NYC01IA046

NTSB incident investigation · Mooney M20C · Hazard, KY · November 30, 2000

Incident · Minor injuriesIncident investigationFinal report
Date
November 30, 2000, 11:00 local (16:00 UTC)
Place
Hazard, KY
Injuries
2 minor, 2 uninjured
Damage
No damage
Phase of flight
Enroute
Aircraft
N942TBMooney M20C
Weather
Visual (VMC) · Day
Status
Completed · report July 10, 2001
Report
Approved by Office Director
FAA report
20001130022099I
Case key
50707

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

On this page

Probable cause

The incorrect routing of the cabin air scat tubing by an unknown person, which resulted in a carbon monoxide leak into the cabin, and subsequent pilot incapacitation.

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.

Miscellaneous/otherCruise
Air conditioning/heating/pressurization system(s) - incorrectUnknownCause
Incapacitation(carbon monoxide)Pilot in command

Analysis

During cruise flight, the pilot became incapacitated. The pilot rated passenger was able to fly the airplane toward an airport and wake the pilot. The pilot landed uneventfully, but suffered from toxic levels of carbon monoxide. Examination of the airplane revealed a hole in the cabin air scat tubing. The hole was in the vicinity of the joint that connected the number one cylinder to the exhaust manifold, and there was a visible gap in the joint. Further examination revealed that the sometime during the airplane's history, the scat tubing had been misrouted.

Factual narrative

On November 30, 2000, about 1100 Eastern Standard Time, a Mooney M20C, N942TB, was not damaged during a pilot incapacitation event near Hazard, Kentucky. The certificated private pilot and pilot rated passenger received minor injuries, and two passengers were not injured. Visual meteorological conditions prevailed for the flight that departed Lynchburg Regional Airport (LYH), Lynchburg, Virginia; destined for Kyle-Oakley Field (CEY), Murray, Kentucky. An instrument flight rules flight plan was filed for the personal flight conducted under 14 CFR Part 91.

The pilot stated that he was in cruise flight at 8,000 feet near Hazard, Kentucky. He began to feel ill, and requested a descent to 6,000 feet. The pilot then began to "go in and out of consciousness." The pilot rated passenger had not flown for over 25 years, but was able to fly the airplane to Big Sandy Regional Airport (K22), Prestonsburg, Kentucky. The pilot rated passenger successfully woke the pilot, and the pilot made an uneventful landing. The pilot stated that he remembered flying a left-hand traffic pattern at K22, but did not remember landing the airplane.

The pilot further stated that hospital tests revealed he and the pilot rated passenger had toxic levels of carbon monoxide in their blood. Carbon monoxide was present in the rear seat passengers, but the levels were not toxic.

Examination of the airplane revealed a hole in the cabin air scat tubing. The hole was next to the joint that connected the exhaust manifold to the exhaust from the number one cylinder. The joint was not secure, and a gap was visible.

Photographs of the engine were forwarded to the airplane manufacturer. The manufacturer stated that sometime during the airplane's history, the scat tubing was misrouted. The tube with the hole, connected the air inlet to the cabin. A second tube connected the air inlet to a heater exchange. The tube with the hole was suppose to be routed underneath the second tube, however, it was resting on top of it. The manufacturer added that the scat tubing was not clamped, but the clamps would only help if the tube was correctly routed.

The pilot stated that maintenance work was performed on his airplane prior to the day of the incident. Specifically, a fixed base operator replaced the alternator. However, a Federal Aviation Administration (FAA) inspector stated that the misrouting could have happened during any of several prior maintenance visits. The inspector could not confirm that the most recent maintenance work was the cause of the misrouting. Additionally, he could not confirm when the gap formed in the joint between the cylinder and exhaust manifold.

The airplane's last annual inspection was performed on October 28, 2000.

Aircraft

Registration
N942TB
Reported as
Mooney M20C
Category
Airplane
Serial number
2587
Airframe hours
1,404
Engine
Lycoming O-360, 180 horsepower, reciprocating
Damage
No damage
Flight
Personal · Part 91
Registered owner
Thomas R. Bailey
Airworthiness certificate
Standard, Normal
Last inspection
Annual · October 28, 2000 · 49 hours before
Departed
LYH · Lynchburg, VA
Destination
CEY · Murray, KY
Flight plan
IFR
Airport
K22 · Big Sandy Regional, runway 21, 5,000 × 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
46
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
751 total · 50 in this make and model · 711 as pilot in command · 56 in the last 90 days · 18 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
1,900 ft overcast
Temperature
34 °F, dew point 25 °F
Altimeter
30.00 inHg
Observed at
JKL, 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.