Pilot Debrief

MOONEY M20J near Lewiston, CA — 2012-02-17

Final reportWPR12LA108
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Date
2012-02-17
Location
Lewiston, CA, USA
Airport
KO54
Aircraft
MOONEY M20J
Registration
N367MR
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Initial climb

Probable cause

A loss of engine power due to oil starvation as a result of improper maintenance.

NTSB narrative

As the airplane climbed to an altitude of about 4,000 feet mean sea level after departure, the engine quit and would not restart. The pilot landed the airplane on a 3-lane section of highway; however, as the highway narrowed, the airplane’s left wing struck two road signs and was substantially damaged. On-scene personnel observed oil streaks on the left side of the airplane’s wing and fuselage that appeared to emanate from the engine cowl. Postaccident examination of the engine revealed that the No. 1 connecting rod bearing had seized and that internal engine damage was consistent with oil starvation. Additionally, examination revealed that a single propeller governor gasket was installed on the engine, whereas the proper gasket configuration was a governor pad plate sandwiched between two gaskets. Maintenance records showed that 10 hours before the accident, maintenance that required the removal and reinstallation of the propeller governor had been performed on the engine. The Mooney service manual does not specify that a 3-piece gasket stack be used when installing the propeller governor; however, the Mooney Illustrated Parts Manual shows a 3-piece gasket stack in place at the propeller governor. Additionally, a Lycoming Service Instruction and a Federal Aviation Administration Special Airworthiness Information Bulletin, both of which were issued in 2005, state that a propeller governor pad plate is necessary in this installation to eliminate the possibility of oil leakage between the propeller governor and the accessory housing.

Analysis

Primary failure mode
Engine power loss
First missed decision gate
Proper installation of propeller governor gaskets could have prevented engine failure.

NTSB coding

Evidence available

  • FDR / data
  • Photos
  • 14 docket documents
View NTSB final reportView NTSB docket

Docket documents14

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