CHI05LA076

NTSB accident investigation · Cessna 177RG · Rochester, MN · March 6, 2005

Accident · Serious injuriesLimited investigationFinal report
Date
March 6, 2005, 13:46 local (19:46 UTC)
Place
Rochester, MN
Injuries
1 serious, 1 minor
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N2019QCessna 177RG
Weather
Visual (VMC) · Day
Status
Completed · report July 31, 2006
Report
Approved by Office Director
Parties
Cessna Aircraft, FAA, Textron Lycoming
FAA report
20050306004459A
Case key
61267

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

The loss of engine power due to oil starvation and the subsequent failure of a connecting rod. Additional causes were the improper maintenance due to under-torqued fasteners, and inadequate airframe manufacturer maintenance procedures resulting in an improper oil gasket installation. The tree encountered during the forced landing was a factor.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of engine power(total) - mech failure/malfCruise
Propeller governor control - loose part/bolt/nut/clamp/etcCause
Maintenance,installation - improperOther maintenance personnelCause
Procedure inadequateManufacturerCause
Lubricating system,oil gasket - improperCause
Fluid,oil - starvationCause
Engine assembly,connecting rod - failureCause
Forced landingDescent - emergency
In flight collision with objectDescent - emergency
Object - tree(s)Factor
In flight collision with terrain/waterDescent - emergency
Terrain condition - ground

Analysis

The airplane was substantially damaged when it impacted a tree and the ground during a forced landing following a loss of engine power. Subsequent to the accident, the engine was found to have a broken connecting rod, and the oil level was below the bottom of the dipstick. According to the pilot and maintenance records, the airplane had recently undergone an annual inspection. The annual inspection included an overhaul of the propeller governor. Examination of the governor installation revealed that the mounting nuts did not have the proper stack up of washers and were not torqued to specifications. In addition, the aircraft maintenance manual for the airplane indicated the use of a single gasket between the governor and the engine accessory housing. An aircraft maintenance manual for later year models of the airplane and an engine manufacturer's Service Instruction indicated the use of 2 gaskets and a plate between the propeller governor and the engine accessory housing. The engine manufacturer’s Service Instruction stated that the 2 gaskets and plate are necessary "to eliminate the possibility of oil leakage between the propeller governor and the accessory housing."

Factual narrative

On March 6, 2005, about 1346 central standard time, a 1973 Cessna 177RG, N2019Q, owned and piloted by a private pilot, sustained substantial damage during a forced landing following a loss of engine power while maneuvering near Rochester Minnesota. The 14 CFR Part 91 personal flight was operating in visual meteorological conditions without a flight plan. The passenger received serious injuries and the pilot received minor injuries. The local flight originated about 1330.

The pilot reported that on the accident flight he checked the oil pressure before takeoff and during the flight. He said that the last time he checked the oil pressure was about 3 to 4 minutes prior to the engine failure. He stated that after over flying his residence the engine began to vibrate "fiercely" and then seized as he attempted to reduce power. The pilot stated that he attempted to land on a local highway and the right wing struck a tree during the landing. The pilot stated that the airplane then came to rest in a field adjacent to the runway.

The pilot reported that an annual inspection had just been completed on the airplane. He stated that he and his son assisted the mechanic by operating the engine while the mechanic checked for leaks. The pilot reported that no leaks were found.

Examination of the airplane's engine subsequent to the accident revealed an oil leak that was traced to the propeller governor mounting pad. The propeller governor mounting nuts were found to be torqued slightly more than finger tight. The aircraft maintenance manual specifies a torque range of 100 to 150 inch pounds of torque for the mounting nuts. In addition, it was found that there were only 3 lock washers and 2 flat washers distributed between the 4 mounting nuts. Further examination of the propeller governor installation revealed a single gasket between the propeller governor and the engine accessory case. The maintenance manual for Cessna 177 airplanes produced between 1971 and 1975 indicated the use of a single gasket during installation of the propeller governor. The maintenance manual for Cessna 177 airplanes produced between 1976 and 1978 indicated the use of 2 gaskets separated by a plate in accordance with Lycoming Service Instruction 1438 or the latest revision. Additionally, Lycoming Service Instruction 1438 stated that the use of 2 gaskets separated by a plate are necessary "to eliminate the possibility of oil leakage between the propeller governor and the accessory housing."

Further examination of the engine revealed that the oil level was below the bottom of the oil dipstick and that the number 4 connecting rod was broken.

According to maintenance records, the date of the annual inspection was March 2, 2005. The maintenance records indicated that the propeller governor was removed, overhauled, and reinstalled during the annual inspection.

Aircraft

Registration
N2019Q
Reported as
Cessna 177RG
Category
Airplane
Serial number
177RG0419
Airframe hours
3,113
Engine
Lycoming IO-360-A1B6D, 200 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Registered owner
Carlton E. Johnson
Airworthiness certificate
Standard, Normal
Last inspection
Annual · March 1, 2005 · 0 hours before
Departed
RST · Rochester, MN

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
59
Injuries
Minor
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
July 1, 2003
Seat
Left
Flight hours
695 total · 265 in this make and model · 695 as pilot in command · 2 in the last 90 days · 0 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
220° at 16 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
57 °F, dew point 30 °F
Altimeter
29.56 inHg
Observed at
KRST, 15 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.