# NTSB LAX95LA189: Ryan Navion, N41151, Flagstaff, AZ, May 16, 1995 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: May 16, 1995, 11:38 local (18:38 UTC) - Place: Flagstaff, AZ - Coordinates: 35.229667, -111.719375 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=35.2297&lon=-111.7194&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: Minor injuries - Injuries: 2 minor - Status: Completed, report December 19, 1995 - Report: Approved by Office Director - NTSB case key (mKey): 29096 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX95LA189 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/29096/pdf - Page: https://openairdocs.org/ntsb/LAX95LA189 ## Probable cause The owner/pilot improper installation of the propeller by failing to properly connect the pitch change mechanism. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Airframe/component/system failure/malfunction, takeoff - initial climb - propeller system/accessories,pitch change mech - not connected (cause) - maintenance,installation - improper, owner/pilot mechanic (cause) - Forced landing, descent - emergency - In flight collision with terrain/water, descent - emergency - terrain condition - drop-off/descending embankment ## Analysis SHORTLY AFTER LIFT-OFF, A PROPELLER BLADE ROTATED TOWARD THE FEATHER POSITION. THE PILOT WAS UNABLE TO MAINTAIN ALTITUDE AND LANDED ADJACENT TO THE RUNWAY ON AN EMBANKMENT. THE AIRPLANE THEN ROLLED DOWN THE EMBANKMENT. EXAMINATION OF THE PROPELLER ASSEMBLY REVEALED THAT A PITCH CHANGE CONTROL ROD END NUT BACKED OFF AND CONTACTED THE ENGINE CASE. THIS CONTACT CAUSED THE PITCH CHANGE CONTROL ROD TO FAIL, WHICH ALLOWED THE PROPELLER BLADE TO ROTATE. THE PILOT, A CERTIFICATED MECHANIC, INSTALLED THE PROPELLER ABOUT 4 DAYS BEFORE THE ACCIDENT. ## Factual narrative On May 16, 1995, at 1138 hours mountain standard time, a Ryan Navion, N41151, crashed about 1/4-mile southwest of the departure end of runway 21 at Pulliam Airport, Flagstaff, Arizona. The pilot was beginning a visual flight rules personal flight to Whiteman Airpark, Pacoima, California, with an intended fuel stop at Kingman Airport, Kingman, Arizona. The airplane, registered to and operated by the pilot, sustained substantial damage. The certificated private pilot and his passenger, a certificated private pilot, sustained minor injuries. Visual meteorological conditions prevailed. The pilot reported in a telephone interview conducted on May 16, 1995, that the engine lost power shortly after the airplane lifted off the runway. The airplane landed on the edge of the runway and then rolled down the embankment. A pilot witness said in a telephone interview conducted on May 16, 1995, that he observed the airplane taking off while he was on final approach to runway 21. He said the airplane appeared to accelerate and lift-off normally; however, after the airplane lifted off, it appeared to decelerate when it reached 25 feet above the ground. The airplane landed on the side of the runway and then rolled down the embankment. The examination of the wreckage showed that one propeller blade had rotated about 90 degrees toward the feather position. During the removal of the propeller, the aircraft retriever discovered that one of the two pitch change rod end nuts was not fully tightened. The nut was on the control rod bolt about 3/16 of an inch. The engine case displayed the nut scrape marks and its associated propeller blade control rod was broken. The pilot told Safety Board investigators that the propeller was installed by Sunstate Propeller, Inc., Tampa, Florida. He sent a copy of a propeller logbook entry that he signed, but did not date, indicating Sunstate Propeller, Inc. (from now on called Sunstate Propeller), installed the propeller. Sunstate Propeller manager reported in a telephone interview and written statement that Sunstate Propeller did not install the propeller. He said that Sunstate Propeller sold the propeller to the pilot, a certificated aircraft mechanic with inspection authorization, and provided him with the necessary tools to install the propeller. He said that the pilot installed the propeller on or about May 12, 1995, at a facility in Lakeland, Florida. A Federal Aviation Administration (FAA) airworthiness inspector from the Scottsdale [Arizona] Flight Standards District Office reported that the airframe logbook entry does not show that Sunstate Propeller installed the propeller. The pilot signed, but did not date, the entry. ## Aircraft - Registration: [N41151](https://openairdocs.org/deregistered/N41151-2017-10-19), registration cancelled 2017-10-19, S/N NAV-4-1151, built 1948 (OpenAirDocs) - Reported make and model: RYAN NAVION - Registry model: [Ryan NAVION](https://openairdocs.org/model/ryan-navion) (registry code 6150160) (OpenAirDocs) - Registry engine: [Continental E185 series](https://openairdocs.org/engine/continental-e185-series) (registry code 17014, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 4-1151 - Engines: CONTINENTAL E-225 225 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Registered owner: George B. Robinson, Jr. - Airworthiness certificate: Standard, Normal - Last inspection: Annual, January 15, 1995 - Destination: WHP, PACOIMA, CA - Airport: FLG, Pulliam Airport, runway 21, 6,999 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 52; private; airplane ratings: single-engine land; medical: class 3, valid medical--no waivers/lim.; seat: left; flight hours: 5,000 total, 2,000 in this make and model, 40 in the last 90 days, 30 in the last 30 days, 8 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 200° at 8 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 54 °F - Altimeter: 29.00 inHg - Observed at: FLG ## 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 19950516033039A](https://openairdocs.org/incident/19950516033039A), May 16, 1995: Tmpson NAVIONH, Flagstaff, AZ, Substantial damage. Power loss on climbout. Landed edge of runway. Rolled down hill. Prop blade feathered. Not secured by pilot mech. 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.