FTW89LA167

NTSB accident investigation · Mooney M20E · Brenham, TX · September 17, 1989

Accident · Minor injuriesLimited investigationFinal report
Date
September 17, 1989, 11:54 local (16:54 UTC)
Place
Brenham, TX
Injuries
2 minor
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N9462VMooney M20E
Weather
Visual (VMC) · Day
Status
Completed · report July 29, 1992
Report
Approved by Office Director
FAA report
19890917035369A
Case key
22919

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

Improper maintenance, improperly secured oil line to the propeller governor, failure of the propeller governor oil line, and subsequent loss of oil, which resulted in oil exhaustion. Factors related to the accident were: failure of maintenance personnel to follow the service bulletin/instruction, and the tree and rough terrain in the emergency landing area.

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 - normal
Lubricating system,oil line - not securedCause
Maintenance,top overhaul - improperOther maintenance personnelCause
Maintenance,service bulletin/letter - not followedOther maintenance personnelFactor
Lubricating system,oil line - failure,totalCause
Propeller governor control - leakCause
Fluid,oil - exhaustionCause
Forced landingDescent - emergency
On ground/water collision with objectLanding - roll
Object - tree(s)Factor
On ground/water encounter with terrain/waterLanding - roll
Terrain condition - rough/unevenFactor

Analysis

During cruise at 6500 ft, oil appeared on the windscreen. Forward visibility was soon restricted & severe vibrations prompted the plt to secure the eng. Subsequently, the acft was dmgd when it hit a small tree & enctrd uneven terrain drg a forced lndg. Inv revealed a 90 deg aluminum fitting on the prop governor oil line had failed where it entered the eng case. The oil line was stainless steel & its movement was designed to be restrained by clamps, which were not in place. A svc instrn, issued in 1986, rcmndd that aluminum fittings be upgraded to stainless steel. A svc bulletin dated 9/8/89 related to numerous 'engine failures due to oil starvation resulting from broken governor lines.' According to that bulletin, failure to re-install the governor line clamps after maint had been the cause of numerous eng failures. Maint personnel accomplished both a top overhaul & an annual inspn, 50 & 12 hrs, respectively, bfr the acdnt.

Aircraft

Registration
N9462V
Reported as
Mooney M20E
Category
Airplane
Serial number
700036
Airframe hours
1,442
Engine
Lycoming IO-360-A1A, 200 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Hall, David W.
Registered owner
David W Hall
Airworthiness certificate
Standard, Normal
Last inspection
Annual · March 2, 1989 · 12 hours before
Departed
9XS2 · Porter, TX
Destination
PEQ · Pecos, TX
Flight plan
VFR

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
63
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
2,226 total · 1,275 in this make and model · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Visibility
9 statute miles
Lowest ceiling
None
Temperature
81 °F

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.