21 Jan 2009: CESSNA 177B — Moore Air

21 Jan 2009: CESSNA 177B (N30740) — Moore Air

No fatalities • Honolulu, HI, United States

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 Determination

Accident 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, engine cowling, 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.

Contributing factors

  • cause Maintenance personnel
  • cause Inadequate inspection
  • cause Engine (reciprocating) — Failure

Conditions

Weather
VMC, wind 350/15kt, vis 10sm

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