ERA22LA064

NTSB accident investigation · Mooney M20M · Tampa, FL · November 15, 2021

Accident · No injuriesClass 3 · LimitedFinal report
Date
November 15, 2021, 10:12 local (15:12 UTC)
Place
Tampa, FL · Tampa Bay
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N21890Mooney M20M
Defining event
Approach-VFR pattern base: 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
20211115019559A
Case key
104268

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 total loss of engine power due to the failure of maintenance personnel to properly tighten the fuel supply line b-nut at the manifold valve during installation.

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 fuel and control: fuel distributionAircraft › Aircraft power plant · Incorrect service/maintenanceMooney M20M: 1 caseAll aircraft: 55 casesProbable cause
Maintenance: installationPersonnel issues › Task performance · Maintenance personnelMooney M20M: 1 caseAll aircraft: 371 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

While in cruise flight, the pilot noticed the turbine inlet temperature (TIT) was about 100° F above the maximum reading and that liquid was on the windshield. He reduced engine power, which lowered the TIT reading and then diverted to his home airport. While on the base leg of the airport traffic pattern at 1,200 ft above gound level, he advanced the throttle, but the engine did not respond. At 800 ft msl he noted he would be unable to reach the airport and ditched the airplane. Both occupants exited the airplane and were transported to land, and the airplane’s fuselage was substantially damaged during the ditching. Following recovery of the airplane, the inlet fuel line at the manifold valve was 7.5 flats of the b-nut from being hand tight against the inlet fitting. There was no provision for safety wiring the b-nut and there was no torque stripe on the b-nut or inlet fitting. Fuel leakage was noted at the loose b-nut during pressure testing, but no leakage occurred after tightening the b-nut. There was no damage to the b-nut or fitting that would have precluded obtaining the proper torque. The manifold valve was overhauled and installed nearly 2 months earlier. The mechanic who signed off the installation indicated he normally would have applied a torque stripe on the b-nut. Based on this information, it is likely that the overheating of the engine and the subsequent loss of engine power was likely due to a fuel leak at the fuel manifold valve, resulting an excessively lean fuel to air mixture. It is also likely that the loose b-nut had not been properly tightened during the reinstallation of the manifold valve.

Factual narrative

On November 15, 2021, about 1012 eastern standard time, a Mooney M20M, N21890, was substantially damaged when it was involved in an accident near Tampa, Florida. The private pilot and one passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot stated that he flew the airplane earlier that day on an uneventful 15-minute flight from Peter O Knight Airport (TPF), Tampa, Florida, to Lakeland Linder International Airport, Lakeland, Florida. After landing he picked up his passenger and departed for Gainesville Regional Airport, Gainesville, Florida. At 3,000 ft mean sea level (msl) with the mixture control full rich and the engine operating at 32 inHg and 2,400 rpm., he noted the turbine inlet temperature (TIT) was in the red range. At the same time of the high TIT reading, he noticed liquid on the bottom portion of the windshield. He confirmed that the mixture control was full rich and reduced engine power, which decreased the TIT reading, but there was still liquid on the windshield. While at 4,000 ft msl, he advised air traffic control of the higher temperature and diverted to TPF, maintaining 4,000 ft msl until on the downwind leg of the airport traffic pattern where he reduced power, extended the landing gear and lowered the 1st notch of flaps. He turned onto the base leg, and at 1,200 ft above ground level before turning onto final, he added throttle, but the engine did not respond. He pushed the mixture, propeller, and throttle controls full forward, which at full throttle automatically turned on the auxiliary fuel pump, but noted the propeller was windmilling. At 800 ft msl, he realized he would be unable to make the runway and told his passenger about the impending ditching. He retracted the landing gear and maintained a nose-up wings level attitude ditching the airplane. Both occupants exited the airplane and were transported to land. The underside of the fuselage was substantially damaged during the ditching. Following recovery of the airplane, examination of the fuel lines in the engine compartment revealed the inlet fuel line at the manifold valve was 7.5 flats of the b-nut from being hand tight against the inlet fitting. There was no provision for safety wiring the b-nut and there was no torque stripe on the b-nut or inlet fitting. Pressure testing of the fuel supply system was performed with the b-nut in the as-found position revealed fuel leaked at the b-nut. After the b-nut was tightened, no leakage was noted at the b-nut. Inspection of the threads of the fitting and of the flexible fuel hose revealed no discrepancies. Torque stripes were noted on the fuel injector nuts at the manifold valve. Review of the maintenance records revealed that nearly 2 months before the accident, fuel system components consisting of the engine-driven fuel pump, servo fuel injector, manifold valve, and fuel injectors were removed for testing and overhaul. The components wereinstalled and according to the pilot, the airplane had been operated about 12 hours over 3 or 4 flights since installation. There was no record of any subsequent engine work after the overhauled components were installed. The mechanic who installed the components after testing and/or overhaul reported that the airplane owner helped with the installation. The mechanic also indicated that he normally would have applied a torque stripe to the inlet hose at the manifold valve.

Aircraft

Registration
N21890
Reported as
Mooney M20M (NO SERIES)
Category
Airplane
Serial number
27-0293
Built
2000
Airframe hours
1,229
Engine
Lycoming TIO-540-AF1B, 270 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · July 13, 2021
Departed
LAL · Lakeland, FL
Destination
GNV · Gainesville, FL
Airport
TPF · Peter O Knight
Equipment
ADS-B, Satellite tracking device, Auto-pilot, Stall warning system, Onboard weather, Handheld GPS

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
70
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
May 7, 2020
Seat
Left
Restraint
Lap only
Flight hours
2,483 total · 1,294 in this make and model · 2,410 as pilot in command · 10.9 in the last 90 days · 3.5 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
20° at 8 knots
Visibility
10 statute miles
Lowest ceiling
10,000 ft broken
Temperature
64 °F, dew point 43 °F
Altimeter
30.22 inHg
Observed at
KTPF, 1 nm away
METAR
METAR KTPF 151515Z AUTO 02008KT 10SM BKN100 BKN120 18/06 A3022 RMK AO2=

Docket · 6

The files NTSB released with the investigation on September 7, 2023, on NTSB’s docket system: statements, records, photos and specialists’ reports. 7.6 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.