ATL05LA051

NTSB accident investigation · Mooney 20P · Smith, AL · February 18, 2005

Accident · Serious injuriesLimited investigationFinal report
Date
February 18, 2005, 14:23 local (20:23 UTC)
Place
Smith, AL
Injuries
1 serious
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N321DTMooney 20P
Weather
Visual (VMC) · Day
Status
Completed · report December 20, 2005
Report
Approved by Office Director
Parties
Birmingham FSDO
FAA report
20050218002379A
Case key
61040

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

Maintenance personnel failure to properly torque the cylinder head during installation that resulted in the separation from the engine assembly and the subsequent loss of power.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of engine power(total) - mech failure/malfApproach
Engine assembly,cylinder - undertorquedCause
Maintenance,installation - improperOther maintenance personnelCause
Fluid,oil - leak
Forced landingDescent - emergency
In flight collision with objectEmergency descent/landing
Object - tree(s)
Terrain condition - ground

Analysis

While on an instrument flight the engine stopped and oil covered the windshield. The pilot declared an emergency and the air traffic controller attempted unsuccessfully to vector the flight to a nearby grass airstrip. The pilot selected an off-airport location for an emergency landing. The airplane collided with a tree while the pilot was maneuvering for the emergency landing. Post-accident examination of the engine revealed that the #2 cylinder assembly had separated from the crankcase. The #2 cylinder was recovered and exhibited fretting on the mating surface of the base flange. Post-accident examination revealed that the torque on the adjacent cylinder hold down nuts were less than what was prescribed for installation. A review of the engine maintenance records revealed that on 12/18/2002, the #1 cylinder assembly was replaced. The cylinder was overhauled by Aviation Engines and installed by North Alabama Aviation. At the time of the accident the engine had accumulated 85.6 hours since the #1 cylinder assembly had been replaced.

Factual narrative

On February 18, 2005, at 1423 central standard time, a Mooney 20P, N321DT, registered to and operated by the private pilot, collided with a tree during a forced landing into a field in Smith, Alabama. The personal flight was operated under the provisions of Title 14 CFR Part 91 and instrument flight rules. Visual meteorological conditions prevailed and an instrument flight plan was filed. The pilot received serious injuries and the airplane sustained substantial damage. The flight originated in Decatur, Alabama, on February 18, 2005, at 1319.

According to the pilot, while descending on approach into the Columbus Metropolitan Airport, the engine stopped and oil covered his wind shield. The Air Traffic Controller at the Atlanta TRACON was unsuccessful in providing the flight with radar vectors to a grass airstrip in Phoenix City, Alabama. The pilot selected an off-airport location for an emergency landing, and established an approach to land in an open field. The airplane collided with a tree as the pilot maneuvered on the approach to land.

Post-accident examination revealed the airplane came to rest 7 miles west of Columbus Metropolitan Airport. The left wing exhibited circular crush damage on the leading edge, the cockpit door was separated from the fuselage, and the fuselage exhibited damage. Oil was observed on the windshield, and vertical and horizontal stabilizers.

Post-accident examination of the propeller revealed that the propeller remained attached to the engine and exhibited slight damage to both blades, which were found loose in the hub. Examination of the fuel injector servo and flow divider revealed that the servo inlet screen was clean and fuel was found in the lines of the servo and flow divider. The pump was fractured at the flange. Examination of the oil system revealed small metal particles in the oil filter element, but no measurable quantity of oil remained in the engine.

Post-accident examination reveled a lack of torque on the adjacent cylinders hold down nuts. Torque requirements per Lycoming Service Instruction SI No.1029D specifies 600 in/lbs for 1/2 diameter nuts, and 300 in/lbs for 3/8 diameter nuts.

Position Reference: Top Forward (TF), Top Aft (TA), Bottom Forward (BF), Bottom Aft (BA), Damaged (D). The Torque readings were record as follows:

#1 Cylinder 1/2 nuts- TF=550, TA=600, BF=500, BA=550. 3/8 nuts-- TF=300, TA=300, BF=300, BA=300.

#3 Cylinder 1/2 nuts- TF=(D), TA=550, BF=(D), BA=600. 3/8 nuts-- TF=300, TA=300, BF=300, BA=300.

#4 Cylinder 1/2 nuts- TF=400, TA=600, BF=350, BA=550. 3/8 nuts-- TF=300, TA=300, BF=300, BA=300.

Post-accident examination of the engine revealed that the #2 cylinder assembly had separated from the crankcase. Fretting was observed on the cylinder mount pad surface of the crankcase and all of the hold down studs were broken. The #2 cylinder was recovered and exhibited fretting on the mating surface of the base flange. The adjacent crankshaft connecting rod throws #1 and #3 showed signs of heat distress from a loss of oil while operating. All cylinders were removed and the crankcase was disassembled for examination. The interior mating surfaces of the crankcase halves exhibited fretting located at the center main bearing web and at the front main bearing web.

A review of the engine maintenance records revealed that on 12/18/2002, at a tach time of 1142.6 hours, the #1 cylinder assembly was replaced. The cylinder was overhauled by Aviation Engines and installed by North Alabama Aviation. At the time of the accident the tach time was 1228.2, or 85.6 hours since the #1 cylinder assembly had been replaced.

Aircraft

Registration
N321DT
Reported as
Mooney 20P
Category
Airplane
Serial number
24-1360
Airframe hours
2,928
Engine
Lycoming IO-23307-51A, 200 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Registered owner
Charles A. Bashore
Airworthiness certificate
Standard, Normal
Last inspection
Annual · January 1, 2005 · 2 hours before
Departed
DCU · Decator, AL
Destination
CSG · Columbus, GA
Flight plan
IFR

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
64
Injuries
Serious
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
May 1, 2004
Seat
Left
Flight hours
1,767 total · 1,014 in this make and model · 1,727 as pilot in command · 13 in the last 90 days · 3 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
360° at 7 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
57 °F, dew point 46 °F
Altimeter
30.25 inHg
Observed at
CSG

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.