PPRuNe Forums - View Single Post - VH-PPA Mooney M20R Fatal Crash on Ferry Flight
Old 24th Apr 2012, 12:23
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Ovation
 
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VH-PPA Mooney M20R Fatal Crash on Ferry Flight

This accident didn't seem to make it into General Aviations and Questions forum at the time, but the NTSB Report is now available on line here:

Untitled Page

The report made findings which are at odds with a post (in a Mooney specific forum) by the pilot of another aircraft VH-PPA was flying with in company from Hollister to Hilo. This pilot firmly believed the cause was engine failure and not load shifting, as was speculated by others.

Significantly, there were some sobering findings that remind us there are significant risks when you operate near to (or outside) the flight envelope, and long over-water ferry flights with auxiliary fuel systems etc will put you smack in the middle of the twilight zone.

In summary, there were four items that each in isolation should not have contributed to the crash (except for the aft CG), but in entirety might have compounded a normally insignificant event into this tragic outcome.

The pilot was well qualified and experienced (including aerobatics), but it would seem no time on the Mooney airframe except for the flight across the USA from point of purchase to Hollister.

The aircraft was approved to operate at 115% MTOW but calculated to be about 122% MTOW.

The fitting of the ferry tank bladder was not in accordance with the Special Flight Permit issued by the Australian Civil Aviation Safety Authority, in that it was not properly secured and relied on being a snug fit between the sides of the fuselage and some suitcases to prevent aft travel.

The post crash W+B determination found the CG was 0.79 outside (aft) of the envelope.

The NTSB inspection could find no reason why the engine should not deliver power.

There was also some discussion about the erratic Autopilot operation the previous owner experienced, although it would be unlikely this was a factor.

The paperwork and other documentation for MTOW plus 15% was provided by a very experienced ferry operation based in Kempsey, NSW, Australia who have facilitated the import of quite a few M20R and M20TN into Australia.

So, from here on is (part of) the NTSB Report:

FERRY CONFIGURATION INCREASED MTOW

The Operating Instructions for the ferry tank system referred to Mooney engineering instructions, which allow for a one-time 15 percent increase in maximum takeoff weight (MTOW) totaling 3,873 pounds. Under this condition, the center of gravity range must be between 47.5 and 51.0 inches.

Additionally, the never exceed speed (Vne) varies linearly between 174 knots at the airplane's standard MTOW of 3,368 pounds through to 124 KIAS at 3,873 pounds. (the calculated MTOW was 4,128 lb)

Here are the CASA documents relating to the Ferry Authorisation. It seems they were released under the FOI (Freedom of Information).

http://www.casa.gov.au/wcmswr/_asset...-ef11-2905.pdf


FERRY TANK SYSTEM

Examination of the airplane wreckage revealed that no bladder tank support straps were installed. The bladder was additionally equipped with orange tie-down straps, stitched into the bladder material, but these were also not attached to the fuselage structure.

The aft seat belts were still in place, and had not been removed to make room for the tank straps. Examination of the bladder tank fragments revealed that it was a 238-gallon-capacity air cargo type, manufactured by Turtle-Pac.

Two 7-foot-long sections of 1/2-inch thick plywood had been installed across the full width of the fuselage spanning from the back of the front seat through to the baggage compartment. The plywood obscured access to the aft seat belt anchor points. Additional plywood strips and foam padding were located along the inner fuselage sidewalls.

The airplane was equipped with baggage tie-down straps. The lower straps were located underneath the plywood, and as such, were obscured from a position where they could be utilized to secure the baggage.

The pilot installed the fuel ferry system, 2 days prior to the accident. Review of the airplane's maintenance records revealed that on November 23, 2010, a certified Airframe and Powerplant mechanic found the airplane's ferry fuel system fit for flight. In a subsequent interview with the IIC, the mechanic stated that he observed yellow tie down straps installed over the bladder tank at the time of the inspection.

The pilot of the other Mooney stated that prior to departure, the tank in the accident airplane was positioned behind the pilot seat, and held in place by the airplane's sidewalls and luggage in the aft baggage area.

Fueling records obtained from Gavilan Aviation, Inc., revealed that the airplane was serviced with the addition of 210 gallons of aviation gasoline at 1730 the night prior to the accident. The pilot of the other airplane reported that the wing fuel tanks were emptied during the installation of the ferry fuel system, and as such, the fuel purchased reflected the total fuel onboard.

WEIGHT AND BALANCE

A weight and balance report, dated November 2004, was located in the airplane. The report indicated a basic empty weight of 2,400.4 pounds. No weight and balance sheet referring to the airplane in the ferry flight configuration was located.

The following approximate loading information was garnered during the on-scene, and follow-up examinations. The weight within the forward cabin area, which included the pilot, baggage, water, and the fuel transfer pump system, was about 285 pounds.

The aft seat area, which contained the bladder fuel tank, its associated plywood supports, long-range radio, and an assumed total fuel of 121 gallons, was about 722 pounds. The equipment in the aft baggage area totaled about 187 pounds, and included both aft seats, plywood supports, additional water, baggage, and a life raft. According to the Mooney Pilot Operating Handbook (POH), the maximum allowable weight in the baggage area was 120 pounds. The wing fuel tanks, with a usable capacity of 89 gallons, were estimated to contain about 534 pounds of fuel.

Based on these values, the airplane's weight at takeoff was about 4,128.4 pounds, 255.4 pounds in excess of the MTOW in the ferry tank configuration, and 760 pounds beyond the standard MTOW. Extrapolation of the weights and cargo positions based on the Mooney loading graph, resulted in a center of gravity position of 51.79 inches, 0.79 inches beyond the aft center of gravity limit.

ENGINE OPERATION

No anomalies were noted, which would have precluded normal engine operation. Refer to the public docket for the complete airframe and engine report.

THE PILOT

The pilot was an Australian citizen, and his flight experience information was provided by the Australian Transport Safety Bureau (ATSB). Review of his logbooks by the ATSB revealed that the last entry was recorded on April 24, 2010. At that time, he had accrued a total of 2,540.3 flight hours. The records revealed that the pilot had flown seven multi-legged international ferry flights, three of which were on the same initial route as the accident flight. No prior Mooney aircraft experience was noted in the logbooks.
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