Pilot Debrief

CIRRUS DESIGN CORP SR22 near Houston, TX — 2015-07-07

Final reportCEN15LA298
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Date
2015-07-07
Location
Houston, TX, USA
Airport
IAH
Aircraft
CIRRUS DESIGN CORP SR22
Registration
N422PB
Category
Airplane
Highest injury
Minor
Fatalities
0
Phase of flight
Initial climb

Probable cause

Maintenance personnel's improper installation of the propeller governor, which resulted in damage to the governor drive gear and its subsequent failure and a subsequent loss of engine power.

NTSB narrative

Before the accident flight, maintenance personnel removed the airplane's propeller governor, checked it for proper operation, and reinstalled it on the engine. The airline transport pilot and passenger departed on the business flight. The pilot reported that, during initial climb, he noticed increasing engine temperature, so he reduced engine power to lower the engine temperature. When the airplane was about 900 ft above ground level, the engine lost partial power and, shortly thereafter, lost total power. With no suitable forced landing area, the airframe ballistic parachute system was deployed, and the airplane impacted terrain next to a residence and sustained substantial damage. Postaccident examination of the engine found that the propeller governor drive gear was fractured, and the gear teeth exhibited damage consistent with the governor drive gear being misaligned. A bench test performed on the governor revealed that it operated within the specified parameters for the unit. The examination also noted the governor washers were improperly stacked; however, this likely did not contribute to the engine failure. A review of engine performance data for the accident flight revealed that the engine rpm reached at least 3,500 rpm during initial climb, which is 800 rpm over the maximum engine speed; it is likely this overspeed condition occurred as a result of the governor drive gear fracturing. The governor drive gear was likely damaged during the installation of the propeller governor, which subsequently failed during takeoff and allowed the engine to overspeed and overheat to the point of losing power.

Analysis

Primary failure mode
Engine power loss
First missed decision gate
Pilot could have aborted the flight upon noticing increasing engine temperatures.

NTSB coding

Evidence available

  • 8 docket documents
View NTSB final reportView NTSB docket

Docket documents8

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