CEN24LA141

NTSB accident investigation · Cozy Mark IV · Gonzales, TX · March 25, 2024

Accident · No injuriesClass 3 · LimitedFinal report
Date
March 25, 2024, 18:53 local (23:53 UTC)
Place
Gonzales, TX · Grassy area adjacent to a runway
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N20MNCozy Mark IV
Defining event
Enroute-cruise: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report April 3, 2026
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
FAA/FSDO
FAA report
20240325005209A
Case key
193992

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 failure to properly torque the crankshaft idler gear hardware according to the engine manufacturer’s service instructions, which resulted in separation of the crankshaft idler gear’s fasteners and disengagement of the camshaft, crankshaft, and crankshaft idler gear and a subsequent total 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.

Engine (reciprocating): recip eng rear sectionAircraft › Aircraft power plant · Related maintenance infoParmelee M/Parmelee N COZY MARK IV: 1 caseAll aircraft: 42 casesProbable cause
MaintenancePersonnel issues › Task performance · Maintenance personnelParmelee M/Parmelee N COZY MARK IV: 1 caseAll aircraft: 143 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

While enroute, at 9,500 ft above mean sea level (msl), the engine lost all power. After multiple attempts to restart the engine, the pilot executed a forced landing to a nearby airport. The airplane landed short of the runway threshold and its nose landing gear separated as the airplane transitioned onto the asphalt runway. The left wing and left canard sustained substantial damage. Postaccident examination of the engine revealed that the left crankshaft idler gear shaft separated from its attach points, which prevented the crankshaft idler gear from engaging its corresponding crankshaft and camshaft gears. The disengagement prevented camshaft rotation and valvetrain timing to the crankshaft. The left crankshaft idler gear’s attachment hardware were both separated into two sections from abrasion. The capscrew was lockwired to the idler shaft but no lockwire was observed through the stud and slotted shear nut. It is likely that maintenance personnel did not follow the engine manufacturer’s service instructions and undertorqued the fasteners during installation, resulting in insufficient clamping force. Additionally, the absence of lockwire likely permitted the shear nut to back off during engine operation. Because the airplane’s maintenance records were not available for review, the investigation was not able to identify when the crankshaft idler gear was last serviced.

Factual narrative

On March 25, 2024, about 1853 central daylight time, a Cozy Mark IV airplane, N20MN, was substantially damaged when it was involved in an accident near Gonzales, Texas. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that while enroute, about 9,500 ft msl, the airplane sustained a total loss of engine power. After multiple attempts to restart the engine, the pilot executed a forced landing to a nearby airport. The airplane landed short of the runway threshold and its nose landing gear separated as the airplane transitioned onto the asphalt runway. The left wing and left canard sustained substantial damage. Postaccident examination of the engine revealed there was no valvetrain continuity when the engine was rotated through at the propeller. Further examination revealed the left crankshaft idler gear was disengaged from the crankshaft and camshaft gears. The 5/16-inch stud, slotted shear nut, and capscrew fasteners that attached the crankshaft idler gear shaft to the crankcase were abraded and separated into two sections. The capscrew was lockwired to the idler shaft but no lockwire was observed through the stud and slotted shear nut and there were no separated sections of lockwire observed in the oil sump. Abrasion was noted to the heads of the cap screw and slotted shear nut. Additionally, circular abrasion observed to the back of the crankshaft idler gear was consistent with the fasteners contacting the idler gear during engine operation. The idler shaft recess in the crankcase exhibited deformation and abrasion. The idler gear shaft contained a bushing that was consistent with the Lycoming Engine’s Service Instruction No. 1197A, Repair of Idler Gear Shaft Recesses, dated March 29, 1974. The bushing was fractured in two sections and deformed. According to the Lycoming Engine’s Service Instruction No. 1310A, Lockwire for Idler Shafts, dated February 25, 1977, the required capscrew torque is 200-inch pounds and the slotted shear nut torque is 150-inch pounds. Additionally, it requires both fasteners to be lockwired. The pilot’s flight logs and airplane maintenance records were not made available during the course of the investigation. Additionally, the pilot did not submit the Pilot/Operator Aircraft Accident/Incident Report Form despite multiple requests.

Aircraft

Registration
N20MN
Reported as
Cozy Mark IV
Category
Airplane, amateur-built
Serial number
425
Built
1999
Airframe hours
1,464
Engine
Lycoming O-360-A3A, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Special, Experimental (Special)
Last inspection
Unknown · October 17, 2023 · 43.6 hours before
Departed
SSF · San Antonio, TX
Destination
EFD · Houston, TX
Airport
T20 · Roger M. Dreyer Memorial Airport, runway 33, 3,200 × 50 ft, asphalt
Equipment
Electronic multifunction display, ADS-B, Electronic primary flight display

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
53
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Medical
BasicMed, Unknown
Seat
Left

Weather

Conditions
Visual (VMC) · Day
Wind
300° at 12 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
77 °F, dew point 34 °F
Altimeter
29.54 inHg
Observed at
BAZ, 32 nm away
METAR
KBAZ 252351Z AUTO 30012KT 10SM CLR 25/01 A2954 RMK AO2 SLP998 T02500011 10267 20244 53008 PWINO $

Docket · 6

The files NTSB released with the investigation on April 3, 2026, on NTSB’s docket system: statements, records, photos and specialists’ reports. 4.8 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.