CEN15LA298

NTSB accident investigation · Cirrus Design SR22 · Houston, TX · July 7, 2015

Accident · Minor injuriesLimited investigationFinal report
Date
July 7, 2015, 11:37 local (16:37 UTC)
Place
Houston, TX
Injuries
2 minor
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N422PBCirrus Design SR22
Defining event
Initial climb: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report June 25, 2019
Report
Approved by Office Director
NTSB office
Central Region
Parties
McCauley Propellers - Textron Aviation, Cirrus Aircraft Corporation, Hartzell Propeller Inc, FAA Houston FSDO, Continental Motors Inc
FAA report
20150707009889A
Case key
91513

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

Maintenance personnel's improper installation of the propeller governor, which resulted in damage to the governor drive gear and its subsequent failure and a subsequent loss of engine power.

Findings · 3

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Propeller system: propeller governorAircraft › Aircraft propeller/rotor · Incorrect service/maintenanceCirrus Design SR22: 1 caseAll aircraft: 16 casesProbable cause
Maintenance: installationPersonnel issues › Task performance · Maintenance personnelCirrus Design SR22: 5 casesAll aircraft: 371 casesProbable cause
Propeller system: propeller governorAircraft › Aircraft propeller/rotor · FailureCirrus Design SR22: 1 caseAll aircraft: 16 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

Before the accident flight, maintenance personnel removed the airplane's propeller governor, checked it for proper operation, and reinstalled it on the engine. The airline transport pilot and passenger departed on the business flight. The pilot reported that, during initial climb, he noticed increasing engine temperature, so he reduced engine power to lower the engine temperature. When the airplane was about 900 ft above ground level, the engine lost partial power and, shortly thereafter, lost total power. With no suitable forced landing area, the airframe ballistic parachute system was deployed, and the airplane impacted terrain next to a residence and sustained substantial damage. Postaccident examination of the engine found that the propeller governor drive gear was fractured, and the gear teeth exhibited damage consistent with the governor drive gear being misaligned. A bench test performed on the governor revealed that it operated within the specified parameters for the unit. The examination also noted the governor washers were improperly stacked; however, this likely did not contribute to the engine failure. A review of engine performance data for the accident flight revealed that the engine rpm reached at least 3,500 rpm during initial climb, which is 800 rpm over the maximum engine speed; it is likely this overspeed condition occurred as a result of the governor drive gear fracturing. The governor drive gear was likely damaged during the installation of the propeller governor, which subsequently failed during takeoff and allowed the engine to overspeed and overheat to the point of losing power.

Factual narrative

On July 7, 2015, about 1137 central daylight time, a Cirrus SR-22 single-engine airplane, N422PB, descended under the canopy of the cirrus airframe parachute system (CAPS) and landed in a residential neighborhood at Houston, Texas. The pilot and passenger sustained minor injuries, and the airplane was substantially damaged. The airplane was registered to and operated by AIRCCS, LLC; Humble, Texas, as a Title 14 Code of Federal Regulations Part 91 business flight. Day visual meteorological conditions (VMC) prevailed, and a flight plan had not been filed. The airplane departed George Bush Intercontinental/Houston Airport (IAH), Houston, Texas, at 1133, and was destined for Austin Bergstrom International Airport (AUS), Austin, Texas. The pilot reported that during initial climb, he noticed increasing engine temperatures, so he reduced power in an attempt to lower the engine temperatures. When the airplane was about 900 feet above ground level (agl), the engine started to "detonate," and soon after, there was a complete loss of engine power. With no suitable forced landing area, the CAPS was deployed, and the airplane impacted terrain and came to rest upright next to a residence. An on-scene wreckage examination showed there was adequate fuel on-board, consistent with aviation low-lead fuel. At the facility where the airplane had most recently been refueled, refueling unit records and a review of security camera video showed that the airplane had been refueled with aviation gasoline and not with jet fuel. Avionics components containing non-volatile memory (NVM), which included engine performance data, were sent to the National Transportation Safety Board (NTSB) Vehicle Recorder Division for download. A review of the data for the accident flight found the engine rpm reached at least 3,500 rpm (engine speed above 3,500 rpm would not be recorded, since the maximum valve for the sensor is 3,500 rpm). Per the engine's Type Certificate, the maximum engine speed is 2,700rpm. A review of maintenance records for the airplane revealed the propeller governor had been removed and inspected for proper operation, prior to the accident flight. The records also noted that no defects were observed on the governor, and the governor was reinstalled by maintenance personnel. During the post-accident examination, the governor was removed from the engine and tested at McCauley Propeller, Columbus, Georgia. The test revealed the governor operated within the specified parameters for the unit. The examination noted that the propeller governor attaching nuts were rounded off and the washers for the governor were improperly stacked. The engine was also removed from the airframe and shipped to Continental Motors, Mobile, Alabama, for examination/disassembly. The examination found that the governor drive gear was fractured in half and located in the oil sump. The governor drive gear teeth exhibited damage consistent with the governor driven gear being misaligned. The governordrive gear teeth also exhibited damage. A broken governor drive gear would result in insufficient oil pressure to drive the propeller governor and cause an engine to over speed. The pilot did not submit an NTSB Pilot/Operator Accident Report form (NTSB Form 6120.1).

Aircraft

Registration
N422PB
Reported as
Cirrus Design SR22
Category
Airplane
Serial number
2379
Built
2007
Engine
Cont Motor IO-550-N, 310 horsepower, reciprocating
Damage
Substantial damage
Flight
Business · Part 91
Operator
Airccs LLC
Registered owner
Airccs LLC
Airworthiness certificate
Standard, Normal
Departed
IAH · Houston, TX
Destination
AUS · Austin, TX
Flight plan
Unknown
Airport
IAH · George Bush Intercontinental/H, runway 15L, 12,001 × 150 ft, concrete
Equipment
Electronic multifunction display, Electronic primary flight display, Stall warning system, Airframe parachute, Angle of attack indicator, Auto-pilot

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
30
Injuries
Minor
Certificate
Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Unknown
Seat
Left
Restraint
3-point

Weather

Conditions
Visual (VMC) · Day
Wind
160° at 15 knots, gusting 20
Visibility
10 statute miles
Lowest ceiling
25,000 ft broken
Temperature
86 °F, dew point 75 °F
Altimeter
30.03 inHg
Observed at
KIAH, 5 nm away

Docket · 8

The files NTSB released with the investigation on March 27, 2019, on NTSB’s docket system: statements, records, photos and specialists’ reports. 4.9 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.