# NTSB MIA97FA242: Mooney M20F, N6417Q, Coral Springs, FL, September 11, 1997 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: September 11, 1997, 08:01 local (12:01 UTC) - Place: Coral Springs, FL - Coordinates: 26.310321, -80.230453 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=26.3103&lon=-80.2305&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal, 1 serious - Status: Completed, report February 28, 2000 - Report: Approved by Office Director - NTSB case key (mKey): 38153 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=MIA97FA242 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/38153/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=38153 - Page: https://openairdocs.org/ntsb/MIA97FA242 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(total) - mech failure/malf, climb - to cruise - engine assembly,bearing - undetermined (contributing factor) - engine assembly,connecting rod - fatigue (contributing factor) - engine assembly,other - fatigue (contributing factor) - Forced landing, descent - emergency - gear down and locked - intentional, pilot in command - In flight collision with terrain/water, emergency descent/landing - terrain condition - water - distance/altitude - misjudged, pilot in command (cause) ## 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](https://openairdocs.org/deregistered/N6417Q-1999-04-01), registration cancelled 1999-04-01, S/N 670496 (OpenAirDocs) - Reported make and model: Mooney M20F - Registry model: [Mooney M20F](https://openairdocs.org/model/mooney-m20f) (registry code 5870214) (OpenAirDocs) - Category: Airplane - Serial number: 670496 - Airframe hours: 4805 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 47; 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 ## 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 19970911026119A](https://openairdocs.org/incident/19970911026119A), Sep 11, 1997: Mooney M20F, Coral Springs, FL, Substantial damage, 1 fatal. Lost oil pressure on climbout. Dragged a wing in a pond trying land in a clearing. Cartwheeled. Engine thru a rod. (.4) the passenger who is a A&P mechanic… ## Docket (32 files) The files NTSB released with the investigation on September 1, 1998, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=38153. 8.5 MB in all. - Supplement A- Wreckage Documentation (item 1, .PDF, 244 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40088795&FileExtension=.PDF&FileName=Supplement%20A-%20Wreckage%20Documentation-Master.PDF - Supplement B- Cockpit Documentation (item 2, .PDF, 349 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40088796&FileExtension=.PDF&FileName=Supplement%20B-%20Cockpit%20Documentation-Master.PDF - Supplement K - Occupant, Survival and Injury Information (item 3, .PDF, 882 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40088797&FileExtension=.PDF&FileName=Supplement%20K%20-%20Occupant,%20Survival%20and%20Injury%20Information-Master.PDF - Supplement S- Aircraft Occupant and Injured Ground Personnel (item 4, .PDF, 59 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40088798&FileExtension=.PDF&FileName=Supplement%20S-%20Aircraft%20Occupant%20and%20Injured%20Ground%20Personnel-Master.PDF - Materials Laboratory 15 - Factual Reports of Group Chairman (item 5, .PDF, 674 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468454&FileExtension=.PDF&FileName=Materials%20Laboratory%2015%20-%20Factual%20Reports%20of%20Group%20Chairman-Master.PDF - Statement from the passenger Joseph Mancine (item 6, .PDF, 85 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468455&FileExtension=.PDF&FileName=Statement%20from%20the%20passenger%20Joseph%20Mancine-Master.PDF - Witness Statements (item 7, .PDF, 145 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468456&FileExtension=.PDF&FileName=Witness%20Statements-Master.PDF - Transcript of Radio Communications (item 8, .PDF, 170 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468457&FileExtension=.PDF&FileName=Transcript%20of%20Radio%20Communications-Master.PDF - Reports from Federal Agencies - FAA (item 9, .PDF, 66 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468459&FileExtension=.PDF&FileName=Reports%20from%20Federal%20Agencies%20-%20FAA-Master.PDF - Reports from Local Agencies (item 10, .PDF, 508 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468458&FileExtension=.PDF&FileName=Reports%20from%20Local%20Agencies-Master.PDF - Reports from Parties to the Investigation (item 11, .PDF, 97 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40088805&FileExtension=.PDF&FileName=Reports%20from%20Parties%20to%20the%20Investigation-Master.PDF - Record of Conversation with Adam Kramser (item 12, .PDF, 58 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468461&FileExtension=.PDF&FileName=Record%20of%20Conversation%20with%20Adam%20Kramser-Master.PDF - Record of Conversation with Dr. Gaston Mendez Jr. (item 13, .PDF, 66 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468470&FileExtension=.PDF&FileName=Record%20of%20Conversation%20with%20Dr.%20Gaston%20Mendez%20Jr.-Master.PDF - Oil Lubrication Diagram. (item 14, .PDF, 120 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40088808&FileExtension=.PDF&FileName=Oil%20Lubrication%20Diagram.-Master.PDF - Engine Installation (item 15, .PDF, 163 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468469&FileExtension=.PDF&FileName=Engine%20Installation-Master.PDF - Copies of the Aircraft Maintenance Records (item 16, .PDF, 2.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468467&FileExtension=.PDF&FileName=Copies%20of%20the%20Aircraft%20Maintenance%20Records-Master.PDF - Statement from James R. Stabley (item 17, .PDF, 55 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468465&FileExtension=.PDF&FileName=Statement%20from%20James%20R.%20Stabley-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 18, .PDF, 51 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468466&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 19, .PDF, 524 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468468&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Master.PDF - Toxicological Report (item 20, .PDF, 178 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468464&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - Photo 1: View looking North from the northern edge of the pond where the airplane crashed. (item 21, .PDF, 153 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40088815&FileExtension=.PDF&FileName=Photo%201%3A%20View%20looking%20North%20from%20the%20northern%20edge%20of%20the%20%20pond%20where%20the%20airplane%20crashed.-Master.PDF - Photo 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 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40088816&FileExtension=.PDF&FileName=Photo%202%3A%20View%20looking%20South%20from%20just%20North%20of%20the%20northern%20edge%20of%20the%20pond.%20%20The%20flag%20was%20tied%20to%20a%20portion%20of%20the%20airplane.-Master.PDF - Photo 3: View of the airplane being pulled from the water, The airplane was facing due south while submerged. (item 23, .PDF, 196 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40088817&FileExtension=.PDF&FileName=Photo%203%3A%20View%20of%20the%20airplane%20being%20pulled%20from%20the%20water,%20%20The%20airplane%20was%20facing%20due%20south%20while%20submerged.-Master.PDF - Photo 4: View of the pilot's seat and the area forward of the pilot's seat. (item 24, .PDF, 172 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40088818&FileExtension=.PDF&FileName=Photo%204%3A%20View%20of%20the%20pilot%27s%20seat%20and%20the%20area%20forward%20of%20the%20pilot%27s%20seat.-Master.PDF - Photo 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 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40088819&FileExtension=.PDF&FileName=Photo%205%3A%20View%20of%20the%20engine%20and%20engine%20compartment.%20%20Note%20the%20hole%20in%20the%20crankcase%20and%20the%20oil%20climging%20to%20the%20engine%20rear%20baffling.-Master.PDF - Photo 6: View of the top of the engine after separation from the airframe. (item 26, .PDF, 210 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40088820&FileExtension=.PDF&FileName=Photo%206%3A%20View%20of%20the%20top%20of%20the%20engine%20after%20separation%20from%20the%20airframe.-Master.PDF - Photo 7: View of the bottom of the engine after removal of the oil sump. (item 27, .PDF, 182 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40088821&FileExtension=.PDF&FileName=Photo%207%3A%20View%20of%20the%20bottom%20of%20the%20engine%20after%20removal%20of%20the%20oil%20sump.-Master.PDF - Photo 8: View of the governor mount pad. Note the ferrous metal. (item 28, .PDF, 160 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40088822&FileExtension=.PDF&FileName=Photo%208%3A%20View%20of%20the%20governor%20mount%20pad.%20%20Note%20the%20ferrous%20metal.-Master.PDF - Photo 9: View of cylinder No. 3 with failed piston pin end plugs. (item 29, .PDF, 181 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40088823&FileExtension=.PDF&FileName=Photo%209%3A%20View%20of%20cylinder%20No.%203%20with%20failed%20piston%20pin%20end%20plugs.-Master.PDF - Photo 10: View of the No. 3 cylinder crankpin journal. Note the discoloration. (item 30, .PDF, 136 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40088824&FileExtension=.PDF&FileName=Photo%2010%3A%20View%20of%20the%20No.%203%20cylinder%20crankpin%20journal.%20%20Note%20the%20discoloration.%20-Master.PDF - Photo 11: View of the failed No. 3 cylinder connecting rod and rod cap. (item 31, .PDF, 141 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40088825&FileExtension=.PDF&FileName=Photo%2011%3A%20View%20of%20the%20failed%20No.%203%20cylinder%20connecting%20rod%20and%20rod%20cap.-Master.PDF - Photo 12: View of the No. 1 cylinder crankpin journal. Pencile points to a particle. (item 32, .PDF, 136 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40088826&FileExtension=.PDF&FileName=Photo%2012%3A%20View%20of%20the%20No.%201%20cylinder%20crankpin%20journal.%20%20Pencile%20points%20to%20a%20particle.-Master.PDF 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.