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NTSB investigation record

CEN14FA356

Completed

Mooney M20M· N72FG

Date
July 11, 2014
Location
Greenwood, IN
Conditions
VMC
Record
Published September 25, 2020

Primary finding

Probable cause

A partial loss of engine power for reasons that could not be determined because postaccident examination of the airframe and engine did not reveal any anomalies that would have precluded normal operation. Also causal to the accident was the pilots' decision to continue the takeoff despite early indications of engine anomalies.

Investigator assessment

Analysis narrative

The private pilot and flight instructor were repositioning the airplane for an annual inspection, and the private pilot planned to receive instrument flight training during the trip. Witnesses reported that the engine sounded good as the airplane taxied to the runway and during the engine run-up. However, several witnesses reported observing blue smoke trailing the airplane at the beginning of the takeoff and hearing the engine "popping" and "misfiring." The airplane was 50 to 100 ft above the ground and about one-quarter of the way down the 5,100-ft-long runway when its nose lowered slightly. Witnesses stated that they thought the pilot was going to land the airplane back on the remaining runway, but the airplane's nose then rose, and the airplane continued climbing. The airplane was described as being slow and "wallowing," with the nose pitching up and down slightly as it continued to climb to a maximum altitude of about 100 to 150 ft above the ground. The right wing dropped, and the airplane descended, contacting a garage and two houses before coming to rest in a residential backyard where a postimpact fire ensued. A postaccident examination of the airplane, engine, and engine components did not reveal any anomalies that would have precluded normal operation.

Source record

Factual narrative

The J.P. Instrument EDM-700/800 panel mounted gauge that can monitor and record up to 24 parameters related to engine operation was recovered from the accident site and sent to the NTSB Vehicle Recorder Division. The unit sustained impact damage and had missing components that were required for a potential recovery of the unit's data. Therefore, no data was recovered from the unit. On August 5, 2014 the magnetos, engine driven fuel pump, and fuel injection servo were examined under the supervision of the NTSB. Both magnetos sustained significant heat damage from the post impact fire. The magnetos were opened and examined. The internal components of both magnetos were in place and melted from heat exposure. Both magnetos contained aftermarket points which were intact. A functional test could not be performed due to the thermal damage. The fuel inlet fitting on the engine driven fuel pump was bent due to impact. The fitting was replaced and the pump was placed on a test bench. The pump operated, but leaked fuel from the housing. The pump was opened and it was determined that the fuel leak was a result of an o-ring and gasket that were melted from the post impact fire. The fuel injection servo was examined. The mixture control functioned. The servo was placed on a test bench for operational testing. The servo functioned to operational specifications. The two upper deck pressure lines, the fuel injection nozzles, and 6 deck pressure orifices were sent to the NTSB Materials Laboratory for examination. The #2 pressure line sustained a 90° bend near one end of the line. There was also evidence that the #2 upper deck line sustained thermal damage including metal discoloration, sooting, and thermal degradation of attached rubber hoses. All of the remaining attached polymeric hosing was damaged to varying degrees. The #1 pressure line did not exhibit similar thermal or mechanical damage. Debris was removed from the interior of the #2 pressure line, the nozzles and the pressure orifices. All of the material removed was examined and the test results indicated a spectral match indicating that the residue was consistent with the damaged fuel hose material. The connections on the #2 deck line were x-rayed to determine clamp position and then were compared to similar x-rays taken of #1 deck line. It was determined that clamp positions were consistent between the two upper deck pressure lines. An August 13, 2014, an exemplar engine was test at Lycoming Engines under the supervision of the NTSB. The purpose of the test was to determine how the engine would operate if one of the upper deck pressure lines disconnected from its associated nozzle. The engine was placed in a test stand, was started and ran normally. The #2 cylinder upper deck pressure line was then disconnected, the engine was again started and it continued to run without interruption. An autopsy of the pilot was performed by Indy JM Forensic Consulting, in Indianapolis, Indiana, on July 12, 2014. The private pilot's death was attributed to blunt force injuries sustained as a result of the accident. The FAA Civil Aerospace Medical Institute (CAMI) toxicology report noted negative results for all substances tested. The accident site was located 0.46 miles from the departure end of runway 19. The left wing contacted the roof of a residential garage and the wingtip became imbedded in the roof. The garage was on the property next to the final impact site. An outboard section of the left wing was located on the driveway at this same residence. The airplane separated the gutter off the back of the house. The airplane contacted the cement pad between the house and garage. The first main ground impact occurred adjacent to the cement pad. This initial ground scar was approximately 12 ft long. The second ground scar began about 13 ft from the end of the first scar. This ground impact mark was about 10 ft long and 12 inches deep and contained the pitot tube. The airplane then traveled through a chain link fence and into the back yard of the neighboring residence. The airplane contacted a riding lawn mower and separated a metal awning from the back of the house. Witnesses stated that there initially was a small fire in the area of the engine. They used a garden hose in an attempt to contain the fire; however, the fuselage was subsequently engulfed in flames. The engine was separated from the firewall. The propeller remained attached to the engine. The fuselage was burned from the firewall to the empennage. The cockpit floor was burned, but the underside of the fuselage was not burned. The fuselage belly panel was separated during the impact sequence. The left wing was separated from the fuselage. The inboard section of the wing was burned with the outboard section of the wing bent up and rearward. The wing did not contain any fuel. Both the flap and aileron were separated from the wing. Control continuity was established in the wing up to the point where it was separated from the fuselage and from the separation forward into the cockpit. The right wing remained attached to the fuselage. The outboard half of the wing was bent up and rearward. The aileron and flap remained attached to the wing. Flight control continuity was established from the flight controls to the forward cockpit area. Fuel was visible in the right wing fuel tank. The main fuel line from the firewall to the fuel pump was severed. The outlet fitting from the firewall was bent from impact. The fitting was straightened and approximately 23 gallons of fuel drained out of the line from the right fuel tank which indicated the fuel selector was positioned on the right fuel tank. The aircraft fuel filter contained clean fuel. The filter contained a minor amount of debris. The empennage was bent and partially separated from the aft fuselage. The elevator and rudder remained attached to their respective stabilizers. The elevators sustained minor impact damage. The top of the rudder was bent to the left. The rudder control tube was separated just forward of the empennage. Control continuity was established from the rudder and elevator up to the base of the cockpit controls. The pitch trim actuator indicated the trim was set in the takeoff position. The cockpit instrumentation was destroyed by impact forces and the post impact fire. The throttle and mixture controls were full forward. The propeller control was missing. The control cables remained attached to their respective components on the engine. Engine and Propeller The propeller remained attached to the engine. One propeller blade was bent rearward beginning near the butt end of the blade. The outer third of the second blade was twisted. The third blade was twisted mid-span and nicks were visible on the tip of the blade. The propeller hub was smashed and showed minor torsional twisting. The propeller was removed from the engine during the engine examination. The dip stick did not contain any oil; however, the engine did not exhibit any evidence of oil starvation and a large oil stain was present on the ground where the engine came to rest. The top spark plugs were removed and the engine crankshaft was rotated at the vacuum pump drive. Valve train and crankshaft continuity were established throughout the engine. Compression and suction were achieved on all cylinders. All of the cylinders were examined with a lighted boroscope and no anomalies were observed. The number two lower spark plug was obstructed by the impact damaged exhaust pipe and it was not removed. The number six lower spark plug electrode porcelain insulator sustained impact damage and the spark plug was observed to be wet with oil. The remainder of the spark plugs showed normal wear when compared to the Champion Aviation Check-A-Plug Card AV-27. The fuel flow divider, fuel injector servo, injector nozzles, and engine driven fuel pump were all secured on the engine. The fue

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