CEN23LA107

NTSB accident investigation · Mooney M20 · Lakeway, TX · February 12, 2023

Accident · No injuriesClass 3 · LimitedFinal report
Date
February 12, 2023, 09:58 local (15:58 UTC)
Place
Lakeway, TX · Golf course
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N304MAMooney M20
Defining event
Approach-VFR pattern downwind: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
Mooney International Corporation, Hartzell Propeller / Hartzell Engine Technologies, FAA San Antonio FSDO
FAA report
20230212001079A
Case key
106726

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

A total loss of engine power due to detonation and preignition in the No. 6 cylinder.

Findings · 2

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.

Engine (reciprocating)Aircraft › Aircraft power plant · FailureMooney M20K: 3 casesAll aircraft: 497 casesProbable cause
Engine (reciprocating)Aircraft › Aircraft power plant · Incorrect use/operationMooney M20K: 3 casesAll aircraft: 497 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

Before purchasing the airplane, the pilot had an inspection performed. One of the findings on the inspection stated that, “spark plugs are worn past limits.” There were no indications that the magneto timing was checked during the inspection. The pilot reported that the airplane had been run with a lean mixture in the past. After the pilot purchased the airplane, he flew the airplane on a cross-country flight to relocate it to his home base. While in flight, the engine had a low manifold pressure reading and then the engine sustained a total loss of power. The pilot attempted to fly to the nearest airport, but instead performed a forced landing to a golf course. During the forced landing sequence, the airplane impacted trees and a wood fence, and came to rest near a diesel generator. The airplane sustained substantial damage to the fuselage and to both wings. Examination of the airframe revealed no mechanical anomalies. Examination of the engine revealed a hole in the corner of the No. 6 piston; however, the No. 6 cylinder was intact. The No. 6 piston had eroded crown material and a darkened periphery. The engine case was found intact. The top spark plugs from the Nos. 3, 5, and 6 cylinders and the bottom spark plugs from the Nos. 3 and 5 cylinders were found in a “worn out - normal condition.” The right magneto timing was found at 22°, when it is supposed to be at 20°. The left magneto timing was found at 15°, when it is supposed to be at 20°. The oil breather tube was found intact, and the slot was not blocked. Engine oil was found splattered in and around the oil breather tube area, including traveling rearward on the area underneath the oil breather tube. No anomalies were noted with the turbocharger system or the propeller. It is likely a total loss of engine power occurred when the No. 6 piston developed a hole from burn through, consistent with detonation and preignition signatures consisting of combustion deposits and excessive temperature exposure. The hole in the piston likely allowed exhaust gases, caused by the detonation and preignition, to force engine oil out of the oil breather tube. The combination of the engine being previously run with a lean mixture, worn spark plugs, and incorrect magneto timing, likely lead to the preignition and detonation and a subsequent total loss of engine power.

Factual narrative

On February 12, 2023, about 0958 central standard time, a Mooney Aircraft Corporation M20K Encore airplane, N304MA, sustained substantial damage when it was involved in an accident near Lakeway, Texas. The pilot sustained no injury. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal cross-country flight. The pilot reported that he had recently purchased the airplane and he was relocating the airplane to his home base at the Outlaw Field Airport (CKV), Clarksville, Tennessee. During the preflight inspection, the pilot did not observe any anomalies. He reported that the airplane had 57 gallons of fuel onboard at takeoff and the engine oil was at a sufficient level for flight operations. A review of ADS-B data showed that the airplane departed from the Kestrel Airpark (1T7), Spring Branch, Texas, and traveled to the northeast. The pilot reported that while in flight, the engine had a low manifold pressure reading and then the engine sustained a total loss of power. The ADS-B data showed that the airplane performed a 180° turn as it approached the Colorado River just to the north of Bee Cave, Texas. The pilot then maneuvered the airplane north toward the Lakeway Airpark (3R9), Lakeway, Texas. Unable to make the airport, the pilot performed a forced landing to a golf course just to the north of 3R9. During the forced landing, the airplane impacted trees and a wood fence, and came to rest upright near a diesel generator. The pilot was able to egress from the airplane without further incident. The airplane sustained substantial damage to the fuselage and to both wings. A Federal Aviation Administration (FAA) inspector responded to the accident site. A large amount of engine oil was observed trailing rearward on the underside of the fuselage. The engine oil level was checked at the accident site and oil was not observed on the dipstick. Examination of the airframe revealed flight control continuity. Both wing fuel tanks were found breached and no anomalies were noted with the airframe. Examination of the engine revealed a hole in the corner of the No. 6 piston; however, the No. 6 cylinder was intact. The No. 6 piston had eroded crown material and a darkened periphery. The engine case was found intact. The top spark plugs from the Nos. 3, 5, and 6 cylinders and the bottom spark plugs from the Nos. 3 and 5 cylinders were found in a “worn out - normal condition.” The right magneto timing was found at 22°; according to the engine manufacturer, it is supposed to be at 20°. The left magneto timing was found at 15°, rather than 20°. The oil breather tube was found intact and the slot was not blocked. Engine oil was found splattered in and around the oil breather tube area, including traveling rearward on the area underneath the oil breather tube. No anomalies were noted with the turbocharger system or the propeller. Before purchasing the airplane, the pilot had an inspection performed by a mechanic. One of the findings on theundated inspection list stated that, “spark plugs are worn past limits.” Additionally, all cylinders were borescoped and the cylinders were listed as, “all appear normal.” The pilot reported that there were no indications that the magneto timing was checked during the prebuy inspection. The pilot further reported that the airplane had been run with a lean mixture in the past. A review of the engine maintenance records showed that the most recent time the spark plugs were cleaned and gapped, and the magneto timing was checked was during a 100-hour inspection on October 8, 2022, at 2,732.4 hours. A review of data obtained from a J.P. Instruments EDM-700 unit onboard the airplane at the time of the accident showed an excessively high No. 6 cylinder head temperature reading about 17 minutes before the unit stopped recording data. The FAA has published the Pilot’s Handbook of Aeronautical Knowledge FAA-H-8083-25C. This document discusses detonation and states in part: Detonation is an uncontrolled, explosive ignition of the fuel-air mixture within the cylinder’s combustion chamber. It causes excessive temperatures and pressures which, if not corrected, can quickly lead to failure of the piston, cylinder, or valves. In less severe cases, detonation causes engine overheating, roughness, or loss of power. Detonation is characterized by high cylinder head temperatures and is most likely to occur when operating at high power settings. A common operational cause of detonation is listed as: Operation of the engine at high power settings with an excessively lean mixture. This document discusses preignition and states in part: Preignition occurs when the fuel-air mixture ignites prior to the engine’s normal ignition event. Premature burning is usually caused by a residual hot spot in the combustion chamber, often created by a small carbon deposit on a spark plug, a cracked spark plug insulator, or other damage in the cylinder that causes a part to heat sufficiently to ignite the fuel-air charge. Preignition causes the engine to lose power and produces high operating temperature. As with detonation, preignition may also cause severe engine damage because the expanding gases exert excessive pressure on the piston while still on its compression stroke. The document further discusses both detonation and preignition and states in part: Detonation and preignition often occur simultaneously and one may cause the other. Since either condition causes high engine temperature accompanied by a decrease in engine performance, it is often difficult to distinguish between the two. Using the recommended grade of fuel and operating the engine within its proper temperature, pressure, and rpm ranges reduce the chance of detonation or preignition. Continental Motors has published Mandatory Service Bullet MSB94-8D Magneto to Engine Timing on February 17, 2010. This document discusses the importance of maintaining correct magneto timing and states in part: Incorrect timing, inaddition to producing a rough running engine, can lead to detonation, preignition and internal engine damage or failure. Failure to properly maintain the magneto, harness and spark plugs will lead to internal engine damage and failure.

Aircraft

Registration
N304MA
Reported as
Mooney M20 (K)
Category
Airplane
Serial number
25-2004
Built
1997
Airframe hours
2,763.7
Engine
Continental Motors TSIO-360-MB, 210 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · October 8, 2022 · 31.3 hours before
Departed
1T7 · Spring Branch, TX
Destination
CKV · Clarksville, TN
Flight plan
VFR
Equipment
Electronic flight bag or handheld device, Electronic primary flight display, Stall warning system, ADS-B, Data recorder, Auto-pilot

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
52
Injuries
None
Certificates
Flight instructor, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane, Helicopter
Medical
Class 2, Without waivers/limitations
Last flight review
April 14, 2022
Seat
Left
Restraint
3-point
Flight hours
5,377.8 total · 7 in this make and model · 3,337.5 as pilot in command · 27.1 in the last 90 days · 12.7 in the last 30 days · 6.5 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
250° at 4 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
46 °F, dew point 32 °F
Altimeter
30.21 inHg
Observed at
KRYW, 8 nm away
METAR
KRYW 121555Z AUTO 25004KT 10SM CLR 08/00 A3021 RMK AO2 T00821003

Docket · 22

The files NTSB released with the investigation on September 11, 2024, on NTSB’s docket system: statements, records, photos and specialists’ reports. 146 MB in all.

Pilot/operator aircraft accident report, NTSB form 6120.1Item 1 · PDF · 11 pages · 6.9 MBVarious statementsItem 2 · PDF · 5 pages · 462 KBPilot - various emailsItem 3 · PDF · 11 pages · 939 KBAccident photographsItem 4 · PDF · 21 pages · 4.8 MBFederal aviation administration - N304MA accident site mapsItem 5 · PDF · 2 pages · 383 KBN304MA - accident flight ADS-B data (google earth .kmz file)Item 6 · KMZ · 102 KBN304MA - accident flight ADS-B data (microsoft excel .csv file)Item 7 · CSV · 4.7 MBN304MA - prebuy inspection reportItem 8 · PDF · 1 page · 216 KBAirframe maintenance records - 2018 to accidentItem 9 · PDF · 18 pages · 37.1 MBEngine maintenance records - 2018 to accidentItem 10 · PDF · 13 pages · 28.3 MBPropeller maintenance records - 2018 to accidentItem 11 · PDF · 4 pages · 6.1 MBNTSB - N304MA airframe and engine examination reportItem 12 · PDF · 7 pages · 166 KBHartzell propeller - N304MA examination reportItem 13 · PDF · 9 pages · 3.2 MBMaterials laboratory factual reportItem 14 · PDF · 32 pages · 36 photos · 6.7 MBNTSB - N304MA fuel flow transducer examination reportItem 15 · PDF · 3 pages · 291 KBEngine data monitors - specialist's factual reportItem 16 · PDF · 12 pages · 11 photos · 1.3 MBAttachment 1 to engine data monitors - specialist's factual reportItem 17 · CSV · 56 KBN304MA - most recent weight and balance sheetItem 18 · PDF · 1 page · 42.2 MBMooney - M20K airplane flight manual, emergency procedures excerptsItem 19 · PDF · 5 pages · 906 KBContinental motors - mandatory service bulletin 94-8D magneto to engine timingItem 20 · PDF · 7 pages · 152 KBRelease of aircraft wreckage, NTSB form 6120.15Item 21 · PDF · 2 pages · 369 KBNTSB party member forms - Mooney international and hartzell propellerItem 22 · PDF · 2 pages · 490 KB

FAA reports on this event · 1

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