# NTSB CHI05LA076: Cessna 177RG, N2019Q, Rochester, MN, March 6, 2005 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: March 6, 2005, 13:46 local (19:46 UTC) - Place: Rochester, MN - Coordinates: 43.907222, -92.498886 - Nearby events: https://openairdocs.org/map.md?lat=43.9072&lon=-92.4989&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Serious injuries - Injuries: 1 serious, 1 minor - Status: Completed, report July 31, 2006 - Report: Approved by Office Director - Parties: Cessna Aircraft, FAA, Textron Lycoming - NTSB case key (mKey): 61267 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CHI05LA076 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/61267/pdf - Page: https://openairdocs.org/ntsb/CHI05LA076 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(total) - mech failure/malf, cruise - propeller governor control - loose part/bolt/nut/clamp/etc (cause) - maintenance,installation - improper, other maintenance personnel (cause) - procedure inadequate, manufacturer (cause) - lubricating system,oil gasket - improper (cause) - fluid,oil - starvation (cause) - engine assembly,connecting rod - failure (cause) - Forced landing, descent - emergency - In flight collision with object, descent - emergency - object - tree(s) (contributing factor) - In flight collision with terrain/water, descent - 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](https://openairdocs.org/deregistered/N2019Q-2018-01-11), registration cancelled 2018-01-11, S/N 177RG0419, built 1973 (OpenAirDocs) - Reported make and model: Cessna 177RG - Registry model: [Cessna 177RG](https://openairdocs.org/model/cessna-177rg) (registry code 2073709) (OpenAirDocs) - Registry engine: [Lycoming IO-360-A1B6D](https://openairdocs.org/engine/lycoming-io-360-a1b6d) (registry code 41593, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 177RG0419 - Airframe hours: 3113 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 59; injuries: minor; 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 (OpenAirDocs). - [Accident 20050306004459A](https://openairdocs.org/incident/20050306004459A), Mar 6, 2005: Cessna 177RG, Rochester, MN, Substantial damage. (-23) This was the first flight conducted since the annual inspection was completed on March 2, 2005. During the annual inspection the #4 cylinder and prop… 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.