Pilot Debrief

CESSNA 177B near Honolulu, HI — 2009-01-21

Final reportWPR09LA097
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Date
2009-01-21
Location
Honolulu, HI, USA
Airport
HNL
Aircraft
CESSNA 177B
Registration
N30740
Category
Airplane
Highest injury
Minor
Fatalities
0
Phase of flight
Initial climb

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.

NTSB narrative

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.

Analysis

Primary failure mode
Mechanical failure
First missed decision gate
Properly securing the propeller governor oil line during maintenance could have prevented failure.

NTSB coding

Evidence available

  • Photos
  • 7 docket documents
View NTSB final reportView NTSB docket

Docket documents7

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