CEN23LA062

NTSB accident investigation · Mooney M20K · Addison, TX · December 13, 2022

Accident · Serious injuriesClass 3 · LimitedFinal report
Date
December 12, 2022, 20:05 local (Dec 13, 2022, 02:05 UTC)
Place
Addison, TX · Aircraft lost 2-mile north of the field, on final for runway 16
Injuries
2 serious
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N231GZMooney M20K
Defining event
Approach-IFR final approach: Loss of engine power (total)
Weather
Instrument (IMC) · Night
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
FAA / FSDO
FAA report
20221212022859A
Case key
106448

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

On this page

Probable cause

The fatigue failure of the engine’s camshaft gear teeth which resulted in a loss of all engine power. Contributing to the accident was the non-compliance with the engine manufacturer’s recommended service bulletin.

Findings · 3

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Maintenance/inspectionsAircraft › Aircraft handling/service · Not serviced/maintainedMooney M20K: 1 caseAll aircraft: 103 casesProbable cause
Maintenance/inspections: scheduled maint checksAircraft › Aircraft handling/service · Not serviced/maintainedMooney M20K: 1 caseAll aircraft: 76 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The airplane lost all engine power during a precision instrument approach for landing to the destination airport. After the pilot was unsuccessful in attempting to restart the engine, he performed an off-airport landing to a road, during which the airplane struck a pole and a postcrash fire ensued. There was substantial damage to the wings and fuselage. Postaccident examination revealed that about 12 of the camshaft gear teeth were fractured due to fatigue cracking. The airplane engine’s camshaft gear part numbers were affected by the engine manufacturer’s service bulletin (SB) for camshaft gear tooth fracture or cracks of the teeth. The SB called for the replacement of the camshaft gear with a newer model. The intent of the SB was to eliminate the possibility of camshaft gear tooth fracture, resulting in power loss or in-flight shutdown; compliance with the SB is not mandatory for Part 91 operations. Based upon the camshaft gear part numbers, the SB was not complied with but likely would have addressed the fatigue failure of the camshaft gear teeth. The maintenance records for the airplane were destroyed in the postimpact fire and could not be examined.

Factual narrative

On December 12, 2022, about 2005 central standard time, a Mooney M20K, N231GZ, was substantially damaged when it was involved in an accident near Addison, Texas. The pilot and passenger were seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The flight originated at the Abilene Regional Airport (ABI) in Abilene, Texas, and was enroute to Addison Airport (ADS) in Addison, Texas. The pilot reported being vectored for an instrument landing system approach to runway 16 at ADS when the engine lost all power and the propeller automatically feathered. He stated that, after an unsuccessful attempt to restart the engine, he aligned the airplane with a road for a forced landing. During the approach to the road, the airplane impacted a power pole, which resulted in substantial damage to the wings and fuselage. A postimpact fire ensued. During a postaccident examination, 12 of the camshaft gear teeth were found either broken or missing. Six of the gear teeth were found in the oil sump. The aircraft owner reported that the maintenance logbooks were in the airplane at the time of the accident and were burned, so a review of engine maintenance could not be performed. In 2005 Continental Motors issued critical service bulletin (SB) CSB05-8C; in 2018, that SB was superseded by CSB05-8D. The SB pertained to certain camshaft gear part numbers on certain engines, including the TSIO-520-NB17N and the camshaft gear (part number 655516) installed on the accident airplane. The SB stated that during the airplane’s next 100 hour or annual inspection, the camshaft gear should be replaced with the newer model, part number 656818, which increased the camshaft gear face circumference by .060 inches to prevent the possibility of camshaft gear tooth failure. At the time of the accident, the accident airplane still had the old camshaft gear installed. Although compliance with the SB is not mandatory for Part 91 operations, laboratory analysis confirmed that the gear teeth fractured due to fatigue cracks, which were consistent with the description from the SB.

Aircraft

Registration
N231GZ
Reported as
Mooney M20K
Category
Airplane
Serial number
25-0253
Built
1980
Engine
Continental Motors TSIO-520-NB17N, 310 horsepower, reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Departed
KABI · Abilene, TX
Destination
KADS · Addison, TX
Flight plan
IFR
Airport
KADS · Addison Airport
Equipment
Auto-pilot, Angle of attack indicator, ADS-B, Stall warning system, Satellite tracking device, Electronic primary flight display, Electronic multifunction display

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
60
Injuries
Serious
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
May 21, 2021
Seat
Left
Restraint
Lap only
Flight hours
2,400 total · 2,000 in this make and model

Weather

Conditions
Instrument (IMC) · Night
Wind
120° at 13 knots, gusting 18
Visibility
2 statute miles
Lowest ceiling
400 ft overcast
Temperature
63 °F, dew point 59 °F
Altimeter
2984.00 inHg
Turbulence
Unknown
Observed at
KADS, 2 nm away
METAR
SPECI KADS 130210Z 12013G18KT 2SM -RABR OVC004 17/15 A2984=

Docket · 6

The files NTSB released with the investigation on April 18, 2024, on NTSB’s docket system: statements, records, photos and specialists’ reports. 20.2 MB in all.

FAA reports on this event · 1

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