WPR12FA297

NTSB accident investigation · Mooney M20L · Scottsdale, AZ · July 9, 2012

Accident · Serious injuriesField investigationFinal report
Date
July 9, 2012, 09:37 local (16:37 UTC)
Place
Scottsdale, AZ
Injuries
1 serious, 1 minor
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N137MPMooney M20L
Defining event
Landing-flare/touchdown: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed · report February 14, 2013
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
FAA FSDO, Continental Motors, Inc.
FAA report
20120709014379A
Case key
84230

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 pilot's failure to maintain airplane control during an aborted landing, and the flight instructor’s delayed remedial action. Contributing to the accident were the pilot’s improper landing flare, which resulted in a bounced landing, and his premature flap retraction while performing a go-around maneuver.

Findings · 5

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.

Action: delayed actionPersonnel issues › Action/decision · Instructor/check pilotMooney M20L: 1 caseAll aircraft: 894 casesProbable cause
Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotMooney M20L: 2 casesAll aircraft: 9,295 casesProbable cause
Performance/control parameters: landing flareAircraft › Aircraft oper/perf/capability · Not attained/maintainedMooney M20L: 1 caseAll aircraft: 1,285 casesProbable cause
Wing structure: trailing edge flapsAircraft › Aircraft structures · Incorrect use/operationMooney M20L: 1 caseAll aircraft: 33 casesProbable cause
Action: incorrect action performancePersonnel issues › Action/decision · PilotMooney M20L: 1 caseAll aircraft: 1,386 casesProbable cause

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

The flight instructor stated that the pilot receiving instruction was practicing touch-and-go landings. On the fifth landing, the pilot flared too high, and the airplane dropped to the runway, landed hard, and bounced into the air. The flight instructor directed the pilot to “go around,” and the pilot applied power and fully retracted the flaps, which is contrary to the procedure in the pilot’s operating handbook to retract the flaps only to the 10-degree position. Both pilots stated that the engine did not respond. A video recording showed that the airplane’s altitude was about 30 feet above the ground when it rolled left to a bank angle of about 90 degrees. The left wing tip impacted the runway, and the airplane cartwheeled and came to rest upright about 200 feet left of the runway centerline. Postaccident examination of the engine revealed that two O-ring seals were installed on each of the engine’s six fuel injector nozzles, whereas the engine’s maintenance manual called for the installation of only one O-ring seal on each nozzle. However, flow testing showed that placing two O-rings on the nozzles had no effect on the operation of the fuel system. No other anomalies were found, and the examination and testing indicated that the engine was capable of operating normally and producing its rated horsepower. Further, the damage to the propeller blades was consistent with the engine operating at a mid-range to high power setting at impact. The airplane’s left roll to a steep bank angle is consistent with the engine developing power as the airplane enters an aerodynamic stall, which resulted in a torque roll to the left.

Factual narrative

HISTORY OF FLIGHT On July 9, 2012, at 0937 mountain standard time, a Mooney M20L, N137MP, was substantially damaged when it experienced a hard landing followed by a loss of control at Scottsdale Airport, Scottsdale, Arizona. The flight instructor was seriously injured, and the pilot receiving instruction received minor injuries. The airplane was being operated by the private pilot/owner under the provisions of 14 Code of Federal Regulations Part 91. A flight plan had not been filed for the local instructional flight, which had originated about 35 minutes before the accident. Visual meteorological conditions prevailed at the time of the accident. The pilot/owner had purchased the airplane in Florida a few days before the accident. He and the flight instructor flew the airplane back to the Phoenix area together, arriving about 2 to 3 days before the accident. The purpose of the flight was to get more flight experience in his recently acquired airplane. The flight instructor reported that the pilot was practicing touch-and-go landings on runway 21. On the fifth landing, the pilot flared too high, and the airplane dropped to the runway and landed hard. The airplane bounced back into the air, and the flight instructor directed the pilot to “go around.” The pilot pushed the power lever to the full open position and then moved his right hand to the flap handle. The pilot reported that he moved the flaps to the up position. Both the pilot and the flight instructor reported that the engine “did not respond.” The flight instructor stated that, in order to prevent the airplane from stalling, he pushed the nose of the airplane down and attempted to level the wings. He said that his actions “resulted in the airplane impacting the ground in a fairly level attitude, which minimized the severity of the impact.” He reported that, after it impacted terrain, the airplane veered off the left side of the runway. The flight instructor said that he inspected the wreckage after the accident and found the flaps in the full up position. Two video cameras documented the accident. One was located at the control tower, and a second one was located approximately 1,700 feet from the threshold of runway 21 and approximately 575 feet to the left of the runway centerline. A study of the videos was performed by the National Transportation Safety Board (NTSB) Vehicle Recorder Division, Washington, D.C., headquarters. The second camera was located much closer to the accident, and its images display the unfolding events more accurately. The video showed that, after the airplane’s hard landing, which was about 500 feet from the runway threshold, it became airborne and reached an altitude of between 24 to 37 feet. The video further showed that the accident airplane entered a left bank with an increasing bank angle that reached approximately 90 degrees. The left wingtip contacted the ground, and the airplane cartwheeled and came to rest upright heading opposite to the direction oflanding approximately 1,330 feet from the initial touchdown point. PERSONNEL INFORMATION The flight instructor held a commercial pilot certificate with single-engine land airplane, land airplane, and instrument ratings. He held a flight instructor certificate with single-engine land airplane, land airplane, and instrument ratings. He held a second-class medical certificate, which was issued on January 26, 2011. The flight instructor’s most recent flight review was on November 4, 2011. He reported that he had 6,397 hours of flight experience and had given 5,066 hours of flight instruction. The pilot receiving instruction held a private pilot certificate with single-engine land airplane and instrument ratings. He reported that he had approximately 1,400 hours of flight experience with about 400 hours in Mooney aircraft. The accident aircraft records indicate that the pilot had approximately 17 hours of flight experience in it since he purchased it a week before the accident. His most recent third-class medical certificate was issued on May 1, 2012. AIRCRAFT INFORMATION The airplane was a single-engine, propeller-driven, four seat airplane, with dual flight controls, which was manufactured by Mooney Aviation Company in 1988. Its maximum takeoff gross weight was 2,900 pounds. It was powered by a Continental IO-550-N reciprocating, direct drive, air-cooled, fuel injected engine, which had a maximum takeoff rating of 310 horsepower at sea level. It was equipped with a McCauley 3-blade propeller. The flight instructor reported on the NTSB’s Pilot/Operator Accident Report form that the airplane received its last annual inspection on July 2, 2012. The airframe had 1,945 flight hours on it at the time of the last inspection. A new engine was installed in the airplane in 2004; at the time of the accident, the engine had accumulated a total of approximately 123 hours. The wing flaps on the Mooney M20L are electrically operated and interconnected through push-pull tubes and bellcranks. Nominal travel is 0 to 33 degrees and limit switches prevent travel above or below these limits. The flap position is controlled by a switch located on the lower control console. The electric flap position indicator, which shows full up, takeoff (10 degrees) and full down positions, is located in the center of the instrument panel. The flaps are lowered by holding the spring-loaded switch in the FLAPS DOWN position until the flaps reach the desired angle of deflection. Simply releasing downward pressure on the switch allows it to return to the OFF position stopping the flaps at any desired intermediate position during extension. When the FLAPS UP position is selected, the flaps will retract to the full up position unless the switch is returned to the neutral position for a desired intermediate setting. The airplane manufacturer’s Pilot Operating Handbook (POH) states: CAUTION Pushing the switch to the UP position retracts the flaps completely. The POH lists the followingprocedure for GO AROUND/ABORTED LANDING: 1. Power Lever full power 2. Wing Flaps TAKEOFF POSITION (10 degrees) 3. Trim as desired CAUTION To minimize the control wheel forces during maneuvering, timely nose-down trimming is recommended to counteract the nose up pitching moment as power is increased and/or the flaps are retracted. 4. Airspeed 75 KIAS 5. Landing Gear UP 6. Wing Flaps UP 7. Airspeed 90 KIAS METEOROLOGICAL INFORMATION At 0935, the reported weather conditions at the Scottsdale Airport(SDL); elevation 1,510 feet), were: wind 160 degrees at 4 knots; visibility 10 statute miles; cloud condition, clear; temperature 100 degrees Fahrenheit; dew point 54 degrees Fahrenheit; altimeter setting 29.92 inches mercury. The density altitude was calculated to be 4,594 feet. WRECKAGE AND IMPACT INFORMATION The airplane came to rest about 1,830 feet from the threshold of runway 21 and 200 feet left of the runway centerline. It was located near the junction of taxiways B12 and B. It was longitudinally aligned on a magnetic heading of about 020 degrees. The main landing gear had collapsed and the nose wheel landing gear had separated from the fuselage; the airplane was resting on its belly. Both wings were bent up about 30 degrees from about 2/3 of the distance from the wing root to the tip. The outer 4 feet of the left wing had separated from the airplane and was found about 50 feet away. The engine had broken free from its mounts, but was in place and attached by wires, cables, and hoses. The propeller blades were deeply scored, their leading edges were gouged, and the blades were S-bent; two of the blade tips had separated from their blades. The airplane was equipped with a Supplemental Type Certificate modification that added additional main landing gear doors. Low Profile Inner Gear Doors, made of fiberglass, were attached to the main landing gear wheels. They covered the brake calipers and were closer to the ground than the outer (factory) main landing gear doors. The lower forward corners of these doors were found to be ground down. Two parallel marks were found by an FAA inspector about 500 feet from the runway threshold. Small flecks of paint, which matched the color of the landing gear doors, were found in the vicinity of the two runway marks. The distance between the two marks matched the distance between the two landing gear doors. TESTS AND RESEARCH Photographs of the propeller blades were reviewed by the propeller manufacturer's representative. The representative stated that the damage to the blades was consistent with the engine operating “in the mid-range to high power” at the time of impact. On July 12, 2012, a team of investigators convened to examine the engine. The team consisted of an NTSB investigator, a Federal Aviation Administration (FAA) inspector and an engine manufacturer’s representative. The spark plugs exhibited normal electrode wear, and each magneto produced good spark when the propeller/crankshaft was rotated. All sixcylinders were borescoped, and none of the cylinders, pistons, valves, or bottom spark plugs displayed any signs of operational distress. Thumb compression and suction were obtained on all six cylinders through manual rotation of the propeller, confirming crankshaft and camshaft continuity. The inspection of the engine did not reveal any anomalies that would have prevented normal operation and production of rated horsepower. On August 16, 2012, the engine was further examined by an NTSB investigator. Five of the six fuel injectors were removed, and it was noted that there were two O-ring seals installed on the nozzle of each fuel injector. On August 17, 2012, the sixth fuel injector was removed by salvage yard personnel, and two O-ring seals were also found installed on the nozzle of this injector. According to the engine manufacturer’s representative, only one O-ring was to be installed on the fuel nozzles of this engine. The NTSB’s investigator-in-charge requested that the engine manufacturer perform a flow test to determine if the installation of two O-rings per nozzle rather than the specified one O-ring per nozzle would have an effect on the operation of the fuel system. The testing indicated that placing two O-rings on the nozzles did not result in a significant difference in fuel flow during bench testing.

Aircraft

Registration
N137MP
Reported as
Mooney M20L
Category
Airplane
Serial number
26-0017
Engine
Continental IO-550, 285 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
Stephen Faliks
Registered owner
Stephen Faliks
Airworthiness certificate
Standard, Normal
Departed
SDL · Scottsdale, AZ
Destination
SDL · Scottsdale, AZ
Flight plan
Unknown
Airport
SDL · Scottsdale Airport, runway 21, 8,249 × 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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Flight instructor
Age
64
Injuries
Serious
Certificates
Flight instructor, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
November 4, 2011
Seat
Right
Flight hours
6,397 total · 187 in this make and model · 47 in the last 90 days · 1 in the last 24 hours
Role
Student pilot
Age
59
Injuries
Minor
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Seat
Left
Flight hours
1,400 total · 400 in this make and model · 25 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
160° at 4 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
100 °F, dew point 54 °F
Altimeter
29.92 inHg
Observed at
SDL

Docket · 34

The files NTSB released with the investigation on January 2, 2013, on NTSB’s docket system: statements, records, photos and specialists’ reports. 33.9 MB in all.

Video 17 - Specialist's Factual ReportItem 1 · .PDF · 403 KBVideo 17 - Attachment 1 - Still Image Sequence from FBO VideoItem 2 · .PDF · 1.5 MBVideo 17 - Attachment 2 - Still Image Sequence from Tower VideoItem 3 · .PDF · 334 KBVideo 17 - Specialist's Video Study ReportItem 4 · .PDF · 152 KBPilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 5 · .PDF · 564 KBFuel Injection System DrawingItem 6 · .PDF · 117 KBCFI StatementItem 7 · .PDF · 271 KBRecord of Conversation - Engine ExamItem 8 · .PDF · 25 KBFAA StatementItem 9 · .PDF · 372 KBFAA Email re Gear Doors ContactItem 10 · .PDF · 142 KBContinental Motors Engine Inspection ReportItem 11 · .PDF · 2.0 MBContinental Motors Fuel Nozzles Examination ReportItem 12 · .PDF · 1.4 MBContinental Motors Permold Series Overhaul ManualItem 13 · .PDF · 96 KBContinental Motors Permold Series Maintenance ManualItem 14 · .PDF · 183 KBContinental Motors Engine Maintenance and Overhaul, August 2011Item 15 · .PDF · 867 KBStatement of Party Representatives to NTSB InvestigationItem 16 · .PDF · 76 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 17 · .PDF · 53 KBBill of SaleItem 18 · .PDF · 132 KBSTC New Engine ChecklistItem 19 · .PDF · 123 KBMooney M20L POH on Flap UseItem 20 · .PDF · 187 KBNew Engine POHItem 21 · .PDF · 157 KBKnopp Email Regarding PowerItem 22 · .PDF · 130 KBCFI Email re ChecklistItem 23 · .PDF · 137 KBEngine Log Showing New O Rings on Engine Fuel InjectorsItem 24 · .PDF · 119 KBRecord of Conversation - Air Transport Regarding O-ring SealsItem 25 · .PDF · 25 KBPhoto 1. Aircraft wreckageItem 26 · .PDF · 2.7 MBPhoto 2. Right front view of wreckageItem 27 · .PDF · 3.6 MBPhoto 3. View of wreckage from behindItem 28 · .PDF · 3.6 MBPhoto 4. Separated nose wheelItem 29 · .PDF · 3.7 MBPhoto 5. Left wing tip of airplaneItem 30 · .PDF · 2.7 MBPhoto 6. Separated left wing tipItem 31 · .PDF · 2.7 MBPhoto 7. Damaged landing gear doorItem 32 · .PDF · 2.0 MBPhoto 8. Propeller damageItem 33 · .PDF · 3.1 MBPhoto 9. O-rings, two on each nozzleItem 34 · .PDF · 175 KB

FAA reports on this event · 1

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