No personal flight records were located for the pilot and the aeronautical experience listed in this report was obtained from a review of the airmen FAA records on file in the Airman and Medical Records Center located in Oklahoma City, Oklahoma. These records indicated the pilot reported accumulating a total time of 28,360 hours.

AIRCRAFT INFORMATION

The airplane was a Cessna 177RG, serial number 177RG-0762. The pilot/owner purchased the airplane in June 2000. The following information was obtained through e-mails submitted to the National Transportation Safety Board after the accident by the moderator for the Cessna Cardinal group that the accident pilot belonged to. Separate e-mails dated October 4, 2001, June 25, 2002, July 13, 2002, August 30, 2003, and September 1, 2003, indicated that the newly overhauled engine was experiencing oil temperature overheating problems during climb out, with very little reduction in temperature during cruise. On September 1, 2003, the pilot/owner reported that the engine had gone through a major field overhaul about 150 hours ago, and posed the question as to whether or not incorrect magneto timing could cause the high oil temperature readings.

At the accident scene the tachometer read 4,220.9 and the Hobbs hour meter read 2,697.3.

A review of the airplane's logbooks revealed a total airframe time of 3,958.0 hours at the last annual inspection, which was completed on August 6, 2002. An entry dated August 11, 2003, reported that an unspecified inspection had been conducted and the airframe total time was 4,151.0 hours.

Recorded in the airplane's logbook, was the annual inspection for June 20, 2000, which contained the following information pertaining to the magneto:

"(MAGNETO) AD 78-18-04 PCW per entry dated 10/29/81, AD (Airworthiness Directive) 79-12-07 DNA per model [number] of magneto, AD 79-18-06R(1) DNA per "K" stamped following s/n, AD 80-17-14 PCW per entry dated 10/29/81, AD 82-11-05 DNA per color of tag, AD 82-20-01 PCW per entry dated 10/19/82, AD 96-12-07 PCW at [overhaul] dated 08/27/98."

The airplane had a Textron Lycoming IO-360-A1B6D engine, serial number L-14190-51A. Total time on the engine at the last annual inspection was recorded as 3,958.0 hours. On September 9, 2003, the dual magneto was removed to set the internal timing, at a total time of 4,182.7 hours. On October 7, 2003, routine maintenance was performed and the engine's total time was reported as 4,201.0 hours.

Maintenance records regarding work completed on the airplane obtained from Wiseman Aviation, Flagstaff, revealed that on July 10, 2003, the magneto was internally timed, and a ground run and operational check were conducted with no mechanical malfunctions encountered.

On May 6, 2002, Professional Aircraft Accessories, Inc., Amelia, Ohio, submitted a FAA Form 8130-3 titled Airworthiness Approval Tag for an overhauled and tested magneto, part number 10-382555-11. On May 14, 2002, Signature Engines, Inc., Cincinnati, Ohio, submitted FAA form 8130-3, which indicated that the engine had been overhauled, and one of the parts/accessories replaced was "2 ea magnetos." The overhauled engine was then shipped to Wiseman Aviation for installation on the airplane.

According to the Bendix-Teledyne Continental Motors (TCM) overhaul manual, the following applicable AD's pertained to the magneto:

96-12-07 - titled Inspection of riveted impulse couplings and stop pins - Inspect Impulse, recurring inspection with a required compliance every 500-hours

78-18-04 - titled Teledyne Continental Motors Ignition System-Coil Retention - Inspect Shimming of Rotor, recurring inspection with a required compliance at every overhaul

82-20-01 - titled Teledyne Continental Motors Ignition System-Impulse Coupling - Inspect Impulse, one time inspection

80-17-14 - titled Teledyne Continental Motors Ignition System-Housing Distortion - Inspect Housing, one time inspection

82-11-05 - titled Teledyne Continental Motors Ignition System-Distributor Gear - Inspect Gears, one time inspection

According to the manufacturer, the above AD's do not pertain to the lubrication of the cam follower. However, TCM Service Bulletin 643A titled Maintenance Intervals for all TCM and Bendix Aircraft Magnetos and related equipment requires the following maintenance inspections: an inspection at either the 100-hour or the annual inspection, or progressive maintenance; at every 500 hours of operation. In addition, the magnetos must be overhauled or replaced at the expiration of 5 years since the date of original manufacture, or last overhaul, or 4 years since the date the magneto was placed in service, whichever occurs first, without regard to accumulated operating hours.

TCM's Service Support Manual for the D-2000 and D-3000 Series High Tension Ignition Systems, lists Periodic Maintenance in section 6, and General Overhaul in section 7. One of the procedures listed in section 6 specifies a detailed maintenance inspection of the magneto after the first 500 hours of service and then every 500 hours thereafter.

Under section 6.2 titled Detailed Maintenance Procedures, subsection 6.2.1 - Contact Assemblies part C, it instructs maintenance personnel to examine contact points for wear, burning, or melting. If the points are deeply pitted or burned they must be discarded.

In section 7 titled General Overhaul, subsection 7.2.3 titled Inspect and Re-lubricate Breaker Cam (1-16, 1-17) and Washer (1-15), maintenance personnel are instructed to inspect the breaker cams for scratches or wear, and to ensure the outer surface is not contaminated with plastic or dried oil. If those conditions exist, the breaker cams are to be replaced. Once the breaker cam has been cleaned, it is to be completely submerged in lubricant at a temperature of 200 degrees Fahrenheit for 30 minutes, with the lubricant allowed to cool with the cam in place. Once cooled, the cam is removed from the lubricant, cleaned, and returned to service.

WRECKAGE AND IMPACT INFORMATION

Investigators from the National Transportation Safety Board, Cessna Aircraft Company, and Textron Lycoming examined the wreckage at the accident scene. The accident site was located in a valley of the Tonto National Forest at 3,700 feet on a 10-degree upslope. The wreckage debris path was oriented along a magnetic bearing of 200 degrees. The first identified point of contact (FPIC) was a tree about 60-feet from the main wreckage.

The Sheriff's Department Back Country Unit reported that the pilot was found secured in his seat and the lap belt remained connected. They had to cut the lap belt to facilitate recovery.

The airframe and engine were examined on-scene. There were no obvious preimpact anomalies noted with the airframe. The manufacturer's representative reported that the landing gear was retracted, the flaps were extended 10 degrees, and the stabilator trim tab was set in a nose-down position. The fuel selector valve was selected to BOTH, and the fuel vent system plumbing was unobstructed.

The cabin area remained intact but the cabin/wing overhead collapsed about 10 inches, which displaced the forward doorposts in an aft and down direction. Investigators noted that the shoulder harness remained over the door in its normal stowed position. An odor of fuel was present; however, the right wing fuel tank had been breached after it collided with a tree. Recovery personnel from Air Transport, Phoenix, Arizona, recovered about 20 gallons of a blue colored liquid, consistent with 100-Low Lead aviation gasoline, out of the left wing.

A visual examination of the engine revealed no obvious preimpact anomalies. The engine remained attached to the airframe by the engine mount. The propeller remained attached to the engine at the propeller hub, and was not damaged.

The engine manufacturer's representative reported that the throttle/mixture controls were secured at their respective control arms. The mixture control arm at the fuel injection servo was positioned about 1/8-inch off the "full rich" stop. However, investigators were able to establish continuity of the mixture control by manipulating the mixture control rod inside the cockpit. Investigators were able to see operation of the mixture control from "stop-to-stop." The throttle control arm at the fuel injection servo was also found positioned about 1/8-inch from the idle stop. The engine manufacturer indicated that the fuel injection servo and induction system were examined and were free of contamination. The fuel flow divider, fuel injection lines, and fuel pump remained secured and attached to their respective attach points, with the fuel lines also secure at their respective fittings.

MEDICAL AND PATHOLOGICAL INFORMATION

The Yavapai County Coroner completed an autopsy on the pilot on November 15, 2003. The Medical Examiner listed the cause of death as blunt force craniocerebral trauma due to an airplane crash.

The FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, performed toxicological testing of specimens from the pilot. The results of analysis of the specimens were negative for carbon monoxide, cyanide, and volatiles. Under the tested drugs section, the pilot tested positive for Metoprolol, which was detected in the blood and urine samples.

According to the airplane manufacturer, when the airplane was delivered new in 1975, standard equipment included shoulder restraints for both the pilot and co-pilot. During the on-scene inspection, investigators noted that the shoulder harness was stowed in its stowage sheath above the pilot's cabin door.

The autopsy report noted only the following injuries under "Pathologic Diagnoses"

1. Blunt Force Craniocerebral Trauma

A) Lacerations of Scalp and Face

B) Comminuted Fractures of Right Frontal Skull

C) Extrusion of Brain

D) Fractures of Face

2. Blunt Force Injury, Thorax

A) Fractures Right Ribs 1,2,3, anterior

B) Anterior Chest Wall Hemorrhage

TESTS AND RESEARCH

Investigators examined the wreckage at Air Transport on November 15, 2003.

Investigators noted that the rear-mounted vacuum pump remained secure at the mounting pad. The pump was removed and examined. Investigators manually rotated the vacuum pump via the drive, with no preimpact anomalies noted. The oil filter and suction screen were secure at their respective mountings.

Investigators removed the propeller to facilitate the engine examination. The top spark plugs were removed, and the electrodes were observed to be gray in color. The coloration corresponded to normal operation according to the Champion Aviation Check-A-Plug AV-27 Chart. The vacuum pump was removed and the crankshaft was manually rotated by hand through the vacuum pump drive pad utilizing a drive tool (a wrench). Mechanical and drive train continuity was established, and thumb compression was obtained in proper firing order. Normal lift action was noted at each rocker assembly. A borescope inspection revealed no mechanical deformation on the valves, cylinder walls, or internal cylinder head.

Investigators noted that the magneto was a single-drive, dual magneto that remained secured at its mounting pad, with the harness cap assembly remaining attached as well. The P-leads remained secure at their respective connectors, and during manual rotation of the crankshaft, investigators could hear "snapping." The engine manufacturer's representative was not able to establish magneto-to-engine timing because the contact points were not breaking electrical continuity. Investigators found that during manual rotation of the magneto drive, the contact points were not opening during the rotation of the contact assembly cam within the magneto. The manufacturer's representative reported that it appeared, without further disassembly, that the contact assembly cam follower(s) were worn beyond serviceable limits. The Safety Board investigator-in-charge (IIC) retained the magneto and harness-cap assembly for further examination.

On January 21, 2004, under the auspices of the Safety Board, an examination of the magneto was conducted at the Teledyne Continental Motors (TCM) facility in Mobile, Alabama. An external examination of the magneto showed a field-overhaul date of May 2002. Prior to disassembly, TCM personnel attached a timing light to the magneto to functionally check the points and timing. Investigators noted that the timing light indicated that both magneto primary circuits short-circuited to ground in

NTSB Probable Cause

a loss of engine power due to the failure of the single-drive dual magneto that resulted from inadequate lubrication of the breaker cam. Also causal was the improper maintenance by other maintenance personnel during a recent inspection, which should have detected the lubrication deficiency. A contributing factor in the accident that likely exacerbated the pilot's injuries was his decision not to wear the installed shoulder harness.