DEN04FA134

NTSB accident investigation · Mooney M20D · Pagosa Springs, CO · September 6, 2004

Accident · FatalField investigationFinal report
Date
September 6, 2004, 10:10 local (16:10 UTC)
Place
Pagosa Springs, CO
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Takeoff
Aircraft
N1907YMooney M20D
Weather
Visual (VMC) · Day
Status
Completed · report March 30, 2005
Report
Approved by Office Director
Parties
FAA Flight Standards District Office
FAA report
20040906022139A
Case key
60060

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

the pilot's inadequate preflight planning and his failure to maintain directional control. Contributing factors were the pilot's failure to abort the takeoff, and the rough and uneven runway surface.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of control - on ground/waterTakeoff - roll/run
Preflight planning/preparation - inadequatePilot in commandCause
Directional control - not maintainedPilot in commandCause
Aborted takeoff - not performedPilot in commandFactor
On ground/water collision with objectTakeoff - roll/run
Airport facilities,runway/landing area condition - rough/unevenFactor
Terrain condition - construction area
Object - other

Analysis

The pilot and his wife made several attempts to take off but aborted each one. Airport personnel said that when the pilot came into the office, he appeared thoroughly shaken by the experience. He told employees he would not take off from the airport until runway construction had been completed and entire length of the runway was made available. He also told a mechanic that there was a shimmy in the nose wheel steering. He contracted with a local flight instructor to deliver the airplane after the repairs had been made. Delivery was postponed on three different occasions and over a period of two months when discrepancies were discovered: the right fuel tank leaked and the VOR receivers did not work; instead of being mounted on the windshield center post, the magnetic compass dangled by a few wires underneath the instrument panel, and the airspeed indicator was twisted about 60 degrees in the instrument panel. The fuel cap O-rings were "severely cracked and worn." The communication radios stopped working, the battery required charging, and the airplane required a jump-start. There were numerous 9-volt and AA batteries on the rear floor and in the door pockets. The flight instructor elected not to deliver the airplane. The pilot elected to ferry the airplane home. During the takeoff roll, the airplane departed the left side of the runway and skipped across the ground before striking a 600-pound concrete block and coming to rest inverted. A post-impact fire ensued. The 9,000-foot runway was undergoing reconstruction and only 3,900 feet was available. An additional 600-foot displaced threshold was available for takeoffs. The useable portion of runway was rough and uneven.

Factual narrative

History of flight

On September 6, 2004, approximately 1010 mountain daylight time, a Mooney M20D, N1907Y, piloted by a private pilot, was destroyed when it impacted terrain during takeoff at Stevens Field, Pagosa Springs, Colorado. Visual meteorological conditions prevailed at the time of the accident. The personal flight was being conducted under the provisions of Title 14 CFR Part 91. No flight plan had been filed. The pilot was fatally injured. The flight was originating at the time of the accident, and was en route to Durango, Colorado (DRO).

The following is based on witness interviews and written statements: The pilot and his wife had visited the Pagosa Springs area in July 2004. When he got ready to return home in Lake Havasu, Arizona, the pilot made several takeoff attempts, but aborted each one. Airport personnel said that when he came into the office, he appeared thoroughly shaken by the experience. He told employees he would not take off from the airport until runway construction had been completed and entire length of the runway was made available. He then told a mechanic that there was a shimmy in the nose wheel steering.

While the mechanic inspected the airplane, the pilot approached a local flight instructor and asked him for his advice on how to take off from the airport. After questioning by the instructor, the pilot said he didn't know how to make a short-field takeoff, and that he had forgotten how to compute density altitude. When asked to produce the aircraft's operating limitations and weight and balance documents, the pilot couldn't find them. The mechanic returned and told the pilot that the steering linkage was missing, the nose gear assembly was "severely worn," and repairs would have to be made. The pilot left the airplane at Pagosa Springs and contracted with the flight instructor to deliver it to Lake Havasu after the repairs had been made.

The first attempt to deliver the airplane was on August 11, 2004. During the preflight inspection, the instructor discovered the right fuel tank was leaking and the VOR (Very high frequency Omnidirectional Radio range) receivers did not work. The tank was stripped and resealed. When told of the delay, the pilot told the instructor that he was aware of the malfunctioning VOR receivers, but suggested that the instructor use a hand-held GPS (Global Positioning System) receiver for navigation.

The next day, August 12, the instructor and mechanic conducted high-speed taxi tests in the airplane. The instructor said he was surprised when he entered the cockpit: The magnetic compass was dangling by a few wires underneath the instrument panel instead of being mounted on the windshield center post, the airspeed indicator was twisted about 60 degrees in the instrument panel, and there were numerous 9-volt and AA batteries on the rear floor and in the door pockets. Taxi tests were satisfactory and indicated the nose wheel steering had been repaired. According to Wind Dancer Aviation Services Work Order No. 3490, a rebuilt nose wheel assembly and shimmy dampner were installed.

The second attempt to deliver the airplane was on August 14, 2004. During the preflight inspection, the instructor noticed the right fuel tank was still leaking slightly. Delivery was postponed until repairs could be made.

The third attempt to deliver the airplane was on September 5, 2004. It had rained the day before. During the preflight inspection, the instructor drained more than a quart of water from the left tank sump. He found the fuel cap O-rings were "severely cracked and worn." The instructor continued draining the sumps until no water appeared. Upon entering the airplane, he discovered the battery was dead. A tug was used to jumpstart the battery. After starting the engine, the instructor received a traffic advisory and taxied to the run-up area where he made pre-takeoff checks. He also turned on the landing light "for safety." Shortly thereafter, he noticed the communication radios were not operating. He decided to cancel the flight and taxied back to the ramp. When he turned the landing light off, the communication radios came back on. He tried making radio contact with the fixed base operator but not successful.

After securing the airplane, the instructor went home and called the pilot. The pilot was upset. When told of the communication difficulties, the pilot replied, "Well, don't you have a hand-held radio you can use?" The pilot then decided to drive a rental car to Pagosa Springs and ferry the airplane home. He and his wife arrived in Pagosa Springs on September 5. He intended to fly the airplane to Durango and meet his wife, who would drive the car to the rental agency for drop-off. They would then continue home.

Several witnesses watched the takeoff and saw the accident. The fixed base operator wrote: "…it appeared the aircraft left the runway. I then saw a puff of dirt on the left side of the runway, after which the aircraft flipped into the air and came down on its nose and top." Another witness, the mechanic who had worked on the airplane, wrote: "I saw him get airborne but he was only 20-50 feet high and then there was a slight puff of dust and I could tell he was to the left of the runway. He then was at a high angle of attack and I could see the belly of his plane. His left wing dropped and he settled back to the ground and he flipped tail over and instantly exploded." Although witnesses were unsure if the pilot had started his takeoff roll from the runway threshold or from the displaced threshold, they agreed that the takeoff roll appeared normal and that the engine sounded like it was developing full power.

Personnel information

The 76-year-old private pilot held airplane single-engine land and instrument ratings. His third class airman medical certificate, dated August 14, 2003, contained no restrictions or limitations. The pilot's logbook was found in the wreckage but, due to fire damage, no useful information was recovered. According to his application for this medical certification, he estimated he had accumulated 2,600 total flight hours, of which 42 hours were accrued in the last six months.

Aircraft information

N1905Y, a model M20D (s/n 202) was manufactured by the Mooney Aircraft Corporation, Kerrville, Texas, in 1964. It was powered by a Lycoming O-360-A1D engine (s/n RL-30590-36A), rated at 180 horsepower), driving a Hartzell all-metal, 2-blade, constant-speed propeller (s/n F7666A). The aircraft maintenance records were found in the wreckage but, due to fire damage, no useful information was recovered. A copy of the work order was obtained from Wind Dancer Aviation and is attached as an EXHIBIT.

Meteorological information

The following pertinent METARs (Aviation Routine Weather Reports) were both recorded at 0953 at Wolf Creek Pass (CPW) and Durango-La Plata County Airport (DRO), located 22 miles north-northeast and 43 miles west-southwest of Stevens Field, respectively:

CPW: Wind, 170 degrees at 7 knots, gusting to 15 knots; visibility, 10 statute miles (or greater); sky condition, clear; temperature, 8 degrees C.; dew point, -1 degree C.; altimeter setting, 30.62 inches of mercury.

DRO: Wind, calm; visibility, 10 statute miles (or greater); sky condition, clear; temperature, 14 degrees C.; dew point, 7 degrees C.; altimeter setting, 30.37 inches of mercury.

Aerodrome information

Stevens Field (2V1) is located 3 miles northwest of Pagosa Springs at an elevation of 7,700 feet msl (mean sea level). It has one asphalt runway: 01-19/9,000 feet x 75 feet. At the time of the accident, only 3,900 feet was available (the other 5,100 feet was closed for reconstruction). An additional 660 feet of displaced threshold was available for takeoffs. While driving the useable portion of runway, the surface felt rough and uneven.

Wreckage and impact information

The on-scene investigation commenced and terminated on September 7 and 8, 200

Aircraft

Registration
N1907Y
Reported as
Mooney M20D
Category
Airplane
Serial number
202
Airframe hours
1,024
Engine
Lycoming O-360-A1D, 180 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · May 7, 2004
Departed
2V1 · Pagosa Springs, CO
Destination
DRO · Durango, CO
Airport
2V1 · Stevens Field, runway 19, asphalt

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
76
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Valid Medical--no waivers/lim.
Seat
Left
Toxicology
Performed
Flight hours
2,600 total · 21 in the last 90 days

Weather

Conditions
Visual (VMC) · Day
Wind
170° at 7 knots, gusting 15
Visibility
10 statute miles
Lowest ceiling
None
Temperature
46 °F, dew point 30 °F
Altimeter
30.37 inHg
Observed at
2V1

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.

Other investigations on N1907Y · 1

Matched to the same aircraft by N-number and date.