# NTSB CEN22LA164: Mooney M20E, N21BS, Kerrville, TX, March 31, 2022 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Limited · Final report - Date: March 31, 2022, 11:00 local (16:00 UTC) - Place: Kerrville, TX - Coordinates: 29.977431, -99.085614 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=29.9774&lon=-99.0856&mi=10 - Phase of flight: [Taxi](https://openairdocs.org/ntsb-phases/250) (OpenAirDocs' grouping) - Defining event: [Taxi-from runway: Medical event](https://openairdocs.org/ntsb-events/850) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: FAA FSDO - NTSB case key (mKey): 104866 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN22LA164 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104866/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=104866 - Page: https://openairdocs.org/ntsb/CEN22LA164 ## Probable cause The pilot’s sudden cardiac event, which resulted in incapacitation, uncontrolled taxi after landing, and collision with a stationary parked airplane. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Impairment/incapacitation: cardiovascular](https://openairdocs.org/ntsb-findings/02012050): Personnel issues › Physical · Pilot (probable cause); cases with it: [Mooney M20E, 1 case](https://openairdocs.org/ntsb-findings/02012050/cases.md?model=5870212), [All aircraft, 69 cases](https://openairdocs.org/ntsb-findings/02012050/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Taxi-from runway: Medical event](https://openairdocs.org/ntsb-events/850) (defining event); cases with it: [Mooney M20E, 1 case](https://openairdocs.org/ntsb-events/850/sequence.md?model=5870212), [All aircraft, 63 cases](https://openairdocs.org/ntsb-events/850/sequence.md) ## Analysis After a local flight, the airplane landed, and a witness saw the airplane taxi over a grass-covered area and then onto the ramp at a higher-than-normal speed. The airplane struck a parked airplane, and the left wing became wedged underneath the empennage of the parked airplane. Airport personnel responded and discovered that the pilot was slumped over the flight controls and unresponsive. Emergency responders attempted CPR, but the pilot did not recover and was transported to a hospital where he was declared deceased. The airplane’s left wing sustained substantial damage. Examination of the airplane’s flight control, brake systems, and related systems did not reveal any mechanical anomalies that would have precluded normal operations. The pilot’s cause of death was atherosclerotic and hypertensive cardiovascular disease in association with obesity; the manner of death was reported as natural. There was significant cardiovascular disease identified by the autopsy without evidence of significant trauma. His cardiovascular conditions placed him at increased risk for a sudden cardiac event. Given the medical findings and the circumstances of this accident, it is likely that the pilot’s incapacitation from a sudden cardiac event caused the accident. ## Factual narrative On March 31, 2022, about 1100 central daylight time, a Mooney M20E airplane, N21BS, was substantially damaged when it was involved in an accident near Kerrville, Texas. The pilot sustained fatal injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. After a local flight, the airplane landed at the Kerrville Municipal Airport (ERV). A witness saw the airplane taxi at a high speed, and it seemed to be out of control. The witness saw the airplane taxi over a grass-covered area and then onto the ramp. The airplane struck the empennage of a parked airplane (a Rockwell Commander, N25CE). The left wing of the Mooney became wedged underneath the empennage of the Rockewell Commander. Airport personnel responded and discovered that the unresponsive pilot was slumped over the flight controls. Medical personnel based on the airport began CPR, but the pilot did not respond. The pilot was transported to a hospital where he was declared deceased. The airplane’s left wing sustained substantial damage. Examination of the airplane’s flight control and brake systems did not reveal any anomalies that would have precluded normal operations. The engine exhaust system was found normal and intact. The Commander’s right horizontal stabilizer also sustained substantial damage. The pilot’s most recent Basic Med certificate was dated August 18, 2020. His third-class medical certificate expired in 2018. His most recent third-class medical examination was on August 31, 2016. During this examination, the pilot reported that he was taking medications for high cholesterol, high blood pressure, and low thyroid function. An autopsy on the pilot was performed by the Travis County Medical Examiner, Austin, Texas. The cause death was atherosclerotic and hypertensive cardiovascular disease in association with obesity, and the manner of death was natural. Toxicology testing performed by the Travis County medical examiner’s office was positive for the high blood pressure medication amlodipine in the pilot’s femoral blood. This substance is generally considered non-impairing. Toxicology testing performed by the Federal Aviation Administration’s (FAA) Forensic Sciences laboratory detected amlodipine and propafenone in the pilot’s heart blood and liver tissue. Propafenone is used to treat life-threatening irregular heartbeats; the medication itself can cause a new irregular heartbeat and increase the risk of death. The use of propafenone would require FAA review and approval. ## Aircraft - Registration: [N21BS](https://openairdocs.org/deregistered/N21BS-2023-10-07), registration cancelled 2023-10-07, S/N 21-1173, built 1975 (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 SER A&C](https://openairdocs.org/engine/lycoming-i0360-ser-a-c) (registry code 41511, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 21-1173 - Year built: 1975 - Airframe hours: 3948 - Engines: LYCOMING IO360 SER A&C 200 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, February 14, 2022 - Departed: ERV, Kerrville, TX - Destination: Same as departure - Airport: ERV, Kerrville Municipal Airport - Equipment: ADS-B ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 71; injuries: fatal; private; airplane ratings: single-engine land; medical: basicmed; seat: left; restraint: 3-point; toxicology performed; flight hours: 3,975 total, 3,975 in this make and model, 6 in the last 90 days, 3 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 30° at 3 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 63 °F, dew point 36 °F - Altimeter: 29.95 inHg - Observed at: KERV - METAR: KERV 311555Z AUTO 03003KT 10SM CLR 17/02 A2995 RMK AO2 T01720024 ## 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 20220331004482A](https://openairdocs.org/incident/20220331004482A), Mar 31, 2022: Mooney M20E, Kerrville, TX, Substantial damage, 1 fatal. March 31, 2022, approx. 1045 hours (CST). Witness stated that the aircraft was exiting ramp E4 and was still on a high rate of speed. Witness noticed the… ## Docket (6 files) The files NTSB released with the investigation on February 8, 2024, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=104866. 1.4 MB in all. - Memorandum for the record eyewitness statement CEN22LA164 (item 1, PDF, 1 page, 116 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16383971&FileExtension=pdf&FileName=Memorandum%20for%20the%20Record%20Eyewitness%20Statement%20CEN22LA164_Redacted-Rel.pdf - Memorandum for the record summary of information from on-scene FAA inspector CEN22LA164 (item 2, PDF, 1 page, 138 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16384114&FileExtension=pdf&FileName=Memorandum%20for%20the%20Record%20Summary%20of%20Information%20from%20On-Scene%20FAA%20Inspector%20CEN22LA164_Redacted-Rel.pdf - Memorandum for the record summary of information provided by the pilot's spouse CEN222LA164 (item 3, PDF, 1 page, 134 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16384270&FileExtension=pdf&FileName=Memorandum%20for%20the%20Record%20Summary%20of%20Information%20Provided%20by%20the%20Pilot%27s%20Spouse%20CEN222LA164_Redacted-Rel.pdf - NTSB medical factual report CEN22LA164 (item 4, PDF, 3 pages, 179 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16384664&FileExtension=pdf&FileName=NTSB%20Medical%20Factual%20Report%20CEN22LA164-Rel.pdf - Toxicology report CEN22LA164 (item 5, PDF, 1 page, 109 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16384806&FileExtension=pdf&FileName=Toxicology%20Report%20CEN22LA164_Redacted-Rel.pdf - Photo array CEN22LA164 (item 6, PDF, 2 pages, 725 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16388610&FileExtension=pdf&FileName=Photo%20Array%20CEN22LA164-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.