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VH-PPA Mooney M20R Fatal Crash on Ferry Flight

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VH-PPA Mooney M20R Fatal Crash on Ferry Flight

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Old 24th Apr 2012, 12:23
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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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Old 25th Apr 2012, 09:23
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IMO the company which organised this ferry is highly respected in the aviation ferry industry. You can give a guy instructions and the onus is on him to comply....or face the consequences.

Last edited by PA39; 25th Apr 2012 at 10:25.
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Old 25th Apr 2012, 16:45
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I get many enquiries from people looking to get into ferrying. It is not easy, it involves getting stuck in places you don't like for long periods and obscure reasons, it is dangerous and there are certain types out there (even well respected in the industry) whom I have seen with setups that left me gobsmacked.

Wait until you have an burning smell three hours into a 12 hour overwater flight with 600L of avgas in the seat behind you and then see how much fun it is.

I'm surprised the pilot of this incident didn't know better.
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Old 26th Apr 2012, 11:54
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Clearedtoreenter

Judging by your handle, I presume you own and/or operate an M20R? How do those things perform on take-off at max weight? Would they be tolerant to overloading and out of balance in the way I hear some types might be?
Yes and yes.

The M20R with full fuel, 2 POB and a bit of baggage will be just under MTOW with the CG close to the forward limit. In a ferry configuration the CG moves well aft, although I was surprised the NTSB found the CG of VH PPA was outside the envelope. I know (not from direct experience of course) that 115% MTOW is nothing for an M20R, having passengered in one about that weight from Lakeland to Orlando back in 2000. In short, easy to go over MTOW if you're not careful, but hard to get the CG outside the envelope in normal configuration.

I've pasted the flight data sequence from the NTSB report which shows the T/O seemed normal considering the additional weight, and right at the end of this post is actual data of what an M20R at MTOW does for comparison.

For VH PPA the ground roll of 36 seconds was unspectacular, and it then achieved a ROC of 490 fpm up to the 84 second mark, then 750 fpm over the next 47 seconds.

At that point it went unhinged, with marked speed and altitude oscillations which I believe were as a result of instability from the rearward CG, and considering the ferry tank was not strapped down, it might have been that the fuel sloshed forward and aft within the unrestrained bladder giving it a dynamic CG.

The accident airplane was equipped with a Garmin GPSMap 496 global positioning systems receiver. Historical flight data from the unit was extracted and revealed the entire accident flight sequence. The data indicated that the airplane entered runway 31 at 0624:20, and immediately commenced with the takeoff roll. The airplane began to accelerate while on a heading of 322 degrees true for the next 36 seconds while remaining at field elevation (230 feet msl).

For the next 84 seconds the airplane continued to accelerate to a ground speed of about 138 miles per hour (mph), climbing to 915 feet mean sea level (msl), while still on runway heading. The airplane then began a left turn to 257 degrees, reaching its maximum altitude of 1,502 feet msl, 47 seconds into the turn.

For the next 24 seconds the airplane's groundspeed increased to 141 mph with a corresponding 222 feet decrease in altitude. Over the next 89 seconds, the airplane began a left turn with an accompanying series of three diverging groundspeed and altitude oscillations varying between 67 and 144 mph, and 1,383 and 502 feet msl, respectively. The last recorded position occurred at an altitude of 467 feet (300 feet agl) with the airplane on a heading of 344 degrees

Derived from GPS data, an actual M20R (not VH PPA) take-off at MTOW took 25 Secs from 6 kt rolling start, to VR +5 and 50 Ft above runway.
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Old 8th May 2012, 11:44
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Probable cause has now been released and confirms earlier findings.

http://dms.ntsb.gov/aviation/Acciden...2012120000.pdf

So longitudinal instability as a result of aft c of g, over approved mtow, all plausible.

One thing I thought of recently - the lack of post crash fire given the considerable fuel level onboard. Not knowing the mooney fuel system intimately, I can only assume the pilot managed to turn off the fuel shutoff valve prior to impact ( and had a while it seems to contemplate what was happening given the aft trim, retarded throttles - recovery from a spin)

Very sad accident. No matter what way you look at it, the pilot set out on what was a routine flight he had done a few times before on the exact same route and became unstuck on this particular day in 2010.

RIP Ben!
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Old 8th May 2012, 22:17
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The Mooney Brothers realised that at most times 4 place aircraft only have 2 up so they designed their aircraft around that. I too have owned a Mooney 231 and thats just right....2 up full fuel and a handbag. Love the model, tight as inside but handle and feel like a sports car.
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Old 9th May 2012, 09:48
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The report details the position of the trim as near full "nose up" this is exactly opposite to what i would expect to see considering the CofG location also the trim failure light was illuminated?

The stabilizer trim aft jackscrew was examined, and about 14 exposed threads were noted. According to Mooney documentation, this is consistent with a nose-up trim setting, with 16 exposed threads corresponding to full nose-up, and 7 exposed threads for takeoff.

The trim position was further corroborated by examination of the stabilizer trim control system assembly, located in cabin floor area. The dimension of the trim stop from the forward jam nuts was measured. The dimension was 0.9 inches, which according to Mooney documentation, was consistent with a nose-up trim setting, with 0.7 inches correlating to full nose-up. Rotation of the assemblies' output shaft resulted in smooth rotation of the drive sprocket. The trim assembly chain appeared intact, and no damage was noted to the sprockets. The plastic trim wheel had become fragmented, with the center hub still in place. Rotation of the trim wheel hub resulted in rotation of output drive shaft at the trim assembly.

The remaining sections of the elevator trim system were examined and exhibited varying degrees of crush and fragmentation damage. No anomalies were noted to the trim system.

During the examination, the lamp filaments from the indicator panel of the KC-191 Flight Computer were examined. All lamp filaments with the exception of the trim failure warning lamp, were either intact and upright, or broken midspan. The trim failure warning lamp filament remained intact, but exhibited stretching to its filament, and was bent in the downwards direction relative to the airplanes vertical axis.

According to the autopilot operating instructions, the illumination of only the trim failure warning lamp indicated that the unit had either been powered-up, and no system self-test had been performed, or that a test was performed but the system failed. Additionally, the illumination could indicate a trim failure during flight. Under all of these conditions, the autopilot is inoperative.
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Old 9th May 2012, 11:43
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I don't see any mention that the bladder tank was in any way baffled. The 750 fpm climb seems quite good. Was the turn onto 257 deg to set course? Did he level off temporarily at 1502', or is it just a coincidence that's were things went awry. Could the back and forth 'wave action' in the bladder tank have caused him the 'chase' the trim until he lost control ?
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Old 9th May 2012, 12:45
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cowl flaps

Could the back and forth 'wave action' in the bladder tank have caused him the 'chase' the trim until he lost control ?
I agree, and think your words described it well. Once the wave action started the instability would be amplified with each successive airframe oscillation until it became uncontrollable.

nkand

One thing I thought of recently - the lack of post crash fire given the considerable fuel level onboard. Not knowing the mooney fuel system intimately, I can only assume the pilot managed to turn off the fuel shutoff valve prior to impact ( and had a while it seems to contemplate what was happening given the aft trim, retarded throttles - recovery from a spin)
I too was surprised by the absence of a post crash fire, particularly when the NTSB report noted the fuel selector as ON, but to the LEFT tank instead of the RIGHT tank as stipulated. The FAA also determined there was fuel available when they tore down the engine, but it would be impossible to determine whether there was a consistent flow.

On the issue of the nose-up trim condition, I would guess the FAA as a long shot would have checked the C/W trim switch and circuitry for transposed operation, which might have explained the nose up trim.

This strikes me as a classic case of the holes in the cheese all coming into line, with a tragic outcome. I would add to the NTSB determination as contributing factors (1) a lack of familiarity with the Mooney airframe and (2) an element of complacency (by operating so far overweight with an unsecured load).

I have some indirect experience in ferry flight planning, and have seen first hand cavalier attitudes and a preparedness to disregard pesky little things such as loading, SFP's, W+B, FAA and CASA regulations etc etc.
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Old 9th May 2012, 14:57
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A 238 (us) gallon ferry tank is a big mother. A bit more than 4 (aussie) 44's.
If oscillation actually occured the back and forth 'wave action' in the bladder tank would have been hard to handle. The trim on the yoke would be fairly slow, I think. So holding the yolk back to stop the oscillation would work, but bad as the aircraft would 'mush' through the air and slow too much. Push forward to re-gain airspeed and the 'wave' comes forward causing the airspeed (and loss of altitude) to be way more than you want,- so heave back on the yolk, and it all happens again!
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Old 10th May 2012, 12:13
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pacflyer7:

So just to be clear, no one here that has commented actually has ferried an aircraft in this configuration? Other than of course the indirect planning?
I'm sure pacflyer7's comment is not intended to be sarcastic, and so to be truthful yes, I have flown an identical Mooney in ferry configuration, but with 2 x 200L drums in the rear (rather than the ferry bag) and a smaller drum in the copilot seat position with the yoke removed.

So just to be clear, there really are some cowboys in the ferry business. One has his own thread in Pprune right here: Robert Weaver.

Then there's another ferry pilot (also a CFI and part time swimmer) incapable of doing a 115% MTOW Mooney W+B, and when an opportunity to revise it was presented, still got it just as wrong but in different ways. Ppacflyer7 may even know him or her.
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