ERA21LA222

NTSB accident investigation · Mooney M20K · Dawson, GA · May 20, 2021

Accident · Serious injuriesClass 3 · LimitedFinal report
Date
May 20, 2021, 09:30 local (13:30 UTC)
Place
Dawson, GA · 3495 Graves Highway
Injuries
2 serious
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N9514RMooney M20K
Defining event
Enroute: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Eastern Region Aviation
Parties
FAA - FSDO
FAA report
20210520009589A
Case key
103119

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

Maintenance personnel’s failure to properly secure the No. 4 connecting rod bolt nut with a cotter pin, resulting in a total loss of engine power.

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.

Maintenance: replacementPersonnel issues › Task performance · Maintenance personnelMooney M20K: 1 caseAll aircraft: 70 casesProbable cause
Engine (reciprocating): recip engine power sectionAircraft › Aircraft power plant · Incorrect service/maintenanceMooney M20K: 4 casesAll aircraft: 233 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 pilot reported that, while en route to the destination airport, the airplane lost total engine power. The pilot declared an emergency with air traffic control and began to divert to the nearest airport. The pilot recognized that the airplane would not be able to glide to the airport, and he decided to land on a road with the landing gear and flaps retracted. The pilot and passenger sustained serious injuries, and the airplane was substantially damaged. A postaccident teardown examination of the engine revealed that the No. 4 connecting rod was fractured midspan. One of the No. 4 connecting rod bolt nuts was found in the oil pan and exhibited no signs of pre- or postaccident damage. The cotter pin for that nut was not found; the other No. 4 connecting rod nut was found secured to its bolt with the cotter pin installed. Additionally, all other connecting rod bolt nuts remained attached to their respective bolts with cotter pins in place. Thus, it is likely that the nut found in the oil pan was not secured with a cotter pin and that the unsecured No. 4 connecting rod bolt nut became loose over time and backed out of the connecting rod bolt during the accident flight, resulting in the total loss of engine power. Review of maintenance records revealed that the engine had accumulated about 1,240 hours of operation since major overhaul, which was completed more than 28 years before the accident. The engine manufacturer recommended that the engine be overhauled every 2,000 hours or 12 calendar years, whichever occurred first. The investigation could not determine when the No. 4 connecting rod nut was installed without a cotter pin.

Factual narrative

On May 20, 2021, about 0930 eastern daylight time, a Mooney M20K, N9514R, was substantially damaged when it was involved in an accident near Dawson Municipal Airport (16J), Dawson, Georgia. The pilot and passenger sustained serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, he had recently purchased the airplane. On the day of the accident, the pilot conducted a preflight inspection with no anomalies noted, and the airplane departed Orlando Apopka Airport (X04), Apopka, Florida, about 0815 for a flight to Birmingham-Shuttlesworth International Airport (BHM), Birmingham, Alabama. While en route to the destination airport, the airplane lost total engine power. The pilot declared an emergency to air traffic control and diverted to the nearest airport, which was 16J. During the descent, the pilot operated the engine controls with no response from the engine. The pilot realized that the airplane would not reach the airport, and he landed the airplane on a road with the landing gear and flaps retracted. The airplane’s right wing and fuselage were substantially damaged. A postaccident teardown examination revealed two holes in the top of the engine crankcase, with the larger hole near the center and the smaller hole just aft. The cylinders remained attached to the crankcase. The No. 4 connecting rod was found fractured about midspan. A No. 4 connecting rod bolt nut was found in the oil pan. This nut exhibited no signs of impact damage or damage that would be consistent with separation. A cotter pin associated with the nut was not located. The other No. 4 connecting rod nut was found secured to its bolt with the cotter pin installed. All other connecting rod bolt nuts remained attached to their respective bolts with cotter pins in place. The oil filter pleats and oil sump contained a large amount of metallic debris. Review of maintenance records revealed that the engine had accumulated about 1,240 hours of operation since its last major overhaul, which was completed on September 18, 1992. The engine manufacturer recommended that the engine be overhauled every 2,000 hours or 12 calendar years, whichever occurred first. Further review of the records revealed that the engine was disassembled, cleaned, and inspected due to a crankcase crack in 2005 and that the No. 3 cylinder was replaced in 2013.

Aircraft

Registration
N9514R
Reported as
Mooney M20K
Category
Airplane
Serial number
25-0484
Built
1980
Airframe hours
3,575.7
Engine
Continental TSIO 360 GB1, 210 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · May 27, 2020 · 25.8 hours before
Departed
X04 · Apopka, FL
Destination
BHM · Birmingham, AL
Equipment
Electronic multifunction display, Electronic primary flight display, Stall warning system, ADS-B, Auto-pilot, Electronic flight bag or handheld device

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
69
Injuries
Serious
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
March 2, 2021
Seat
Left
Restraint
3-point
Flight hours
1,030 total · 25 in this make and model · 1,030 as pilot in command · 19 in the last 90 days · 7 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
110° at 17 knots, gusting 23
Visibility
10 statute miles
Temperature
79 °F, dew point 61 °F
Altimeter
30.31 inHg
Observed at
ABY, 21 nm away
METAR
KABY 201353Z 11017G23KT 10SM FEW028 26/16 A3031 RMK AO2 SLP262 T02560156

Docket · 4

The files NTSB released with the investigation on June 22, 2023, on NTSB’s docket system: statements, records, photos and specialists’ reports. 6.2 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.

Other investigations on N9514R · 1

Matched to the same aircraft by N-number and date.