MIA91FA008

NTSB accident investigation · Mooney M20C · Kissimmee, FL · October 7, 1990

Accident · Serious injuriesField investigationFinal report
Date
October 7, 1990, 12:30 local (16:30 UTC)
Place
Kissimmee, FL
Injuries
2 serious
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N1389WMooney M20C
Weather
Visual (VMC) · Day
Status
Completed · report April 14, 1992
Report
Approved by Office Director
FAA report
19901007047279A
Case key
32732

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

Malfunction of both magnetos due to deterioration of the coils, failure of maintenance personnel to comply with an airworthiness directive, and failure of the pilot to maintain adequate visual lookout while on an approach for an emergency landing. Factors related to the accident were: the obstruction (tree) in the emergency landing area, and diversion of the pilot's attention while approaching to land.

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(partial) - mech failure/malfCruise
Ignition system,magneto - deterioratedCause
Maintenance,compliance with ad - not performedOther maintenance personnelCause
Forced landingDescent - emergency
In flight collision with objectApproach
Object - tree(s)Factor
Visual lookout - inadequatePilot in commandCause
Diverted attentionPilot in commandFactor
In flight collision with terrain/waterDescent - uncontrolled

Analysis

The plt rprtd the eng started & ran normally before takeoff. However, during flt, it began running rough. The plt reduced the power setting which initially eliminated the eng roughness. He checked each magneto & noted no malfunction; however, while diverting to a nearby arpt, the eng again began running rough & a severe loss of power occurred. According to witnesses, the acft struck a palm tree during a left descending turn at low altitude & crashed. The eng was equipped with bendix model S4LN-200 series magnetos. During a bench check both magnetos began misfiring after about 15 to 20 min of opn. Disassembly of the magnetos revealed the nonconductive material in the coils was cracked & was beginning to liquefy; this resulted in misdirection of the high voltage spark. The magnetos had aprx 2316 hrs in svc. According to AD 73-07-04, the coils in the magnetos of this acft should have been replaced after accumulating aprx 2000 hrs of opn. The acft had flown 11 hrs since the last annual inspn.

Aircraft

Registration
N1389W
Reported as
Mooney M20C
Category
Airplane
Serial number
2667
Airframe hours
2,316
Engine
Lycoming O-360-A1D, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Registered owner
L. G. & P. W. Blendermann
Airworthiness certificate
Standard, Normal
Last inspection
Annual · May 13, 1990 · 22 hours before
Departed
SUA · Stuart, FL
Destination
TOC · Toccoa, GA

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
47
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
581 total · 581 as pilot in command · 2 in the last 90 days · 1 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
80° at 14 knots
Visibility
15 statute miles
Lowest ceiling
None
Temperature
84 °F, dew point 66 °F
Altimeter
29.89 inHg
Observed at
MCO, 12 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.