Pilot Debrief

PIPER PA-18-150 near McGrath, AK — 2011-09-04

Final reportANC11FA093
Sign in to save
Date
2011-09-04
Location
McGrath, AK, USA
Airport
PAMC
Aircraft
PIPER PA-18-150
Registration
N13973
Category
Airplane
Highest injury
Serious
Fatalities
0
Phase of flight
Approach

Probable cause

The pilot inadvertently switched off the engine magnetos during short final approach, which resulted in a loss of engine power. Contributing to the accident was the manufacturer's placement of the magneto switches in the cabin.

NTSB narrative

The airplane was on short final approach to the airport when its engine would not respond to throttle input. The airplane descended into trees and impacted terrain. The pilot reported that immediately prior to the loss of engine power, he had made an elevator trim control adjustment and was in the process of making a throttle adjustment when he heard a snap and the engine quit operating, "as if the magnetos had been shut off." Examination of the airplane established that the throttle cable was intact. The engine was run, and no anomalies were noted. During the engine run, the magneto switches were turned off while the engine was at cruise rpm. The switches made an audible click/snap when turned off. Following a similar August 29, 2011, accident also involving a Piper PA-18 airplane, the pilot reported that, during the initial climb, he inadvertently switched off the engine magnetos with his coat sleeve while using the trim handle, causing the airplane’s engine to shut down. As with this accident airplane, the magneto switches were located on the left side of the cabin, just above the trim handle. As a result of incidents involving the inadvertent shutting off of the magneto switches, the Federal Aviation Administration published a notice of proposed rulemaking announcing its intent to issue an airworthiness directive requiring the reconfiguration of the magneto switches on Piper PA-18 airplanes. Given the absence of any mechanical issues with the airplane, as well as the location of the magneto switches and the trim handle, it is likely the pilot inadvertently shut off the magnetos switches while trimming the airplane on short final approach.

Analysis

Primary failure mode
Automation / mode confusion
First missed decision gate
Pilot could have checked magneto switches before final approach.

NTSB coding

Evidence available

  • Photos
  • 2 docket documents
View NTSB final reportView NTSB docket

Docket documents2

Related mishaps