# NTSB WPR09LA097: Cessna 177B, N30740, Honolulu, HI, January 21, 2009 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: January 20, 2009, 15:49 local (Jan 21, 2009, 01:49 UTC) - Place: Honolulu, HI - Coordinates: 21.318611, -157.922225 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=21.3186&lon=-157.9222&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-climb to cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: Minor injuries - Injuries: 1 minor, 1 uninjured - Status: Completed, report October 19, 2009 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 73271 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR09LA097 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/73271/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=73271 - Page: https://openairdocs.org/ntsb/WPR09LA097 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Inspection: scheduled/routine inspection](https://openairdocs.org/ntsb-findings/02061520): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Cessna 177B, 2 cases](https://openairdocs.org/ntsb-findings/02061520/cases.md?model=2073708), [All aircraft, 167 cases](https://openairdocs.org/ntsb-findings/02061520/cases.md) - [Misc hardware: hoses and tubes](https://openairdocs.org/ntsb-findings/01071410): Aircraft › Fluids/misc hardware · Inadequate inspection (probable cause); cases with it: [Cessna 177B, 1 case](https://openairdocs.org/ntsb-findings/01071410/cases.md?model=2073708), [All aircraft, 40 cases](https://openairdocs.org/ntsb-findings/01071410/cases.md) - [Engine (reciprocating)](https://openairdocs.org/ntsb-findings/01058500): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [Cessna 177B, 1 case](https://openairdocs.org/ntsb-findings/01058500/cases.md?model=2073708), [All aircraft, 497 cases](https://openairdocs.org/ntsb-findings/01058500/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Aircraft maintenance event](https://openairdocs.org/ntsb-events/040); cases with it: [Cessna 177B, 2 cases](https://openairdocs.org/ntsb-events/040/sequence.md?model=2073708), [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md) - [Enroute-climb to cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Cessna 177B, 9 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=2073708), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Landing: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Cessna 177B, 10 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=2073708), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing-landing roll: Nose over/nose down](https://openairdocs.org/ntsb-events/096); cases with it: [Cessna 177B, 5 cases](https://openairdocs.org/ntsb-events/096/sequence.md?model=2073708), [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md) ## 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](https://openairdocs.org/deregistered/N30740-2017-06-19), registration cancelled 2017-06-19, S/N 17701434, built 1969 (OpenAirDocs) - Reported make and model: CESSNA 177B - Registry model: [Cessna 177B](https://openairdocs.org/model/cessna-177b) (registry code 2073708) (OpenAirDocs) - Registry engine: [Lycoming O&VO-360 series](https://openairdocs.org/engine/lycoming-o-vo-360-series) (registry code 41514, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 17701434 - Airframe hours: 3580 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 56; injuries: minor; 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 ## 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 20090120008559A](https://openairdocs.org/incident/20090120008559A), Jan 20, 2009: Cessna 177B, Honolulu, HI, Substantial damage. (-23) Pilot reported an engine oil leak that was spraying out and covering the cockpit windshield. Attempted to return back the phnl airport to land. Finding:… ## Docket (7 files) The files NTSB released with the investigation on August 31, 2009, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=73271. 3.7 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 890 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40318129&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Mechanic Interview Summaries and Maintenance Information (item 2, .PDF, 228 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40318133&FileExtension=.PDF&FileName=Mechanic%20Interview%20Summaries%20and%20Maintenance%20Information-Redacted.PDF - Aircraft Records (item 3, .PDF, 157 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40318134&FileExtension=.PDF&FileName=Aircraft%20Records-Redacted.PDF - Propeller Governor Oil Line Diagram (item 4, .PDF, 60 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40318135&FileExtension=.PDF&FileName=Propeller%20Governor%20Oil%20Line%20Diagram-Master.PDF - Photo 1. Oil coating windshield. (item 5, .PDF, 772 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40318136&FileExtension=.PDF&FileName=Photo%201.%20%20Oil%20coating%20windshield.-Master.PDF - Photo 2. Hole in case. (item 6, .PDF, 846 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40318137&FileExtension=.PDF&FileName=Photo%202.%20Hole%20in%20case.-Master.PDF - Photo 3. Broken propeller govenor oil line. (item 7, .PDF, 793 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40318138&FileExtension=.PDF&FileName=Photo%203.%20%20Broken%20propeller%20govenor%20oil%20line.-Master.PDF 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.