CEN22LA322

NTSB accident investigation · Aero Commander 112 · Granbury, TX · July 18, 2022

Accident · No injuriesClass 3 · LimitedFinal report
Date
July 18, 2022, 11:00 local (16:00 UTC)
Place
Granbury, TX
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N1181JAero Commander 112
Defining event
Enroute-climb to cruise: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
Federal Aviation Administration, North Texas FSDO
FAA report
20220718020539A
Case key
105513

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

On this page

Probable cause

The loss of engine power due to metal contamination within the cylinder following poor maintenance.

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.

Ignition systemAircraft › Aircraft power plant · Not specifiedAero Commander 112: 1 caseAll aircraft: 18 casesProbable cause
MaintenancePersonnel issues › Task performance · Maintenance personnelAero Commander 112: 1 caseAll aircraft: 143 casesProbable cause
Record-keeping: aircraft/maintenance logsPersonnel issues › Task performance · Maintenance personnelAero Commander 112: 1 caseAll aircraft: 21 cases

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

The pilot stated that he performed a new engine run-up on the day of the accident. He stated that after he conducted a preflight inspection of the airplane, he taxied and performed multiple engine run-ups. He then shut down the engine and added fuel. The pilot started the engine and performed multiple engine run-ups both before and after taxiing to the runway with no engine anomalies noted. After takeoff, the engine sustained a loss of power while climbing through about 100 ft above ground level. The pilot performed a forced landing to a road, during which the airplane sustained substantial damage to the fuselage. Postaccident examination of the airplane revealed one of the airbox’s three aluminum spacers was missing. Pieces of the spacer were found in cylinder Nos. 1 and 2 with additional material within the No 1 spark plug lead. The cylinders exhibited pitting damage from the spacer. It is likely that the metallic pieces within the engine cylinder shorted the engine ignition, thus reducing and/or ceasing engine power production on those cylinders. An examination of the remaining engine and systems revealed no anomalies that would have precluded normal operations. The accident occurred on the first flight following an annual inspection and engine installation following a propeller strike inspection. Investigators were not able to determine how the spacer was introduced to the cylinder.

Factual narrative

On July 18, 2022, at 1100 central daylight time, an Aero Commander 112, N1181J, was substantially damaged with it was involved in an accident near Granbury, Texas. The pilot was uninjured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot, who was also the airplane owner, stated that he performed a new engine run-up on the day of the accident. He stated that after he preflighted the airplane, he taxied the airplane and performed multiple run-ups. He then shut down the airplane and allowed it to cool for about 15 minutes. He restarted the airplane and taxied to the airport fuel facility, where he added about 10 gallons of fuel per tank so that the total fuel aboard was about 28 gallons. After he started the airplane, he performed additional runups, and “no irregularities or abnormalities were indicated.” The pilot then taxied to the runway and performed additional runups while holding for takeoff and “no irregularities or abnormalities were indicated.” After takeoff, the engine sustained a loss of power while the airplane climbed through about 100 ft above ground level. The pilot extended the landing gear, pitched the nose down with the stall warning horn sounding, and performed a forced landing on a road. The airplane impacted a highway guard rail and the terrain, resulting in substantial damage to the fuselage. Postaccident examination of the airplane revealed that one of the airbox’s three metal spacers was missing. Pieces of the spacer were found in cylinder Nos. 1 and 2. These cylinders exhibited pitting damage from the spacer. The No. 1 cylinder spark plug gap contained spacer material within the gap. There were no other anomalies with the engine or airframe that would have precluded normal operations. The airframe logbook showed that an annual inspection and engine installation, following a propeller strike teardown inspection, was completed September 15, 2021, with a tachometer time of 3,593.9 hours and an airframe time of 3,563.9 hours. The accident occurred on the first flight following the annual inspection. The airframe logbook entry showed that the last annual inspection was dated July 12, 2022, with a tachometer time of 3,595.49 hours, and was performed by a different airframe and powerplant mechanic (later mechanic) than the one who performed the September 15, 2021, annual inspection. The later mechanic stated to the Federal Aviation Administration (FAA) inspector that he did not have the airplane’s engine logbook when he performed his annual inspection. The later mechanic’s entry stated, “performed an annual inspection,” and there was no verbiage in the entry that stated that the annual inspection was limited to the airframe.

Aircraft

Registration
N1181J
Reported as
Aero Commander 112
Category
Airplane
Serial number
181
Built
1974
Airframe hours
3,565.49
Engine
Lycoming IO-360-C1D6, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Registered owner
Pilot
Airworthiness certificate
Standard, Utility
Last inspection
Annual · July 12, 2022
Departed
GDJ · Granbury, TX
Destination
GDJ · Granbury, TX
Airport
GDJ · Granbury Regional Airport
Equipment
ADS-B, Auto-pilot, Electronic flight bag or handheld device, Stall warning system

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
68
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land, Single-engine sea
Medical
Class 3, With waivers/limitations
Last flight review
March 8, 2021
Seat
Left
Flight hours
640 total · 35 in this make and model · 540 as pilot in command · 10 in the last 90 days · 6 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
220° at 9 knots
Visibility
7 statute miles
Lowest ceiling
None
Temperature
95 °F, dew point 64 °F
Altimeter
29.94 inHg
Observed at
GDJ, 0.25 nm away

Docket · 6

The files NTSB released with the investigation on March 28, 2024, on NTSB’s docket system: statements, records, photos and specialists’ reports. 26.5 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.