ASN Wikibase Occurrence # 359281
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| Date: | Saturday 4 March 1995 |
| Time: | 09:38 LT |
| Type: |  Mooney M20J |
| Owner/operator: | Private |
| Registration: | N11385 |
| MSN: | 24-1150 |
| Total airframe hrs: | 2046 hours |
| Engine model: | LYCOMING IO-360-A3B6D |
| Fatalities: | Fatalities: 0 / Occupants: 2 |
| Aircraft damage: | Substantial |
| Category: | Accident |
| Location: | Pacoima, CA -
 United States of America
|
| Phase: | En route |
| Nature: | Private |
| Departure airport: | El Monte, CA (KEMT) |
| Santa Barbara, CA | |
| Investigating agency: | NTSB |
| Confidence Rating: |  Accident investigation report completed and information captured |
AFTER OVERHAUL AT AN ENGINE FACILITY, THE ENGINE WAS INSTALLED IN THE AIRPLANE BY A MAINTENANCE SHOP. THE ENGINE WAS GROUND RUN FOR ONLY 40 MINS INSTEAD OF THE 2 HRS AND 25 MINS SPECIFIED BY LYCOMING. DURING THE TEST, AN OIL LEAK WAS FOUND IN THE AREA OF THE PROP GOVERNOR OIL PRESSURE LINE FITTING. THE FITTING WAS TIGHTENED AND THE AIRCRAFT PUT IN THE OWNER'S HANGAR. ON THE FIRST FLIGHT BY THE OWNER, THE ENGINE SEIZED AFTER 15 MINS. THE AIRCRAFT COLLIDED WITH OBSTRUCTIONS DURING THE FORCED LANDING. A LARGE SMEAR OF OIL WAS FOUND ON THE FUSELAGE BELLY AND LEFT SIDE. THE DISASSEMBLY OF THE ENGINE REVEALED DAMAGE CONSISTENT WITH LACK OF LUBRICATION DUE TO OIL EXHAUSTION. THE DIP STICK WAS IN PLACE AND ALL OIL LINES AND FITTINGS WERE TIGHT AND NOT LEAKING. WHEN THE PROP GOVERNOR WAS REMOVED ONLY A MS9144-01 SCREEN GASKET WAS FOUND INSTALLED. A RAISED CHANNEL AND OIL TRAIL WAS OBSERVED FROM A PRESSURE PORT IN THE GOVERNOR PAD UNDER THE GASKET TO THE PAD EDGE. LYCOMING'S PARTS MANUAL AND SERVICE INSTRUCTIONS SPECIFY THAT THIS ENGINE REQUIRES ANOTHER SPECIAL GASKET AND PLATE TO BE INSTALLED WITH THE MS9144-01 GASKET TO PREVENT OIL LEAKAGE. THE OVERHAUL SHOP WAS UNAWARE OF THE SPECIAL GASKET STACK REQUIREMENT AND DELIVERED THE ENGINE TO THE MAINTENANCE SHOP WITHOUT GASKETS ON THE GOVERNOR PAD. THE MAINTENANCE SHOP USED ONLY THE MOONEY MAINTENANCE MANUAL, WHICH DOES NOT MENTION SPECIAL GASKETS, FOR THE ENGINE INSTALLATION AND INSTALLED THE PROP GOVERNOR WITH ONLY THE MS9144 GASKET.
Probable Cause: the failure of the engine overhaul shop to install the correct gasket stack on the propeller governor pad as required by the engine manufacturer.
Accident investigation:
 |
|
Sources:
NTSB LAX95LA125
Location
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 15-Mar-2024 08:55 | ASN Update Bot | Added |
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