WPR15LA175

NTSB accident investigation · Mooney M20K · Fresno, CA · June 3, 2015

Accident · No injuriesLimited investigationFinal report
Date
June 2, 2015, 19:55 local (Jun 3, 2015, 02:55 UTC)
Place
Fresno, CA
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N3567HMooney M20K
Defining event
Enroute-cruise: Powerplant sys/comp malf/fail
Weather
Visual (VMC) · Day
Status
Completed · report March 6, 2017
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration FSDO, Continental Motors
FAA report
20150602019669A
Case key
91298

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

On this page

Probable cause

A total loss of engine power during cruise flight due to a failure of the No. 1 piston and connecting rod assembly.

Findings · 1

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.

Engine (reciprocating): recip eng cyl sectionAircraft › Aircraft power plant · FailureMooney M20K: 1 caseAll aircraft: 373 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 private pilot was conducting a personal cross-country flight. During cruise, the engine experienced a catastrophic failure and a total loss of power. The pilot performed a forced landing to an airport, landed long, and collided with an airport fence. Postaccident examination of the engine revealed internal damage consistent with the initial failure of the No. 1 piston and connecting rod assembly, most likely at the piston end, which caused a cascading failure of the adjacent piston and rod assemblies. Damage to the engine components precluded an accurate assessment of the specific initiating event, and evidence suggested that the engine contained oil at the time of the failure. The engine had been involved in a propeller strike accident about 310 flight hours prior, which required an engine teardown, examination, and replacement of two connecting rods and one piston pin. Maintenance records did not disclose which rods were replaced. Following the repair, the engine went through a 10-year period of inactivity, during which time internal corrosion occurred. No precautionary steps were taken to monitor the effects of the corrosion, such as oil filter examination or oil analysis. The extent to which the corrosion contributed to the failure of the No. 1 piston and connecting rod assembly could not be determined.

Factual narrative

The airplane was manufactured in 1980, and equipped with its original Continental Motors, six-cylinder, turbocharged engine, model number TSIO-360-GB(1), serial number 309443. At the time of the accident, the engine had accrued about 1,340 flight hours since new. The last oil change occurred 19.6 hours prior, on April 13, 2015, with the last inspection being an annual, which was completed on December 1, 2014, 46.6 hours prior to accident. Maintenance records indicated that the engine had been disassembled and inspected in 1991, about 310 hours prior to the accident, after the airplane was involved in a ground collision while taxing (See NTSB Accident Report: LAX91LA063B). A series of engine components were replaced following the inspection, including two connecting rods, twelve lifters, and one piston pin. The records did not specify for which cylinders the connecting rods and piston pin were replaced. The airplane appeared to have gone through a period of inactivity from 1998 through to 2008. The first entry following that period stated, "Borescoped cylinders and portions of the crankcase, found surface corrosion on portions of the cylinders and hardware." The maintenance records did not document any subsequent repair in response to the corrosion, nor was there any evidence to suggest the engine had ever undergone a subsequent oil analysis or oil filter examination. On June 2, 2015, about 1955 Pacific daylight time, a Mooney M20K, N3567H, landed long following a total loss of engine power and subsequent forced landing at Fresno Chandler Executive Airport, Fresno, California. The airplane was registered to and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91. The private pilot, who was the sole occupant, was not injured, and the airplane sustained substantial damage to both wings and the forward fuselage during the landing. The cross-country personal flight departed Shafter Airport-Minter Field, Shafter, California, about 1915, with a planned destination of Mc Clellan Airfield, Sacramento, California. Visual meteorological conditions prevailed, and a visual flight rules flight plan had been filed. The pilot reported that the preflight inspection did not reveal any anomalies, and he added one quart of oil to the engine. About 30 minutes after takeoff, while cruising at an altitude of 8,500 ft mean sea level, he heard an explosion, and smoke and oil billowed from the cowl. The engine lost all power, and he initiated a descent into Fresno. He reached the airport environment with about 2,500 feet of altitude remaining, and attempted a landing on Runway 30R, which at that time was closed. The airplane landed on the overrun area and came to rest on a dirt verge after striking the perimeter fence. Post accident examination revealed multiple perforations in the engine crankcase, with oil streaks along the underside of the airplane's fuselage. The engine was removed from the airframe and examined at the facilities ofContinental Motors in Mobile, Alabama under the oversight of the FAA and NTSB. Inspection revealed puncture holes in the crankcase above the number two, and below the number three cylinders. No measurable oil remained in the engine. All spark plugs appeared undamaged, with the exception of both plugs for cylinder number one, which sustained mechanical damage displacing their electrodes. The engine was disassembled, and cylinder head assemblies one, four, five, and six were removed. Skirt damage prevented the removal of cylinders two and three. The most significant internal damage was to the number one piston, which had separated from the connecting rod, was loose within the cylinder, and appeared to have been pulverized and fragmented to about 1/4 of its normal size. The connecting rod had fragmented into multiple pieces, and although the rod remained attached to the piston pin, it had been displaced to the pin's outer edge where it had seized. The piston-end of the rod had bent and separated at the beam, about 1 inch from the boss. All piston and rod assembly separation surfaces had been obliterated. The connecting rods for cylinders two and three remained attached to their respective pistons, but their caps had both detached, resulting in separation from the crankshaft. The number four connecting rod was still attached to the crankshaft, but exhibited heat distress around the connecting rod cap. The remaining connecting rods for cylinder five and six appeared undamaged, with their caps intact at the crankshaft. The caps were removed, and the bearing and corresponding crankpin journal surfaces appeared undamaged and coated in oil. The crankshaft number one, two, and four main journal's exhibited normal operating appearance; with the number three journal displaying rotational scores and bluing. The oil sump contained remnants of connecting rod, bearing, rod bolt, and aluminum material. The oil pump was disassembled, and scoring was observed on its rotational surfaces and the impellor gear tips. The oil filter was opened, and contained a sludge/metal mixture inside the canister, with fine sand-sized metal debris in the filter's paper element. Continental Critical Service Bulletin CSB916-13, provides connecting rod inspection and replacement instructions for IO-360 series engines, manufactured around the period of the accident engine. The service bulletin addressed replacement of connecting rods which were manufactured with a beam width of less than 0.625 inches. It required inspection and/or replacement of the affected rods at the next annual or 100-hour inspection, "Due to the potential for overstressed connecting rods associated with abnormal conditions or incidents". The engine did not fall within the serial number range applicable to the bulletin, and examination of the undamaged rods for cylinders four, five and six, revealed that all beam widths were 0.655, 0.658, and 0.657 inches respectively, and therefore greater than the minimumrequired. Furthermore, the maintenance records for the connecting rod replacement in 1991 indicated that the part numbers of the two replaced rods were of the correct type required by the service bulletin. A complete engine report is contained within the public docket.

Aircraft

Registration
N3567H
Reported as
Mooney M20K
Category
Airplane
Serial number
25-0423
Built
1980
Airframe hours
1,340
Engine
Continental TSIO-360-GB1, 230 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · December 1, 2014 · 47 hours before
Departed
MIT · Shafter, CA
Destination
MCC · Sacramento, CA
Flight plan
VFR
Airport
FCH · Fresno Chandler Executive, runway 30R, 3,627 × 75 ft, gravel
Equipment
Auto-pilot, Handheld GPS, Stall warning system

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
68
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land, Single-engine sea
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
August 13, 2013
Seat
Left
Restraint
3-point
Flight hours
1,570 total · 313 in this make and model · 1,570 as pilot in command · 38 in the last 90 days · 15 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
310° at 13 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
82 °F, dew point 46 °F
Altimeter
29.87 inHg
Observed at
KFAT, 6 nm away

Docket · 6

The files NTSB released with the investigation on January 18, 2017, on NTSB’s docket system: statements, records, photos and specialists’ reports. 12.0 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.

Other investigations on N3567H · 1

Matched to the same aircraft by N-number and date.