MIA04LA127

NTSB accident investigation · Mooney M20F · Brandon, MS · September 5, 2004

Accident · No injuriesLimited investigationFinal report
Date
September 5, 2004, 14:32 local (19:32 UTC)
Place
Brandon, MS
Injuries
3 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N9708MMooney M20F
Weather
Visual (VMC) · Day
Status
Completed · report September 13, 2005
Report
Approved by Office Director
Parties
FAA
FAA report
20040905021489A
Case key
60164

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

A loss of engine power due to the fatigue failure of all studs and/or thru-bolts of the No. 3 cylinder for undetermined reasons causing separation of the cylinder. Contributing to the accident was the unsuitable terrain encountered by the pilot.

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.

Loss of engine power(total) - mech failure/malfCruise
Engine assembly,cylinder - fatigueFactor
Engine assembly,cylinder - separation
Forced landingDescent - emergency
On ground/water collision with objectEmergency descent/landing
Unsuitable terrain or takeoff/landing/taxi area - encounteredPilot in commandCause
Object - vehicle

Analysis

The pilot stated that he performed a preflight inspection of the airplane and noted the oil capacity was full (8 quarts). Approximately 2 hours into the flight while flying at 10,500 feet, the engine began running rough. He advised air traffic control (ATC), and attempts to correct the rough running engine were unsuccessful. The flight continued and shortly afterwards, the engine developed a severe roughness and he then heard a bang with smoke entering the cockpit. He declared "mayday" with ATC, and requested vectors to the nearest airport. Unable to land there, he executed a forced landing on a nearby highway and collided with a vehicle during the landing roll-out. The No. 3 cylinder was found separated from the crankcase, and all cylinder studs and/or thru-bolts exhibited various forms of fatigue. The No. 3 cylinder connecting rod bolts which were fractured exhibited evidence of either bending or shear overstress. The No. 2 cylinder connecting rod bearing was found welded to the crankpin, and a piece of aluminum lined bearing material was found inside the oil passage of the No. 2 cylinder crankpin journal. Fretting was noted at the No. 3 cylinder contact area, and also at the split-line surface of the right crankcase half at the main bearing locations. The fretting was the greatest at the cylinder contact area between studs Nos. 1 and 2, and also at the split line surface on the right crankcase half at the No. 3 main bearing location. The engine had accumulated 1,390 hours since major overhaul and approximately 873 hours since the No. 3 cylinder was removed and reinstalled.

Factual narrative

On September 5, 2004, about 1432 central daylight time, a Mooney M20F, N9708M, registered to a private individual, experienced a total loss of engine power and collided with a vehicle during a forced landing on a highway near Brandon, Mississippi. Visual meteorological conditions prevailed at the time and a visual flight rules (VFR) flight plan was filed for the 14 CFR Part 91 personal flight from Dekalb-Peachtree Airport, Atlanta, Georgia, to Shreveport Downtown Airport, Shreveport, Louisiana. The airplane was substantially damaged and there were no injuries to the private-rated pilot and two passengers in the airplane, or to the driver of the vehicle. The flight originated about 1310, from Dekalb-Peachtree Airport.

The pilot stated that he performed a preflight inspection of the airplane and noted the oil capacity was full (8 quarts). The flight departed and approximately 2 hours into the flight while flying at 10,500 feet, the engine began running rough. He advised air traffic control (ATC) and attempts to correct the rough running engine were unsuccessful. The flight continued and shortly afterwards, the engine developed a severe roughness and he then heard a bang with smoke entering the cockpit. He declared "mayday" with air traffic control and requested vectors to the nearest airport. Recognizing that he would be unable to reach the Jackson International Airport, he advised ATC of his intention of landing on a nearby highway. After landing on the highway during the landing roll, the left wing of the airplane collided with the left rear portion of a truck. He and his passengers exited the airplane which was later taken to a fixed-base operator (FBO) located on the Jackson International Airport.

Postaccident examination of the engine by an FAA airworthiness inspector revealed the No. 3 cylinder was separated from the engine crankcase; all cylinder studs were fractured. The No. 3 cylinder connecting rod cap was found at the accident site; the connecting rod bearing was missing. Two fractured 7/16 inch cylinder hold down studs with nuts attached, two fractured 5/16 inch cylinder hold down studs with nuts attached, one partial connecting rod bolt with nut, and one hydraulic lifter were found on the bottom engine cowling. Disassembly of the engine revealed that the No. 2 piston and connecting rod exhibited extreme heat discoloration. The No. 2 connecting rod bearing was "welded" to the crankpin journal, and a foreign object was noted in the oil passage at the journal; the foreign object was retained for further examination. Examination of the oil pump revealed the gears were not failed; metal particles were present in the oil pump housing. The right crankcase half which contains cylinder Nos. 1 and 3 was retained for further examination by the NTSB Materials Laboratory, located in Washington D.C.

NTSB examination of the right crankcase half revealed cylinder hold down studs identified for the investigation as Nos. 1 and 8 which were the aft two cylinder hold down studs exhibited fracture features consistent with low-stress, long-term fatigue propagation. The fracture features of studs identified as Nos. 2, 3, 6, and 7, and thru-bolt No. 5 were consistent with rapid, high-stress fatigue propagation. The fracture features of thru-bolt identified as No. 4 was consistent with reverse bending fatigue. Examination of the No. 3 cylinder connecting rod bolt remaining inside the separated connecting rod cap revealed fracture features consistent with shear overstress, while the section of connecting rod bolt which was found at the bottom of the engine cowling exhibited fracture features consistent with bending overstress. The two available connecting rod bolt sections did not appear to mate with each other, and the remaining fracture halves of both bolts were not recovered. The cylinder attachment area for the No. 3 cylinder exhibited a large circular impression which was consistent with impact damage from the piston contacting the crankcase. Some fretting, which appears as a brown stain, was found around most of the contact surface of the No. 3 cylinder contact area, with the most significant fretting between studs Nos. 1 and 2. Additionally, wear lips were observed mostly in the vicinity of the large diameter studs/bolts, with the damage being more severe adjacent to thru-bolts Nos. 4 and 5. Some fretting was also noted at the split-line surface of the right crankcase half at the No. 3 main bearing location, while "...minimal fretting..." was noted at the split-line surface of the right crankcase half at the Nos. 1, 2, and 4 main bearing locations. The object retrieved from the oil passage of the No. 2 crankpin journal was examined and found to be consistent with aluminum lined bearing material.

Review of the maintenance records revealed the engine was overhauled on June 9, 1978; there was no entry in the airframe logbook indicating engine installation following overhaul. On July 22, 1984, the Nos. 2 and 3 cylinders were removed and an oversized thru-bolt was installed at the "center upper thru-bolt" location. The engine had accumulated 1,390 hours (by tachometer time) since overhaul at the time of the failure, and 873.3 hours since the No. 3 cylinder was removed and reinstalled.

The airplane minus the retained components were released to Shaen Phillips of U.S. Aviation Underwriters, Inc., on October 21, 2004. The retained components were also released to Shaen Phillips on May 5, 2005.

Aircraft

Registration
N9708M
Reported as
Mooney M20F
Category
Airplane
Serial number
670268
Airframe hours
4,020.7
Engine
Lycoming I0-360-A1A, 200 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · August 1, 2004 · 3 hours before
Departed
KPDK · Atlanta, GA
Destination
KDTN · Shreveport, LA
Flight plan
VFR

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
46
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Valid Medical--w/ waivers/lim
Last flight review
May 1, 2004
Seat
Left
Flight hours
319 total · 37 in this make and model · 265 as pilot in command · 30 in the last 90 days · 4 in the last 30 days · 4 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
310° at 4 knots
Visibility
9 statute miles
Lowest ceiling
4,700 ft broken
Temperature
88 °F, dew point 68 °F
Altimeter
29.93 inHg
Observed at
KJAN

FAA reports on this event · 1

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