# NTSB CEN11FA124: Mooney M20E, N79869, Colorado Springs, CO, December 22, 2010 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: December 22, 2010, 11:59 local (18:59 UTC) - Place: Colorado Springs, CO - Coordinates: 38.814998, -104.684448 - Nearby events: https://openairdocs.org/map.md?lat=38.8150&lon=-104.6844&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-IFR missed approach: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report December 19, 2011 - Report: Approved by Office Director - NTSB office: Central Region - Parties: FAA, Lycoming Engines - NTSB case key (mKey): 78045 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN11FA124 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/78045/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=78045 - Page: https://openairdocs.org/ntsb/CEN11FA124 ## Probable cause The pilot’s decision to initiate an approach into weather conditions where the ceiling and visibility were below the minimums for the approach and where reported icing existed, in an airplane not certified for flight in icing conditions, and his failure to maintain control of the airplane during the missed approach. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Mooney M20E, 5 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=5870212), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Ceiling/visibility/precip: below approach minima](https://openairdocs.org/ntsb-findings/03035070): Environmental issues › Conditions/weather/phenomena · Decision related to condition (probable cause); cases with it: [Mooney M20E, 1 case](https://openairdocs.org/ntsb-findings/03035070/cases.md?model=5870212), [All aircraft, 11 cases](https://openairdocs.org/ntsb-findings/03035070/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Mooney M20E, 16 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=5870212), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Temp/humidity/pressure: conducive to structural icing](https://openairdocs.org/ntsb-findings/03031025): Environmental issues › Conditions/weather/phenomena · Effect on equipment; cases with it: [Mooney M20E, 1 case](https://openairdocs.org/ntsb-findings/03031025/cases.md?model=5870212), [All aircraft, 103 cases](https://openairdocs.org/ntsb-findings/03031025/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach-IFR missed approach: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Mooney M20E, 11 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=5870212), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Mooney M20E, 28 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=5870212), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis During the initial phase of an instrument approach to the destination airport, the airplane was in visual meteorological conditions above clouds that contained reported icing conditions. Prior to and during the approach, the air traffic controller, who was vectoring the airplane, advised the pilot of two pilot reports of icing conditions encountered immediately after departure. The airplane entered the clouds at 8,500 feet and reported a missed approach several feet above the decision altitude; the pilot did not report any problems or declare an emergency. No further radio communications were recorded. The wreckage was located on the airport, about 440 feet south of the approach end of the runway. The ground scars and damage to the airplane were consistent with a low-airspeed and high-angle-of-attack impact. Instrument flight rules (IFR) conditions existed over the area with conditions favorable for icing below 8,500 feet. AIRMET advisories for IFR, mountain obscuration, turbulence, and icing conditions had been issued. At the time of the accident, visibility was reported as less than 1/4 mile in freezing fog, with a ceiling at 100 feet. The approach minimums were 200-foot ceilings and 1/2 mile visibility. The airplane was not equipped with anti-icing or deicing equipment and was not approved for flight in known icing conditions. ## Factual narrative HISTORY OF FLIGHT On December 22, 2010, at 1159 mountain standard time, a Mooney M20E airplane, N79869, impacted terrain following a missed approach to City of Colorado Springs Municipal Airport (COS), Colorado Springs, Colorado. The commercial pilot and one passenger were fatally injured. The personal flight was being conducted under the provisions of 14 Code of Federal Regulations Part 91 with an Instrument Flight Rules (IFR) flight plan. Instrument meteorological conditions (IMC) prevailed at the time of the accident. The cross-country flight departed Rapid City Regional Airport (RAP), Rapid City, South Dakota, at 0917 and was en route to COS. The pilot contacted COS approach control at 1138 and was told to expect the Instrument Landing System (ILS) approach to Runway 17L. At 1147, N79869 was cleared for the ILS 17L approach and the pilot acknowledge the clearance. Prior to the approach clearance and then once during the approach, the controller advised of two pilot reports. An MD 80 had experienced light clear ice in the clouds after departure and a CRJ had experienced light rime ice in the clouds after departure. At 1150, N79869 was cleared to land and the pilot acknowledged the clearance. At 1152:47, the pilot reported “VFR on top” and at 1153:29, reported entering clouds at 8,500 feet mean sea level (MSL). At 1158:24, the pilot report going missed approach, stating that he could not see the runway environment at 6,400 feet. The controller directed the pilot to fly runway heading and the pilot acknowledged. No further voice communications were recorded from the accident airplane. The flight did not report any problems or declare an emergency. The airplane wreckage was located about 440 feet south of the approach end of Runway 17L and about 400 feet east of the runway centerline. PERSONNEL INFORMATION The pilot, age 25, held a commercial pilot certificate with ratings for airplane single engine land, airplane multiengine land limited to centerline thrust, and instrument airplane. The pilot also held a certificate for flight instructor with ratings for airplane single engine and instrument airplane. His last Federal Aviation Administration (FAA) third-class medical certificate was issued on June 13, 2007, with no limitations. The pilot satisfied the requirements for a flight review on April 15, 2010. The pilot was a United States Air Force B-1B pilot. He had received an “exceptionally qualified” rating on last military mission and instrument flight review on April 14, 2010. A review of the pilot’s logbook indicated he had logged 913 total flight hours, 658 hours in single engine land airplane, and 254 hours in multiengine land airplane. He had logged 38 hours in actual instrument conditions and 78 hours of simulated instrument time. The pilot had logged 58 hours in the make and model since purchasing the airplane in July of 2010. AIRCRAFT INFORMATION The 1964 model Mooney M20E, serial number 532, was a single engine, low wing, metal coveredairplane, with retractable tricycle landing gear, and was configured for four occupants. The airplane was powered by a direct drive, horizontally opposed, fuel injected, air-cooled, four-cylinder engine. The engine was a Lycoming IO-360-A1A, serial number L-5656-51A, rated at 200 horsepower at 2,700 RPM, and was driving a three-bladed Hartzell, fixed pitch propeller. The last airplane inspection was an annual type performed on July 15, 2010. The airplane was not equipped with de-icing or anti-icing equipment and was not approved for flight in known icing conditions. METEOROLOGICAL INFORMATION The National Weather Service (NWS) Surface Analysis Chart for 1100) depicted s stationary front over southwest Colorado. The station models in the vicinity of the accident site indicated east-southeasterly winds from 5 to 10 knots over eastern Colorado with fog and or mist reported, overcast skies, temperatures in the upper 20’s degrees Fahrenheit (F), with temperature-dew point spreads of 4 degrees or less. The NWS regional radar mosaic depicted no significant weather echoes over the area. Visible data from the Geostationary Operational Environmental Satellite 13 depicted an extensive area of low stratiform clouds over the region. Sounding for Denver indicated a strong frontal inversion between 8,000 and 9,000 feet and supported light to moderate rime type icing below 10,000 feet with over 80% probability of occurrence. Conditions between the surface and 8,500 feet had temperatures between -6.5 to -1.5 degrees. Airmen Meteorological Information (AIRMET) SIERRA, TANGO, and ZULU, were issued for the airplane’s route of flight and the accident location. The AIRMET ZULU advised of moderate icing between the freezing level and flight level 240. The freezing level ranged from the surface to 10,000 feet. In addition, several pilot reports illustrated icing conditions below 8,000 feet at COS. The closest official weather observation station was COS located one miles west of the accident site. The elevation of the weather observation station was 6,187 feet msl. The routine aviation weather report (METAR) for COS, issued at 1154, reported winds 160 degrees at 7 knots, visibility less than 1/4 mile in freezing fog, runway 17L visual range 700 variable 1,200 feet, vertical visibility 100 feet, temperature 27 degrees F, dew point 25 degrees F, altimeter 30.18 inches of mercury. Tower visibility was reported at 1/4 mile. A special METAR for COS was issued at 1150 and reported winds 160 degrees at 8 knots, visibility less than 1/4 mile in freezing fog, 17L visual range 700 variable 1,400 feet, vertical visibility 100 feet, temperature 27 degrees F, dew point 25 degrees F, altimeter 30.18 inches of mercury. AIRPORT INFORMATION City of Colorado Springs Municipal Airport is a public airport in Class Charlie airspace, (located 6 miles southeast of Colorado Springs, Colorado, at a surveyed elevation of 6,187 feet. The airport had three open runways (17L/35R, 17R, 35L, and13/31) and 13 different instrument approaches at the time of the accident. The ILS approach for runway 17L was aligned on a course of 171 degrees. The approach minimums for all category of aircraft for the full ILS approach included a decision altitude of 6,387 feet, a minimum runway visual range (RVR) of 1,800 feet, or flight visibility of 1/2 mile. The missed approach procedure instructed the pilot to fly runway heading to an altitude of 7,200 feet, then initiate a climbing left turn to 9,000 feet on a heading of 020 degrees, and to proceed to ADANE, off the 086 radial from the Black Forest VOR and hold. FLIGHT RECORDERS The accident airplane was equipped with a Garmin Aera 500 handheld global positioning system (GPS) unit. The unit was sent to the National Transportation Safety Board (NTSB) Vehicle Recorders Lab in Washington D.C. for download. There unit’s memory chip was missing and no data was recovered. WRECKAGE AND IMPACT INFORMATION The wreckage and initial impact were aligned on a 285-degree magnetic heading. All wreckage was contained within about 100 feet, with the main wreckage consisting of the engine, both wings, and the fuselage aft of the cockpit mostly collocated about 20 feet south and east of the initial impact point. The cockpit was mostly consumed by post crash fire. The fuselage and the empennage were upright with the right wing attached. The left wing was partially attached to the fuselage and inverted. The leading edge of both wings exhibited accordion type crushing consistent with a near vertical impact. The landing gear was in the retracted position. The engine was located next to the left side of the cockpit area in an inverted position. The engine exhaust and intake were exposed to the elements and to fire-fighting efforts, which included spraying the wreckage with fire retarding foam. One propeller blade was partially embedded at the initial impact site and exhibited leading edge polishing. The remaining two blades were attached to the propeller hub. Flight control continuity was verified on scene from the right aileron, rudder, and elevator to the cockpit. Flight control continuity could not be verified from the left aileron to the cockpit due to impact damage to the left wing. Flight control continuity could not be verified through the cockpit area to the control yoke and rudder pedals due to damage from impact and post crash fire. Investigators from the NTSB and Lycoming engines examined the engine on January 12, 2011. Drive train continuity and cylinder compression were verified by hand rotating the engine propeller. Rotational scarring was noted on the face of the starter housing. No anomalies were noted which would have precluded normal engine operation. MEDICAL AND PATHOLOGICAL INFORMATION The Office of the Coroner, El Paso County, Colorado, located in Colorado Springs, Colorado, performed an autopsy on the pilot on December 23, 2010. The cause of death was attributed to multiple blunt force injuries. TheFAA’s Civil Aerospace Medical Institute, Oklahoma City, Oklahoma, conducted toxicological testing on the pilot. Testing for carbon monoxide and cyanide were negative. No volatiles or drugs were detected. ## Aircraft - Registration: [N79869](https://openairdocs.org/deregistered/N79869-2013-10-28), registration cancelled 2013-10-28, S/N 532, built 1964 (OpenAirDocs) - Reported make and model: MOONEY M20E - Registry model: [Mooney M20E](https://openairdocs.org/model/mooney-m20e) (registry code 5870212) (OpenAirDocs) - Registry engine: [Lycoming I0360 series](https://openairdocs.org/engine/lycoming-i0360-series) (registry code 41515, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 532 - Engines: LYCOMING IO-360 Series 180 horsepower reciprocating - Damage: Substantial damage - Fire: On-Ground - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, July 15, 2010 - Departed: RAP, Rapid City, SD - Destination: COS, Colorado Springs, CO - Flight plan: IFR - Airport: COS, Colorado Springs Municipal Air, runway 17L, 13,500 × 150 ft ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 25; injuries: fatal; commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 3, without waivers/limitations; toxicology performed; flight hours: 913 total, 58 in this make and model ## Weather - Conditions: Instrument (IMC), Day - Wind: 160° at 7 knots - Visibility: 0 statute miles - Lowest ceiling: 100 ft overcast - Temperature: 27 °F, dew point 25 °F - Altimeter: 30.18 inHg - Observed at: KCOS, 1 nm away ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20101222054729A](https://openairdocs.org/incident/20101222054729A), Dec 22, 2010: Mooney M20E, Colorado Spring, CO, Destroyed, 2 fatal. Pilot was cleared for the ILS 17L approach to Colorado Springs airport. The weather was IMC. The last communication was that the pilot was going around.… ## Other investigations on N79869 (1) From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. - [NTSB DEN79FTM17](https://openairdocs.org/ntsb/DEN79FTM17), May 13, 1979: Mooney M20E (N79869), Hanksville, UT, substantial damage ## Docket (14 files) The files NTSB released with the investigation on November 9, 2011, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=78045. 6.5 MB in all. - Weather Information (item 1, .PDF, 145 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40356663&FileExtension=.PDF&FileName=Weather%20Information-Master.PDF - Satellite Image - CEN11FA124 (item 2, .PDF, 40 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40356736&FileExtension=.PDF&FileName=Satellite%20Image%20-%20CEN11FA124-Master.PDF - Global Positioning System - Specialist's Factual Report (item 3, .PDF, 58 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40352098&FileExtension=.PDF&FileName=Global%20Positioning%20System%20-%20Specialist%27s%20Factual%20Report-Master.PDF - ATC Transcripts - RAP (item 4, .PDF, 83 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40356660&FileExtension=.PDF&FileName=ATC%20Transcripts%20-%20RAP-Redacted.PDF - ATC Transcripts - COS (item 5, .PDF, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40356657&FileExtension=.PDF&FileName=ATC%20Transcripts%20-%20COS-Redacted.PDF - Approach Plate - ILS runway 17L (item 6, .PDF, 556 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40356714&FileExtension=.PDF&FileName=Approach%20Plate%20-%20ILS%20runway%2017L-Master.PDF - Toxicological Report (item 7, .PDF, 40 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40357644&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 8, .PDF, 775 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40356684&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 9, .PDF, 54 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40357716&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Photograph 01 - Main Wreckage - Front (item 10, .PDF, 355 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40356670&FileExtension=.PDF&FileName=Photograph%2001%20-%20Main%20Wreckage%20-%20Front-Master.PDF - Photograph 02 - Main Wreckage - Right Side (item 11, .PDF, 404 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40356671&FileExtension=.PDF&FileName=Photograph%2002%20-%20Main%20Wreckage%20-%20Right%20Side-Master.PDF - Photograph 03 - Main Wreckage - Rear (item 12, .PDF, 458 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40356675&FileExtension=.PDF&FileName=Photograph%2003%20-%20Main%20Wreckage%20-%20Rear-Master.PDF - Photograph 04 - Main Wreckage - Left Side (item 13, .PDF, 599 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40356676&FileExtension=.PDF&FileName=Photograph%2004%20-%20Main%20Wreckage%20-%20Left%20Side-Master.PDF - Photograph 05 - Main Wreckage - Engine and Propeller (item 14, .PDF, 468 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40356678&FileExtension=.PDF&FileName=Photograph%2005%20-%20Main%20Wreckage%20-%20Engine%20and%20Propeller-Master.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.