# NTSB LAX90LA035: Cessna 177RG, N2069Q, Van Nuys, CA, November 17, 1989

- Type: NTSB accident investigation
- Classification: Accident · Serious injuries · Limited investigation · Final report
- Date: November 17, 1989, 15:00 local (23:00 UTC)
- Place: Van Nuys, CA
- Coordinates: 34.190849, -118.489768 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=34.1908&lon=-118.4898&mi=10
- Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping)
- Highest injury: Serious injuries
- Injuries: 1 serious, 1 minor
- Status: Completed, report July 22, 1992
- Report: Approved by Office Director
- NTSB case key (mKey): 26686
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX90LA035
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/26686/pdf
- Page: https://openairdocs.org/ntsb/LAX90LA035

## Probable cause

THE INCORRECT INSTALLATION OF THE ENGINE COWL AND BAFFLE SEALS DURING THE INSTALLATION OF THE ENGINE FOLLOWING AN OVERHAUL.

## 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, approach - vfr pattern - downwind
  - cooling system,cowling - incorrect (cause)
  - maintenance,installation - improper, other maintenance personnel (cause)
  - cooling system,baffle - incorrect (cause)
  - maintenance,installation - improper, other maintenance personnel (cause)
  - engine assembly,cylinder - overtemperature (cause)
  - engine assembly,cylinder - distorted (cause)
  - fluid,oil - leak (cause)
  - fluid,oil - failure,total (cause)
  - engine assembly,crankcase - failure,total (cause)
- Forced landing, descent - emergency
  - terrain condition - none suitable (contributing factor)
- In flight collision with object, descent - emergency
  - object - wire,transmission
- In flight collision with terrain/water, descent - uncontrolled

## Analysis

NEAR THE END OF THE FIRST FLIGHT FOLLOWING INSTALLATION OF AN OVERHAULED ENGINE, THE ENGINE SIEZED AFTER THE PILOT NOTICED A RAPID DROP IN OIL PRESSURE. AFTER THE ACCIDENT, THE LEFT SIDE LOWER EXTERIOR FUSELAGE WAS FOUND TO BE COVERED WITH FRESH OIL, WITH THE OIL SMEAR ORIGINATING NEAR THE OIL BREATHER LINE. THE ENGINE COWL BAFFLE SEALS WERE FOUND INSTALLED INCORRECTLY. LESS THAN 1 QUART OF OIL WAS FOUND IN THE ENGINE SUMP. ON THE EXTERNAL REAR SIDES OF THE #3 & #4 CYLINDER BARRELS, AN OVAL AREA OF HEAT DISTRESS WAS NOTED. THE CRANKSHAFT & PISTON RODS EXHIBITED PROGRESSIVE HEAT DISTRESS ON ALL ROD BEARINGS AND CRANKSHAFT JOURNALS, WITH THE #1 ROD EXHIBITING THE LEAST HEAT SIGNATURES & THE #4 THE MOST SEVERE. THE #3 ROD CAP WAS FOUND LOOSE IN THE ENGINE; EXAMINATION OF THE CAP BOLTS REVEALED SEVERE NECKING SIGNATURES AT THE POINT OF TENSION FAILURE. A MICROMETER WAS USED TO MEASURE THE CYLINDER BARRELS FOR ROUNDNESS. THE #3 CYL WAS FOUND TO BE OUTSIDE THE FACTORY SPEC BY .002 INCHES.

## Aircraft

- Registration: [N2069Q](https://openairdocs.org/deregistered/N2069Q-2007-09-18), registration cancelled 2007-09-18, S/N 177RG0469, 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: 177RG0469
- Engines: LYCOMING IO-360-A1B6D 200 horsepower reciprocating
- Damage: Substantial damage
- Flight: Personal, Part 91
- Operator: William A. Ryan
- Departed: VNY

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; private, commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, valid medical--w/ waivers/lim; flight hours: 435 total, 100 in this make and model, 275 as pilot in command, 20 in the last 90 days, 15 in the last 30 days, 1 in the last 24 hours

## Weather

- Conditions: Visual (VMC), Day
- Wind: 120° at 8 knots
- Visibility: 5 statute miles
- Lowest ceiling: none
- Temperature: -0 °F, dew point -0 °F
- Observed at: VNY, 1 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 19891117045759A](https://openairdocs.org/incident/19891117045759A), Nov 17, 1989: Cessna 177RG, Van Nuys, CA, Substantial damage. Engine seized on flight after overhaul,lost oil. Baffle seals put in backwards. Two cylinders out of round.

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.

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