CEN19FA279
2019-08-20 · Howell, Michigan, United States · Fatal · 1 aircraft · Status: Completed
Airport KOZW
Aircraft involved
Probable cause & findings
The improper installation of the engine’s metal intake screen, which allowed the filter element to become displaced and subsequently lodge in the intake, blocking intake air and causing the total loss of engine power, at low altitude and low airspeed resulting in the airplane impacting terrain.
Factual narrative
HISTORY OF FLIGHTOn August 20, 2019, about 1118 eastern daylight time, an Aero Commander (Meyers) 200D airplane, N200HS, was substantially damaged when it was involved in an accident at the Livingston County Spencer J Hardy Airport (OZW), Howell, Michigan. The pilot and pilot-rated passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The airplane had undergone recent maintenance, during which the passenger had installed a fieldoverhauled engine and a three-bladed propeller. The pilot, who was seated in the left seat, and passenger, who was seated in the right seat, were conducting a postmaintenance check flight. The accident flight was the second flight of the day in the accident airplane. Before the first flight, the airplane was filled with 34.4 gallons of fuel. It could not be determined if any adjustments or maintenance items were accomplished on the airplane after the first flight and before the accident flight. One witness reported that the airplane took off normally from OZW, but when the airplane was between about 300 and 400 ft above ground level, it stopped climbing. One witness reported that it looked like the airplane tried to turn back to the runway before entering a rapid descent. Another witness reported that he did not hear the engine but that he could not remember whether the propeller was turning. A review of the airport security video that captured the airplane’s departure revealed that it began climbing but then stopped. The airplane then entered a slight descent before it disappeared out of the camera’s view. Another camera captured the airplane rapidly descending just before it impacted terrain. A smart phone recorded two videos from inside the airplane. One of the videos captured the accident flight starting just after takeoff. Several seconds later, a decrease in the engine sound was heard, followed by a momentary warning horn. One of the occupants then stated, “we’re stalling,” which was followed by the sound of the stall warning horn and impact with terrain. AIRCRAFT INFORMATIONThe airplane was originally equipped with a Continental IO-520-A engine and a McCauley two-bladed propeller. The airplane was modified by the installation of a Continental IO-550-F engine and a McCauley three-bladed propeller. The engine and propeller modification is typically recorded on a Federal Aviation Administration (FAA) Form 337, “Major Repair and Alternation,” and adopted by a field approval. Neither the form nor maintenance records regarding the modification were found during the investigation. AIRPORT INFORMATIONThe airplane was originally equipped with a Continental IO-520-A engine and a McCauley two-bladed propeller. The airplane was modified by the installation of a Continental IO-550-F engine and a McCauley three-bladed propeller. The engine and propeller modification is typically recorded on a Federal Aviation Administration (FAA) Form 337, “Major Repair and Alternation,” and adopted by a field approval. Neither the form nor maintenance records regarding the modification were found during the investigation. WRECKAGE AND IMPACT INFORMATIONThe airplane impacted terrain and came to rest about 600 ft beyond the departure end of runway 13. Examination of the airplane revealed that the forward cabin/cockpit area, fuselage, and both wings exhibited impact damage. All the major airplane components were located at the crash site. Two of the three propeller blades came to rest in the main wreckage path, and the third blade remained in the propeller hub and engine. No postcrash fire ensued. Control continuity was established from the cockpit to the elevator and rudder. Aileron continuity was continuous from the cockpit to the left and right aileron bellcranks. The landing gear and flap handles were in the “down” position, and damage to the wings near the landing gear struts was consistent with the gear being extended during the accident. The front seats were equipped with only a lap belt. Examination of the engine revealed that the air filter element was displaced and lodged in the intake tube (see figures 1 and 2). Figure 1: Engine intake Figure 2: Engine intake and air filter element The engine crankshaft was rotated by hand. Compression and suction were obtained for all cylinders at the top spark plug openings. Internal engine continuity was confirmed through the valve train and to the accessory section. When the engine was rotated, a snap/click sound was heard from two magneto impulse couplings, and spark was observed from each top ignition lead. The engine-driven fuel pump was intact, and the drive shaft rotated freely when operated by hand. The top set of sparkplugs exhibited dark-colored combustion deposits and normal electrodes. Cylinder Nos. 4 and 6 exhibited evidence of carbon fouling. MEDICAL AND PATHOLOGICAL INFORMATIONThe Michigan Medicine Pathology and Clinical Laboratories, Ann Arbor, Michigan, under the authority of the Livingston Country Medical Examiner, conducted an autopsy on the pilot. The cause of death was determined to be "multiple traumatic injuries.” The FAA’s Forensic Sciences Laboratory, Oklahoma City, Oklahoma, conducted toxicological testing of specimens from the pilot. The tests were negative for ethanol and carbon monoxide and positive for doxylamine and dextromethorphan, which are over-the-counter medicines often used to treat cold or allergy symptoms. TESTS AND RESEARCHThe airplane was equipped with a JPI engine monitor, and the data were downloaded. The single-engine airplane had undergone recent maintenance, including the installation of a fieldoverhauled engine and a three-bladed propeller. The pilot and pilot-rated passenger were conducting a maintenance check flight. One witness reported that the airplane took off normally, but when it reached between about 200 to 300 ft above ground level, it stopped climbing. Another witness reported that he did not hear the engine but that he could not remember whether the propeller was turning. The accident engine was a modification to the airplane’s original configuration. Such a modification is typically recorded on a Federal Aviation Administration Form 337, “Major Repair and Alternation,” and adopted by a field approval. However, neither the form nor maintenance records regarding the installation of the modified engine were found during the investigation. A smart phone recorded two videos from inside the airplane. One of the videos captured the accident flight just after takeoff. Several seconds later, a decrease in engine sound was heard, followed by a momentary warning horn. One of the occupants then stated, “we’re stalling,” followed by the sound of the stall warning horn and impact with terrain. Examination of the airplane revealed substantial damage to the wings and fuselage. During examination of the engine, the air filter element was found displaced and lodged in the intake. The metal screen used to hold the filter element was found improperly installed. The evidence indicates that the improper installation of the metal screen allowed the filter element to become displaced and subsequently lodged in the intake, which blocked the intake air and resulted in a total loss of engine power. Source: NTSB Aviation Accident Database Retrieved: 2026-02-12
NTSB Findings
FAA avdata. C = Cause, F = Factor.
- C Aircraft-Aircraft handling/service-Maintenance/inspections-(general)-Incorrect service/maintenance
- — Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Airspeed-Attain/maintain not possible
- — Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Altitude-Attain/maintain not possible
- — Aircraft-Aircraft power plant-Power plant-Air intake-Design
Verbatim from NTSB's published report. Source file
NTSB_2019_CEN19FA279.txt.
Findings + structured fields enriched from FAA avall.mdb.
Full investigation docket on
data.ntsb.gov ↗.
Search this event elsewhere
External sources are reported, not agency: signal that something happened, not fact about what happened.
- TallyAero Live Wire Aviation press
- NTSB CAROL Agency ↗
- NTSB Docket Agency ↗
- Aviation Safety Network Aviation press ↗
- Kathryn's Report Aviation press ↗
- Aviation Herald Aviation press ↗
- AVweb Aviation press ↗
- Pilots of America Community ↗
- Reddit /r/flying Community ↗
- FlightAware Aviation press ↗
- AOPA accident database Aviation press ↗
- Google News News ↗
- DuckDuckGo News ↗
Related research
Matched on aircraft type or causal vocabulary (stall, maintenance). All research papers
- NASA NTRS 2019 · Book The Airline Quality Rating 2003
The Airline Quality Rating (AQR) was developed and first announced in early 1991 as an objective method of comparing airline quality on combined multiple performance criteria.
- NASA NTRS 2019 · Contractor Report (CR) Frequency of Specific Categories of Aviation Accidents and Incidents During 2001-2010
The purpose of this study was to determine the types of accidents or incidents that are most important to the aviation safety risk.
- NASA NTRS 2019 · Contractor Report (CR) An Application of CICCT Accident Categories to Aviation Accidents in 1988-2004
Interventions or technologies developed to improve aviation safety often focus on specific causes or accident categories. Evaluation of the potential effectiveness of those interventions is dependent …
- Embry-Riddle Scholarly Commons 2016 · Journal article (JAAER) The Tornado that Struck Embry-Riddle Aeronautical University on Christmas Day, 2006: Lessons Learned from a Near-Miss
An F2 tornado that touched down in Daytona Beach on Christmas Day afternoon caused over $50 million of damage to the Embry-Riddle Aeronautical University campus and nearby neighborhoods.
- Embry-Riddle Scholarly Commons 2015 · Conference paper Assessing the Commercial Aviation Impact of the Year 2000 Open Skies Agreements between the United States and African Countries with Longstanding Flights
The U.S. started a comprehensive campaign towards Open Skies agreement in 1992. The major benefits of Open sky agreement are reported to include increase of passenger and cargo volume between partners…
- Embry-Riddle Scholarly Commons 2009 · Industry report (AQRR) Airline Quality Rating 2009
The Airline Quality Rating (AQR) was developed and first announced in early 1991 as an objective method for assessing airline quality on combined multiple performance criteria.