The pilot departed Brookhaven Airport (KHWV), in Shirley, New York, with a final destination of Hampton Roads Executive Airport (KPVG), in Chesapeake, Virginia.
The first segment of the cross-country flight was uneventful and the trip required a fuel stop, which was the purpose for landing at Central Jersey Regional Airport (47N), in Manville, New Jersey.
After adding about 70 gallons of 100LL in the Mooney M20K, the pilot taxied for departure from Runway 25.
He told investigators that on takeoff all engine gauges were in the green and he began the rotation after about 1,500 feet of ground roll. However, as the airplane entered the initial climb, “something just didn’t feel right.”
Upon reaching about 300 feet above ground level, he stated the engine began “slowing down,” similar to the sensation of taking one’s foot off the gas pedal while driving on a highway.
He ensured that the throttle, propeller, and mixture were full forward, but power was not restored. Shortly after the reduction in engine power, the left wing dropped and the airplane banked to the left and crashed in an open field.
Airport surveillance video captured the entire takeoff roll, initial climb, and descent towards the accident site. The video showed the airplane begin its takeoff rotation about 1,200 feet down the runway.
Once the airplane entered the initial climb, its wings rocked back and forth, and three distinct pitch up control applications could be observed as the airplane’s nose pitched up from a level attitude. Subsequently, the airplane entered a left bank with a pitch up attitude and descended towards the terrain south of Runway 25 before exiting out of the camera view.
The pilot sustained minor injuries in the crash.
Examination of the airplane revealed substantial damage to the fuselage and wings.
The engine remained attached to the firewall. Significant accumulation of dirt and sand was present on the bottom of the engine due to the impact with terrain, but the engine was largely free of any substantive impact damage. The propeller remained attached to its hub. It displayed leading edge gouging, blade polishing, and rearward bending.
The Nos. 1 and 5 cylinder top spark plug ignition harnesses were found loose to their respective spark plugs when touched by hand. The No. 3 top spark plug ignition harness was found completely unscrewed, detached, and lying next to the spark plug on top of the cylinder shroud.
The Nos. 2, 4, and 6 cylinder ignition harnesses were all found secured and tight to their spark plugs.
All top and bottom spark plugs were removed. Each were tight within the cylinders and each spark plug displayed normal combustion signatures.
The crankshaft was rotated by hand. Thumb compression was observed on all the cylinders. The accessory section components rotated normally. All ignition harnesses produced spark when the crankshaft was rotated by hand. The rocker covers were removed and each valve moved normally with crankshaft rotation.
There was no evidence of oil leakage on the engine or cowling.
The fuel manifold valve was intact and installed to its installation area. It was removed and disassembled. The manifold contained fuel and the fuel filter screen was free of debris. The engine-driven mechanical fuel pump rotated by hand without anomalies and fuel was present in the pump.
On April 16, 2023, a maintenance endorsement noted that the crankshaft seal was replaced. The intake gaskets on the Nos. 2, 4, and 6 cylinders were replaced. The propeller was removed, overhauled, and re-installed.
The pilot reported that after that maintenance, a 30-minute test flight was performed with no anomalies observed.
The cross-country flight that he initiated on the day of the accident, May 6, 2023, was the first flight since the maintenance test flight. Based upon the airplane’s tachometer, a total of 1.5 hours had been flown since the maintenance was performed.
The mechanic who performed the maintenance in April of 2023 reported that the airplane owner wanted him to troubleshoot a small amount of oil leakage coming from the engine, which the pilot noticed accumulating on the forward windscreen during past flights.
During the mechanic’s troubleshooting, he observed evidence of oil leakage on the top of the engine and near the propeller hub. The propeller was removed, overhauled, and reinstalled. While the propeller was being overhauled, he removed the old crankshaft sealant and applied new sealant on the spine of the engine.
The mechanic reported that he did not recall servicing any spark plugs during this most recent maintenance in April 2023, nor did he recall removing any ignition harnesses while accomplishing work on other areas of the engine.
Probable Cause: The partial loss of engine power due to maintenance personnel’s failure to ensure that the ignition harnesses were properly secured and the pilot’s inappropriate pitch control inputs, which resulted in the airplane exceeding its critical angle of attack and subsequently entering an aerodynamic stall.
To download the final report. Click here. This will trigger a PDF download to your device.
This May 2023 accident report is provided by the National Transportation Safety Board. Published as an educational tool, it is intended to help pilots learn from the misfortunes of others.
Airplanes get wrecked daily from fuel exhaustion, fuel miss management, inadequate preflight, scud running, VFR into IMC, CFIT, and the list goes on. But according to Joe Henry Gutierrez, that’s OK. All preventable accidents and the planes performed flawlessly right up to the point of impact. Once the plane leaves a shop, the shop can’t control what the owner does to his plane. Now there are a lot of mechanically inclined pilots out there and there are some that shouldn’t be allowed to own a screwdriver. It’s the “I can fix my lawnmower, I can fix my plane” that scares me!
Per the regs, a pilot is the final authority on the airworthiness of his aircraft. So, it is imperative that he pilot have an indepth of the aircraft systems…when thye are working correctly and when they are not.
It doesn’t require an engineering degree, but it would help. Maybe work with a willing A&P and get familiar with EVERYTHING in the aircraft.!
Doing an ‘owner assisted annual’ would be a great education, [ now that they are again allowed, hopefully not temporarily ?]
I’ve been lucky to have been doing these for the last 15 years, and I have ‘touched’ every part of the aircraft that I own..!!
Oh, BTW I have an engineering degree…it helps a bit.!
This problem should have found in the pre-flight check. A proper serious preflight check should ALWAYS include an engine bay & engine inspection. Do your pre-flight THOROUGHLY – your life may depend on it – your not just jumping in your car to go shopping Even a non-mechanically minded person should do a main fuel sump water check, oil check and check that everything is in order. I’ve found a loose magneto, 1/2 pint of water in the main fuel sump – make sure you check ALL fuel sumps, not just the main tanks. By checking spark plug leads I have even found a loose magneto and on another occasion loose (but not detached) spark plug lead as well as the occasional oil leak. Do your pre-flight bearing in mind your life & that of any passengers is/are at stake.
I believe that the upper cowl on the M20 is screwed on, like my older Cessna. So, it is not possible to check much of the engine, only what you can see through the air inlets, and the oil fill opening.
If a plug wire was off on start up, there would be a ‘tick, tick’ sound in the headset, changing with engine rpm.
This happened to me, and I verified a bad mag check with only 5 plugs firing.
I taxied back to the ramp and the mechanic found a lower plug wire off the plug.
It sounds like you need a different A&P to work for you.
Having worked GA Maintenance for lotsa years, when an acft mech reports to work (1) he/she needs to leave everything else at the hangar door. Didn’t say it was easy to do that, but it’s necessary. (2) you gotta focus on the level of your responsibility of your job, the acft owner and the public. If you’re gonna change the oil, great. But while the oil’s draining LOOK AT OTHER STUFF! Bad stuff can happen to good mechs, but we gotta stay focused. And before you walk away from that aerospace vehicle for whatever reason, find a good stopping place and make a mental note of where & what you’re doing!
I agree the aircraft didn’t crash because of a shoddy mechanic. The Mechanic bashing isn’t doing anyone any good Mr. Gutierrez. There are missing pieces to this story that need to be thought out. Why was the pilot refueling in NJ approximately 70 miles from his base?? His aircraft could make it to Hampton Roads if starting with full tanks at home. What kind of a customer was this guy?? Penny Pincher, Jack Wagon, Argumentative Know it All, or the appreciative owner we wish we all had. We just don’t know. If over torqued, the nut on the lead can crack. The Mechanic claims to not have removed the leads or plugs. Had he done so and a nut failed, would the owner have said thanks for finding the issue or I didn’t authorize you to go looking for work?? The Mechanic is only responsible for the work he completed. I had a lovely couple come into the shop a year or so back. They were from Europe and rented a 172 to fly/tour around the States for a couple weeks and had flown approximately 20 hours thus far. They were taxing out after refueling but came back after a rough Mag Check. What I found was the bottom right front lead off and all leads loose on the right side both top and bottom. This aircraft had an oil change just before leaving on tour with no mention of sparkplug maintenance. Did a mechanic miss this? Probably so, but when?? 20 hours previous with un-documented sparkplug maintenance?? We just don’t know but it was caught by a proficient pilot with a Mag Check. A missing lead will be found with a properly performed Mag Check. I would like to know if the pilot of the accident aircraft did a “proper” Mag Check which would have caught the problem or a “Rolling” Mag Check? The report also fails to determine why the 3 pitch changes. Was the aircraft over weight and out of CG?? Was it trimmed properly on take off?? Was it rigged correctly?? Again, we don’t know. As previously mentioned above, could “Cell-Phone itis” have played a significant roll in this accident. I would guess either that or a iPad or some other electronic gizmo distracting the pilots attention away from “Fly the Airplane”. With reduced power the aircraft could have made it back to the airport. The report didn’t say he lost all power. Could a mechanic have played a roll in this?? Possibly. But the airplane crashed due to the Pilot not maintaining control of the aircraft and stalling it into the ground. I would suggest he was “behind” the airplane, possibly due to lack of training or lack of attention by distraction.
Agree. Good points. (And BTW I’m not a mechanic!) But these frustrating reports always seem to leave out something. Nothing said about 1, 3, and 5 BOTTOM plugs wires. And if the top 1 and 5 were loosely connected they would be proving some juice too. This is a classic reason for having dual ignition. Correct me if I’m wrong. Losing one plug would barely be felt.
Nick, I waited this long to answer to let the posts pass into the history book and because I don’t normally post unless really bothered by idiots with little else to do but bash mechanics. I’ve been an A&P/IA for a long time as well as Pilot. Yes there are questionable mechanics but yes I have seen things missed by some of the very best I know. That wasn’t the problem here. The Pilot was fairly low time overall and only had 14 hours in the aircraft which is not much for a Mooney or for one so inexperienced. If he was in a hurry did his arrogance or inexperience cause him to miss something?? I think probably. Was it a Mag Check? Possibly. Could it be something else? Possibly! Was it investigated thoroughly?? I just don’t know but think not. Was the aircraft secured after the accident or did the owner or anyone else have access to the aircraft before the investigators arrived? Could something have been tampered with?? The Plug leads maybe?? Again, I don’t know. However in 50+ years of maintenance, I’ve seen folks taking parts, switching this and that or loosening fuel lines to hide the fact they mismanaged fuel. The blame usually get cast upon the mechanic so forgive me if I’m a bit skeptical.
But to answer your questions, The couple from Belgium had a lead off of 1 spark plug and did notice it on Mag Check. It was an easy fix and they were on their way. If the accident plane had completely failed 1 Mag it would have only lost a couple to 3 hundred RPM at most and should have been able to make it back.
As for a classic reason for dual mags…not so much. Will the aircraft run on one mag? Absolutely! The main reason for 2 mags is: Back in the Day (1920’s and 30’s) magnetos were totally unreliable. Case (I believe) was a popular manufacture and as you might guess, their magnetos were utilized on farm tractors. From the even older timers than me, a good set of mags might last 100 hours or so back then and 3-400 hours as late as the 60’s and early 70’s. It’s rare to have such problems today but that’s why we have two mags. The extra 100 =/- RPM is a bonus. It’s the same with many components. The pioneers in aviation had to use what was available and tractor parts were available, relatively cheap easily cannibalized to repair aircraft mags in the field. To compensate for reliability issues engine manufactures gave us dual mags and we still utilize them. Today our components are far better engineered and despite what some think; in comparison they really do last a long time, they just ain’t cheap.
The loose harness did not cause the accident. The harness completely off the plug was from the landing jolt. And his losing power like letting off the gas doesn’t cut it either. It would have been the same as before.
Another very nice airplane destroyed and a pilot has been screwed out of his flying privileges by more shoddy A&P alleged work. Where does this leave the pilot ?? And what does this do the the shoddy mech. that screwed this airplane up to the point of destruction ??? So far this goes on almost every week to some poor souls airplane because of some lowlife mechanic not doing his or her job and charging for such sabotage, & walking away Scott free !! My question is, how much longer is this going to be allowed to continue ?? Does any one look at this way of eliminating airplanes and potentially killing pilots ??? Where are all the safety personal at and why is this continuing to happen without consequences ??? I’m very afraid to even thing of a six place airplane loaded with six people and go down because of a loose spark plug wire or loose fuel line that some lowlife mechanic neglected to tighten !! God forbid,
There was 4 opportunities to check the plug wires, the annual, 2 oil changes and the prop overhaul, but no one checked the #1,3,and 5 wires…sad.!!
This poor pilot only flew it for 15 hours, and hopefully had insurance coverage.?
I do my own oil & filter changes and it allows me to ‘put a wrench’ on all the hardware under the cowl.!! I cut open the filter to examine it for ‘stuff’; none found so far. I also send an oil sample off for analysis.
I have found valve cover screws loosening, causing an oil leak, but not much else….so far.!
Sounds suspiciously like “cell-phone itis” to me.
IF I had an airplane and had maintenance done on it, I would be the final inspector prior to paying the bill and release of the plane. From time-to-time I open my car hood and go over the engine, hoses, etc., to make sure everything is tight and clean. I do find hose clamps and other items work themselves loose over time. When it comes to shop work: trust but verify.
Regards/J