Individually Owned: 150,657
Corporate Owned: 137,281
Aircraft Accident/Incident Report
Pacoima, California 91331
Saturday, March 4, 1995 8:38 PST
NTSB Narrative Summary Released at Completion of Accident
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.
NTSB Probable Cause Narrative
the failure of the engine overhaul shop to install the correct gasket stack on the propeller governor pad as required by the engine manufacturer.
Event Information
| Type of Event | Accident |
| Event Date | 3/4/1995 |
| Event Day of the Week | Saturday |
| Time of Event | 838 |
| Event Time Zone | Pacific Standard Time |
| Event City | PACOIMA |
| Event State | CALIFORNIA |
| Event Country | -- |
| Zipcode of the event site | 91331 |
| Event Date Year | 1995 |
| Event Date Month | 3 |
| MidAir Collision Indicator | No |
| On Ground Collision occurred ? | No |
| Event Location Latitude | |
| Event Location Longitude | |
| Event Location Airport | |
| Event Location Nearest Airport ID | |
| Indicates whether the acc/inc occurred off or on an airport | Off Airport/Airstrip |
| Distance from airport in statute miles | -- |
| Degrees magnetic from airport | -- |
| Airport Elevation | -- |
| Weather Briefing Completeness | Not pertinent |
| Investigator's weather source | Weather Observation Facility |
| Time of the weather observation | 837 Pacific Standard Time |
| Direction of event from weather observation facility (degrees) | 268 |
| Weather Observation Facility ID | WHP |
| Elevation of weather observation facility | 1002 |
| Distance of event from weather observation facility (units?) | 3 |
| Time Zone of the weather observation | PST |
| Lighting Conditions | Day |
| Lowest Ceiling Height | 6000 |
| Lowest Non-Ceiling Height | 3000 |
| Sky/Lowest/Cloud Conditions | Scattered |
| Sky Condition for Lowest Ceiling | Broken |
| Visibility Runway Visual Range (Feet) | 0 |
| Visibility Runway Visual Value (Statute Miles) | 0 |
| Visibility (Statute Miles) | 10 |
| Air Temperature at event time (in degrees celsius) | 16 |
| Dew Point at event time (in degress fahrenheit) | -- |
| Wind Direction (degrees magnetic) | 0 |
| Variable Wind Indicator | Unknown |
| Wind Speed (knots) | 0 |
| Wind Velocity Indicator | Calm |
| Wind Gust Indicator | Not Gusting |
| Wind Gust (knots) | 0 |
| Altimeter Setting at event time (in. Hg) | 30 |
| Density Altitude (feet) | -- |
| Intensity of Precipitation | Unknown |
| METAR weather report | -- |
| Event Highest Injury | Minor |
| On Ground, Fatal Injuries | 0 |
| On Ground, Minor Injuries | 0 |
| On Ground, Serious Injuries | 0 |
| Injury Total Fatal | -- |
| Injury Total Minor | 2 |
| Injury Total None | -- |
| Injury Total Serious | -- |
| Injury Total All | 2 |
| Investigating Agency | NTSB |
| NTSB Docket Number (internal use) | 681 |
| NTSB Notification Source | -- |
| NTSB Notification Date | Mar 4 1995 12:00AM |
| NTSB Notification Time | 945 |
| Fiche Number and/or location -used to find docket information | IMAGE |
| Date of most recent change to record | Dec 7 2000 4:09PM |
| User who most recently changed record | dbo |
| Basic weather conditions | Visual Meteorological Cond |
| FAA District Office | -- |
Aircraft Involved |
|
|---|---|
Aircraft #1 |
|
| Aircraft Registration Number | N11385 |
| NTSB Number | LAX95LA125 |
| Missing Aircraft Indicator | N |
| Federal Aviation Reg. Part | Part 91: General Aviation |
| Type of Flight Plan filed | None |
| Flight plan Was Activated? | -- |
| Damage | Substantial |
| Aircraft Fire | None |
| Aircraft Explosion | None |
| Aircraft Manufacturer's Full Name | MOONEY |
| Aircraft Model | M20J |
| Aircraft Series Identifier | M20J |
| Aircraft Serial Number | 24-1150 |
| Certified Max Gross Weight | 2740 |
| Aircraft Category | Airplane |
| Aircraft Registration Class | U.S. Registered/U.S. Soil |
| Aircraft is a homebuilt? | No |
| Flight Crew Seats | -- |
| Cabin Crew Seats | -- |
| Passenger Seats | -- |
| Total number of seats on the aircraft | 4 |
| Number of Engines | 1 |
| Fixed gear or retractable gear | Retractable |
| Aircraft, Type of Last Inspection | Annual |
| Date of Last Inspection | Mar 3 1995 12:00AM |
| Airframe hours since last inspection | 1 |
| Airframe Hours | 2046 |
| ELT Installed | Yes |
| ELT Activated | No |
| ELT Aided Location of Event Site | Unknown |
| ELT Type | -- |
| Aircraft Owner Name | GILBERT J. HUM |
| Aircraft Owner Street Address | 1771 W. LONG HILL DRIVE |
| Aircraft Owner City | MONTEREY PARK |
| Aircraft Owner State | CA |
| Aircraft Owner Country | |
| Aircraft Owner Zipcode | 91754 |
| Operator is an individual? | -- |
| Operator Name | |
| Operator Same as Owner? | Yes |
| Operator Is Doing Business As | -- |
| Operator Address Same as Owner? | Yes |
| Operator Street Address | |
| Operator City | |
| Operator State | |
| Operator Country | |
| Operator Zip code | |
| Operator Code | |
| Owner has at least one certificate | None |
| Other Operator of large aircraft? | No |
| Certified for Part 133 or 137 Operation | Unknown |
| Operator Certificate Number | -- |
| Indicates whether an air carrier operation was scheduled or not | -- |
| Indicates Domestic or International Flight | -- |
| Operator carrying Pax/Cargo/Mail | -- |
| Type of Flying (Per_Bus / Primary) | Personal |
| Second Pilot on Board | Yes |
| Departure Point Same as Event | No |
| Departure Airport Code | EMT |
| Departure City | EL MONTE |
| Departure State | CA |
| Departure Country | |
| Departure Time | 830 |
| Departure Time Zone | PST |
| Destination Same as Local Flt | -- |
| Destination Airport Code | SBA |
| Destination City | SANTA BARBARA |
| Destination State | CA |
| Destination Country | |
| Specific Phase of Flight | Climb |
| Report sent to ICAO? | -- |
| Evacuation occurred | -- |
| Date of most recent change to record | Jan 2 2001 10:30AM |
| User who most recently changed record | dbo |
| Since inspection or accident | -- |
| Event Location Runway Number and Location | 0 |
| Runway Length | -- |
| Runway Width | -- |
| Sight Seeing flight | No |
| Air Medical Flight | No |
| Medical Flight | -- |