# NTSB LAX99LA276: Mooney M20E, N6022Q, Lakeport, CA, August 20, 1999 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: August 20, 1999, 15:10 local (22:10 UTC) - Place: Lakeport, CA - Coordinates: 39.039512, -122.929367 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=39.0395&lon=-122.9294&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: Serious injuries - Injuries: 1 serious - Status: Completed, report August 14, 2001 - Report: Approved by Office Director - NTSB case key (mKey): 47117 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX99LA276 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/47117/pdf - Page: https://openairdocs.org/ntsb/LAX99LA276 ## Probable cause The failure of engine shop maintenance personnel to tighten the fuel line fitting during assembly of the engine, and failure of the installing maintenance personnel to detect and tighten the loose fitting during the engine installation and annual inspection. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(total) - mech failure/malf, takeoff - initial climb - fuel system,line fitting - loose - maintenance,installation - improper, other maintenance personnel (cause) - maintenance,annual inspection - inadequate, company maintenance personnel (cause) - Forced landing, emergency landing after takeoff - In flight collision with terrain/water, descent - uncontrolled - terrain condition - crop ## Analysis The airplane's engine lost power during takeoff climb out on a post maintenance check flight, which was performed following repair of damage caused by a gear-up landing. Among other repairs, the engine had been removed, inspected, and reinstalled. The pilot reported that soon after takeoff, while passing the departure end of the runway, the engine started losing power and running rough. He started a turn, intending to land downwind on the departure runway using the partial engine power available. During the turn the engine ceased producing power completely. Because of low airspeed and altitude, the pilot was unable to glide the aircraft to the runway and crashed in a vineyard. An FAA inspector examined the engine and reported there was a loose B-nut on a fuel injection system hose where the hose attached to the fuel divider on top of the engine. When the electric fuel pump was turned on fuel sprayed from the loose B-nut. The inspector reported that the B-nut required about one turn in the tightening direction to reach the snug position. No other discrepancies were noted. The engine was installed on a test stand and run. With the B-nut tight, the engine was started and ran smoothly. The engine was accelerated to full power and smoothly produced about 2,700 rpm. After about 5 minutes at full throttle, the B-nut was loosened. After 1/8 of a turn fuel came out of the hose end. After 1/4 turn the engine began to run rough and between 1/4 and 1/2 turn the engine abruptly stopped. ## Factual narrative On August 20, 1999, at 1510 hours Pacific daylight time, a Mooney M20E, N6022Q, was substantially damaged when it impacted terrain during a post maintenance check flight at Lampson Airport, Lakeport, California. Visual meteorological conditions prevailed and no flight plan was filed. The aircraft, operated by Lake Aero Styling & Repair under the provisions of 14 CFR Part 91, was on departure climb out from Lampson at the time of the accident. The commercial licensed pilot was seriously injured. The post maintenance check flight was performed following repair of damage caused by a gear-up landing. According to the operator, the repairs consisted of replacement of (fuselage) belly skin panels and nose gear doors, replacement of the propeller, and removal and reinstallation of the engine. The engine was shipped to an engine repair station for a "prop strike" inspection. An annual inspection of the aircraft was performed coincident with the repairs. The engine repair station reported that the engine was disassembled and inspected for a prop strike in accordance with applicable Textron Lycoming Service Bulletins. No damage from the prop strike was found. Although the engine was received as an assembly with the engine mount and baffling installed, the engine repair station returned the assembled engine with the engine mount and baffling not installed. A witness reported the aircraft's engine sounded normal during takeoff on runway 28 (3,600 feet long, 60 feet wide), and he observed the landing gear retract during initial climb out. He then observed the landing gear extend again and it appeared to the witness that the pilot was attempting to reverse course to land on the departure runway. During the turn, the aircraft stalled and crashed in a vineyard. The pilot reported his recollection that soon after takeoff, while passing the end of the runway, the engine started losing power, "running rough". He started a left turn, intending to land downwind on runway 10 using the partial engine power available. During the turn the engine stopped completely and because of low airspeed and altitude, the pilot was unable to glide the aircraft to the runway. An inspector from the Federal Aviation Administration (FAA) Sacramento FSDO examined the engine and reported that the spark plugs were clean and light gray color, and the oil and oil filter were clean. There was clean fuel in lines and fuel tanks. When the fuel lines were examined it was found that there was a loose B-nut on the line from the fuel control servo where it attaches to the fuel divider on top of the engine. When the electric fuel pump was turned on fuel sprayed from the loose nut. The inspector reported that the B-nut required about one turn in the tightening direction to reach the snug position. The inspector noted that there was "torque seal" present on the threads of the elbow fitting but not on the body of the B-nut. No other discrepancies were noted. On October 4, 1999, the engine was installed on a test stand at Clarksburg Air Repair, Clarksburg, California. The muffler was removed due to impact damage; however, the flame tubes were intact. A cracked casting in the intake manifold was repaired using soft putty. With the above mention B-nut tight, the engine was started and ran smoothly. A magneto check at 1,700 rpm produced drops of 75 - 100 rpm's on each magneto. The engine was accelerated to full power and smoothly produced about 2,700 rpm using a fixed pitch test propeller (test club). After about 5 minutes at full throttle, the above mentioned B-nut was loosened. After 1/8 turn fuel came out of the hose end. After 1/4 turn the engine began to run rough and between 1/4 and 1/2 turn the engine abruptly stopped. The B-nut was again tightened and the engine was started. The engine was operated at full throttle again for 3 minutes and produced smooth power about 2,700 rpm. Another additional person (party) was Mr. Danny S. Phillips, Lake Aero Styling & Repair, Lakeport, California 95453. ## Aircraft - Registration: [N6022Q](https://openairdocs.org/deregistered/N6022Q-1999-11-04), registration cancelled 1999-11-04, S/N 870 (OpenAirDocs) - Reported make and model: Mooney M20E - Registry model: [Mooney M20E](https://openairdocs.org/model/mooney-m20e) (registry code 5870212) (OpenAirDocs) - Category: Airplane - Serial number: 870 - Airframe hours: 8743 - Engines: Lycoming IO-360-A1A 200 horsepower reciprocating - Damage: Substantial damage - Flight: Part 91 - Operator: Lake Aero Styling & Repair - Registered owner: Corwin W. Nichols - Airworthiness certificate: Standard, Normal - Last inspection: Annual, August 20, 1999, 1 hours before - Departed: 1O2 - Airport: 1O2, Lampson Field, runway 28, 3,600 × 60 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 58; private, commercial; airplane ratings: single-engine sea, multi-engine land, single-engine land; instrument ratings: airplane; medical: class 3, valid medical--w/ waivers/lim; seat: left; flight hours: 10,035 total, 10,035 as pilot in command, 25 in the last 90 days, 10 in the last 30 days, 2 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: variable at 5 knots - Visibility: 30 statute miles - Lowest ceiling: none - Temperature: 93 °F, dew point 52 °F - Altimeter: 29.00 inHg - Observed at: UKI, 17 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 (OpenAirDocs). - [Accident 19990820013209A](https://openairdocs.org/incident/19990820013209A), Aug 20, 1999: Mooney M20E, Lakeport, CA, Substantial damage. Pilot was attempting to return to the arpt for unknown reasons shortly after take-off when the acft crashed in an orchid field, other circumstances are unknown. 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.