Mooney M20J accident near Pacoima, California, March 4, 1995
On March 4, 1995 at about 4:38 pm local time, a Mooney M20J, registered N11385, was substantially damaged in an accident near Pacoima, California. It was a personal flight under general aviation rules (Part 91). 2 people had minor injuries. The weather was visual conditions (good weather).
The NTSB's probable cause their words, unchanged
the failure of the engine overhaul shop to install the correct gasket stack on the propeller governor pad as required by the engine manufacturer.
Source: NTSB aviation accident database, copy made October 5, 2026. Docket and reports at the NTSB.
What the record shows
- Date
- March 4, 1995 · about 4:38 pm local time
- Place
- Pacoima, California · map
- Type
- Accident
- Injuries
- 2 people had minor injuries.
- Weather
- visual conditions (good weather)
- Aircraft
- Mooney M20J · all M20Js on the register
- Registration
- N11385 · no longer on the register · serial 24-1150
- Damage
- Substantial damage
- Flight
- Personal flight · general aviation rules (Part 91)
The NTSB's narrative final · quoted from the NTSB record
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.
The complete narrative as the NTSB published it. The NTSB's docket holds the report as a PDF and any photographs, statements and other documents from the investigation.
The factual record from the NTSB's investigation tables, in plain English
Pilot
- Certificate: private
- Ratings: single-engine land; instrument: airplane
- Flight time: 1,593 hours in all; 1,373 in this make and model; 16 in the last 90 days; 1,440 as pilot in command
- Medical certificate: Class 3 (valid medical--w/ waivers/lim.)
- Seat: left
The aircraft
- Airframe total time: 2,046 hours
- Last inspection: annual inspection, March 3, 1995; 1 hours since
- Maximum gross weight: 2,740 lb
- Seats: 4
- Landing gear: retractable
- Engine: Lycoming IO-360-A3B6D (piston); 0 hours total
The flight
- Departed from: EMT El Monte CA at 4:30 pm
- Destination: SBA Santa Barbara CA
- Flight plan: none
- Runway 0
- A second pilot was aboard
Weather at the time
- Light: daylight
- Visibility: 10 statute miles
- Sky: broken clouds at 6,000 ft; scat at 3,000 ft
- Temperature: 61°F (16°C), dew point 0°F (-18°C)
- Altimeter: 30.00 inHg
- Observation at 4:37 pm from WHP, 3 miles away
Injuries
| Fatal | Serious | Minor | None | |
|---|---|---|---|---|
| Crew | 1 | |||
| Passengers | 1 |
Documents from the investigation the NTSB's docket: the evidence folder behind the report
The docket, the folder of records gathered during an investigation (maintenance records, photographs, witness statements, examinations), has not been read from the NTSB for this case yet; the list appears here once it has. Open the docket at the NTSB.
Everything on this page comes from the NTSB's public records. The narrative, probable cause and findings are the NTSB's own words; the coded tables behind the report are written out in plain English, with pilots' ages, home towns and medical details left out. The documents and photographs are the NTSB's docket, shown as the NTSB released them. This site's own text never names anyone involved. A preliminary report can change; the final report usually follows one to two years later, and the page is refreshed when it does.