ERA22LA159

NTSB accident investigation · Dwyer Michael D Q · Spring Hill, FL · March 17, 2022

Accident · No injuriesClass 3 · LimitedFinal report
Date
March 17, 2022, 11:30 local (15:30 UTC)
Place
Spring Hill, FL
Injuries
1 uninjured
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N3QPDwyer Michael D Q
Defining event
Enroute-cruise: Loss of engine power (partial)
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20220317003559A
Case key
104798

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 pilot’s improper modification of the pull starter motor, which resulted in its failure and the subsequent loss of engine power.

Findings · 2

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.

Maintenance: modification/alterationPersonnel issues › Task performance · Owner/builderDwyer Michael D Q-200: 1 caseAll aircraft: 69 casesProbable cause
Engine starting: starterAircraft › Aircraft power plant · Damaged/degradedDwyer Michael D Q-200: 1 caseAll aircraft: 2 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

The pilot was also the owner and builder of the experimental amateur-built airplane. While returning to the airport after a local flight, the engine lost oil pressure, so the pilot diverted toward the nearest airport. The engine then began to run roughly and lost partial power. The airplane was not able to glide to the runway and collided with a ditch in a field during the forced landing. The pilot described that his postaccident examination of the engine revealed that the pinion gear on the pull starter motor fractured into several pieces that entered the accessory gear case, likely seizing the oil pump. About 4 years and 100 flight hours before the accident, the pilot had modified the pull starter motor from its original design so that the motor would fit in the airplane. Postaccident metallurgical examination found that the pull starter motor’s pivot lever was shortened. The pivot lever arm was designed to move the starter clutch and engage the pinion (small) gear to the crankshaft gear. The pinion gear teeth displayed indentations in their surfaces that indicated that they were only partially engaged to the crankshaft gear when the starter was being operated, a condition which was likely the result of the shortened pivot lever. This ultimately resulted in increased stress on the gear teeth during engine start and the subsequent failure of the gear in overstress. The liberated gear teeth likely damaged and seized the engine oil pump, and resulted in the partial loss of engine power.

Factual narrative

On March 17, 2022, about 1130 eastern daylight time, an experimental amateur-built Q 200 airplane, N3QP, was substantially damaged when it was involved in an accident near Spring Hill, Florida. The private pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot, who was also the airplane owner, built the airframe and engine. He stated that, during a local flight, the engine lost oil pressure, so he diverted toward the nearest airport. The engine then began to run roughly and lost partial power. Because the airplane would not be able to glide to the runway, the pilot performed a forced landing to a field. Subsequently, the airplane collided with a ditch, resulting in substantial damage to the wings and fuselage. The airplane was equipped with a pull starter motor, which turned a large gear (through a sprag clutch) to a small gear, which drove the crankshaft. The pilot stated that the starter motor was a certificated airplane part that had been operated for about 100 hours since its overhaul in 2018. The pilot also stated that he had modified the pull starter motor to fit in the airplane. The pilot’s postaccident examination of the small gear found that it was fractured into several pieces that had entered the accessory gear case. The pilot added that oil streaks were present on the empennage. The pull starter motor was provided to the National Transportation Safety Board Materials Laboratory, Washington, DC. Metallurgical examination confirmed that the pull starter motor had been modified from its original design. Specifically, the pivot lever was shortened, and the starter motor power switch was removed and replaced with a power cable leading to a battery post. The pivot lever arm that was shortened was designed to move the starter clutch and engage the pinion (small) gear to the crankshaft gear. The pinion gear teeth had displayed indentations in their surfaces that indicated that they were only partially engaged to the crankshaft gear when the starter was being operated. The pinion gear teeth had fractured edges consistent with overstress.

Aircraft

Registration
N3QP
Reported as
Dwyer Michael D Q (200)
Category
Airplane, amateur-built
Serial number
2841
Built
1985
Airframe hours
1,415
Engine
Continental O-200A, 100 hp, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Airworthiness certificate
Special, Experimental (Special)
Last inspection
Condition · February 1, 2022 · 2 hours before
Departed
PIE · Saint Petersburg, FL
Airport
BKV · Brookville-Tampa Bay Regional Airport, runway 21, 5,014 × 150 ft, concrete
Equipment
ADS-B, Electronic flight bag or handheld device, Electronic multifunction display, 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
67
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Medical
BasicMed, With waivers/limitations
Last flight review
September 25, 2020
Seat
Left
Restraint
4-point
Flight hours
2,300 total · 1,400 in this make and model · 2,300 as pilot in command · 10 in the last 90 days · 10 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
280° at 4 knots
Visibility
10 statute miles
Lowest ceiling
2,600 ft broken
Temperature
72 °F, dew point 61 °F
Altimeter
30.09 inHg
Observed at
KBKV, 2 nm away
METAR
KBKV 171532Z 28004KT 10SM BKN026 BKN031 22/16 A3009

Docket · 5

The files NTSB released with the investigation on September 20, 2023, on NTSB’s docket system: statements, records, photos and specialists’ reports. 2.4 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.