ERA16FA208

NTSB accident investigation · Mooney M20E · Collegedale, TN · June 11, 2016

Accident · FatalField investigationFinal report
Date
June 11, 2016, 12:46 local (16:46 UTC)
Place
Collegedale, TN
Injuries
3 fatal, 1 serious
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N7830VMooney M20E
Defining event
Approach-VFR go-around: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed · report June 12, 2018
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO, Lycoming Engines
FAA report
20160611006599A
Case key
93359

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 failure to maintain adequate airspeed and his exceedance of the airplane's critical angle of attack while maneuvering after a go-around, which resulted in an aerodynamic stall.

Findings · 3

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotMooney M20E: 16 casesAll aircraft: 9,295 casesProbable cause
Performance/control parameters: airspeedAircraft › Aircraft oper/perf/capability · Not attained/maintainedMooney M20E: 4 casesAll aircraft: 1,681 casesProbable cause
Performance/control parameters: angle of attackAircraft › Aircraft oper/perf/capability · Not attained/maintainedMooney M20E: 3 casesAll aircraft: 990 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

At the end of the second leg of a cross-country flight, the private pilot made an approach to runway 3 at the destination airport and subsequently performed a go-around. A flight instructor, who was about 3 miles from the airport and preparing to land on runway 21 did not hear any radio communications from the accident pilot. He observed the airplane in a climbing left turn near the departure end of runway 3, about 80 to 100 ft above the ground. The airplane then made a steep 45° to 60° bank to the right, with a nose-high attitude. As it progressed through the turn, the airplane's nose dropped, and it began a slow 270° rotation at a high descent rate. The airplane impacted the ground and came to rest upright on a grass area adjacent to the east side of runway 3. Data from an onboard GPS confirmed the flight path described by the flight instructor and showed that the airplane's groundspeed was about 74 mph during the right turn. The airplane owner's manual indicated that the airplane's stall speed in a 60° bank varied from 90 to 96 mph indicated airspeed depending on flap setting. Examination of the airframe and engine did not reveal evidence of any preimpact mechanical malfunctions that would have precluded normal operation. Based on witness information and recorded GPS data, it is likely that the pilot failed to maintain airspeed while maneuvering after the go-around, which resulted in an exceedance of the airplane's critical angle of attack, an aerodynamic stall, and subsequent loss of control.

Factual narrative

The four-seat, low-wing, retractable-gear, all-metal airplane was manufactured in 1964. It was powered by a 200-horsepower Lycoming IO-360-A1A engine, equipped with a three-blade constant-speed Hartzell propeller assembly. According to FAA records, the pilot purchased the airplane on February 13, 2015. Review of the airplane's logbooks revealed that its most recent annual inspection was performed on February 1, 2016, at an airframe total time of about 2,990 hours. At the time of the inspection, the engine had accumulated about 93 hours of operation since major overhaul. At the time of the accident, the airplane had been operated about 25 hours since the annual inspection and about 70 hours since it was purchased by the pilot. Stall speed information for the airplane was contained in a stall speed vs bank angle chart located in the owner's manual (see figure 2). Figure 2. – Stall Speed vs Bank Angle Chart FGU was owned by the City of Collegedale and classified by the FAA as a public airport. The airport elevation was 860 ft above mean sea level, and the asphalt runway was configured in a 3/21 orientation. The runway was 4,986 ft-long by 75 ft-wide. The runway 3 threshold was displaced 400 ft due to trees before the approach end of the runway. On June 11, 2016, about 1246 eastern daylight time, a Mooney M20E, N7830V, was substantially damaged when it impacted terrain while maneuvering after a go-around at the Collegedale Municipal Airport (FGU), Collegedale, Tennessee. The private pilot and two passengers were fatally injured, and one passenger was seriously injured. The airplane was owned and operated by the pilot under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91. Visual meteorological conditions prevailed, and no flight plan had been filed for the personal flight. According to information obtained from the Federal Aviation Administration (FAA), the flight originated from the North Perry Airport (HWO), Hollywood, Florida, and landed at the Harris County Airport, Pine Mountain (PIM), Georgia, before continuing to FGU. Flight track data recovered from an onboard GPS device showed that the airplane departed PIM at 1128:14 and proceeded toward FGU. A flight instructor reported that he was conducting a flight with a student pilot and was about 3 miles east of FGU setting up to land on runway 21, when he saw the accident airplane on short final approach to land on runway 3. The flight instructor contacted airport personnel via the common traffic advisory frequency and confirmed that the wind was favoring runway 21. The flight instructor did not hear any radio communications from the accident airplane. Shortly thereafter, he observed the accident airplane in a climbing left turn near the departure end of runway 3, about 80 to 100 ft above the ground. The airplane then made a steep 45° to 60° bank to the right, with a nose-high attitude. As it progressed through the turn, the airplane's nose dropped, and it began a slow 270°rotation at a high descent rate. Figure 1 shows the airplane's GPS track during the approach and go-around at FGU. The go-around began at 1245:20; the airplane made a left climbing turn at groundspeeds that varied between 79 and 67 mph and, about 1245:50, reached a maximum GPS altitude of about 1,080 ft. The left turn continued for another 10 seconds as the airplane descended to 990 ft with an average groundspeed of about 75 mph. The airplane's last GPS target recorded at 1246:01 indicated a right turn, at a GPS altitude of 971 ft and a groundspeed of about 74 mph. Figure 1. Plotted GPS Data for Approach and Go-Around The airplane impacted the ground and came to rest upright on a grass area adjacent to the east side of runway 3, about 1,000 ft from the approach end of runway 21. The Office of the Hamilton County Medical Examiner, Chattanooga, Tennessee, performed an autopsy on the pilot. According to the autopsy report, the cause of death was "multiple blunt forces injuries." No significant natural disease was identified. Toxicological testing performed on specimens from the pilot as part of the autopsy was negative for any tested substances. Toxicological testing performed by the FAA Bioaeronautical Science Research Laboratory, Oklahoma City, Oklahoma on specimens obtained from the pilot's initial hospital admission identified midazolam in blood and serum. Midazolam is a sedative hypnotic benzodiazepine medication commonly used during resuscitative efforts. Hospital records indicated that paramedics administered midazolam to the pilot as part of the his on-scene care. The 1253 weather observation at Lovel Field Airport, Chattanooga, Tennessee, located about 9 nautical miles west of the accident site, reported calm wind, 10 statute miles visibility, few clouds at 5,000 ft above ground level, temperature 33°C, dew point 16°C, and an altimeter setting of 30.14 inches of mercury. The pilot held a private pilot certificate with a rating for airplane single-engine land. His most recent FAA third-class medical certificate was issued on January 26, 2015, with no limitations. At that time, he reported a total flight experience of 550 hours. A pilot logbook obtained by an FAA inspector indicated that the pilot had logged about 16 hours in the airplane between February and April 2015 and that he had satisfactorily completed a flight review in accordance with 14 CFR Part 61.56 on January 28, 2015. The last entry in the logbook was dated April 11, 2015. The investigation could not determine the pilot's flight experience during the 14-months preceding the accident. A 70-ft-long ground scar, oriented on a magnetic heading of about 200° led to the main wreckage, which was resting on a magnetic heading of about 050°. All major portions of the airplane were accounted for at the accident site. The airplane was not equipped with shoulder harnesses. The landing gear was in the retracted position, and the fuel selector was positioned to the left fuel tank. The rightwing separated near its wing root. The right flap remained attached to the wing, which was compressed aft, bent upward, and twisted at the outboard end. The right fuel tank was compromised, and no fuel was observed in the right fuel tank. The left wing remained attached to the fuselage. The left flap was separated and located under the wing. The underside of the left wing was compressed upward along the entire leading edge. An undetermined amount of fuel was observed leaking from the left fuel tank, and about 15 gallons of fuel were recovered from the tank. The aft 5 ft of the fuselage before the empennage was deformed. The airplane's flight controls were actuated by push-pull tubes. All primary flight controls remained connected at their respective attach points. Flight control continuity was confirmed from the elevator and rudder control surfaces to the forward cockpit area. Due to impact damage, flight control continuity could not be confirmed from the forward cockpit area to the control yokes or from the left and right ailerons to the forward cockpit area. In addition, the preimpact position of the hydraulically-controlled flaps could not be determined due to impact damage. The front portion of the airplane, which included the engine, was displaced downward and to the right. The engine crankshaft was rotated by hand via the three-blade propeller assembly, which remained attached and displayed evidence consistent with rotation on two of the three blades. Valve train continuity was observed, and thumb compression was obtained on each cylinder. In addition, all cylinders were examined using a borescope, and no anomalies were observed. The oil suction and fuel servo inlet screens were absent of contamination. Both magnetos were impact damaged; however, they produced spark from their respective towers when rotated by hand.

Aircraft

Registration
N7830V
Reported as
Mooney M20E
Category
Airplane
Serial number
452
Built
1964
Airframe hours
3,015
Engine
Lycoming IO-360-A1A, 200 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · February 1, 2016 · 25 hours before
Departed
PIM · Pine Mountain, GA
Destination
FGU · Collegedale, TN
Airport
FGU · Collegedale Muni, runway 03, 4,986 × 75 ft, asphalt
Equipment
Handheld GPS, Stall warning system

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
57
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Without waivers/limitations
Last flight review
January 28, 2015
Seat
Left
Restraint
Lap only
Toxicology
Performed
Flight hours
550 total · 70 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
None
Temperature
91 °F, dew point 61 °F
Altimeter
30.13 inHg
Turbulence
Unknown
Observed at
CHA, 9 nm away

Docket · 15

The files NTSB released with the investigation on May 23, 2018, on NTSB’s docket system: statements, records, photos and specialists’ reports. 8.6 MB in all.

FAA reports on this event · 1

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