# NTSB CEN20FA034: Mooney M20C, N5557Q, Flower Pot, AZ, December 8, 2019 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: December 8, 2019, 13:00 local (20:00 UTC) - Place: Flower Pot, AZ - Coordinates: 34.479442, -111.989166 - Nearby events: https://openairdocs.org/map.md?lat=34.4794&lon=-111.9892&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: Lycoming, FAA - Scottsdale FSDO - NTSB case key (mKey): 100687 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN20FA034 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/100687/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=100687 - Page: https://openairdocs.org/ntsb/CEN20FA034 ## Probable cause The noninstrument-rated pilot’s decision to initiate and continue the visual flight rules flight into an area of forecast instrument meteorological conditions, which resulted in the pilot’s spatial disorientation and loss of airplane control. Contributing was the pilot's lack of instrument flight experience. ## 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 M20C, 11 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=5870208), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Experience/qualifications: total instrument experience](https://openairdocs.org/ntsb-findings/02031030): Personnel issues › Experience/knowledge · Pilot (probable cause); cases with it: [Mooney M20C, 1 case](https://openairdocs.org/ntsb-findings/02031030/cases.md?model=5870208), [All aircraft, 66 cases](https://openairdocs.org/ntsb-findings/02031030/cases.md) - [Perception/orientation/illusion: situational awareness](https://openairdocs.org/ntsb-findings/02022035): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Mooney M20C, 1 case](https://openairdocs.org/ntsb-findings/02022035/cases.md?model=5870208), [All aircraft, 111 cases](https://openairdocs.org/ntsb-findings/02022035/cases.md) - [Performance/control parameters](https://openairdocs.org/ntsb-findings/01062000): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Mooney M20C, 4 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md?model=5870208), [All aircraft, 1,269 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: Loss of visual reference](https://openairdocs.org/ntsb-events/402); cases with it: [Mooney M20C, 1 case](https://openairdocs.org/ntsb-events/402/sequence.md?model=5870208), [All aircraft, 242 cases](https://openairdocs.org/ntsb-events/402/sequence.md) - [Enroute-cruise: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Mooney M20C, 10 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=5870208), [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 M20C, 39 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=5870208), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The non-instrument rated private pilot received two separate weather briefings before departing on the accident flight. During both briefings, he was informed of an AIRMET for mountain obscuration along his intended route of flight. During the second briefing, he was also informed that there was an AIRMET for instrument meteorological conditions (IMC) that included the intended route of flight. The pilot then departed on the cross-country flight and was witnessed flying at very low altitude below an overcast cloud layer. Witnesses captured photographs of the airplane as it flew over their car and stated that it appeared to be following the road. One of the photographs showed that the airplane was about 227 ft above the ground and showed low clouds and obscuration of the mountain peaks in the background. There were no witnesses to the accident. Radar track data ended about 23 miles from the accident site but showed the airplane flying between 250 and 1,600 ft above the terrain for the portions of the flight that were captured. Postaccident examination of the airplane, engine, propeller, and control system did not reveal any preimpact anomalies. Based on the available evidence, the accident was the result of the pilot's decision to initiate the flight in poor weather conditions, which resulted in an encounter with instrument meteorological conditions. The non-instrument rated pilot was unable to maintain situational awareness, lost control of the airplane, and impacted the ground. ## Factual narrative The FAA Civil Aeromedical Institute's publication, "Introduction to Aviation Physiology," defines spatial disorientation as a “loss of proper bearings; state of mental confusion as to position, location, or movement relative to the position of the earth.” Factors contributing to spatial disorientation include changes in acceleration, flight in IFR conditions, frequent transfer between visual flight rules and IFR conditions, and unperceived changes in aircraft attitude. The FAA’s Airplane Flying Handbook (FAA-H-8083-3B) describes some hazards associated with flying when the ground or horizon are obscured. The handbook states, in part, the following: The vestibular sense (motion sensing by the inner ear) in particular can and will confuse the pilot. Because of inertia, the sensory areas of the inner ear cannot detect slight changes in airplane attitude, nor can they accurately sense attitude changes that occur at a uniform rate over a period of time. On the other hand, false sensations are often generated, leading the pilot to believe the attitude of the airplane has changed when, in fact, it has not. These false sensations result in the pilot experiencing spatial disorientation. The pilot purchased the airplane on December 4, 2018. It is unknown if the pilot received any flight instruction or familiarization training in the airplane before the accident flight. On December 8, 2019, about 1300 mountain standard time, a Mooney model M20C airplane, N5557Q, was destroyed when it was involved in an accident near Flower Pot, Arizona. The pilot was fatally injured. The aircraft was operated by the pilot as a Title 14 Code of Federal Regulations Part 91 personal flight. The accident site was discovered by a rancher on the morning of December 13, 2019. There were no witnesses to the impact, but witnesses that saw the airplane on December 8, 2019, came forward after learning that the airplane had crashed. The witnesses were driving in a car southbound on Interstate 17 near Munds Park, Arizona, when an orange and white low-wing airplane flew over their car at low altitude. The witnesses reported a low cloud ceiling with good visibility below the clouds. The witnesses provided three pictures of the airplane that showed it travelling in the same direction as the car, close to the ground. The witnesses said that the airplane appeared to be following the road. The pictures also showed low clouds with obscuration of mountain peaks in the background. The witnesses reported that, about 20 minutes after taking the pictures, in the approximate area of the accident site, visibility reduced to about ¼ mile and the clouds extended to the ground. Examination of one of the photographs provided by the witnesses showed that the airplane was about 227 ft. above ground level (agl) (see figure). Figure 1. Photograph of accident airplane provided by a witness with distance markers added to the image showing the airplane's height above ground. Radar track data correlated to theaccident airplane ended about 23 nautical miles (nm) northeast of the accident site but showed the airplane following Interstate 17 during the portion of the flight that was captured. Based on the altitude return data, the portion of the flight recorded by radar was operating at altitudes between about 250 and 1,600 feet above ground level (agl). The straight-line course from KFLG to KDVT was 193° and 90 nautical miles. An autopsy of the pilot was conducted on December 16, 2019, by the Yavapai County Medical Examiner's Office, Prescott Valley, Arizona. The autopsy attributed the cause of death to multiple injuries received during the accident. No significant natural disease was identified. Toxicology testing performed at the request of the medical examiner by Axis Forensic Toxicology, found that cavity blood and urine were negative for alcohols and drugs of abuse. Toxicology testing performed by the FAA Forensic Sciences Laboratory identified ethanol at 0.015 gm/dl in cavity blood as well as N-propanol and N-butanol. No ethanol or other alcohols were identified in vitreous or urine. Ethanol is primarily a social drug with a powerful central nervous system depressant. After ingestion, ethanol is quickly distributed throughout the body's tissues and fluids fairly uniformly. The distribution pattern parallels the water content and blood supply of each organ. Ethanol may also be produced in body fluids and tissues after death by microbial activity. N-propanol and N-butanol are other alcohols that can be produced in postmortem fluids and tissues. The pilot contacted the FAA Prescott Automated Flight Service Station (AFSS) provider Leidos at approximately 0848 and requested a 6-hour outlook briefing. He was advised that a series of AIRMETs were current for the route of flight, including AIRMET Sierra for mountain obscuration with terrain obscured by clouds and precipitation and mist, AIRMET Tango for turbulence, and AIRMET Zulu for icing conditions. At 1207, the pilot again contacted the FAA Prescott AFSS and requested a standard briefing for a visual flight rules flight from Flagstaff, Arizona, to Phoenix, Arizona. He noted that the flight was to be conducted at a planned altitude of 8,000 ft, with an estimated time enroute of 30 minutes. The briefer advised the pilot of an AIRMET for moderate icing above 7,000 ft, and a Center Weather Advisory for icing about 20 miles south of the intended destination. The pilot was also informed of an AIRMET for mountain obscuration for the entire route and an AIRMET for instrument flight rules conditions over northern Arizona. The briefer indicated that marginal VFR conditions (MVFR) were reported along the route with scattered rain showers. At 1255, the recorded weather conditions at Sedona Airport, Sedona, Arizona, included wind from 160° at 8 knots, 10 statute miles visibility, scattered clouds at 1,000 ft agl, broken clouds at 1,800 ft agl, overcast clouds at 6,000 ft agl, temperature 10°C, dewpoint 9°C,altimeter setting 30.04 inches of mercury. The pilot held a private pilot certificate with a rating for airplane single-engine land. His most recent first-class medical certificate was issued on October 14, 2019, with no limitations, at which time he reported 110 hours of total flight experience and 70 hours in the previous 6 months. The pilot’s logbook was not available for review. The airplane impacted the ground about 1 mile east of Interstate 17 on a heading of about 60°. The main wreckage came to rest about 320 ft from the initial impact point. Examination of the airplane, engine, propeller, and control system did not reveal any preimpact anomalies. The propeller exhibited leading edge nicks and S-shaped bending. ## Aircraft - Registration: [N5557Q](https://openairdocs.org/deregistered/N5557Q-2020-10-10), registration cancelled 2020-10-10, S/N 2967, built 1965 (OpenAirDocs) - Reported make and model: Mooney M20C (No Series) - Registry model: [Mooney M20C](https://openairdocs.org/model/mooney-m20c) (registry code 5870208) (OpenAirDocs) - Registry engine: [Lycoming O&VO-360 series](https://openairdocs.org/engine/lycoming-o-vo-360-series) (registry code 41514, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 2967 - Year built: 1965 - Engines: Lycoming O&VO-360 SER reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, May 12, 2019 - Departed: FLG, Flagstaff, AZ - Destination: DVT, Phoenix, AZ - Equipment: Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 23; injuries: fatal; private; airplane ratings: single-engine land; medical: class 1, without waivers/limitations; seat: left; restraint: 3-point; toxicology performed; flight hours: 110 total ## Weather - Conditions: Day - Wind: 160° at 8 knots - Visibility: 10 statute miles - Lowest ceiling: 1,800 ft broken - Temperature: 50 °F, dew point 48 °F - Altimeter: 30.04 inHg - Observed at: SEZ, 25 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 20191208022129A](https://openairdocs.org/incident/20191208022129A), Dec 8, 2019: Mooney M20C, Flower Pot, AZ, Destroyed, 1 fatal. On 12/13/2019 a rancher tending cattle found the wreckage of an aircraft. On 12/15/2019 the girlfriend of the pilot reported him missing saying that he had… ## Docket (13 files) The files NTSB released with the investigation on December 20, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=100687. 67.6 MB in all. - Weather study (item 1, PDF, 30 pages, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9075155&FileExtension=pdf&FileName=CEN20FA034%20-%20Flower%20Pot,%20AZ-Rel.pdf - Meteorology attachment 1 - afss briefing (item 2, WAV, 6.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9074949&FileExtension=wav&FileName=N5557Q%2012-8-19%201548Z-Rel.wav - Meteorology attachment 2 - updated afss briefing (item 3, WAV, 9.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9075451&FileExtension=wav&FileName=N5557Q%2012-8-19%201907Z-Rel.wav - Toxicological report (item 4, PDF, 1 page, 652 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9885914&FileExtension=pdf&FileName=2019_264_001_Redacted-Rel.pdf - Aircraft bill of sale (item 5, PDF, 1 page, 4.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9886646&FileExtension=pdf&FileName=Aircraft%20Bill%20of%20Sale_Redacted-Rel.pdf - Airframe logbook excerpt (item 6, PDF, 14 pages, 14.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9886237&FileExtension=pdf&FileName=Airframe%20log_Redacted-Rel.pdf - Engine logbook excerpts (item 7, PDF, 23 pages, 25.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9886248&FileExtension=pdf&FileName=Engine%20Log_Redacted-Rel.pdf - Propeller logbook excerpts (item 8, PDF, 3 pages, 2.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9886257&FileExtension=pdf&FileName=Prop%20log_Redacted-Rel.pdf - Aircraft examination notes (item 9, PDF, 2 pages, 85 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9902112&FileExtension=pdf&FileName=Examination%20notes-Rel.pdf - Photos (item 10, PDF, 6 pages, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9901814&FileExtension=pdf&FileName=Photos-Rel.pdf - Plotted radar data (item 11, PDF, 1 page, 337 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9902859&FileExtension=pdf&FileName=Radar%20plot-Rel.pdf - Tabular radar data (item 12, CSV, 1 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9903760&FileExtension=csv&FileName=N5557Q%20tabular%20radar%20data-Rel.csv - Statement of party representatives to NTSB investigation (item 13, PDF, 1 page, 59 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9904062&FileExtension=pdf&FileName=NTSB%20party%20form_Lycoming-CEN20FA034_Redacted-Rel.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.