Pilot Debrief

Aero Commander 200 near Howell, MI — 2019-08-20

Final reportCEN19FA279
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Date
2019-08-20
Location
Howell, MI, USA
Airport
KOZW
Aircraft
Aero Commander 200
Registration
N200HS
Category
Airplane
Highest injury
Fatal
Fatalities
2
Phase of flight
Initial climb

Probable cause

The improper installation of the engine’s metal intake screen, which allowed the filter element to become displaced and subsequently lodge in the intake, blocking intake air and causing the total loss of engine power, at low altitude and low airspeed resulting in the airplane impacting terrain.

NTSB narrative

The single-engine airplane had undergone recent maintenance, including the installation of a field overhauled engine and a three-bladed propeller. The pilot and pilot-rated passenger were conducting a maintenance check flight. One witness reported that the airplane took off normally, but when it reached between about 200 to 300 ft above ground level, it stopped climbing. Another witness reported that he did not hear the engine but that he could not remember whether the propeller was turning. The accident engine was a modification to the airplane’s original configuration. Such a modification is typically recorded on a Federal Aviation Administration Form 337, “Major Repair and Alternation,” and adopted by a field approval. However, neither the form nor maintenance records regarding the installation of the modified engine were found during the investigation. A smart phone recorded two videos from inside the airplane. One of the videos captured the accident flight just after takeoff. Several seconds later, a decrease in engine sound was heard, followed by a momentary warning horn. One of the occupants then stated, “we’re stalling,” followed by the sound of the stall warning horn and impact with terrain. Examination of the airplane revealed substantial damage to the wings and fuselage. During examination of the engine, the air filter element was found displaced and lodged in the intake. The metal screen used to hold the filter element was found improperly installed. The evidence indicates that the improper installation of the metal screen allowed the filter element to become displaced and subsequently lodged in the intake, which blocked the intake air and resulted in a total loss of engine power.

Analysis

Primary failure mode
Mechanical failure
First missed decision gate
Proper maintenance records and checks after engine installation could have prevented the failure.

NTSB coding

Evidence available

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

Docket documents10

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