The passenger of the Cessna 182 reported that he and the pilot had been flying around the Pacific Northwest for several days. On the evening of June 11, 2023, they arrived at McCall Municipal Airport (KMYL) in Idaho and stayed overnight. Due to forecasted weather they elected to depart the following morning for a short flight to Indian Creek, Idaho.
The passenger reported that the pilot conducted a preflight inspection of the airplane and pre-takeoff checks on the morning of the accident. During the taxi to the runway, the pilot commented on the slight tailwind for the departure runway, and that it may result in a slightly longer takeoff roll.
As the airplane rotated for takeoff, the pilot said, “We have a power problem.”
The passenger told investigators that the pilot stated that he wanted to return to the runway to land, but the airplane was not climbing and did not have enough altitude to fly over the trees at the departure end of the runway.
Witnesses who observed the airplane departing to the north from KMYL noted that the departure roll appeared to be “unusually long.”
One witness reported that, “the engine was not developing too much power, but it sounded smooth, very low power, no coughing or sputtering….”
From their vantage point, they saw the airplane’s nose pitch up and begin to climb, but it did not gain enough altitude to clear the trees that were near the departure end of the runway.
The airplane hit the top of a pine tree before it descended below the tree line and out of visual range.
The pilot died in the crash and the passenger was seriously injured.
A post-accident examination of the engine revealed that a single-drive dual magneto was installed. The magneto was located in its normal relative position on the mounting pad, however it was not securely attached to the mounting pad.
Both the upper and lower retaining hardware were loose, and the lower retaining hardware was also backed off from the magneto. When the magneto was manually manipulated, there was movement between the mounting pad and the magneto.
A review of the airplane’s maintenance records revealed that a single-drive dual (D-style) magneto had been replaced about 15 hours before the accident flight.
The maintenance facility that replaced the magneto reported that the airplane was brought in for service due to a possible malfunctioning magneto.
According to the mechanic, while he was troubleshooting the malfunction, he noted that the “P” leads were crossed. The “P” leads were switched to their proper positions. An engine run was conducted, confirming that the right side of the magneto had failed.
The mechanic told investigators that the maintenance facility was only able to perform limited to basic diagnostic testing and replacement of magnetos, and that his experience with a D-style magneto was limited. As a result, the airplane owner ordered and supplied another single-drive dual magneto to the maintenance facility. After installing the replacement magneto, several engine runs were conducted, with no further discrepancies noted. A separate mechanic conducted the quality control check of the maintenance performed.
The airplane was returned to service and the pilot was advised to conduct a run-up and in-flight ignition test. If any abnormalities were present during the run-up and in-flight ignition test, the pilot was to return the airplane to the maintenance facility for further troubling shooting and diagnostics. The pilot conducted a run-up of the airplane, completed a couple of circuits in the airport traffic pattern, and then departed the area.
A service instruction letter issued by the engine manufacturer provided guidance for the installation and maintenance of the single-drive dual magneto. The service instruction letter cautioned that the magneto and/or attaching hardware on the engine accessory housing can become loose or unfastened after maintenance.
This condition can be caused by any, or a combination, of the following: Incorrect fastening hardware installation, incorrect torquing of the fastening hardware, incorrect gasket used for the magneto installation, incorrect magneto clamps installed, and incorrect gap between the magneto clamp and the accessory housing. The letter noted that failure to comply with the service instruction could result in a loss of engine power.
Probable Cause: Maintenance personnel’s failure to properly torque and inspect the magneto hardware, which resulted in a partial loss of engine power.
To download the final report. Click here. This will trigger a PDF download to your device.
This June 2023 accident report is provided by the National Transportation Safety Board. Published as an educational tool, it is intended to help pilots learn from the misfortunes of others.
1, It would have been great it the magneto (re) manufacturer would have supplied a copy of the SB with a warning. I know…Not their circus not their monkey, but we are really in this together.
2. Also, have a way of identifying the correct clamps as unique and applicable to the SB. .020 of an inch is (almost) indiscernible without either comparing or measuring.
3. Use torque seal – would be easy to see any relative movement.
4. On some installs, it is indeed impossible to get a torque wrench on a fastener.
Would, coulda, shoulda…easy to be an armchair Q-back.
Unfortunate incident all around.
Note that his log book showed that he had about 10 hrs total in this borrowed aircraft over 11 days..
Most of his flying was in Germany during this year, and some in the USA in 2022.
So, he was not very familiar with the C182RG aircraft .
It looks like that there was sufficient open space off the end of the runway in order to land straight ahead…..sad that he didn’t do that. He would probably be alive today.
What quality of pilot do we have who does not meet all the parameters that should be met before leaving the ground – comprehensive initial” walk around”, necessary engine parameters met during pre T.O.- engine inspections (oil, etc etc.) & run-up, closest into wind runway, adequate acceleration, take-off by or before a pre-determined airborne point. If the pilot is too careless to be thorough in carrying out basic safety checks before leaving the ground then the responsibility for his mis-hap rests on squarely on him. He is the one who “lined up the holes in the Swiss cheese”. He should have aborted the mission. The pilot appears to exhibit poor training or the “she’ll be right” attitude. This incident has the distinct smell of “who can I blame for this?” about it. Is it too much to suggest that personal responsibility appears lacking in this incident ?
Where do I start? Where do WE start? Looking at the GA industry and the regular carnage it produces says there’s something radically wrong here. Way too many holes in the Swiss Cheese — pilot and machine. I’m not a pilot, but I have close friends who are who are very, very cautious and astute regarding their own health, the weather and the health of their airplanes. They’re technicians and engineers who are so-attuned to machinery. What about pilots who aren’t? They die terribly in a crumpled airframe leaving friends and family behind. And, running-up insurance premiums to the point where they will eventually be out of reach by the average hobby pilot.
When to abort an underpowered takeoff? When to turn on the carb heater? How to decipher that bewildering spattering of symbols on an aeronautical chart around an airport? How to afford that additional 50% fuel load just in case you can’t land in your preferred destination airport? When do you switch between fuel tanks and not run out of gas in the air? And many more of these questions. How about a master control computer which takes all these factors into account and forces life-saving decisions on an incautious unwary pilot? How about letting the pilots of those ill-fated B 737 Max flying coffins disable that engine lift “feature” which was an extra-cost option? Why give the pilot a chance to save his and his passenger’s lives? I still shake my head in disbelief.
Mechanical problems: There shouldn’t be any reason why the hold-down clamps on magnetos should be inaccessible or so complicated that the average mechanic can’t figure it out without downloading the manual and needing a supervisor to look his shoulder. That’s just plain bad mechanical design, period. Good design engineering takes into account the maintenance mechanic’s struggle to keep things running. Lazy engineers just don’t care. In cars, a good example is needing to jack up the engine to change the plugs, and other impediments to getting hands, eyes and wrenches to the part that needs attention. Sheesh!
Yes, aircraft mechanics should be better paid to attract more into the near-profession. Dealership mechanics working on modern cars are practically graduate students to acquire the knowledge of all the computers and sensors in the cars they’re working on, and this is reflected in the charges for their service. Furthermore: In the event investigation shows the mechanical fault is traceable to a mechanic’s sub-standard labor on an engine, there should be sanctions — pull his cert, and in some cases lodge criminal charges against him in the case of demonstrable negligence. Doctors and accountants and other certified professionals sweat about botched surgeries and gross accounting errors, and so should aircraft mechanics. Until that day comes, more weekly stories of GA fatalities by threading the holes in that wheel of Swiss Cheese.
When do some of you active GA pilots recommend a practical working group to kick around and recommend solutions to the above?
One man’s opinions. /J
JBP,
You apparently have no clue as to how and why aircraft are designed. So, please don’t comment on things that you know nothing about.
Most of us pilot/ commenters are interested to know why some problem occurs, and how we might be able to avoid having this problem on our own aircraft.
General Aviation Joint Safety Committee.
https://www.gajsc.org/
I have installed and adjusted tens of thousands of automobile distributors. I always tried to rotate them by hand After they were set. And annuals are damaging. A competent owner knows what perpetual condition his aircraft is in and what doesn’t need 12 month dismantling just because.
If you want to read about the statistical probablility that something will go wrong after maintenance — in this case, fatally wrong — read the following mathematical analysis on the subject:
preprints.org/manuscript/202502.1463/v1
As a very long time A&P, I live in fear of being involved in something like this and have my own way of dealing with QC’ing my work … esp. on critical systems.
I feel VERY strongly that we’re over maintaining airplanes, as well. Anytime you fool with something that’s working introduces the possibility that you’ll hose it up in some way. The above analysis proves that. I would like to see less inspection maintenance and more as needed maintenance. In WWII, the British discovered that, too.
Beyond that, pilots are ‘taught’ that they shouldn’t ‘touch’ their airplanes … leave it to the A&P’s. That may be good for people who might buy a left-handed screwdriver set on sale but not for most guys with some modicum of mechanical knowledge. Even if they’re no good with tools, they should get more involved in the maintenance process with their airplanes to learn more about them. They ARE — in the end — responsible for the airworthiness of their airplanes. (I’m NOT excusing the mechanics here!)
Electronic magnetos are much more reliable, they’re virtually maintenance free. Highly recommended as a safety upgrade.
But they use the same clamps and hardware….if it’s not correct, they can rotate too..!!!
I’m retired from Aviation Maintenance. I have performed maintenance on Commercial and Military and General Aviation Aircraft. Taught Aviation Maintenance in a Aviation Maintenance school. Graduated from a Aviation Maintenance high school. Was licensed as a AI and A&P. Managed the Airport Maintenance facility at a major college. My advice for All Aviation Maintenance personnel is to always inspect your aircraft before you return the aircraft to service. Make sure to comply with ADs and service bulletins. And make sure that the service bulletins and ADs are current. And that way you know you did due diligence in your inspection and maintenance on any aircraft. Always update your maintenance log books. And look at the aircraft manufacturer maintenance manual for details on the aircraft. Any questions contact the Aircraft Manufacturer. Always be safe first. Good luck. God bless.
Heck, this is no different than a pilot going to a white coat physician and getting a coodie cocktail or a booster, because the ‘white coat’ with his emblematic “DOCTOR” stenciled on his white coat, along with his stethoscope wrapped around his neck, is PERCEIVED AS THE EXPERT and is DEEMED to know what he’s doing. But in fact, the white coat who gave the pilot the coodie cocktail or booster, was DEFINITELY INCOMPETENT, and went-along-to-go-along… because THAT’s what the government and the so-called ‘public health officials’ promoted in their “NARRATIVE!” Oh, how wrong they were! SAY IT ISN’T SO!
Sounds like they just didn’t get it tight enough. The dual magneto uses block-type hold-down clamps that are difficult to install. You have to pull the mag off it’s pad a little to get the clamp blocks in place on the mag and on the stud at the same time, then slide it all back on at once. There is no specific torque on the nuts- they get a standard torque of about 204 in.-lbs. for 5/16 stud size nuts. Lockwashers are a must. It’s often difficult to get a torque wrench on those nuts. Lots of well-experienced mechanics just get them good and tight, and that’s about right on the money for standard torque range.
The double mags can be difficult with those clamps and the way the drive cushions used to fall out of the drive cups so easily, but honestly, if that mechanic had tightened those nuts up the way you tighten the bolts on an old Ford truck’s water pump, that mag would never have come loose.
They got the timing set, then something distracted them and they forgot to tighten them up the rest of the way.
So involuntary manslaughter?
From the service letter, the old clamps will bottom out on the accessory case but are not tight against the mag housing flange, allowing it to slip.
The new clamps have a 0.020 inch gap with the accessory case and ‘wedge’ the mag flange tightly.
Very sad situation. As an A&P /IA, everything I do, I must consider the circumstances if I do not do it correctly. I couldn’t count the times that pilots and owners have requested “shortcuts” or “alternative” methods because they were either too stingy to pay or in too big of a hurry to go. It seems that some of the pilots in this discussion want to make the mechanic the evil villain. My guess is that the mechanic did the best he was capable of. Maybe he did or maybe he didn’t. The fact is that we all make mistakes and miss things. We are human. That’s why there is the necessity for preplanning, preflighting, and training for emergencies. I’m also a CFI. I cringe to see how many pilots are so complacent and take things for granted. Bottom line is that Flying is inherently safe, but Extremely unforgiving. We all have to do everything we can to keep ourselves and everyone our jobs affect safe.
I’m so glad to be a retired A&P from a major US airline. Never worked GA nor did I ever want to. We had a few guys that were A&P & also IA’s & had their own business on the side. Fortunately the few mistakes I made were caught by me before the plane left the ground. FLY NAVY!!!
How do you know for sure it was the mechanics fault maybe the guys wife wanted to get rid of him. You can’t prove beyond a reasonable doubt that it’s the mechanics fault! Surely the mechanic is going to say he positively tightened the bolts up.
Oh sure, the guy’s wife tampered with his mags to get rid of him. And the tooth fairy told her to do it.
There must be something missed I cannot believe two trained mechanics did not tighten down the screws
Here it is again, this time it cost a man his life !!! Duel mags are no different than a single mag, you just need to know how the job is done !! This is just another case of an A&P not knowing what the heck he is doing. Is this mechanic still walking the streets like if nothing happened ? I bet he didn’t even offer to return the mans money for making the problem worse than it was, no guarantee for his alleged work practices, just another, oh well !! I didnt have enough knowledge of the duel mags. so I did what I thought was the thing to do, so I failed to do it correct, well heck man, It cost a mans life, but it tried !!! How much longer is this going to continue without holding these creeps responsible for killing these innocent people and getting away with it ???????? Wheres the FAA all this time?? all the safety people that get paid a lot of money to do all the research, end result, it still continues, and continues, and continues…. crap man, this is very bad !!!!!
They got it wrong. The loose magneto may have caused a reduction of power, but it was the pilot that decided to take it airborne when it obviously was not performing properly. Hundred bucks says this guy has never done a pre-takeoff brief.
So, how much does this passenger weigh?
As an A&P/IA this is the nightmare scenario that I strive for as if my own life depends on it to get right. I would not ever be able to live with myself if something like this was to happen because of me. The customers that I have all complain that I take so long. But I’m usually the one that finds the things that others miss or figure out the screwy problems that no one else has been having any success.
I hear you. Best to do it right the first time!!
I was a flight line mechanic in the AirForce. Worked on C124 Globmasters.
I always felt the best preflight and post flight inspections wet done when needing a flashlight, Every square inch of a 6 inch
beam was painted with that light beam.
Nothing was left to chance…. but that was just me!!
I hate dual mags. They should have never been certified.
Where’s the redundancy?
Similar Tobagos
The mechanic surely should have used a torque wrench at least?? Or grabbed the mag and tried to rotate it by hand??
Some mechanic’s just don’t have a mechanical aptitude… The IA was Also lackadaisical..
From a very old A&P
‘Single drive dual magneto’ always makes me cringe….
AMEN!!!!!!!!!!!!
“the departure roll appeared to be “unusually long.”” Just as important as checking ‘all in the green’ is estimating during the takeoff roll that rotation speed will be reached at the expected point on the runway where the POH estimates it will be reached.
This airport is at 5020′ with a 6100′ Rwy. The “Recommended” departure in the Takeoff Minimums is Rwy 16 and it literally says, “winds permitting.” Instead they took off from Rwy 34 with a tailwind and it is also slightly uphill at this high altitude airport. This a bad idea, beyond the guidance, just because it makes it hard to determine when your normal takeoff roll is not normal. In this case, the tailwind was 3kts and the uphill run was 17′ of elevation. At the end of this runway they had over 1000′ of clearing. There seemed to be plenty of opportunity to abort the takeoff. Yes, a known and briefed abort point, even at a mile down the rwy, would have saved the day for a takeoff into the wind and down hill as recommended.
So that A&P didn’t comply with the service bulletin on replacing the mag claps and use the correct gasket and hardware.
But then, it’s the owner/pilot who is responsible as to the airworthiness of the aircraft.
It’s sad that this omission got him killed. !
But the reason pilots (w/o an A&P license) aren’t allowed to do their own work is because you have A&P’s that you pay the big bucks to make sure it IS – theoretically! – done right. Pilots ARE responsible for the preflight inspection. They are are NOT required to inspect, vefify and buy off on an A&P’s work. That’s why A&P’s get payed the big bucks.
Sadly A&Ps are not paid “big bucks”. A&Ps are WAY under paid. Car mechanics make more, even with the realization if we mess up, someone can die. With that said, there is no excuse for this negligence. Instructions specifically states mechanic can only perform maintenance on items he/she has direct knowledge of. So if this mechanic didnt know, he should have performed under supervission. The same goes for the IA. Duel mags are not that difficult to work with. Line up the gears, pin, installl at proper degree. Tighten and adjust accordingly. Once timing verified and tight, TORQUE. These are the simple, makes sence sequence. Too many mechanics and shops assume they can just do anything. There were a lot of “checks” bypassed. If anyone of them would have been observant enough, this tradgedy may not have happened!
A&P IA
The pilot lined up the last few holes in the Swiss cheese. He paid the price. The mechanic failed, but the pilot also failed set up safe departure and abort option.
How is a pilot suppose to supervise the IA’s work in order to be “”responsible for the airworthiness… ” Seriously? He hired two a&p mechanics to do that for him.
A&P, ATP CFII.
Besides doing a mag check during the run up, during the preflight, he could grab the mag and try t rotate it….if he did, it would probably move, affecting the timing..!!