WINSTON-SALEM, NC, USA
N9365V
Mooney M-20E
The pilot/mechanic with inspection authority conducted a maintenance test flight with a known unairworthy servo fuel injector. During takeoff climb, he reported a partial loss of engine power, notified Air Traffic Control, and maneuvered the airplane in an attempt to return to the departure airport. He was unable to return to the airport. The airplane collided with trees, electrical wires, and a private residence during a forced landing. According to Title 14 CFR Section 91.7 (b) states, 'The pilot in command of a civil aircraft is responsible for determining whether the aircraft is in a condition for safe flight. The pilot in command shall discontinue the flight when unairworthy mechanical, electrical, or structural condition occur'.
HISTORY OF FLIGHT On June 3, 1998, about 1055 eastern daylight time, a Mooney M-20E, N9365V, registered to two private owners, operated by Air Winston, as a 14 CFR Part 91 maintenance test flight, crashed into a house in a residential area while attempting to return to the Smith Reynolds Airport, Winston-Salem, North Carolina. Visual meteorological conditions prevailed and no flight plan was filed. The airplane was destroyed. The commercial pilot and one passenger were fatally injured. The flight originated from the Smith Reynolds Airport about 4 minutes before the accident. Review of recorded transmissions between Smith Reynolds Tower and N9365V revealed N9365V took off from runway 33 at 1051. The pilot was cleared to depart to the northwest. At 1054, N9365V informed the tower, "uh power lost and uh we're just to the north." The tower informed N9365V to do whatever he needed to do, and cleared another airplane (Carolina) to turn left on course. The tower asked N9365V what kind of assistance he needed. N9365V replied, "straight in for runway one five." N9365V was initially cleared to land on runway 15, and was cleared to land on any runway, 28 seconds later at 1055. N9365V stated , "I don't believe we're gonna make it." There were no other recorded conversations with N9365V. A witness located in the parking lot of Forsyth Technical Community College Wooddruff Center, observed the airplane about .45 miles from the northeast end of the Smith-Reynolds Airport. The witness stated, "A departing aircraft attracted my attention because the engine noise did not sound normal. I can only describe the noise as "spluttering" or not running smoothly. The sound at the time made me wonder if the aircraft had been fully warmed up on the ground before takeoff or if the mixture was off. I first observed the aircraft in what appeared to be a normal ascent in line with the runway at about 200-250' AGL. The aircraft continued to ascend to an estimated 400' AGL and made a sudden transition to level flight. The aircraft continued in level flight for a period that I estimate to be 3-5 seconds and made a sudden 90 degree left turn to a heading of approximately 300. The airplane appeared to gain airspeed and disappeared from view in a few seconds still in level flight." Another witness who was standing in his front yard at 4214 Tise Avenue, located about 3/4 of a mile northwest of the Smith Reynolds Airport, stated he heard an engine sputtering, looked up, observed an airplane descending, and turning to the left towards the airport just above the trees. The airplane was in a 45-degree left bank. The airplane collided with a tree located to the left of a house at 4240 Tise Avenue. It continued forward across Tise Avenue, collided with the tops of some more trees and a house. He instructed his step son to call 911, and he ran to the house to assist. PERSONNEL INFORMATION According to the President of Air Winston, the 39-year-old pilot was the Director of Maintenance (DOM), and the passenger was a company mechanic. The Federal Aviation Administration Information Management Section records indicate the pilot held a commercial pilot certificate with ratings for airplane single and multiengine land instrument airplane. In addition, he held a mechanic certificate with ratings for airframe and powerplant. He was also issued an inspection authorization from the FAA on March 24, 1998. A review of the pilot's logbook indicated the pilot had 1,272.4 total hours with 107.6 hours in the Mooney M-20E. The pilot's last recorded flight was on April 15, 1998. (Additional information pertaining to First Pilot Information is found on page 3 of this report, and in NTSB Form 6120.1/2 Pilot Information). AIRCRAFT INFORMATION The aircraft airframe, propeller, and engine logbooks were requested from the operator. All logbooks were located except for the current engine logbook. Review of aircraft records on file at the FAA Aircraft Registration Branch, Oklahoma City, Oklahoma, revealed that N9365V was involved in a collapse of the left main landing gear on September 7, 1997, at Tri-Cities Regional Airport, Bristol-Johnson, Tennessee. The DOM for Air Winston, submitted a bid to the registered owner for repairs to the airplane on November 19, 1997. The bid was accepted by the registered owner and his insurance company. The engine assembly was removed by the DOM and two Air Winston company mechanics. The engine assembly was transported to Piedmont Aviation Services, Inc., Winston-Salem, North Carolina, for disassembly and inspection. The inspection was completed on January 16, 1998, and signed off on January 22, 1998. The engine was transported back to Bristol-Johnson by the DOM and two company mechanics, and installed on the airplane. The DOM obtained a ferry permit from the FAA Nashville Flight Standards District Office on February 9, 1998, to ferry N9365V from Tri-Cities to Winston-Salem. The ferry permit expired on February 19, 1998. The ferry flight was conducted on February 25, 1998, by the DOM. According to the Vice President, Piedmont Aviation Services, Inc., and the Manager of Piston Engine and Accessory Services for Piedmont Aviation Services, the DOM for Air Winston brought a fuel injector to their facility to determine what was wrong with it. Examination of the unit by Piedmont Aviation Services, Inc., revealed that someone had installed an air scoop mount screw into the servo that was too long. The screw had penetrated into the servo cavity and caused a leak. In addition, a considerable amount of RTV sealant was evident on the mounting face for the air scoop in order to stop or control the leak. The DOM for Air Winston was informed that the servo was not repairable, and that it needed to be replaced. He was also informed that a replacement servo would cost $1,250.00. The servo was left at Piedmont Aviation Services, Inc., by the DOM. A couple of days later, the DOM returned and picked up the servo. He stated he had obtained a servo core from an after market company for $650.00. The registered owner of N9365V stated the DOM called him on the day of the accident and stated he was having a problem with the fuel injection system, but he could fix it. (Additional Aircraft Information is contained on page 2 of this report and in NTSB Form 6120.1/2 Aircraft Information). METEOROLOGICAL INFORMATION Visual meteorological conditions prevailed at the time of the accident. (For additional information see Weather Information). WRECKAGE AND IMPACT INFORMATION. The wreckage of N9365V was located about 3/4 of a mile north-northwest of the Smith-Reynolds Airport. The wreckage came to rest in the northwest corner of a house located at 4233 Tise Avenue. Examination of the crashsite revealed the airplane collided with a tree about 60 feet above the base of the tree in a descending left turn. The airplane continued across Tise Avenue, collided with two electrical power lines, treetops, and the northwest corner of a house roof and bedroom. The house was moved backwards about 19 inches off the foundation. The airplane came to rest on a heading of 095 degrees magnetic. The left wing was resting on the ground. The right wing, right side of the engine compartment, and cockpit area were imbedded in the house in about a 45-degree left bank. The engine assembly was displaced to the left, downward, and remained partially attached to the engine mounts and firewall. The propeller assembly and spinner remained attached to the engine. One electrical power line was found in the vicinity of the right side of the engine compartment and cabin area. The right side of the engine compartment, and right wing root were compressed inward into the cockpit area. Roof joists were found imbedded in the cockpit area. There was no evidence of torsional twisting, "s" bending, or chordwise scarring on all three propeller blades. Two propeller blades had evidence of electrical arcing. Electrical wire marks were present on one propeller blade and the propeller spinner. The leading edge of the left wing had evidence of a tree strike 76 inches, 104 inches and 125 inches outboard of the wing root. The left wing was bent upward 120 inches outboard of the wing root. The left fuel tank was not ruptured and 18 gallons of fuel were removed from the left fuel tank. The landing gear was found in the retract position. The leading edge of the right wing sustained impact damage extending from the wing root outboard 25 inches and 146 1/2 inches. The right fuel tank was ruptured. There was no evidence of browning of vegetation in the vicinity of the right fuel tank. The leading edge of the right horizontal stabilizer had evidence of a tree strike and the right elevator counter balance weight separated. Examination of the airframe and flight control assembly revealed no evidence of a precrash mechanical failure or malfunction. Continuity of the flight control system was confirmed for pitch, roll, and yaw. The engine assembly and accessories were transported to an authorized FAA repair facility for further examination. Initial examination of the engine assembly and accessories revealed no evidence of any precrash mechanical failure or malfunction. The engine was mounted in a test cell. The engine was started, but would only run at idle rpm. When the throttle was brought off the idle stop, the engine would stop. Several adjustment were made to the idle mixture setting, but the engine would only run at the idle setting. The Bendix servo fuel injector, serial No. 29077/50, was removed and replaced with another servo fuel injector servo. The engine was started and rpm was increased to 2,700 rpm and a little over 29 inches of manifold pressure. A magneto check was completed and the left magneto ran rough; however the rpm drop was not excessive. The engine ran at all throttle settings. Rapid increases of the throttle produced immediate response in engine rpm. The original Bendix servo fuel injector, serial No. 29077/50, was shipped to the NTSB IIC for further examination. Review of Lycoming Aviation Engine records revealed the Bendix servo fuel injector, serial No. 29077/50, was installed on the engine when the engine departed the factory new. Review of serviceable components tags revealed the Bendix servo fuel injector, serial No. 29077/50, was last overhauled by Aircraft Fuel Systems, Loveland, Colorado, on October 22, 1993. MEDICAL AND PATHOLOGICAL INFORMATION Postmortem examination of the pilot was conducted by Dr. Patrick L. Lantz, Director of Autopsy Services, Wake Forrest University, Baptist Medical Center, Winston-Salem, North Carolina, and Andrew R. Brant, Pathology Resident, on June 4, 1998. The cause of death was multiple injuries. Postmortem toxicology of specimens from the pilot was performed by the Forensic Toxicology Research Section, Federal Aviation Administration, Oklahoma City, Oklahoma. These studies were negative for ethanol, basic, acidic, and neutral drugs. A postmortem examination of the passenger was not conducted. A Report of Investigation was conducted by the Director of Autopsy Services, Wake Forrest University, Baptist Medical Center, Winston-Salem, North Carolina, on June 4, 1998, and a death certificate was issued. The cause of death was multiple injuries. Postmortem toxicology of specimens from the passenger was not conducted. TEST AND RESEARCH Title 14 CFR Section 91.7 (b) states, "The pilot in command of a civil aircraft is responsible for determining whether the aircraft is in a condition for safe flight. The pilot in command shall discontinue the flight when unairworthy mechanical, electrical, or structural condition occur". Textron Lycoming Operator's Manual, O-360 and associated models, Section 5, 2. Fuel System, a. Repair of fuel leaks states, " In the event a line or fitting in the fuel system is replaced, only a fuel soluble lubricant such as clean engine oil or Locite Hydraulic Sealant may be used on tapered threads. Do not use any other form of thread compound." A bench test was performed on the Bendix servo fuel injector. The servo revealed a high hysteresis which would have caused erratic operation. Red silicone sealant was present around the airbox flange. Examination of the manual mixture control valve/plate/lever assembly revealed, "Mixture control stop screw is bent. Valve assembly had to be pried out of the body due to a mound of, what appears to be, epoxy/aluminum in the mixture control bore. The epoxy was apparently introduced through an airbox screw hole which had broken through into the mixture control bore. Epoxy is present in the mixture control spring and a few loose pieces laying in the mixture bore. The delrin bushing was cracked, probably during disassembly." Examination of the regulator air diaphragm revealed, "Greenish oil present on suction side. Small amount of dark oil on center circle of impact side and corresponding area on back of bellows. Diaphragm has no part number or date code, is red silicone type." Examination of the venturi revealed, "Greenish oil present behind suction slots, otherwise ok." (For additional information see Precision Airmotive Corporation Preliminary Incident Investigation Report PAC File Number 060398). Examination of the fuel sample obtained from the left main fuel tank revealed the sample met the specifications required for Avgas grade 100 low lead. (For additional information see Panair Laboratory, Inc., Lab No. 9271G). ADDITIONAL INFORMATION The wreckage of N9365V was released to Mr. James T. Brewer, Inflite Services, Charlotte, North Carolina, on June 5, 1998. The recovered aircraft and pilot logbooks were released to Mr. Daniel J. Earnest, Federal Aviation Administration, on June 5, 1998. The Bendix servo fuel injector was released to Mr. Brewer on June 29, 1998.
The pilot's improper decision to conduct a maintenance test flight with a known unairworthy mechanical condition (unserviceable servo fuel injector), resulting in a partial loss of engine power on climb out, subsequent forced landing, and in-flight collision with trees and a private residence.
Source: NTSB Aviation Accident Database
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