# NTSB ERA13LA391: Mooney M20C, N78951, Mitchellville, MD, September 2, 2013 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: September 2, 2013, 15:40 local (19:40 UTC) - Place: Mitchellville, MD - Coordinates: 38.941387, -76.772224 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=38.9414&lon=-76.7722&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Collision during takeoff/land](https://openairdocs.org/ntsb-events/490) - Highest injury: Serious injuries - Injuries: 3 serious - Status: Completed, report August 14, 2014 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 87940 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA13LA391 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/87940/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=87940 - Page: https://openairdocs.org/ntsb/ERA13LA391 ## Probable cause The pilot’s failure to ensure that the wing flaps were properly configured before takeoff. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Flight control system: tE flap control system](https://openairdocs.org/ntsb-findings/01022750): Aircraft › Aircraft systems · Incorrect use/operation (probable cause); cases with it: [Mooney M20, 1 case](https://openairdocs.org/ntsb-findings/01022750/cases.md?model=5870202), [All aircraft, 74 cases](https://openairdocs.org/ntsb-findings/01022750/cases.md) - [Performance/control parameters: configuration](https://openairdocs.org/ntsb-findings/01062017): Aircraft › Aircraft oper/perf/capability · Incorrect use/operation (probable cause); cases with it: [Mooney M20, 1 case](https://openairdocs.org/ntsb-findings/01062017/cases.md?model=5870202), [All aircraft, 80 cases](https://openairdocs.org/ntsb-findings/01062017/cases.md) - [Action: incorrect action selection](https://openairdocs.org/ntsb-findings/02041010): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Mooney M20, 1 case](https://openairdocs.org/ntsb-findings/02041010/cases.md?model=5870202), [All aircraft, 397 cases](https://openairdocs.org/ntsb-findings/02041010/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Preflight or dispatch event](https://openairdocs.org/ntsb-events/030); cases with it: [Mooney M20, 1 case](https://openairdocs.org/ntsb-events/030/sequence.md?model=5870202), [All aircraft, 355 cases](https://openairdocs.org/ntsb-events/030/sequence.md) - [Takeoff: Collision during takeoff/land](https://openairdocs.org/ntsb-events/490) (defining event); cases with it: [Mooney M20, 1 case](https://openairdocs.org/ntsb-events/490/sequence.md?model=5870202), [All aircraft, 1,309 cases](https://openairdocs.org/ntsb-events/490/sequence.md) ## Analysis The airplane departed from the 2,420-foot-long asphalt runway near its maximum gross weight. Review of witness statements and a video revealed that the airplane initially lifted off and climbed out of ground effect; however, it subsequently descended in a nose-up attitude into trees about 250 feet beyond the departure end of the runway. Examination of the wreckage revealed that the flaps were in the fully extended position and that the flap position indicator was indicating the "down" position (fully extended). No other preimpact anomalies were observed with the airframe or engine that would have precluded normal operation. The takeoff checklist indicated that the pilot should pump the hydraulically actuated flap handle twice, which would extend the flaps to a 15-degree takeoff position. If the flap handle were pumped four and one-half times, the flaps would extend to the full-down position. It is likely that the pilot repeated that checklist item twice, which would have placed the flaps at or near the fully extended position. Review of performance data revealed that adequate runway length existed for the airplane to take off if its flaps had been in the takeoff position. ## Factual narrative On September 2, 2013, about 1540 eastern daylight time, a Mooney M20C, N78951, operated by a private individual, was substantially damaged when it collided with trees during takeoff from Freeway Airport (W00), Mitchellville, Maryland. The private pilot and two passengers were seriously injured. The personal flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and a visual flight rules flight plan was filed for the planned local flight.The airplane was owned by the pilot and based at W00. It was departing on runway 36, a 2,420-foot-long asphalt runway. Due to his injuries, the pilot did not recall the accident. He estimated that the airplane was approximately 38 pounds below its maximum gross weight at takeoff. Two witnesses, in their respective vehicles, were traveling on a highway perpendicular to the departure end of runway 36. Both witnesses reported that the airplane crossed the highway at a low altitude. One of the witnesses added that the airplane's "…nose appeared higher than its tail…" as it crossed the highway and descended to a height of about 10 feet above the ground before impacting trees. A video recorder, which was installed on a parked airplane at W00, captured part of the accident airplane's takeoff. Review of the video revealed that the accident airplane initially climbed out of ground effect; however, in then began to settle back down toward the ground in a nose-up attitude prior to exiting the frame. Examination of the wreckage by a Federal Aviation Administration inspector revealed that the airplane came to rest upright, in a grassy area off the side of the highway, about 250 feet beyond the departure end of the runway. Fuel was present in both fuel tanks and the fuel selector was positioned to the left fuel tank. The inspector observed that the landing gear and flaps were both in the extended position. In addition, the flap position indicator was in the "DN" (full extended) position. He also noted that one propeller blade exhibited s-bending, chordwise scratching, and leading edge gouging. Except for the flaps position, the inspector did not observe any other anomalies with the airframe or engine. The four-seat, low-wing, retractable tricycle-gear airplane, serial number 2140, was manufactured in 1962. It was powered by a Lycoming O-360, 180-horsepower engine, equipped with a Hartzell constant-speed propeller. The airplane's most recent annual inspection was completed on December 31, 2012. At that time, the airplane had accumulated 3,702.83 total hours of operation. The engine had also accumulated 3,702.83 total hours and 1,163.49 hours since major overhaul. The pilot reported a total flight experience of 388 hours; of which, 168 hours were in the accident airplane. The pilot had flown 5 hours and 3 hours during the 90-day and 30-day periods preceding the accident, respectively. Those hours were all flown in the accident airplane. The recorded weatherat 1540, at an airport located approximately 5 miles northwest of the accident site, included calm wind, visibility 10 miles, scattered clouds at 5,000 feet, and temperature 32 degrees C (90 degrees F). Review of a checklist recovered from airplane revealed, "…RUNUP & TAKEOFF…Flaps – two pumps…" Review of a make and model owner's manual revealed: "Flaps The wide span flaps are hydraulically controlled by a hand operated pump which actuates a hydraulic cylinder. A relief valve is provided which releases the flaps at a slow rate as the springs (or air pressure) raise them. Hydraulic fluid used is the same as the brake system fluid and is stored in the brake reservoir on the aft side of the firewall. To lower the laps, first set the flap-shaped control (adjacent to the flap handle) in the down position. Then pump the handle to obtain the desired setting: two strokes for take-off; four and one-half strokes for full deflection or any intermediate setting. To raise the flaps, place the control in the up position. The flaps will then rise at a controlled rate to the up position or they may be stopped at an intermediate position by placing the control in the down position again. The position of the flaps is indicated by a pointer on the aft side of the nose wheel well. The intermediate mark in the pointer range is for the flap take-off setting. " Further review of a make and model owner's manual, takeoff and climb data, revealed that at a maximum gross weight of 2,575 pounds, at 2,500 above sea level (density altitude), at 90 degrees F, the airplane required 1,345 feet of ground run or 2,305 feet to clear a 50-foot obstacle. The data assumed a takeoff configuration of the landing gear extended, mixture full rich, flaps extended 15 degrees (takeoff position), wind calm, and a hard surface runway. There was no data for a flaps full-extended takeoff. ## Aircraft - Registration: [N78951](https://openairdocs.org/deregistered/N78951-2018-01-09), registration cancelled 2018-01-09, S/N 2140, built 1962 (OpenAirDocs) - Reported make and model: MOONEY AIRCRAFT CORP. M20C - Registry model: [Mooney M20](https://openairdocs.org/model/mooney-m20) (registry code 5870202) (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: 2140 - Year built: 1962 - Airframe hours: 3703 - Engines: Lycoming O-360 180 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Tivay Alireza - Registered owner: Tivay Alireza - Airworthiness certificate: Standard, Normal - Last inspection: Annual, December 31, 2012 - Departed: W00, Mitchellville, MD - Destination: W00, Mitchellville, MD - Flight plan: VFR - Airport: W00, Freeway Airport, runway 36, 2,420 × 40 ft, asphalt - Equipment: Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 58; injuries: serious; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; seat: left; restraint: 3-point; flight hours: 388 total, 168 in this make and model, 305 as pilot in command, 5 in the last 90 days, 3 in the last 30 days, 0 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 90 °F, dew point 70 °F - Altimeter: 29.73 inHg - Observed at: CGS, 5 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 20130902018429A](https://openairdocs.org/incident/20130902018429A), Sep 2, 2013: Mooney Aircraft Corp. M20, Mitchellville, MD, Destroyed. On September 2, 2013, at approximately 1612 local time, [privacy data omitted] took off on runway 36 at Freeway Airport in the Mooney 20C aircraft [privacy… ## Docket (13 files) The files NTSB released with the investigation on April 8, 2014, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=87940. 5.4 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 3.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40410652&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Interview Summaries (item 2, .PDF, 63 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40410653&FileExtension=.PDF&FileName=Interview%20Summaries-Master.PDF - Witness Statements (item 3, .PDF, 206 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40408105&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - External Video of Take-off (item 4, .PDF, 70 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40411049&FileExtension=.PDF&FileName=External%20Video%20of%20Take-off-Master.PDF - Police Report (item 5, .PDF, 159 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40410637&FileExtension=.PDF&FileName=Police%20Report%20-Master.PDF - Copy of Checklist From Airplane (item 6, .PDF, 149 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40408106&FileExtension=.PDF&FileName=Copy%20of%20Checklist%20From%20Airplane-Master.PDF - Excerpts From Make And Model Owner's Manual (item 7, .PDF, 322 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40408107&FileExtension=.PDF&FileName=Excerpts%20From%20Make%20And%20Model%20Owner%27s%20Manual-Master.PDF - Shelf Item - Copy of FSS Audio (item 8, .PDF, 11 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40410636&FileExtension=.PDF&FileName=Shelf%20Item%20-%20Copy%20of%20FSS%20Audio-Master.PDF - Weather Report (item 9, .PDF, 12 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40408108&FileExtension=.PDF&FileName=Weather%20Report-Master.PDF - Photograph : 1: Main Wreckage (Photo Courtesy of FAA) (item 10, .PDF, 232 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40408109&FileExtension=.PDF&FileName=Photograph%20%3A%201%3A%20%20Main%20Wreckage%20(Photo%20Courtesy%20of%20FAA)-Master.PDF - Photograph # 2: Propeller Blade (Photo Courtesy of FAA) (item 11, .PDF, 62 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40408110&FileExtension=.PDF&FileName=Photograph%20%23%202%3A%20%20Propeller%20Blade%20(Photo%20Courtesy%20of%20FAA)-Master.PDF - Photgraph # 3: Left Flap (Photo Courtesy of FAA) (item 12, .PDF, 174 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40408111&FileExtension=.PDF&FileName=Photgraph%20%23%203%3A%20%20Left%20Flap%20(Photo%20Courtesy%20of%20FAA)-Master.PDF - Photograph # 4: Flap Indicator (Photo Courtesy of FAA) (item 13, .PDF, 125 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40408112&FileExtension=.PDF&FileName=Photograph%20%23%204%3A%20%20Flap%20Indicator%20(Photo%20Courtesy%20of%20FAA)-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.