# NTSB WPR09FA133: Mooney M20E, N3463X, Rio Linda, CA, February 28, 2009 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: February 28, 2009, 09:05 local (17:05 UTC) - Place: Rio Linda, CA - Coordinates: 38.679443, -121.446388 - Nearby events: https://openairdocs.org/map.md?lat=38.6794&lon=-121.4464&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report April 28, 2011 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration, Textron Lycoming - NTSB case key (mKey): 73409 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR09FA133 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/73409/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=73409 - Page: https://openairdocs.org/ntsb/WPR09FA133 ## Probable cause A partial loss of engine power for undetermined reasons and the pilot's failure to maintain an adequate airspeed while maneuvering during the initial climb, which resulted in a stall/spin. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Aircraft](https://openairdocs.org/ntsb-findings/01050000): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [Mooney M20E, 1 case](https://openairdocs.org/ntsb-findings/01050000/cases.md?model=5870212), [All aircraft, 151 cases](https://openairdocs.org/ntsb-findings/01050000/cases.md) - [Not determined](https://openairdocs.org/ntsb-findings/05000000): Not determined › Not determined · Unknown/Not determined (probable cause); cases with it: [Mooney M20E, 5 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md?model=5870212), [All aircraft, 2,247 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Mooney M20E, 16 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=5870212), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Performance/control parameters: airspeed](https://openairdocs.org/ntsb-findings/01062010): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Mooney M20E, 4 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=5870212), [All aircraft, 1,681 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342); cases with it: [Mooney M20E, 9 cases](https://openairdocs.org/ntsb-events/342/sequence.md?model=5870212), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) - [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Mooney M20E, 11 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=5870212), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Initial climb: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241); cases with it: [Mooney M20E, 4 cases](https://openairdocs.org/ntsb-events/241/sequence.md?model=5870212), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Mooney M20E, 28 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=5870212), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The flight was planned to be a maintenance test flight following an annual inspection, which included the installation of a field overhauled engine by the mechanic/passenger. Witnesses reported that a "popping" sound was heard during the takeoff ground roll. After liftoff, they heard the engine surge followed by a puff of black smoke emanating from the right rear of the engine. A videotape recording obtained from a camera located on a nearby building captured the airplane on the initial climb-out before it made a left turn back to the runway. The left wing and nose dropped as the airplane entered a spin prior to descending out of view of the camera. The airplane came to rest in an open field about 300 feet from the end of the runway and was consumed by a post-crash fire. During the postaccident inspection of the airframe and engine, no mechanical failures or malfunctions were found that would have prevented normal operation. The fuel lines, hoses, and fuel pump were too badly fire damaged to be able to determine if any pre-existing malfunctions affected those components. ## Factual narrative HISTORY OF FLIGHT On February 28, 2009, at 0905 Pacific standard time, a Mooney M20E, N3463X, collided with the ground shortly after takeoff from the Rio Linda airport, Rio Linda, California. The pilot/owner operated the airplane under the provisions of 14 Code of Federal Regulations Part 91, as a maintenance test flight. The certificated private pilot and mechanic/passenger were killed. The airplane was substantially damaged in the post-impact fire. Visual meteorological conditions prevailed for the local area flight, and no flight had been filed. WITNESS INFORMATION According to witnesses on the airport and surrounding the airport, they heard the engine sputtering and smoke emanating from the engine. Witnesses then saw the airplane enter a spin and impact the ground, and burst into flames. A witness, a part owner in the airplane, standing adjacent to the runway videotaping the flight, reported that as the airplane passed overhead he could hear popping and sputtering followed by a puff of black smoke emanating from the right rear of the engine. The same witness reported that the airplane had recently gone through an annual inspection and the accident flight was the first flight following that maintenance. The inspection included the installation of a field major overhauled engine and tail section. VIDEOTAPE The witness/part owner of the airplane submitted his videotape of the accident flight. The videotape showed the engine start and run-up at the hangar, a high-speed taxi brake check, the takeoff roll and climb out, and turn back toward the runway. The videotape was reviewed by the National Transportation Safety Board (NTSB) investigator-in-charge (IIC), no problems were observed during the start up or high-speed taxi. However, as the pilot added power, and was on the takeoff roll, a "popping" sound was heard. After liftoff, the engine was surging followed by a puff of black smoke. Another video was obtained from Rio Linda Junior High School, which is located at the departure end of the runway. There is no sound associated with the video. The video does show the airplane on the initial climb-out. The airplane then makes a left turn back to the runway. The airplane's nose and left wing drop and the airplane begins to spin before it drops out of view of the camera. PERSONNEL INFORMATION Pilot A review of FAA airman and medical records on file in Oklahoma City, Oklahoma, revealed that the 53-year-old pilot held a private pilot certificate with ratings for airplane single-engine land and single-engine sea. The pilot also held a mechanic certificate with ratings for airframe and power plant. The pilot held a first-class medical certificate issued on January 29, 2009. It had the limitation that the pilot shall possess glasses for near vision. The pilot reported 841 total flight hours on his most recent medical application; a pilot's logbook was not made available to the NTSB IIC for review. Mechanic/passenger A review of the FAA mechanic, airman,and medical records on file in Oklahoma City revealed that the 54-year-old passenger held a mechanic certificate with ratings for airframe and power plant. He also held an inspection authorization (IA) certificate. The review of his records also revealed that the mechanic held a combined student pilot and third-class medical certificate issued on June 27, 2008; at that time he reported a total of 340 flight hours. It had the limitation that he must wear corrective lenses. AIRCRAFT INFORMATION The airplane was a 1966 Mooney M20E, serial number 1143. The last annual inspection was dated May 5, 2007, at a total time of 3,715.52 hours. A Lycoming IO-360-A1A, serial number L-2302-51A, was installed on the airplane on May 26, 1969 at 910 total hours. The last 100-hour inspection was dated May 5, 2007, at a total time of 664.72 hours since major overhaul. According to records made available to the NTSB IIC, the mechanic was shipped a repaired crankcase from Divco, Inc., Tulsa, Oklahoma, on September 10, 2008. Various engine parts were shipped to the mechanic in September and October 2008. WRECKAGE AND IMPACT The NTSB IIC and a representative from Lycoming, a party to the investigation, responded to the accident site. The entire airplane came to rest adjacent to the airport property at the Roy Hayer Memorial Speedway in an open area. The airplane came to rest at global position system (GPS) coordinates of latitude of 38 degrees 40.770 minutes north, and a longitude of 121 degrees 26.779 minutes west, at an elevation of 41 feet. The entire airplane came to rest at the accident site; the cockpit and cabin areas, as well as the empennage were thermally destroyed in the fire. Fire damage was noted to the tail section, and both wings. Both wings were crushed from the leading to trailing edge. The left wing center section was thermally destroyed. The right wing remained intact, with sooting evident at the center section of the wing. The engine remained attached to the firewall, and the propeller assembly remained connected to the engine. MEDICAL AND PATHOLOGICAL INFORMATION Pilot The Sacramento County Coroner completed an autopsy on March 1, 2009. The manner of death was listed as multiple blunt force injuries. The FAA Forensic Toxicology Research Team, Oklahoma City, performed toxicological testing of specimens of the pilot. Analysis of the specimens contained no findings for carbon monoxide, cyanide, volatiles, or tested drugs. Mechanic/passenger The Sacramento County Coroner completed an autopsy on March 2, 2009. The manner of death was listed as multiple blunt force injuries. The autopsy report identified that chest blood from the mechanic was retained for toxicology testing. TEST AND RESEARCH INFORMATION The NTSB IIC and a participant from Lycoming Engines examined the airframe and engine at Plain Parts, Sacramento, California, on March 2, 2009. Inspection of the airframe found no anomalies with the flight control system. A visual examination of theengine revealed no obvious mechanical malfunctions. Mechanical and drive train continuity was established through manual rotation of the crankshaft; thumb compression was also obtained. The fuel fitting connection between the firewall to the fuel pump line was tight. The fuel pump to servo line hose was loose in the fitting where it connected to the servo. The oil filter hose to fitting was loose, but the fitting to the oil filter connection was secure. The fuel pump was mostly consumed by fire. The accessories above the fuel pump sustained thermal damage. Both magnetos remained attached to their respective mounting pads on the engine, but sustained thermal damage. The right magneto was free to rotate but produced no spark, and as a result of the fire damage, the left magneto would not rotate. The spark plugs appeared normal as compared to the Champion check-a-plug chart AV-27. All four of the cylinders were removed and inspected; investigators noted no detonation or foreign debris along the cylinder walls, no piston to cylinder damage, and no stuck valves. There was no internal damage to the connecting rods or thermal discoloration, nor were any of the push rods bent. The oil pick-up screen was free of debris, and the fuel servo inlet screen was also clear. The fuel flow divider was opened and the diaphragm was not damaged and was free of debris. The fuel injectors were clear. According to the Lycoming representative, there were no abnormalities that would have prevented normal operation. The propeller assembly remained attached to the engine with the spinner crushed and torn. The propeller governor was broken at the flange at the accessory housing. The propeller blades were randomly labeled Blade A and Blade B. Blade A was bent aft at the hub with diagonal scratch marks evident about 1 foot from the hub outboard. Blade B was bent aft at the hub with chordwise scratch marks evident the length of the blade. Fuel lines, hoses, and the fuel pump were shipped to the NTSB metallurgical laboratory in Washington, D.C., for additional inspection. According to the metallurgical specialist, the fuel lines and hoses were installed as a kit. One of the fuel lines had a data plate on it identifying it as a Stratoflex 111. The hose had a rubber interior; the lines themselves were thermally damaged and a determination of pre-existing damage could not be ascertained. The fuel pump also sustained heavy fire damage. The outer aluminum case was melted with sections of the pump missing, most likely consumed during the fire. Due to the fire damage a determination of any pre-existing mechanical failures or malfunctions was not possible. ## Aircraft - Registration: [N3463X](https://openairdocs.org/deregistered/N3463X-2010-05-28), registration cancelled 2010-05-28, S/N 1143, built 1966 (OpenAirDocs) - Reported make and model: MOONEY M20E - Registry model: [Mooney M20E](https://openairdocs.org/model/mooney-m20e) (registry code 5870212) (OpenAirDocs) - Registry engine: [Lycoming I0360 series](https://openairdocs.org/engine/lycoming-i0360-series) (registry code 41515, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 1143 - Airframe hours: 2715 - Engines: Lycoming IO-360 reciprocating - Damage: Substantial damage - Fire: On-Ground - Flight: Personal, Part 91 - Operator: David Michaud - Registered owner: David Michaud - Airworthiness certificate: Standard, Normal - Last inspection: Annual, April 5, 2007 - Departed: L36, Rio Linda, CA - Destination: L36, Rio Linda, CA - Airport: L36, Rio Linda Airport, runway 35, 2,625 × 42 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 53; injuries: fatal; private; airplane ratings: single-engine sea, single-engine land; medical: class 1, without waivers/limitations; last flight review October 15, 2006; seat: left; toxicology performed; flight hours: 824 total, 46 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 54 °F, dew point 48 °F - Altimeter: 30.03 inHg - Observed at: SMF, 7 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 20090228001279A](https://openairdocs.org/incident/20090228001279A), Feb 28, 2009: Mooney M20E, Rio Linda, CA, Destroyed, 2 fatal. Pilot and mechanic were conducting a first flight after engine overhaul and long annual inspection. The pilot made a high speed run then turned around and took… ## Other investigations on N3463X (1) 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. - [NTSB CHI68F0217](https://openairdocs.org/ntsb/CHI68F0217), Jul 3, 1967: Mooney M20E (N3463X), South Bend, IN, substantial damage ## Docket (12 files) The files NTSB released with the investigation on February 17, 2011, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=73409. 7.7 MB in all. - Photo (NTSB) (item 1, .PDF, 3.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40342883&FileExtension=.PDF&FileName=Photo%20(NTSB)-Master.PDF - Photo 1 - Cockpit Area (Lycoming) (item 2, .PDF, 734 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40342887&FileExtension=.PDF&FileName=Photo%201%20-%20Cockpit%20Area%20(Lycoming)-Master.PDF - Videos of Accident WPR09FA133 (item 3, .PDF, 51 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40345593&FileExtension=.PDF&FileName=Videos%20of%20Accident%20WPR09FA133-Master.PDF - NTSB Fuel Lines Fuel Pump Report (item 4, .PDF, 38 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40343388&FileExtension=.PDF&FileName=NTSB%20Fuel%20Lines%20Fuel%20Pump%20Report-Master.PDF - Excerpt from Aircraft Logbook (item 5, .PDF, 497 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40342885&FileExtension=.PDF&FileName=Excerpt%20from%20Aircraft%20Logbook-Redacted.PDF - Airplane Work Feb 9 2006 (item 6, .PDF, 32 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40342886&FileExtension=.PDF&FileName=Airplane%20Work%20Feb%209%202006-Master.PDF - Excerpt Engine Logbook (item 7, .PDF, 872 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40342888&FileExtension=.PDF&FileName=Excerpt%20Engine%20Logbook-Redacted.PDF - Toxicological Report - D Michaud (item 8, .PDF, 103 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40342875&FileExtension=.PDF&FileName=Toxicological%20Report%20-%20D%20Michaud-Master.PDF - Toxicological Report - G Maack (item 9, .PDF, 102 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40342876&FileExtension=.PDF&FileName=Toxicological%20Report%20-%20G%20Maack-Master.PDF - G Maack Outside Toxicology Report (item 10, .PDF, 360 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40342878&FileExtension=.PDF&FileName=G%20Maack%20Outside%20Toxicology%20Report-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 11, .PDF, 966 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40342890&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 12, .PDF, 80 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40343806&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.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.