# NTSB ERA22LA064: Mooney M20M, N21890, Tampa, FL, November 15, 2021 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: November 15, 2021, 10:12 local (15:12 UTC) - Place: Tampa, FL · Tampa Bay - Coordinates: 27.903517, -82.455067 - Nearby events: https://openairdocs.org/map.md?lat=27.9035&lon=-82.4551&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-VFR pattern base: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 104268 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA22LA064 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104268/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=104268 - Page: https://openairdocs.org/ntsb/ERA22LA064 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Engine fuel and control: fuel distribution](https://openairdocs.org/ntsb-findings/01057310): Aircraft › Aircraft power plant · Incorrect service/maintenance (probable cause); cases with it: [Mooney M20M, 1 case](https://openairdocs.org/ntsb-findings/01057310/cases.md?model=5870222), [All aircraft, 55 cases](https://openairdocs.org/ntsb-findings/01057310/cases.md) - [Maintenance: installation](https://openairdocs.org/ntsb-findings/02062035): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Mooney M20M, 1 case](https://openairdocs.org/ntsb-findings/02062035/cases.md?model=5870222), [All aircraft, 371 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Aircraft maintenance event](https://openairdocs.org/ntsb-events/040); cases with it: [Mooney M20M, 1 case](https://openairdocs.org/ntsb-events/040/sequence.md?model=5870222), [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md) - [Enroute-cruise: Miscellaneous/other](https://openairdocs.org/ntsb-events/900); cases with it: [Mooney M20M, 5 cases](https://openairdocs.org/ntsb-events/900/sequence.md?model=5870222), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) - [Approach-VFR pattern base: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Mooney M20M, 4 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=5870222), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Mooney M20M, 2 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=5870222), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Emergency descent: Ditching](https://openairdocs.org/ntsb-events/441); cases with it: [Mooney M20M, 1 case](https://openairdocs.org/ntsb-events/441/sequence.md?model=5870222), [All aircraft, 186 cases](https://openairdocs.org/ntsb-events/441/sequence.md) ## 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](https://openairdocs.org/deregistered/N21890-2022-05-17), registration cancelled 2022-05-17, S/N 27-0293, built 2000 (OpenAirDocs) - Reported make and model: MOONEY M20M (NO SERIES) - Registry model: [Mooney M20M](https://openairdocs.org/model/mooney-m20m) (registry code 5870222) (OpenAirDocs) - Registry engine: [Lycoming TI0-540 series](https://openairdocs.org/engine/lycoming-ti0-540-series) (registry code 41533, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: 27-0293 - Year built: 2000 - Airframe hours: 1229 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 70; injuries: none; 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= ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20211115019559A](https://openairdocs.org/incident/20211115019559A), Nov 15, 2021: Mooney M20M, Tampa, FL, Substantial damage. N21890 departed tpf and landed at lal to pick up a passenger. After approximately 30 minutes on the ground at lal, N21890 departed lal, enroute to gvl. During… ## Docket (6 files) The files NTSB released with the investigation on September 7, 2023, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=104268. 7.6 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 12 pages, 4.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13093807&FileExtension=pdf&FileName=6120%20Recd%2012%2027%202021_Redacted-Rel.pdf - Record of NTSB conversations (item 2, PDF, 17 pages, 568 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13441671&FileExtension=pdf&FileName=Record%20of%20NTSB%20Conversations_Redacted-Rel.pdf - Excerpts from maintenance records (item 3, PDF, 1 page, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13094630&FileExtension=pdf&FileName=Excerpt%20From%20Maintenance%20Records_Redacted-Rel.pdf - Memorandum for record - NTSB virtual engine examination (item 4, PDF, 4 pages, 3 photos, 470 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13442131&FileExtension=pdf&FileName=Memorandum%20For%20Record%20-%20NTSB%20Virtual%20Engine%20Examination-Rel.pdf - Investigative photographs (item 5, PDF, 2 pages, 2 photos, 915 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13443074&FileExtension=pdf&FileName=Investigative%20Photographs_ERA22LA064-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 6, PDF, 1 page, 90 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13439727&FileExtension=pdf&FileName=Fully%20Executed%20Wreckage%20Release%20(signed)%20N21890_Redacted-Rel.pdf From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.