NYC06LA101

NTSB accident investigation · Mooney M20J · Norwood, MA · April 24, 2006

Accident · Minor injuriesLimited investigationFinal report
Date
April 24, 2006, 08:20 local (12:20 UTC)
Place
Norwood, MA
Injuries
1 minor
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N201BDMooney M20J
Weather
Instrument (IMC) · Day
Status
Completed · report July 25, 2007
Report
Approved by Office Director
Parties
FAA/FSDO
FAA report
20060424008309A
Case key
63555

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

Improper maintenance, which resulted in a fatigue fracture of the dual magneto mounting flange, and a subsequent loss of engine power.

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 powerTakeoff - initial climb
Ignition system,magneto - fatigue
Maintenance - improperOther maintenance personnelCause
Forced landingDescent - emergency
On ground/water encounter with terrain/waterDescent - emergency
Terrain condition - ground

Analysis

The Mooney M20J accelerated and lifted off normally from the runway; however, during the initial climb after takeoff, it experienced a significant loss of engine power. The pilot performed a forced landing to a golf course adjacent to the airport. The airplane came to rest upright; however, the engine was torn away from the firewall, and the airframe was substantially damaged. Examination of the engine revealed that the Bendix single drive, dual magneto mounting flange was fatigue fractured, consistent with inadequate torque on the mounting nuts. The airplane had been operated for about 275 hours since its most recent annual inspection, which was performed about a year prior to the accident. The logbook entry for the annual inspection specifically included maintenance performed on the magneto.

Factual narrative

On April 24, 2006, about 0820 eastern daylight time, a Mooney M20J, N201BD, was substantially damaged during a forced landing, after a loss of engine power while climbing after takeoff from Norwood Memorial Airport (OWD), Norwood, Massachusetts. The certificated commercial pilot sustained minor injuries. Instrument meteorological conditions prevailed, and an instrument flight rules flight plan was filed for the flight destined for the Solberg-Hunterdon Airport (N51), Readington, New Jersey. The personal flight was conducted under 14 CFR Part 91.

The airplane was departing from runway 35, a 4,008-foot-long, 100-foot-wide, asphalt runway.

The pilot reported that the airplane accelerated and lifted off normally from the runway; however, during the initial climb after takeoff, the airplane experienced a significant loss of engine power. The pilot declared an emergency, and performed a forced landing to a golf course, that was located adjacent to the airport. The airplane came to rest upright; however, the engine was torn away from the firewall, and the airframe was substantially damaged.

The airplane was equipped with a Lycoming IO-360-A3B6D engine. Examination of the engine by a Federal Aviation Administration inspector did not reveal any catastrophic engine failures; however, it was noted that the Bendix single drive, dual magneto was separated from its mount. Additional examination revealed that the mounting clips remained attached to the engine. The magneto mounting flange was fractured on both sides where the mounting clips would normally be located. The magneto assembly was forwarded to the Safety Board's Materials Laboratory, Washington, D.C., for further examination.

Magnified optical examination of the fractures contained on the magneto mounting flange revealed surface features and beach markings indicative of fatigue crack progression. Both fracture surfaces showed surface damage consistent with re-contact between the fracture faces; however, significantly more damage was observed on one side then the other. The clamping nuts and internal toothed lock washers were intact. The nut washer faces contained marks and dents which indicated contact with the locking washers. See the Materials Laboratory Factual Report, located in the public docket for additional information.

The airplane had been operated for about 275 hours since its most recent annual inspection, which was performed on April 1, 2005. The logbook entry for the annual inspection specifically included maintenance performed on the magneto.

On August 15, 2003, Lycoming issued Service Instruction No. 1508A, which included IO-360-A3B6D engines installed on Mooney M20J airplanes. The service instruction stated, in part:

"There have been reports of the hardware attaching the dual magneto to the studs in the engine accessory housing becoming loose after maintenance in the field...It is possible that during magneto maintenance, such as timing changes or checks, the attachment nuts are not being torque to specifications or that hardware has not been installed properly. At the next oil change interval, but not to exceed 50 hours of operation, and any time the magneto is serviced, the correct attachment of the magneto should be verified...."

A weather observation taken at OWD, about the time of the accident, reported: Winds from 360 degrees, at 6 knots; visibility 3 statue miles in mist, ceiling 400 feet overcast; temperature 44 degrees F; dew point 43 degrees F; altimeter 29.85 in/hg.

Aircraft

Registration
N201BD
Reported as
Mooney M20J
Category
Airplane
Serial number
24-0612
Airframe hours
2,530
Engine
Lycoming IO-360-A3B6D, 200 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Registered owner
Mark A. Wilkinson
Airworthiness certificate
Standard, Normal
Last inspection
Annual · April 1, 2005 · 275 hours before
Departed
OWD · Norwood, MA
Destination
N51 · Readington, NJ
Flight plan
IFR
Airport
OWD · Norwood, runway 35, 4,008 × 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
42
Injuries
Minor
Certificate
Commercial
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
January 1, 2005
Seat
Left
Flight hours
1,601 total · 323 in this make and model · 1,526 as pilot in command · 47 in the last 90 days · 7 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Day
Wind
360° at 6 knots
Visibility
3 statute miles
Lowest ceiling
400 ft overcast
Temperature
45 °F, dew point 43 °F
Altimeter
29.85 inHg
Observed at
OWD

Docket · 5

The files NTSB released with the investigation on June 24, 2007, on NTSB’s docket system: statements, records, photos and specialists’ reports. 4.8 MB in all.

FAA reports on this event · 1

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