NTSB CAROL · Event
Event ERA22LA064
Aircraft involved
Probable cause & findings
The total loss of engine power due to the failure of maintenance personnel to properly tighten the fuel supply line b-nut at the manifold valve during installation.
Factual narrative
On November 15, 2021, about 1012 eastern standard time, a Mooney M20M, N21890, was substantially damaged when it was involved in an accident near Tampa, Florida. The private pilot and one passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot stated that he flew the airplane earlier that day on an uneventful 15-minute flight from Peter O Knight Airport (TPF), Tampa, Florida, to Lakeland Linder International Airport, Lakeland, Florida. After landing he picked up his passenger and departed for Gainesville Regional Airport, Gainesville, Florida. At 3,000 ft mean sea level (msl) with the mixture control full rich and the engine operating at 32 inHg and 2,400 rpm., he noted the turbine inlet temperature (TIT) was in the red range. At the same time of the high TIT reading, he noticed liquid on the bottom portion of the windshield. He confirmed that the mixture control was full rich and reduced engine power, which decreased the TIT reading, but there was still liquid on the windshield. While at 4,000 ft msl, he advised air traffic control of the higher temperature and diverted to TPF, maintaining 4,000 ft msl until on the downwind leg of the airport traffic pattern where he reduced power, extended the landing gear and lowered the 1st notch of flaps. He turned onto the base leg, and at 1,200 ft above ground level before turning onto final, he added throttle, but the engine did not respond. He pushed the mixture, propeller, and throttle controls full forward, which at full throttle automatically turned on the auxiliary fuel pump, but noted the propeller was windmilling. At 800 ft msl, he realized he would be unable to make the runway and told his passenger about the impending ditching. He retracted the landing gear and maintained a nose-up wings level attitude ditching the airplane. Both occupants exited the airplane and were transported to land. The underside of the fuselage was substantially damaged during the ditching. Following recovery of the airplane, examination of the fuel lines in the engine compartment revealed the inlet fuel line at the manifold valve was 7.5 flats of the b-nut from being hand tight against the inlet fitting. There was no provision for safety wiring the b-nut and there was no torque stripe on the b-nut or inlet fitting. Pressure testing of the fuel supply system was performed with the b-nut in the as-found position revealed fuel leaked at the b-nut. After the b-nut was tightened, no leakage was noted at the b-nut. Inspection of the threads of the fitting and of the flexible fuel hose revealed no discrepancies. Torque stripes were noted on the fuel injector nuts at the manifold valve. Review of the maintenance records revealed that nearly 2 months before the accident, fuel system components consisting of the engine-driven fuel pump, servo fuel injector, manifold valve, and fuel injectors were removed for testing and overhaul. The components were installed and according to the pilot, the airplane had been operated about 12 hours over 3 or 4 flights since installation. There was no record of any subsequent engine work after the overhauled components were installed. The mechanic who installed the components after testing and/or overhaul reported that the airplane owner helped with the installation. The mechanic also indicated that he normally would have applied a torque stripe to the inlet hose at the manifold valve. While in cruise flight, the pilot noticed the turbine inlet temperature (TIT) was about 100° F above the maximum reading and that liquid was on the windshield. He reduced engine power, which lowered the TIT reading and then diverted to his home airport. While on the base leg of the airport traffic pattern at 1,200 ft above gound level, he advanced the throttle, but the engine did not respond. At 800 ft msl he noted he would be unable to reach the airport and ditched the airplane. Both occupants exited the airplane and were transported to land, and the airplane’s fuselage was substantially damaged during the ditching. Following recovery of the airplane, the inlet fuel line at the manifold valve was 7.5 flats of the b-nut from being hand tight against the inlet fitting. There was no provision for safety wiring the b-nut and there was no torque stripe on the b-nut or inlet fitting. Fuel leakage was noted at the loose b-nut during pressure testing, but no leakage occurred after tightening the b-nut. There was no damage to the b-nut or fitting that would have precluded obtaining the proper torque. The manifold valve was overhauled and installed nearly 2 months earlier. The mechanic who signed off the installation indicated he normally would have applied a torque stripe on the b-nut. Based on this information, it is likely that the overheating of the engine and the subsequent loss of engine power was likely due to a fuel leak at the fuel manifold valve, resulting an excessively lean fuel to air mixture. It is also likely that the loose b-nut had not been properly tightened during the reinstallation of the manifold valve. Source: NTSB Aviation Accident Database Retrieved: 2026-02-12
NTSB Findings
Hierarchical cause / factor breakdown from the FAA bulk avdata database. Each finding tagged C (Cause) or F (Factor).
- — Aircraft-Aircraft power plant-Engine fuel and control-Fuel distribution-Incorrect service/maintenance
- — Personnel issues-Task performance-Maintenance-Installation-Maintenance personnel
Verbatim from NTSB's published report. Source file
NTSB_2021_ERA22LA064.txt.
Findings + structured fields enriched from FAA avall.mdb.
Full investigation docket on
data.ntsb.gov ↗.
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Related research
What the literature says.
Academic papers and agency reports matching this event's aircraft type or causal vocabulary (stall, maintenance). Sourced from NASA NTRS, NTSB Safety Studies, FAA CAMI, AOPA Air Safety Institute, Embry-Riddle Scholarly Commons, arXiv, and the Semantic Scholar academic graph.
- Embry-Riddle Scholarly Commons 2023 · Conference paper
The Value of Strong Partnerships to Build a Successful Aviation Maintenance Career Pathway Program for Transitioning Military Service Members
The aerospace industry is competing with other industries for a qualified workforce, and many of those competing industries are investing heavily in creating workforce development pipelines.
- Embry-Riddle Scholarly Commons 2026 · Journal article (IJAAA)
From Reactive to Predictive: A hybrid Trust-Mediated Adoption Framework for Data-Driven Maintenance in Distributed-Authority Aviation Environments
Modern aviation maintenance operates within increasingly data-intensive technological environments, yet the operational integration of predictive maintenance into routine decision-making remains incon…
- NASA NTRS 2026 · Conference Paper
Computational Analysis of Steady State Aerodynamics of Transonic Truss-Braced Wing Configuration in Deep Stall
This study presents a computational investigation of steady state aerodynamics of the Subsonic Ultra-Green Aircraft Research (SUGAR) Transonic Truss-Braced Wing (TTBW) configuration over a wide range …
- Semantic Scholar 2025 · Article (Applied Sciences)
Decision-Making Framework for Aviation Safety in Predictive Maintenance Strategies
The implementation of predictive maintenance (PM) in aviation presents unique challenges due to strict safety requirements, complex operational environments, and regulatory constraints.
- Embry-Riddle Scholarly Commons 2024 · Journal article (JAAER)
Low-Resource Automatic Speech Recognition Domain Adaptation – A Case-Study in Aviation Maintenance
With timeliness and efficiency being critical in the aviation maintenance industry, the need has been growing for smart technological solutions that optimize and streamline the different underlying ta…
- Embry-Riddle Scholarly Commons 2024 · Journal article (JAAER)
A New Trajectory in UAV Safety: Leveraging Reinforcement Learning for Distance Maintenance Under Wind Variations
In the field of aviation, safety is a critical cornerstone, and the operation of Unmanned Aerial Vehicle (UAV) systems is deeply connected with this principle.
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