Accident Details
Probable Cause and Findings
The manufacture and installation of a nonstandard part by unknown maintenance personnel to compensate for a bent, misaligned crankshaft propeller flange, which resulted in the improper clearance of the bearings on the crankshaft journal, a loss of oil pressure, overheating of the bearings, and the failure of a connecting rod during cruise flight.
Aircraft Information
Registered Owner (Historical)
Analysis
HISTORY OF FLIGHTOn March 28, 2013, about 1119 mountain standard time, a Mooney M20A, N6018X, made an off airport forced landing near Wikieup, Arizona. The pilot/owner was operating the airplane under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91. The private pilot and one passenger sustained serious injuries; one passenger sustained fatal injuries. The airplane sustained substantial damage from impact forces. The cross-country personal flight departed Sedona, Arizona, with a planned destination of Shafter, California. Visual meteorological (VMC) conditions prevailed, and no flight plan had been filed.
The Federal Aviation Administration (FAA) reported that the pilot contacted Albuquerque Air Route Traffic Control Center (ABQ ARTCC) at 1028:07 requesting visual flight rules flight following. The estimated position was about 15 miles west of Sedona at 8,600 feet msl. At 1106:01, the pilot informed the controller that the engine lost oil pressure, and he needed vectors to the closest airport. The controller provided vectors to Bagdad airport (elevation 4,183 ft), and at 1109:30, the pilot advised that the airplane was losing altitude. The controller contacted another airplane in the area at 1111:16, and requested that airplane provide assistance. At 1113:28, the accident airplane was 5 miles from Bagdad at 6,600 feet. At 1115:56, the pilot stated that the engine was running rough, then within 1 minute that there was smoke in the cockpit, and he was shutting the engine off. The controller advised the pilot to look for an open field, clean the airplane up, and shut the fuel off. The pilot advised that he could see an open area. The last transmission from the pilot was at 1118:07, when he responded to the assist airplane that he had a cell phone; although the number was not recorded, the assist airplane's readback was recorded at 1118:49.
The pilot made a forced landing in rough terrain. The pilot and front seat passenger were pinned in the wreckage. His son in the back seat sustained a serious injury, but was able to egress from the airplane.
A witness was camping about 1 mile from the accident site. He stated that the airplane flew about 300-400 feet over him, and the wings were rocking about 3-4 feet as if the pilot was waving to him. He said that the engine was silent, but he could not recall if the propeller was stopped or turning. He noted that the landing gear was down, and he did not observe any smoke or fluids emanating from the airplane. He did not hear the crash, and had observed airplanes flying low over this area on previous occasions. PERSONNEL INFORMATIONA review of FAA airman records revealed that the 48-year-old-pilot held a private pilot certificate with a rating for airplane single-engine land. The pilot held a third-class medical certificate issued on February 22, 2013, with the limitation that it was not valid for any class after February 22, 2014.
No personal flight time records were received from the pilot. The IIC obtained the aeronautical experience listed in this report from a review of the FAA airmen medical 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 time of 156 hours with 5 hours logged in the previous 6 months. A logbook excerpt recorded a biennial flight review and FAR 61.31(e) endorsement for operating a complex airplane on October 11, 2011. AIRCRAFT INFORMATIONThe airplane was a Mooney M20A, serial number 1606. A review of the airplane's logbooks revealed that the airplane had a total airframe time of 3,761.8 hours at the last annual inspection dated October 3, 2012. The tachometer read 1,048.8 hours at the last inspection. The tachometer read 1,053.8 hours at the last recorded maintenance (an oil change) on February 1, 2013; it read 1,064.37 hours at the accident scene.
The airplane was not equipped with shoulder harnesses.
The engine was a 180 horsepower Lycoming O-360-A1D, serial number L-9731-36A. Total time on the engine at the last annual inspection was 3,739.6 hours, and time since major overhaul was 1,179.8 hours. AIRPORT INFORMATIONThe airplane was a Mooney M20A, serial number 1606. A review of the airplane's logbooks revealed that the airplane had a total airframe time of 3,761.8 hours at the last annual inspection dated October 3, 2012. The tachometer read 1,048.8 hours at the last inspection. The tachometer read 1,053.8 hours at the last recorded maintenance (an oil change) on February 1, 2013; it read 1,064.37 hours at the accident scene.
The airplane was not equipped with shoulder harnesses.
The engine was a 180 horsepower Lycoming O-360-A1D, serial number L-9731-36A. Total time on the engine at the last annual inspection was 3,739.6 hours, and time since major overhaul was 1,179.8 hours. WRECKAGE AND IMPACT INFORMATIONThe NTSB investigator-in-charge (IIC) examined the wreckage at the accident scene.
The airplane came to rest upright in mountainous terrain on the crest of a descending ridge. The first identified point of contact (FIPC) was on the upslope of the ridge; it was an ocotillo cactus plant with the top branches broken off about 4-6 feet above the ground. There was a ground scar about 15 feet left and upslope of the cactus. About 12 feet forward and 10 feet to the left of the FIPC was a 1-foot by 1-foot piece of the outboard leading edge of the left wing, which contained the red navigation light.
Twenty feet from the FIPC was the principal impact crater (PIC) ground scar, which was about 5 feet wide and 10 feet long. A damaged bush was about 10 feet right of the PIC.
The main wreckage was about 60 feet from the FIPC on the debris path centerline.
The last major piece of wreckage was the pilot's window at 65 feet 4 left.
There was black viscous fluid on the belly of the fuselage all the way to the tail skid and end of the tail cone. The ground underneath the fuselage had some black liquid stains as well.
The belly of the airplane was crushed up and aft from the spinner to the engine compartment and through the bottom of the cabin area. The nose gear was crushed up and aft into the airframe.
The Johnson bar landing gear operating handle was in the vertical position with the locking arm in place.
The ignitions switch was in the off position.
Both control yokes had the hand grips intact. TESTS AND RESEARCHThe IIC and investigators from the FAA and Lycoming examined the wreckage at Air Transport, Phoenix, Arizona, on March 30, 2013.
A full report is contained within the public docket for this accident.
Engine
The top spark plugs were removed; all center electrodes were circular, and clean with no mechanical deformation. The spark plug electrodes were gray, which corresponded to normal operation according to the Champion Aviation Check-A-Plug AV-27 Chart.
The engine crankshaft would not rotate.
The propeller was removed and a non-Lycoming manufactured shim was located between the face of the propeller hub and the crankshaft propeller flange that varied in thickness. From a review of the airplane's logbooks, it could not be determined who manufactured and installed the shim, or when it was installed.
The magnetos were manually rotated, and both magnetos produced spark at all posts.
A visual inspection of the engine revealed a fracture that emanated from the top of the cam follower area of the crankcase at the number two cylinder.
No oil registered on the dipstick, and a burning smell emanated from the filler tube. The oil filter was removed and cut open; the filter element displayed magnetic and bronze material impregnated in the element. The oil sump was removed, and approximately 1/2 quart of a black fluid was observed in the bottom; the liquid had a burnt smell. There were numerous pieces of debris in the oil pan including parts of the number two connecting rod end cap, beam, and pieces of rod bolts and nuts along with plasticized rod bearing material. The oil suction screen was removed, and it was obscured with magnetic material.
All cylinders were removed from the crankcase. All cylinder skirts were impact damaged, and pry bars were required to remove the cylinders. The cylinder bores did not exhibit scoring or scraping. All pistons displayed normal carbon deposit on their tops.
The crankcase was disassembled. It was noted that the two crankcase halves were coated with a substance consistent with automotive Permatex gasket sealer on the mating surfaces.
The number one connecting rod moved freely on its journal.
The number two piston remained in the cylinder; its connecting rod beam fractured and separated at the crankshaft rod journal. The fracture surface sustained heavy mechanical damage. The connecting rod cap, saddle, nuts and bolts separated at the connecting rod.
The crankshaft rod journal for the number two connecting rod beam was thermally damaged and scored. The number two connecting rod bearing was not in place.
The number three connecting rod was thermally seized to the crankshaft.
The number four connecting rod was moveable, but thermal and impact damage was evident in the area of the connecting rod bearing.
The crankshaft was dimensionally examined using V blocks and a dial indicator. The flange was ~0.87 out of round. The manufacturer's limits for a run-out (out of round) were 0.002 inch minimum and 0.005 inch maximum.
Materials Laboratory Examinations
The crankshaft, the shim, and rod end nut pieces were sent to the NTSB Office of Research and Engineering Materials Laboratory for examination. A full report is in the public docket.
The main journals were labeled M1, M2, and M3, and the connecting rod journals were labeled C1, C2, C3, and C4 for reference. The crankshaft journals showed varying levels of heat tinting and scoring. Journals C2 and C4 had the highest levels of damage with smeared deposits and scoring.
The edges of the propeller flange showed numbers marked in bl...
Data Source
Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# WPR13FA169