MIA97FA242

NTSB accident investigation · Mooney M20F · Coral Springs, FL · September 11, 1997

Accident · FatalField investigationFinal report
Date
September 11, 1997, 08:01 local (12:01 UTC)
Place
Coral Springs, FL
Injuries
1 fatal, 1 serious
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N6417QMooney M20F
Weather
Visual (VMC) · Day
Status
Completed · report February 28, 2000
Report
Approved by Office Director
FAA report
19970911026119A
Case key
38153

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

The pilot's misjudging the distance vs. altitude resulting in the collision with the water short of the intended touchdown point of the rough field. Contributing to the accident was the total loss of engine power due to failure of the No. 3 cylinder connecting rod bearing for undetermined reasons and fatigue failure of the No. 3 cylinder connecting rod and piston pin end plugs.

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/malfClimb - to cruise
Engine assembly,bearing - undeterminedFactor
Engine assembly,connecting rod - fatigueFactor
Engine assembly,other - fatigueFactor
Forced landingDescent - emergency
Gear down and locked - intentionalPilot in command
In flight collision with terrain/waterEmergency descent/landing
Terrain condition - water
Distance/altitude - misjudgedPilot in commandCause

Analysis

The passenger who is a A&P mechanic stated that about 5-10 minutes after takeoff while climbing through 1,000 to 1,500 feet on a northerly heading with the landing gear retracted, he first noted that the oil pressure dropped to zero then returned to the green arc. The airplane was at that time abeam the point where the airplane eventually crashed. The pilot noted this and began orbiting the area. He then heard a loud sound from the engine and while descending with the landing gear extended, the airplane descended into a man-made pond right wing low. The airplane then cartwheeled and sank in about 17-20 feet of water. The passenger exited the airplane out the main cabin door but the pilot did not escape. He was rescued about 12 minutes later but died in a hospital days after the accident. The airplane was recovered and examination of the engine revealed that the No. 3 cylinder connecting rod and piston pin end plugs failed due to fatigue. Also, a particle was found in the oil passage way of the crankshaft for the No. 1 crankpin. The engine was last inspected in accordance with a 100-hour inspection about 39 hours, and 2 months and 10 days earlier. The engine was a factory new engine that was installed on July 21, 1993 in accordance with a Supplemental Type Certificate. Requests were made following the accident to examine the maintenance records; they were not provided. Copies of the maintenance records were first provided to the National Transportation Safety Board 1 year and 11 months after the accident, by the engine manufacturer. The engine manufacturer obtained copies of the maintenance records from an attorney related to the case. The Nos. 3 and 1 cylinder pistons were installed in the opposite cylinders.

Factual narrative

History of flight

On September 11, 1997, about 0801 eastern daylight time, a Mooney M20F, N6417Q, registered to B J Aviation, Inc., crashed into a pond near Coral Springs, Florida. Visual meteorological conditions prevailed at the time and no flight plan was filed for the 14 CFR Part 91 business flight. The airplane was substantially damaged and the commercial-rated pilot and an unrestrained dog were fatally injured. The passenger sustained serious injuries. The flight originated about 0752 from the Ft. Lauderdale Executive Airport, Ft. Lauderdale, Florida.

According to the passenger, about 5-10 minutes after takeoff while climbing on a northerly heading through 1,000-1,500 feet with the landing gear retracted, he first observed that the oil pressure dropped to zero momentarily then returned to the normal green arc range. He inquired to the pilot about landing on the Sawgrass Expressway, but the pilot elected not to land there due to the amount of traffic. The pilot began orbiting the area, during which, he then heard a loud sound. The pilot then initiated a descent for a forced landing to an open field. With the landing gear extended and the flaps positioned to the takeoff range, while in a nose and right wing-low attitude, the right wing collided with water in a pond about 10 yards from the water's edge. The airplane then cartwheeled to the right and began sinking. The passenger exited the airplane out the cabin entry door, but the pilot did not escape. The passenger further stated that at the time he first noticed the drop in oil pressure, he thought the airplane was abeam the point where the airplane eventually crashed. He also stated that the propeller did not stop rotating.

According to a witness near the crash site, he reported seeing the airplane flying northbound, then heard the engine quit followed by a stream of white smoke. The airplane then turned to the east and while descending, a "puff" of dark smoke was noted. The airplane circled to the south and he then lost sight of the airplane due to obstructions.

Another witness saw smoke trailing the airplane then the airplane flew over his location which was reportedly about 1/4 mile north of the crash site. He heard a "popping" noise and observed the airplane turn to the west then to the north, as if to land in the field. He noted that the airplane was descending quickly and saw water splash into the air. He did not actually witness the airplane impact the water.

Personnel information

Review of the FAA records revealed that the pilot was a certificated airframe and powerplant mechanic. Further information pertaining to the pilot is contained on page 3 of the Factual Report-Aviation. The passenger is not pilot-rated but is a FAA certificated airframe and powerplant mechanic.

Aircraft information

On July 21, 1993, a factory new Lycoming IO-360-A3B6 engine was installed in the airplane. The recorded tachometer time at that time indicated 2731.52. The engine was installed in accordance with Supplemental Type Certificate SA250GL, which did not require the previous rpm restriction between 2,100 and 2,350; the maximum rpm restriction remained the same. The tachometer indicated post accident, 3,440.65. The airplane was last inspected in accordance with an annual inspection which was signed off on July 1, 1997, according to the mechanic who performed the inspection. He stated that he used Appendix D of 14 CFR Part 43 as a reference and was assisted by the pilot who did the 100-hour inspection. The mechanic with inspection authorization (IA) stated that he did not remove the oil suction screen, that the pilot may have, and that the oil filter was changed. He did not cut open the filter and didn't know if the pilot did. Review of Appendix D revealed in part that there is a requirement to check the oil screens and metal drain plugs for metal particles or foreign matter. Review of recovered paperwork revealed that the oil and oil filter were changed on June 30, 1997, at a tachometer time of 3,401.2 hours and the next oil change was due at 3,451 hours.

Requests were made to the co-owner of the airplane and the insurance adjuster following the accident to examine the maintenance records; they were not provided. Copies of the aircraft and engine maintenance records were first made available to the National Transportation Safety Board on August 27, 1999, by the engine manufacturer. According to personnel from the engine manufacturer, they obtained copies of the maintenance records from an attorney related to this case. A letter from a consultant to the engine manufacturer and copies of the maintenance records are attachments to this report.

The airplane was registered with the Federal Aviation Administration (FAA) in the name of B J Aviation, Inc., on February 21, 1997. The pilot was one of two owners of the airplane.

According to the previous owner of the airplane, who bought it in late 1979, a factory new engine was installed in 1981, and another factory new engine was installed in 1993. The engine installed in 1981 was replaced due to being at the engine manufacturers time between overhaul limit. The previous owner also stated that while he owned the airplane, he had no problems/discrepancies with the engine that was installed in 1993. The oil consumption was reported to be "low." Additional information pertaining to the airplane is contained on page 2 of the Factual Report-Aviation.

Meteorological information

Visual meteorological conditions prevailed in the area at the time of the accident. Additional meteorological information is contained on page 4 of the Factual Report-Aviation.

Communications

The pilot was in contact with the Fort Lauderdale Executive Airport Air Traffic Control Tower (ATCT) and a transcript of communications is an attachment to this report.

Wreckage and impact information

Examination of the accident site revealed that the airplane crashed into a pond that was about 17-20 feet deep, located near a residential area. The airplane was submerged and a buoy that had been tied to the airplane was observed to be floating about 10 yards south of the north shoreline. According to the diver who helped recover the airplane, it was upright and facing due south while submerged. Examination of the area surrounding the accident site revealed an open, rough field about 2/3 square mile with a mound of trees located slightly less than 1/3 mile north of the northern edge of the pond. The field extended about 200 feet east, from the eastern edge of the pond and about 600 feet west, from the western edge of the pond. About 100 feet south of the southern edge of the pond was a mound of trees. Additionally, an east-west oriented expressway was located about 1/3 mile north from the northern edge of the pond. The airplane was recovered for further examination.

Examination of the airplane revealed that the main and nose landing gears were failed aft due to overload with the landing gear selector handle in the down and locked position. The flaps were positioned to the takeoff range. Examination of the flight controls revealed no evidence of preimpact failure or malfunction. The left side of the fuselage just aft of the firewall and the engine rear baffling exhibited evidence of oil clinging to the skin. The lower engine cowling was coated with oil and an oil film was coating the lower firewall. The engine was attached to the airframe and the propeller was attached to the engine. Visual examination of the propeller revealed slight spanwise scratches on one of the two propeller blades. Visual examination of the engine revealed a hole in the top portion of the crankcase between the Nos. 2 and 4 cylinders. The oil dipstick and oil filter were in place and tightly secured, with the oil filter being safety wired. Also, all flexible oil hos

Aircraft

Registration
N6417Q
Reported as
Mooney M20F
Category
Airplane
Serial number
670496
Airframe hours
4,805
Engine
Lycoming IO-360-A3B6, 200 horsepower, reciprocating
Damage
Substantial damage
Flight
Business · Part 91
Operator
John J. Kelly
Registered owner
B J Aviation, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
Annual · July 1, 1997 · 39 hours before
Departed
FXE · Ft. Lauderdale, FL
Destination
JVY · Jeffersonville, IN

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
Certificates
Flight instructor, Private, 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
Seat
Left
Toxicology
Performed
Flight hours
8,700 total

Weather

Conditions
Visual (VMC) · Day
Wind
150° at 5 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
84 °F, dew point 75 °F
Altimeter
29.00 inHg
Observed at
FXE, 6 nm away

Docket · 32

The files NTSB released with the investigation on September 1, 1998, on NTSB’s docket system: statements, records, photos and specialists’ reports. 8.5 MB in all.

Supplement A- Wreckage DocumentationItem 1 · .PDF · 244 KBSupplement B- Cockpit DocumentationItem 2 · .PDF · 349 KBSupplement K - Occupant, Survival and Injury InformationItem 3 · .PDF · 882 KBSupplement S- Aircraft Occupant and Injured Ground PersonnelItem 4 · .PDF · 59 KBMaterials Laboratory 15 - Factual Reports of Group ChairmanItem 5 · .PDF · 674 KBStatement from the passenger Joseph MancineItem 6 · .PDF · 85 KBWitness StatementsItem 7 · .PDF · 145 KBTranscript of Radio CommunicationsItem 8 · .PDF · 170 KBReports from Federal Agencies - FAAItem 9 · .PDF · 66 KBReports from Local AgenciesItem 10 · .PDF · 508 KBReports from Parties to the InvestigationItem 11 · .PDF · 97 KBRecord of Conversation with Adam KramserItem 12 · .PDF · 58 KBRecord of Conversation with Dr. Gaston Mendez Jr.Item 13 · .PDF · 66 KBOil Lubrication Diagram.Item 14 · .PDF · 120 KBEngine InstallationItem 15 · .PDF · 163 KBCopies of the Aircraft Maintenance RecordsItem 16 · .PDF · 2.0 MBStatement from James R. StableyItem 17 · .PDF · 55 KBStatement of Party Representatives to NTSB InvestigationItem 18 · .PDF · 51 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 19 · .PDF · 524 KBToxicological ReportItem 20 · .PDF · 178 KBPhoto 1: View looking North from the northern edge of the pond where the airplane crashed.Item 21 · .PDF · 153 KBPhoto 2: View looking South from just North of the northern edge of the pond. The flag was tied to a portion of the airplane.Item 22 · .PDF · 193 KBPhoto 3: View of the airplane being pulled from the water, The airplane was facing due south while submerged.Item 23 · .PDF · 196 KBPhoto 4: View of the pilot's seat and the area forward of the pilot's seat.Item 24 · .PDF · 172 KBPhoto 5: View of the engine and engine compartment. Note the hole in the crankcase and the oil climging to the engine rear baffling.Item 25 · .PDF · 187 KBPhoto 6: View of the top of the engine after separation from the airframe.Item 26 · .PDF · 210 KBPhoto 7: View of the bottom of the engine after removal of the oil sump.Item 27 · .PDF · 182 KBPhoto 8: View of the governor mount pad. Note the ferrous metal.Item 28 · .PDF · 160 KBPhoto 9: View of cylinder No. 3 with failed piston pin end plugs.Item 29 · .PDF · 181 KBPhoto 10: View of the No. 3 cylinder crankpin journal. Note the discoloration.Item 30 · .PDF · 136 KBPhoto 11: View of the failed No. 3 cylinder connecting rod and rod cap.Item 31 · .PDF · 141 KBPhoto 12: View of the No. 1 cylinder crankpin journal. Pencile points to a particle.Item 32 · .PDF · 136 KB

FAA reports on this event · 1

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