WPR11FA114

NTSB accident investigation · Mooney M20J · Furnace Creek, CA · January 29, 2011

Accident · FatalField investigationFinal report
Date
January 29, 2011, 00:00 local (08:00 UTC)
Place
Furnace Creek, CA
Injuries
1 fatal
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N50BJMooney M20J
Defining event
Enroute-climb to cruise: Loss of engine power (partial)
Weather
Visual (VMC) · Day
Status
Completed · report November 5, 2012
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Lycoming, FAA FSDO
FAA report
20110129005209A
Case key
78248

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 magneto clamps were not securely fastened to the mount, which led to a partial loss of engine power and a subsequent forced landing on unsuitable terrain.

Findings · 3

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Ignition system: magneto/distributorAircraft › Aircraft power plant · Not serviced/maintainedMooney M20J: 2 casesAll aircraft: 101 casesProbable cause
Power plant: mountsAircraft › Aircraft power plant · Fatigue/wear/corrosionMooney M20J: 1 caseAll aircraft: 5 casesProbable cause
Terrain: rough terrainEnvironmental issues › Physical environment · Contributed to outcomeMooney M20J: 2 casesAll aircraft: 442 cases

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

A witness reported observing the airplane take off to the south and stated that the ground operations and takeoff appeared to be normal. The wreckage was located 2 days later on a flat, dry salt lake bed 7 miles south of the departure airport. The surface of the ground was deep jagged salt deposits, with crevasses between 6 and 18 inches deep, and unsuitable for making a successful off-field landing. During the postaccident engine examination, the single-drive dual magneto was found mounted on the accessory pad and could be easily rotated by hand. The magneto had sustained no apparent impact damage and remained in good condition externally. Further examination of the attachment hardware found all required mounting studs, lock washers, and respective nuts to be in place and undamaged. The magneto clamps, respective magneto flange, and the accessory case interface areas exhibited wear signatures consistent with fretting, which suggested that the clamps were not securely fastened. These signatures were most prominent on the lower clamps and flange area. The magneto flange remained intact and revealed no evidence of cracking. It is likely that this could have produced a partial power loss, which led to the pilot’s decision to make an off-airport landing. No other mechanical failures or malfunctions were found that would have precluded normal operation. The airplane had accumulated about 10 hours since the last annual inspection. No maintenance records were located to determine if further maintenance had been performed on the engine since the inspection 5 months prior to the accident.

Factual narrative

HISTORY OF FLIGHT On January 29, 2011, at an undetermined time, a Mooney M20J, N50BJ, impacted terrain near Furnace Creek, California. The owner/pilot was operating the airplane under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The certificated private pilot was fatally injured; the airplane sustained substantial damage by impact forces. The cross-country personal flight departed Furnace Creek between 1430 and 1515 Pacific standard time (PST) with a planned destination of Santa Monica, California. Visual meteorological conditions prevailed, and no flight plan had been filed. A witness reported that the accident airplane departed from Furnace Creek Airport (L06) between 1430 and 1515 on January 29, 2011, and departed to the south. The witness observed the airplane’s ground operations and the takeoff, which appeared normal to him. The airplane wreckage was not discovered until January 31, 2011, around 0830 PST by National Park personnel. The wreckage was located 7 miles south of the departure airport. PERSONNEL INFORMATION The 61-year-old pilot held a private pilot certificate for single-engine land operations and an instrument rating. No personal flight records were located for the pilot. The aeronautical experience listed in this report was obtained from a review of the Federal Aviation Administration (FAA) records on file in the Airman and Medical Records Center located in Oklahoma City, Oklahoma. The pilot reported on his medical application that he had a total flight time of 2,000 hours with 20 hours logged in the last 6 months. AIRCRAFT INFORMATION The airplane was a Mooney M20J, serial number 24-0657. No aircraft or engine logbooks could be located. The mechanic A&P/IA that performed the last annual inspection reported that the airplane had a total airframe time of 1,703 hours at the time of the inspection, which was completed on August 11, 2010. The engine was a Lycoming IO-360-A3B6D, serial number L-19390-51A. Total time recorded on the engine at the last annual inspection was 1,703.0 hours, and time since major overhaul was estimated to be 150.0 hours. The tachometer read 1,712.8 hours at the accident scene. WRECKAGE AND IMPACT INFORMATION The accident site was located on a dry salt lake bed. The surface of the ground was deep jagged salt deposits, with deep crevasses between 6 to 18 inches deep. A ground surface scar was the first identified point of contact (FIPC) with the remains of the left wing tip navigation light. The debris path was 160 feet in length, along a magnetic heading of 185 degrees. The orientation of the fuselage was 300 degrees. The airplane appeared to have collided with level terrain in a slightly left bank, nose low attitude. The flaps and landing gear were retracted. The throttle, propeller, and mixture controls were full forward. The propeller blades exhibited damage signatures consistent with the absorption of rotational forces being applied at the time of impact with terrain. Furthermore,significant rotational blue paint signatures were observed on the spinner bulkhead. MEDICAL AND PATHOLOGICAL INFORMATION The Inyo County Coroner completed an autopsy on February 4, 2011. The cause of death was listed as multiple traumatic injuries. The FAA Civil Aerospace Medical Institute (CAMI), Oklahoma City, performed toxicological testing of specimens of the pilot. Analysis of the specimens contained no findings for carbon monoxide, cyanide, volatiles. The report contained the following findings for tested drugs: Rosuvastatin was detected in liver and Urine. TESTS AND RESEARCH Investigators examined the wreckage at Aircraft Recovery Service, Littlerock, California, on June 1, 2011. Examination of the airframe revealed no evidence of pre-impact mechanical malfunction or fire. Examination of the engine revealed that the engine remained attached to the airframe by the engine mount. The engine had sustained moderate impact energy damage to the forward lower section encompassing the associated accessories and exhaust system components. Visual examination of the engine revealed no evidence of pre-impact catastrophic mechanical malfunction or fire. Examination of the single drive dual magneto found that it was mounted on the accessory pad but could be easily rotated by hand. The magneto had sustained no apparent impact energy damage and remained in good condition externally. Examination of the attachment hardware found all required mounting studs, lock washers, and respective nuts to be in place and undamaged. The magneto was removed to be further examined and tested. The examination found that the proper clamps, gasket, and attachment hardware had been utilized in accordance with Lycoming Service Instruction SI-1508B, dated 12/19/2007, and SAIB NE-08-26R2, dated 04/22/2010. Examination of the associated magneto clamps, part number 66M19385, revealed the clamps had been contacting the accessory case and magneto flange in a proper configuration; however, the magneto clamps, respective magneto flange, and accessory case interface areas exhibited wear signatures consistent with fretting. These signatures were most prominent on the lower clamps and flange areas. The magneto flange remained intact and revealed no evidence of cracking. No other abnormalities were noted that would have precluded normal operation.

Aircraft

Registration
N50BJ
Reported as
Mooney M20J
Category
Airplane
Serial number
24-0657
Airframe hours
1,713
Engine
Lycoming IO-360, 200 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · August 11, 2010 · 10 hours before
Departed
L06 · Furnace Creek, CA
Destination
SMO · Santa Monica, CA
Airport
L06 · Furnace Creek Airport

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
61
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Seat
Left
Toxicology
Performed
Flight hours
2,000 total

Weather

Conditions
Visual (VMC) · Day
Wind
Variable at 5 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
63 °F, dew point 23 °F
Altimeter
29.96 inHg
Observed at
DRA, 42 nm away

Docket · 13

The files NTSB released with the investigation on August 29, 2012, on NTSB’s docket system: statements, records, photos and specialists’ reports. 7.4 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.