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Maintenance mishap leads to Mooney accident

By NTSB · July 17, 2015 ·

The pilot was practicing instrument maneuvers about 1,500 feet mean sea level in a Mooney M20J near Leonardtown, Maryland, with a CFI on board, when the engine stopped responding to throttle control inputs and producing enough power to maintain level flight.

The CFI unsuccessfully attempted to restore engine power, and the pilots chose to conduct an off-airport landing to a field, which resulted in substantial damage to the fuselage and wings.

Following the accident, one of the airplane’s owners inspected the Mooney before the wreckage recovery. He removed the engine cowling and found a bolt and nut resting on the bottom of the cowling. He also noted that the throttle arm linkage was not connected to the throttle body arm.

He reported that the throttle linkage was found in the full-forward position and that the throttle body arm was found in the low-power setting. When the throttle control in the cockpit was moved, he noted the throttle linkage moved but that the throttle body arm did not move.

Review of maintenance logbook records revealed that the most recent annual inspection was completed on April 15, 2013. The mechanic who performed the inspection reported that all engine control cables were “checked” and lubricated and that the throttle linkage bolt, nut, and cotter key were in place.

The most recent engine maintenance was performed six days and one flight hour before the accident by the same mechanic. During the maintenance, the starter was removed, overhauled, and reinstalled on the engine, and no maintenance was conducted in the area of the throttle linkage and throttle body arm.

It is likely that, during maintenance at a previous undetermined time, the cotter pin was removed from the throttle linkage bolt and nut and not reinstalled. The nut then gradually loosened and fell off, which allowed the bolt to become loose. The missing cotter pin should have been detected during the most recent annual inspection or engine maintenance.

The NTSB determined the probable cause as the improper installation and inspection of the throttle linkage by maintenance personnel, which resulted in the throttle linkage coming loose and a subsequent partial loss of engine power.

NTSB Identification: ERA13LA342

This July 2013 accident report is are provided by the National Transportation Safety Board. Published as an educational tool, it is intended to help pilots learn from the misfortunes of others.

About NTSB

The National Transportation Safety Board is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant events in the other modes of transportation, including railroad, transit, highway, marine, pipeline, and commercial space. It determines the probable causes of accidents and issues safety recommendations aimed at preventing future occurrences.

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Comments

  1. John says

    July 20, 2015 at 10:23 pm

    A Co-Owner removed the cowl of the aircraft and took a series of photos, including a photo which showed the castle nut and throttle pin lying in proximity to one another on the bottom cowl beneath the engine. The A&P asked the NTSB how likely it was that these two parts would come apart and off of the throttle assembly, then remained in very close proximity through the crash sequence. Certainly the Co-Owner contaminated the evidence chain by taking it upon himself to open the cowl with no witnesses other than his spouse. The Co-Owner took seventeen photos (which can be found in the accident Docket on http://www.ntsb.gov) which include images of the suspect bolt and nut.

  2. John says

    July 20, 2015 at 9:56 am

    This is a reminder that 20% of GA accidents have a maintenance error as the ‘defining event’.

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