WPR09LA097

NTSB accident investigation · Cessna 177B · Honolulu, HI · January 21, 2009

Accident · Minor injuriesLimited investigationFinal report
Date
January 20, 2009, 15:49 local (Jan 21, 2009, 01:49 UTC)
Place
Honolulu, HI
Injuries
1 minor, 1 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N30740Cessna 177B
Defining event
Enroute-climb to cruise: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report October 19, 2009
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration
FAA report
20090120008559A
Case key
73271

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

An oil starvation induced catastrophic engine failure due to the fracture and separation of the propeller governor oil line, which was a result of inadequate inspection by maintenance personnel.

Findings · 3

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.

Inspection: scheduled/routine inspectionPersonnel issues › Task performance · Maintenance personnelCessna 177B: 2 casesAll aircraft: 167 casesProbable cause
Misc hardware: hoses and tubesAircraft › Fluids/misc hardware · Inadequate inspectionCessna 177B: 1 caseAll aircraft: 40 casesProbable cause
Engine (reciprocating)Aircraft › Aircraft power plant · FailureCessna 177B: 1 caseAll aircraft: 497 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

Shortly after takeoff, the pilot noticed that oil began to spray onto the windshield, which limited his visibility to only what he could see out of the left and right side windows. The pilot informed air traffic control of the situation and made a 180-degree turn back towards the airport. While returning to the airport, the pilot felt a severe vibration from the engine and shortly thereafter, the engine lost power. Due to the oil on the windshield obstructing his vision, the pilot overshot the runway and landed in a grassy area on the airport. The nose landing gear separated and the airplane nosed down. Post-accident examination of the engine revealed a hole in the top of the engine case above the number 3 cylinder. The propeller governor oil line was found fractured at the "B" nut securing it to the front of the crankcase. Both of the line's securing clamps were found broken. Examination of the engine logbook revealed that the last 100-hour inspection was completed about 89 hours before the accident. Federal Aviation Regulations stipulate that during a 100-hour or annual inspection, all engine lines, hoses, and clamps are to be inspected for leaks, improper condition, and looseness. Two days prior to the accident, an oil leak was reported on the aircraft. A mechanic reported that he determined the source of the oil leak was probably the crankshaft seal. He changed the crankshaft seal and test ran the engine with no oil leaks noted. The accident flight was the first flight after this repair.

Factual narrative

On January 20, 2009, at 1549 Hawaiian standard time, a Cessna 177B, N30740, was substantially damaged during a forced landing following a loss of engine power at Honolulu International Airport, Honolulu, Hawaii. The private pilot received minor injuries and his passenger was not injured. Moore Air, Inc., was operating the airplane under 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed for the local flight, which was originating at the time of the accident. A flight plan had not been filed. The pilot reported that after taking off from runway 22L, he leveled off at 1,500 feet and reduced propeller rpm to 2,300 rpm. As he started to reduce manifold pressure, oil sprayed onto the windshield, limiting the pilot's visibility to the left and right cockpit windows. The pilot informed air traffic control of the situation and initiated a 180-degree turn back to the airport. Air traffic control cleared the pilot to land on runway 8L, a 12,300-foot by 150-foot runway. As the airplane approached the airport, the pilot felt a "severe vibration," and shortly thereafter, the engine "seized." The pilot established best glide speed. Due to the lack of forward visibility resulting from the oil on the windshield, the pilot overshot runway 8L and executed a forced landing onto a grassy area. During the landing roll, the nose landing gear separated, and the airplane nosed down. Examination of the airplane by a Federal Aviation Administration (FAA) inspector revealed that the firewall was buckled, and the outboard 4 feet of the right wing's leading edge was crushed aft. There was a hole in the top of the engine case above the number 3 cylinder. The propeller governor oil line was found fractured at the "B" nut securing it to the front of the crankcase. Examination of the engine by an airframe and powerplant mechanic revealed that the propeller governor oil line was not properly secured. The engine manufacturer's parts manual calls for the line to be secured by two clamps. The forward clamp and its securing bolt and washers were missing. The aft clamp was broken with the rounded part of the clamp missing. Review of the engine maintenance logbook revealed that on November 13, 2008, at a tachometer time of 2,816.5 hours, a 100-hour inspection was performed and the airplane was determined to be in airworthy condition. FAR Part 43, Appendix C states in part: "Each person performing an annual or 100-hour inspection shall inspect components of the engine and nacelle group as follows: (7) Lines, hoses, and clamps – for leaks, improper condition and looseness." At the time of the accident, the airplane had been flown 89 hours since this inspection. On January 18, 2009, a discrepancy was written in the airplane's "Aircraft Discrepancy Log" stating "Oil leak." In a written statement, the certified airframe and powerplant mechanic, who was assigned to correct this discrepancy, reported that he found oil deposited on the windshield, enginecowling, the front of the engine, and the propeller blades. The location of these oil deposits led him to conclude that the oil was probably leaking from the front crankshaft seal. The mechanic reported that he "did inspect the governor oil pressure line for tight torque and leaks" and "found it to be dry and secured." After replacing the crankshaft seal and the propeller base o-ring, he and another mechanic started and ran the engine at various speeds with no oil leaks noted. This repair was completed on January 19, 2009, and the accident flight was the first flight following the repair.

Aircraft

Registration
N30740
Reported as
Cessna 177B
Category
Airplane
Serial number
17701434
Airframe hours
3,580
Engine
Lycoming O-360-A1F, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Moore Air
Registered owner
Benjamin J. Fulk
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · November 13, 2008 · 89 hours before
Departed
HNL · Honolulu, HI
Destination
PHJR · Kapolei, HI
Airport
HNL · Honolulu International Airport, runway 08L, 12,300 × 150 ft, asphalt

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
56
Injuries
Minor
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 2, With waivers/limitations
Last flight review
June 24, 2007
Seat
Left
Flight hours
320 total

Weather

Conditions
Visual (VMC) · Day
Wind
350° at 15 knots, gusting 22
Visibility
10 statute miles
Lowest ceiling
None
Temperature
75 °F, dew point 55 °F
Altimeter
30.04 inHg
Observed at
HNL

Docket · 7

The files NTSB released with the investigation on August 31, 2009, on NTSB’s docket system: statements, records, photos and specialists’ reports. 3.7 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.