MIA03LA072

NTSB accident investigation · Mooney M20M · Destin, FL · March 2, 2003

Accident · Serious injuriesLimited investigationFinal report
Date
March 2, 2003, 11:00 local (17:00 UTC)
Place
Destin, FL
Injuries
1 serious
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N101PBMooney M20M
Weather
Visual (VMC) · Day
Status
Completed · report April 28, 2004
Report
Approved by Office Director
Parties
FAA Flight Standards District Office
FAA report
20030302002869A
Case key
56592

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 inadequate annual/100-hour inspection of the engine by the mechanic for his failure to properly secure the tailpipe assembly to the turbocharger resulting in separation of the tailpipe and subsequent in-flight fire. Contributing factors in the accident were the inadequate design of the plastic brake line in the cockpit adjacent to the firewall by the airplane manufacturer, and the inadequate certification of the airplane by the FAA for failure to take into account radiant heat when designing components aft of the firewall.

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.

FireTakeoff - initial climb
Exhaust system,clamp - separation
Exhaust system,manifold/pipe - separation
Inadequate certification/approval,aircraftFaa(organization)Factor
Hydraulic system,line - melted
Aircraft/equipment inadequateManufacturerFactor
Maintenance,annual inspection - inadequateOther maintenance personnelCause
Forced landingDescent - emergency
Miscellaneous/otherEmergency landing after takeoff
Emergency procedure - performedPilot in command

Analysis

The pilot stated that he performed a normal preflight of the airplane using the airplane's checklist; the only discrepancy he found was related to the cabin entry door seal. He did add 1 quart of oil to the engine. The flight departed from runway 32 and while climbing between 2,500 and 2,800 feet, the cockpit was enveloped suddenly in thick black smoke. Additionally, he observed flames underneath the instrument panel behind the rudder pedals on both sides of the cockpit. He turned off the master switch and initiated a descending left turn with the intention of ditching the airplane. He reduced the mixture control and opened the cabin entry door in anticipation of ditching but he was able to see outside and elected to return to the airport for landing. He momentarily turned on the master switch and lowered the landing gear; he landed on runway 14. After touchdown, the airplane exited the north side of the runway onto grass where he evacuated the airplane by the cabin entry door. A fire department was not located at the airport. A nearby fire department was alerted at 1101:34, arrived at 1107:09, and extinguished the fire. Examination of the airplane by an FAA Airworthiness inspector-in-charge (FAA-IIC) revealed fire consumed the upper and side fuselage skin of the cockpit and cabin area, and damaged the inboard portion of the right wing including consumption of the area of the right fuel tank. The tailpipe assembly (tailpipe) was found separated from the turbocharger exhaust turbine housing (turbocharger); the coupling used to secure the tailpipe to the turbocharger was found resting on the tailpipe but not in the normally installed position. No safety wire was observed in the coupling; the nut was not recovered. There was no mention of damage to either of the flanges of the tailpipe or of the turbocharger. Additionally, examination of other components of the exhaust system by the FAA-IIC revealed evidence of deterioration that should have been detected during the previous inspection 1.8 hours earlier. Burn damage was noted to plastic tubing in the cockpit forward of the rudder pedals; the tubing was associated with the brake system. Examination of the firewall and cockpit by the NTSB revealed no evidence of burn through or compromise of the firewall. Visual examination of the recovered coupling by the NTSB revealed no damage to the threads. The coupling was determined to be manufactured by Aeroquip as part number (55677-340M), which is specified in the Illustrated Parts Catalog. Review of the Aircraft Log revealed an entry dated November 12, 1990, which indicates replacement of the coupling in accordance with Mooney Special Letter 90-6, dated November 1, 1990. Review of the maintenance records revealed the engine was overhauled on February 22, 1996, and installed in the airplane on May 8, 1996; the entry does not indicate whether a new coupling was installed to connect the tailpipe to the turbocharger. An entry dated March 14, 2001, indicates the exhaust stack was repaired; the entry does not specify what exhaust stack was repaired. An entry dated April 25, 2001, indicates the engine was removed from the airplane for repair. The next entry dated April 20, 2001, indicates the engine was repaired and the wastegate, controllers, and turbo were repaired by Main Turbo Systems, Inc. The entry does not specify if a new coupling was installed to connect the tailpipe to the turbocharger. No other entries related to the exhaust system were noted between that entry and the last annual inspection which occurred on February 13, 2003; the inspection was accomplished using the Mooney Service Guide. The airplane had accumulated approximately 1.8 hours since the inspection at the time of the accident. The mechanic who performed the last annual/100-Hour inspection reported to the FAA-IIC that during the inspection, he removed the turbocharger wastegate for cleaning and also removed the tailpipe. He reported reinstalling the tailpipe using the same nut. Review of the Mooney Aircraft Corporation Service and Maintenance Manual pertaining to the 100-Hour or Annual inspection revealed the exhaust system components are inspected for security. When the airplane was certificated, there was no requirement to protect components aft of the firewall from radiant heat.

Factual narrative

On March 2, 2003, about 1100 central standard time, a Mooney M20M, N101PB, registered to Makaira Aircraft Sales LLC, experienced an in-flight fire shortly after takeoff from the Destin-Ft Walton Beach Airport, Destin, Florida. Visual meteorological conditions prevailed at the time and an instrument flight rules (IFR) flight plan was filed for the 14 CFR Part 91 personal flight. The airplane was substantially damaged by the fire and the commercial-rated pilot, the sole occupant, sustained serious injuries due to burns. The flight originated about 1057, from the Destin-Ft Walton Beach Airport.

The pilot stated that he performed a normal preflight of the airplane using the airplane's checklist; the only discrepancy he found was related to the cabin entry door seal. He did add 1 quart of oil to the engine. The flight departed from runway 32 and while climbing between 2,500 and 2,800 feet, the cockpit was enveloped suddenly in thick black smoke. Additionally, he observed flames underneath the instrument panel behind the rudder pedals on both sides of the cockpit. He turned off the master switch and initiated a descending left turn with the intention of ditching the airplane. He reduced the mixture control and opened the cabin entry door in anticipation of ditching but he was able to see outside and elected to return to the airport for landing. He momentarily turned on the master switch and lowered the landing gear; he landed on runway 14. After touchdown, the airplane exited the north side of the runway onto grass where he evacuated the airplane by the cabin entry door. A fire department was not located at the airport. A nearby fire department was alerted at 1101:34, arrived at 1107:09, and extinguished the fire.

Examination of the airplane by an FAA Airworthiness inspector-in-charge (FAA-IIC) revealed fire consumed the upper and side fuselage skin of the cockpit and cabin area, and damaged the inboard portion of the right wing including consumption of the area of the right fuel tank. The tailpipe assembly (tailpipe) was found separated from the turbocharger exhaust turbine housing (turbocharger); the coupling used to secure the tailpipe to the turbocharger was found resting on the tailpipe but not in the normally installed position. No safety wire was observed in the coupling; the nut was not recovered. There was no mention of damage to either of the flanges of the tailpipe or of the turbocharger. Additionally, examination of other components of the exhaust system by the FAA-IIC revealed evidence of deterioration that should have been detected during the previous inspection 1.8 hours earlier. Burn damage was noted to plastic tubing in the cockpit forward of the rudder pedals; the tubing was associated with the brake system.

Examination of the firewall and cockpit by the NTSB revealed no evidence of burn through or compromise of the firewall. Visual examination of the recovered coupling by the NTSB revealed no damage to the threads. The coupling was determined to be manufactured by Aeroquip as part number (55677-340M), which is specified in the Illustrated Parts Catalog.

Review of the Aircraft Log revealed an entry dated November 12, 1990, which indicates replacement of the coupling in accordance with Mooney Special Letter 90-6, dated November 1, 1990.

Review of the maintenance records revealed the engine was overhauled on February 22, 1996, and installed in the airplane on May 8, 1996; the entry does not indicate whether a new coupling was installed to connect the tailpipe to the turbocharger. An entry dated March 14, 2001, indicates the exhaust stack was repaired; the entry does not specify what exhaust stack was repaired. An entry dated April 25, 2001, indicates the engine was removed from the airplane for repair. The next entry dated April 20, 2001, indicates the engine was repaired and the wastegate, controllers, and turbo were repaired by Main Turbo Systems, Inc. The entry does not specify if a new coupling was installed to connect the tailpipe to the turbocharger. No other entries related to the exhaust system were noted between that entry and the last annual inspection which occurred on February 13, 2003; the inspection was accomplished using the Mooney Service Guide. The airplane had accumulated approximately 1.8 hours since the inspection at the time of the accident.

The mechanic who performed the last annual/100-Hour inspection reported to the FAA-IIC that during the inspection, he removed the turbocharger wastegate for cleaning and also removed the tailpipe. He reported reinstalling the tailpipe using the same nut.

Review of the Mooney Aircraft Corporation Service and Maintenance Manual pertaining to the 100-Hour or Annual inspection revealed the exhaust system components are inspected for security.

When the airplane was certificated, there was no requirement to protect components aft of the firewall from radiant heat.

The airplane minus the retained components was released to insurance adjuster Phil Powell, of Leading Edge Investigations, on November 9, 2003. The retained components were also released to Phil Powell on November 19, 2003.

Aircraft

Registration
N101PB
Reported as
Mooney M20M
Category
Airplane
Serial number
27-0008
Airframe hours
1,441.2
Engine
Lycoming TIO-540-AF1B, 270 horsepower, reciprocating
Damage
Substantial damage
Fire
Both
Flight
Personal · Part 91
Operator
James A. Massey
Registered owner
Makaira Aircraft Sales, LLC
Airworthiness certificate
Standard, Normal
Last inspection
Annual · February 13, 2003 · 1.8 hours before
Departed
KDTS · Destin, FL
Destination
KEKY · Bessemer, AL
Flight plan
IFR
Airport
KDTS · Destin-Fort Walton Beach, runway 14, 4,999 × 100 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
62
Injuries
Serious
Certificates
Flight instructor, Commercial, Airline transport
Airplane ratings
Single-engine sea, Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Last flight review
December 1, 2002
Seat
Left
Flight hours
6,988 total · 302 in this make and model · 6,575 as pilot in command · 11 in the last 90 days · 2 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
330° at 8 knots
Visibility
7 statute miles
Lowest ceiling
12,000 ft broken
Temperature
66 °F, dew point 55 °F
Altimeter
29.95 inHg
Observed at
KVPS

FAA reports on this event · 1

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