# NTSB CEN14LA081: Rockwell International 112, N1203J, Hammond, LA, December 10, 2013 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: December 10, 2013, 10:02 local (16:02 UTC) - Place: Hammond, LA - Coordinates: 30.591388, -90.286941 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=30.5914&lon=-90.2869&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report April 23, 2014 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Federal Aviation Administration, Baton Rouge FSDO - ADs cited in the narratives: [AD 90-04-06 R1](https://openairdocs.org/ad/90-04-06-R1) (OpenAirDocs) - NTSB case key (mKey): 88538 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN14LA081 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/88538/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=88538 - Page: https://openairdocs.org/ntsb/CEN14LA081 ## Probable cause The total loss of engine power due to oil starvation because of a fractured governor oil line, which resulted from the improper installation of the governor oil line assembly during the last oil line replacement. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Engine (reciprocating): recip eng oil sys](https://openairdocs.org/ntsb-findings/01058550): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [Aero Commander 112, 1 case](https://openairdocs.org/ntsb-findings/01058550/cases.md?model=0144701), [All aircraft, 130 cases](https://openairdocs.org/ntsb-findings/01058550/cases.md) - [Engine (reciprocating): recip eng oil sys](https://openairdocs.org/ntsb-findings/01058550): Aircraft › Aircraft power plant · Incorrect service/maintenance (probable cause); cases with it: [Aero Commander 112, 1 case](https://openairdocs.org/ntsb-findings/01058550/cases.md?model=0144701), [All aircraft, 130 cases](https://openairdocs.org/ntsb-findings/01058550/cases.md) - [Maintenance: installation](https://openairdocs.org/ntsb-findings/02062035): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Aero Commander 112, 1 case](https://openairdocs.org/ntsb-findings/02062035/cases.md?model=0144701), [All aircraft, 371 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Aircraft maintenance event](https://openairdocs.org/ntsb-events/040); cases with it: [Aero Commander 112, 2 cases](https://openairdocs.org/ntsb-events/040/sequence.md?model=0144701), [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md) - [Enroute: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340); cases with it: [Aero Commander 112, 1 case](https://openairdocs.org/ntsb-events/340/sequence.md?model=0144701), [All aircraft, 820 cases](https://openairdocs.org/ntsb-events/340/sequence.md) - [Enroute: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Aero Commander 112, 2 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=0144701), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Landing: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Aero Commander 112, 2 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=0144701), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing-landing roll: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Aero Commander 112, 5 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=0144701), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot reported that, while in cruise flight, he noticed a lack of engine oil pressure after smelling an odor in the cockpit and that he had to reduce engine power to keep the propeller from exceeding its maximum operating speed. The engine gradually lost total power over a period of 90 seconds. The pilot conducted a forced landing in a field, and the left wing was substantially damaged when it collided with a fence post. A postaccident examination revealed an engine oil leak from a fractured propeller governor oil supply line. The oil line was found inadequately supported by a single clamp, which was also fractured. The engine manufacturer had previously issued a service bulletin (SB) to address several reports of engine failures due to oil starvation that had resulted from fractured governor lines. In all cases, either one or both of the manufacturer-specified clamps and/or supports were missing. The SB stated that the oil line assembly should be visually inspected to determine whether both supports were properly installed and intact. Additionally, the Federal Aviation Administration had previously issued an airworthiness directive (AD) that required the external governor oil line to be supported by at least two clamps/clips to prevent the oil line from fracturing. The airplane's governor oil supply line had been replaced about 47 hours before the accident; however, the oil line assembly was not installed in compliance with the AD, SB, or the engine overhaul manual. ## Factual narrative On December 10, 2013, at 1002 central standard time, a Rockwell International model 112 airplane, N1203J, was substantially damaged during a forced landing near Hammond, Louisiana. The pilot receiving instruction and his flight instructor were not injured. The airplane was registered to and operated by Sunflower Farm & Ranch LLC, under the provisions of 14 Code of Federal Regulations Part 91, while on an instrument flight rules flight plan. Day visual meteorological conditions prevailed for the local area training flight, which departed Hammond Northshore Regional Airport (HDC), Hammond, Louisiana, at 0913. The pilot receiving instruction reported that the purpose of the flight was to practice instrument approach procedures and holding patterns in the local area. He reported that while at 3,000 feet mean sea level he noticed a lack of engine oil pressure after smelling an odor in the cockpit. He stated that he had to reduce engine power to keep the propeller from exceeding its maximum operating speed. He reported that the engine gradually lost total power over a period of 90 seconds. The pilot completed a forced landing in a field about 8 miles northeast of HDC after the airplane descended below an overcast cloud layer into visual meteorological conditions. The left wing was substantially damaged during the forced landing when it collided with a fence post. A postaccident examination, completed by inspectors with the Federal Aviation Administration (FAA), revealed engine oil on the lower fuselage, firewall, and lower right side of the engine. Further examination established that the source of the oil leak was a fractured propeller governor oil supply line. The stainless steel line fractured about 2 inches aft of the crankshaft collar attachment fitting, located toward the front of the engine crankcase. A fractured Adel clamp was found attached to the oil line, located at the approximate midpoint of the oil line. The remaining portion of the Adel clamp was found bolted to the crankcase, located aft of the right rear cylinder. There were no additional supports located along the oil line, and the exterior surface of the oil line did not exhibit any evidence of another support having been installed. On April 2, 1990, the engine manufacturer, Lycoming Engines, issued Mandatory Service Bulletin No. 488A, entitled "Propeller Governor Line Support", to address several reports of engine failures that were the result of oil starvation from fractured external governor oil lines. The service bulletin stated that upon inspection, the fractured oil lines had not been properly supported per Lycoming service documentation. The service bulletin indicated a visual inspection of the oil line assembly was required to determine if both supports (clamps and/or clips) were properly installed and intact. If a visual inspection revealed that any supports were missing from the assembly, the service bulletin stated that the oil line should be replaced or thoroughlyinspected to insure that no cracks exist. The accident engine configuration required an Adel clamp (part no. LW-16266-25-38) and a hose clip (part no. 75165) to be installed on the oil supply line at specified locations. On May 28, 1991, the FAA issued Airworthiness Directive No. 90-04-06 rev. 1, applicable to four-cylinder Lycoming engines with rear-mounted propeller governors, which specified that the external governor oil supply line be supported by at least two clamps/clips to prevent the oil line from fracturing. The airworthiness directive required that the oil line to be replaced if it was not properly supported, or if the line exhibited any leaks, chafing, or interference conditions. The engine, a Lycoming model IO-360-C1D6, serial number L-12411-51A, was last overhauled on May 6, 2004, at 3,755.75 hours total service time. At the time of the accident, the engine had accumulated 786.89 hours since the last overhaul. The last engine maintenance was completed on November 27, 2013, at 4,538.96 hours total service time, when the engine oil and filter were replaced. The engine had accumulated 3.68 hours since that oil change. A review of available maintenance records established that the propeller governor oil supply line (part no. 75167) was replaced on September 18, 2012, at 4,496.00 hours total service time; however, there was no documentation establishing if the oil line had been installed in compliance with Airworthiness Directive No. 90-04-06, Lycoming Mandatory Service Bulletin No. 488A, or the engine overhaul manual. The oil line had accumulated 46.64 hours since it had been replaced. ## Aircraft - Registration: [N1203J](https://openairdocs.org/deregistered/N1203J-2018-03-08), registration cancelled 2018-03-08, S/N 203, built 1974 (OpenAirDocs) - Reported make and model: ROCKWELL INTERNATIONAL 112 - Registry model: [Aero Commander 112](https://openairdocs.org/model/aero-commander-112) (registry code 0144701) (OpenAirDocs) - Registry engine: [Lycoming I0360 series](https://openairdocs.org/engine/lycoming-i0360-series) (registry code 41515, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 203 - Year built: 1974 - Airframe hours: 4543 - Engines: Lycoming IO-360-C1D6 200 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Operator: Sunflower Farm & Ranch LLC - Registered owner: Sunflower Farm & Ranch LLC - Airworthiness certificate: Standard, Normal; Standard, Utility - Last inspection: Annual, April 1, 2013, 38 hours before - Departed: HDC, Hammond, LA - Destination: HDC, Hammond, LA - Flight plan: IFR - Equipment: Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 60; injuries: none; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; last flight review December 18, 2010; seat: left; restraint: 3-point; flight hours: 870 total, 462 in this make and model, 16 in the last 90 days, 9 in the last 30 days, 2 in the last 24 hours - Flight instructor; age 25; injuries: none; flight instructor, commercial; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 1, with waivers/limitations; last flight review August 7, 2013; seat: right; restraint: 3-point; flight hours: 371 total, 0 in this make and model, 305 as pilot in command, 133 in the last 90 days, 28 in the last 30 days, 3 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 360° at 15 knots, gusting 19 - Visibility: 10 statute miles - Lowest ceiling: 1,200 ft overcast - Temperature: 39 °F, dew point 32 °F - Altimeter: 30.39 inHg - Observed at: HDC, 8 nm away ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20131210024919A](https://openairdocs.org/incident/20131210024919A), Dec 10, 2013: Rockwell International 112, Folsom, LA, Substantial damage. At FL30, pilot smelled oil, then noticed oil pressure gauge was "bottomed out". Made turn back towards airport. At VMC, engine failed @ FL16. Headed towards… ## Other investigations on N1203J (1) From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. - [NTSB CHI04LA081](https://openairdocs.org/ntsb/CHI04LA081), Feb 27, 2004: Aero Commander 112 (N1203J), Jackson, MI, substantial damage. Probable cause: The left main tire failed which resulted in the CFI's inability to maintain directional control of the airplane during the landing. A factor associated with the accident was the snow bank which the… ## Docket (8 files) The files NTSB released with the investigation on February 6, 2014, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=88538. 2.1 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 506 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40407900&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Memorandum of Conversation (Pilot, Nicholas Burtchaell) (item 2, .PDF, 60 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40407902&FileExtension=.PDF&FileName=Memorandum%20of%20Conversation%20(Pilot,%20Nicholas%20Burtchaell)-Master.PDF - Memorandum of Conversation (FAA Inspector David Heydt) (item 3, .PDF, 60 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40407903&FileExtension=.PDF&FileName=Memorandum%20of%20Conversation%20(FAA%20Inspector%20David%20Heydt)-Master.PDF - Memorandum of Conversation (FAA Inspector Michael Stanley) (item 4, .PDF, 59 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40407907&FileExtension=.PDF&FileName=Memorandum%20of%20Conversation%20(FAA%20Inspector%20Michael%20Stanley)-Master.PDF - Lycoming Engines Service Bulletin No. 488A (item 5, .PDF, 387 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40407909&FileExtension=.PDF&FileName=Lycoming%20Engines%20Service%20Bulletin%20No.%20488A-Master.PDF - Lycoming Engines Overhaul Manual (Excerpt) (item 6, .PDF, 220 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40407911&FileExtension=.PDF&FileName=Lycoming%20Engines%20Overhaul%20Manual%20(Excerpt)-Master.PDF - FAA Airwothiness Directive No. 90-04-06 (item 7, .PDF, 443 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40407912&FileExtension=.PDF&FileName=FAA%20Airwothiness%20Directive%20No.%2090-04-06-Master.PDF - Engine Maintenance Logbook (Excerpts) (item 8, .PDF, 315 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40407967&FileExtension=.PDF&FileName=Engine%20Maintenance%20Logbook%20(Excerpts)-Redacted.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.