Aircraft Accident/Incident Report

San Carlos, California 94070
Saturday, September 13, 2008 10:00 PDT

NTSB Narrative Summary Released at Completion of Accident

The pilot departed on a local area flight when the engine had higher than normal RPMs. The pilot elected to return to the departure airport and his mechanic inspected the airplane. The mechanic discovered a blister in the engine casing and fragments of metal in the oil. The engine was then disassembled and a ball bearing from the propeller governor was located in the engine which had the potential of resulting in a catastrophic engine failure. Examination of the engine showed that the ball bearings from the governor were able to pass through the oil drain hole of the governor. Follow up examinations of the propeller governor showed that the governor bearing race and plunger were assembled with the bearing race set screw and plunger hole misaligned. When the bearing race set screw was torqued down, the set screw tip flattened against the harder plunger surface. During operation, the set screw/plunger race separated.

NTSB Probable Cause Narrative

The improper assembly of the governor during manufacture.

Event Information

Type of Event Incident
Event Date 9/13/2008
Event Day of the Week Saturday
Time of Event 1000
Event Time Zone Pacific Daylight Time
Event City San Carlos
Event State CALIFORNIA
Event Country --
Zipcode of the event site 94070
Event Date Year 2008
Event Date Month 9
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 373043N
Event Location Longitude 1221458W
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 --
Investigator's weather source Weather Observation Facility
Time of the weather observation 947 Pacific Daylight Time
Direction of event from weather observation facility (degrees) 300
Weather Observation Facility ID SQL
Elevation of weather observation facility 5
Distance of event from weather observation facility (units?) 2
Time Zone of the weather observation PDT
Lighting Conditions Day
Lowest Ceiling Height --
Lowest Non-Ceiling Height --
Sky/Lowest/Cloud Conditions Clear
Sky Condition for Lowest Ceiling None
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) 10
Air Temperature at event time (in degrees celsius) 15
Dew Point at event time (in degress fahrenheit) 12
Wind Direction (degrees magnetic) --
Variable Wind Indicator --
Wind Speed (knots) --
Wind Velocity Indicator Calm
Wind Gust Indicator --
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) 29.93
Density Altitude (feet) --
Intensity of Precipitation --
METAR weather report --
Event Highest Injury None
On Ground, Fatal Injuries --
On Ground, Minor Injuries --
On Ground, Serious Injuries --
Injury Total Fatal --
Injury Total Minor --
Injury Total None 1
Injury Total Serious --
Injury Total All --
Investigating Agency NTSB
NTSB Docket Number (internal use) 25986
NTSB Notification Source FAA San Jose FSDO
NTSB Notification Date --
NTSB Notification Time --
Fiche Number and/or location -used to find docket information --
Date of most recent change to record Sep 15 2009 4:36PM
User who most recently changed record stam
Basic weather conditions Visual Meteorological Cond
FAA District Office --

Aircraft Involved

Aircraft #1

Aircraft Registration Number N419JS
NTSB Number SEA08IA217
Missing Aircraft Indicator --
Federal Aviation Reg. Part Part 91: General Aviation
Type of Flight Plan filed None
Flight plan Was Activated? --
Damage Minor
Aircraft Fire None
Aircraft Explosion None
Aircraft Manufacturer's Full Name DIAMOND
Aircraft Model DA 40
Aircraft Series Identifier --
Aircraft Serial Number 40-439
Certified Max Gross Weight 2535
Aircraft Category Airplane
Aircraft Registration Class --
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 Fixed
Aircraft, Type of Last Inspection Annual
Date of Last Inspection Jan 18 2008 12:00AM
Airframe hours since last inspection 559
Airframe Hours 559
ELT Installed Yes
ELT Activated No
ELT Aided Location of Event Site No
ELT Type C91
Aircraft Owner Name Brian Curry
Aircraft Owner Street Address --
Aircraft Owner City San Francisco
Aircraft Owner State CA
Aircraft Owner Country USA
Aircraft Owner Zipcode 94107
Operator is an individual? No
Operator Name Brian Curry
Operator Same as Owner? Yes
Operator Is Doing Business As --
Operator Address Same as Owner? Yes
Operator Street Address --
Operator City San Francisco
Operator State CA
Operator Country USA
Operator Zip code 94107
Operator Code --
Owner has at least one certificate None
Other Operator of large aircraft? No
Certified for Part 133 or 137 Operation --
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 No
Departure Point Same as Event No
Departure Airport Code SQL
Departure City San Carlos
Departure State CA
Departure Country USA
Departure Time 940
Departure Time Zone PDT
Destination Same as Local Flt dest & departure same, accident can occur anywhere
Destination Airport Code SQL
Destination City San Carlos
Destination State CA
Destination Country USA
Specific Phase of Flight --
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record Sep 15 2009 4:36PM
User who most recently changed record stam
Since inspection or accident Time of Accident
Event Location Runway Number and Location N/A
Runway Length --
Runway Width --
Sight Seeing flight No
Air Medical Flight No
Medical Flight --