CHI05LA190

NTSB accident investigation · Mooney M20M · White Cloud, MI · July 15, 2005

Accident · No injuriesLimited investigationFinal report
Date
July 15, 2005, 13:54 local (17:54 UTC)
Place
White Cloud, MI
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N355RZMooney M20M
Weather
Visual (VMC) · Day
Status
Completed · report April 25, 2006
Report
Approved by Office Director
Parties
Federal Aviation Administration
FAA report
20050715027279A
Case key
62002

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

A loss of engine power during cruise flight due to the mechanic's improper maintenance, the disconnected oil line, the oil leak from the disconnected line, and the unsuitable terrain the pilot encountered during the forced landing. Factors were the outside pressures on the maintenance personnel and the uneven terrain.

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 powerCruise
Pressure induced by othersOther maintenance personnelFactor
Maintenance - improperOther maintenance personnelCause
Lubricating system,oil line - disconnectedCause
Fluid,oil - leakCause
Forced landingEmergency descent/landing
On ground/water encounter with terrain/waterEmergency landing
Terrain condition - rough/unevenFactor
Unsuitable terrain or takeoff/landing/taxi area - encounteredPilot in commandCause

Analysis

The airplane sustained substantial damage on impact with terrain during a forced landing following an in-flight loss of engine power. The pilot's accident report stated, "Climbing through 9,000 feet I noticed that my climb performance had been reduced substantially. I then noticed that I had a serious problem. The [oil] temp was then red-lined, the oil pressure low, and power drastically reduced. At that point I disconnected the autopilot and lowered the nose to avoid a stall and attempt to cool the engine. I contacted [Minneapolis] center and reported the problem. The controller asked if I was declaring an emergency, and I said yes, and requested vectors to the closest airport. At this point I could see oil coming down the left window. ... I had a scattered layer around 3-4,000 feet that I descended through. I got visual on the airport. At that point airspeed and altitude [were] minimal and the power reduced to almost nothing. ... I aimed the aircraft towards mid field and figured if I put the aircraft down without stalling or hitting trees I would walk away. ... I put the aircraft down on the uneven terrain at the south end of [the runway]." An examination of the wreckage revealed a disconnected oil line. The disconnected oil line went to the cylinder valve guides for cooling. The other end of the line was connected at the outlet of the oil cooler from where the oil is supplied to the valve guides. A representative of the fixed base operator stated that three cylinders were removed and replaced. During the engine's operational check, no oil leaks were noted. The technician that performed the work also inspected the work. The representative stated that oil would begin to flow from the disconnected line once the engine warmed up and the vernatherm opened. The representative stated that human factors were also involved, as there was pressure to get the work done as the owner requested. The representative stated that secondary inspectors will be used whenever possible and that the entire maintenance staff will be trained on human factors.

Factual narrative

On July 15, 2005, about 1354 eastern daylight time, a Mooney M20M, N355RZ, piloted by a commercial pilot, sustained substantial damage on impact with terrain during a forced landing at the White Cloud Airport, near White Cloud, Michigan. The flight encountered an in-flight loss of engine power. The personal flight was operating under 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed at the time of the accident. An instrument flight rules (IFR) flight plan was on file and was activated. The pilot reported no injuries. The flight originated from the Gerald R. Ford International Airport, near Grand Rapids, Michigan about 1317, and was destined for the Brainerd Lakes Regional Airport, near Brainerd, Minnesota.

The pilot's accident report stated:

This is to explain the facts of the engine failure of Mooney N355RZ.

The Mooney Bravo was left at Grand Rapids (KGRR) airport for engine

repair for a rough running engine. The airplane was inspected and left

for repair to have three cylinders sent in to be repaired.

On Friday July 15th, 2005, I drove to (KGRR) to pick the aircraft up

and return it to Bismarck, ND. The mechanics where still working on

the engine so I waited until mid-afternoon until the repairs [were]

finished. In the meantime I filed IFR and checked weather with

Lansing [Flight Service Station]. I planned my route of flight direct

Beaver Island, and then direct Brainerd, MN. I planned this route to

avoid flying over the widest part of Lake Michigan.

I taxied out to runway 8R at (KGRR) did my run-up and was cleared

for take off. I filed for 14,000 feet [above mean sea level]. Tower

had me runway heading to 4000 feet and then to contact departure.

Departure had cleared me direct and up to 14,000 feet. At that point I

had the climb power set and the auto-pilot flying [global positioning

system] GPS direct to Beaver Island with all engine instruments

reading normal. Climbing through 9,000 feet I noticed that my climb

performance had been reduced substantially.

I then noticed that I had a serious problem. The [oil] temp was then

red-lined, the oil pressure low, and power drastically reduced. At that

point I disconnected the autopilot and lowered the nose to avoid a stall

and attempt to cool the engine. I contacted [Minneapolis] center

and reported the problem. The controller asked if I was declaring an

emergency, and I said yes, and requested vectors to the closest

airport. At this point I could see oil coming down the left window.

He turned me heading west and gave me the identifiers for White

Cloud airport. I put the identifiers in the GPS and was trimming the

aircraft to conserve altitude. Then the aircraft began to shake

extremely rough, making me wonder what was going to happen next. I

still had some power but was wondering how long until the engine

would totally fail.

I had a scattered layer around 3-4,000 feet that I descended through. I

got visual on the airport. At that point airspeed and altitude where

minimal and the power reduced to almost nothing. The power then

seized to nothing, I adjusted the manifold and got no response. The

terrain around the airport was heavily congested with trees, houses, and

power lines. I aimed the aircraft towards mid field and figured if I put

the aircraft down without stalling or hitting trees I would walk away. At

that point I was low, out of altitude, out of power and [decided] to take the

side of the runway at [White Cloud].

I put the aircraft down on the uneven terrain at the south end of runway

18-36 at White Cloud. The aircraft came to a stop promptly. I then

opened the door and exited the aircraft. Local authorities then arrived. I

could then see the stream of oil going down the side of the fuselage.

A Federal Aviation Administration Inspector along with an airplane mechanic examined the wreckage. The mechanic found a disconnected oil line. The disconnected oil line went to the cylinder valve guides for cooling. The other end of the line was connected at the outlet of the oil cooler from where the oil is supplied to the valve guides.

A representative of the fixed base operator at KGRR stated that three cylinders were removed and replaced. During the engine's operational check, no oil leaks were noted. The technician that performed the work also inspected the work. The representative stated that oil would begin to flow from the disconnected line once the engine warmed up and the vernatherm opened. The representative stated that human factors were also involved, as there was pressure to get the work done as the owner requested. The representative stated that secondary inspectors will be used whenever possible and that the entire maintenance staff will be trained on human factors.

Aircraft

Registration
N355RZ
Reported as
Mooney M20M
Category
Airplane
Serial number
27-0235
Airframe hours
745
Engine
Lycoming TIO-540-AF1B, 270 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Registered owner
Remc Leasing LLC
Airworthiness certificate
Standard, Normal
Last inspection
Annual · February 1, 2005 · 60 hours before
Departed
GRR · Grand Rapids, MI
Destination
BRD · Brainerd, MN
Flight plan
IFR
Airport
42C · White Cloud, runway 18, 2,917 × 60 ft, asphalt

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
26
Injuries
None
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
September 1, 2004
Seat
Left
Flight hours
1,870 total · 210 in this make and model · 1,494 as pilot in command · 42 in the last 90 days · 8 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
110° at 4 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
86 °F, dew point 66 °F
Altimeter
30.02 inHg
Observed at
RQB, 15 nm away

FAA reports on this event · 1

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