# NTSB LAX04FA162: Mooney M20K, N1148V, Los Angeles, CA, March 17, 2004 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: March 16, 2004, 17:03 local (Mar 17, 2004, 01:03 UTC) - Place: Los Angeles, CA - Coordinates: 34.014999, -118.4375 - Nearby events: https://openairdocs.org/map.md?lat=34.0150&lon=-118.4375&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report April 25, 2006 - Report: Approved by Office Director - Parties: Continental Motors, Federal Aviation Administration - NTSB case key (mKey): 58910 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX04FA162 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/58910/pdf - Page: https://openairdocs.org/ntsb/LAX04FA162 ## Probable cause The pilot's loss of airplane control while maneuvering due to spatial disorientation. Contributing factors were the low ceiling, reduced visibility (fog), and the pilot's lack of instrument flying currency. An additional factor was the failure of air traffic control personnel to follow established Federal Aviation Administration directives to disseminate updated weather information. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, missed approach (ifr) - weather condition - fog (contributing factor) - updating of recorded weather information - delayed, atc personnel(lcl/gnd/clnc) (contributing factor) - weather condition - low ceiling (contributing factor) - missed approach - attempted, pilot in command - aircraft control - not maintained, pilot in command (cause) - lack of recent instrument time, pilot in command (contributing factor) - spatial disorientation, pilot in command (cause) - In flight collision with terrain/water, descent - uncontrolled - object - residence ## Analysis During an attempted missed approach in instrument meteorological conditions (IMC), the airplane descended into a residence. The pilot had successfully completed a flight review 10 days before the accident flight. During the review the pilot flew his airplane about 2 minutes under simulated instrument flight conditions. No other evidence of instrument flying was found during the preceding 6 months. The accident occurred while the pilot was returning home following a vacation. As the pilot approached the airport, a fog bank moved in and the local weather conditions deteriorated. The VOR/GPS circling instrument approach procedure for the airport lists a minimum descent altitude of 680 feet mean sea level (msl), with a 1-mile minimum visibility requirement. The overcast ceiling was 400 feet above ground level (597 feet msl), and the visibility was 1 mile as the flight entered the terminal area. Near the time that the pilot received his instrument approach clearance, the visibility decreased to 1/2-mile and the ceiling lowered to 200 feet above ground level (agl) (397 feet msl); however, that information was not disseminated to the pilot by either the tower or approach controller, contrary to Federal Aviation Administration (FAA) internal directives. The pilot's approach was monitored by both the radar approach controller, and by the local tower controller on the tower's digital bright radar indicator (DBrite). Radar data showed that the airplane was consistently left of course and the local tower controller advised the pilot of that fact and asked him if he was correcting back. About 0.4 miles from the runway's end, the pilot advised the controller that he was going around. The pilot failed to adhere to the published missed approach procedure. During the next 1 to 2 minutes, the radar data showed the airplane making 360 degree turns about 0.5 miles from the runway until descending with what ground witnesses described as increasingly steep angles of bank into a house. The airplane was certificated and equipped for flight into IMC. Examination of the wreckage found no evidence of any mechanical malfunction. ## Factual narrative HISTORY OF FLIGHT On March 16, 2004, about 1703 Pacific standard time, a Mooney M20K, N1148V, descended into a single family residence about 0.5 nautical miles south-southeast (122 degrees, magnetic) of the Santa Monica Municipal Airport (SMO), in Los Angeles, California. Impact forces and fire destroyed the airplane and a portion of the private residence. The two private pilots in the airplane were fatally injured. The male pilot in the left front seat held an instrument rating. The female passenger in the right front seat was not instrument-rated. Neither the sole occupant in the residence nor anyone else on the ground was injured. The male pilot was the registered co-owner of the airplane. Instrument meteorological conditions prevailed, and an instrument flight plan was in effect at the time of the accident. The personal flight was performed under the provisions of 14 CFR Part 91, and it originated from the Mammoth Yosemite (uncontrolled) Airport, near Mammoth Lakes, California, at an undetermined time before 1538. A friend of the pilot reported to the National Transportation Safety Board investigator that he believed the purpose of the accident flight was to return home following a brief vacation in the Mammoth area where the accident pilot and his wife (the passenger-pilot) had been skiing. According to the Federal Aviation Administration (FAA), after takeoff the male pilot contacted the Oakland, California, Air Route Traffic Control Center (ARTCC) at 1538. The pilot requested an instrument flight rules (IFR) clearance to SMO. The pilot had previously filed an IFR flight plan for the flight. The controller radar identified the airplane and issued the requested clearance. The flight proceeded without mishap during its en route phase, and all communications were normal. Approaching the Los Angeles basin area, the pilot was handed off to a radar controller at the Southern California Terminal Radar Approach Control facility (SCT). At 1643, the SCT controller asked the pilot if he had received SMO's automatic terminal information service (ATIS) "Information Yankee." At 1644, the pilot responded to SCT that he had received "Information Yankee." The SCT controller provided a clearance for the pilot to proceed toward SMO, and to descend to 4,300 feet mean sea level (msl). The pilot acknowledged the clearance. At 1655, the SCT controller, after noticing that the airplane's altitude was 4,100 feet and that it was descending to 3,600 feet, reminded the pilot that the assigned altitude was 4,300 feet. The controller told the pilot "you need a clearance prior to making a change of altitude." The pilot replied "I misunderstood," and the airplane's altitude increased. At 1657:24, SCT issued the pilot an instrument approach clearance to perform the VOR runway 21 instrument approach into SMO. The pilot acknowledged the clearance and proceeded inbound on the approach. According to the FAA's recorded radar data, about 1659, the airplane flew past the Bevey Intersection (final approach fix) at 2,500 feet, as indicated by the airplane's Mode C altitude reporting transponder. Thereafter, the airplane continued descending while proceeding toward the airport. As the airplane passed the Culve Intersection (step down fix) it was about 0.3 miles left (south) of the prescribed course. At 1701:05, the SMO tower controller, who was observing the accident airplane approach the airport on the control tower's digital bright radar indicator (DBrite), transmitted to the pilot "...you appear to be left of course, verify correcting to the right." No reply was recorded from the pilot. At 1701:36, the SCT controller advised the SMO tower controller to "...watch this guy he is all over." About 1702:06, when the airplane was approximately 0.4 miles east of the approach end of runway 21 and at 700 feet, the pilot advised the controller that he was "going around." This location was also about 1,000 feet northwest of the crash site. Thereafter, no recorded radar evidence was found of the airplane departing the area. At 1702:26, the airplane was approximately 900 feet southeast of the crash site at an elevation of 500 feet. About the time of the last radar return, at 1703:08, the airplane was approximately 400 feet north-northwest of the crash site. The radar data indicates that during the airplane's last (approximate) 1.5 minutes of flight its flight path was consistent with the airplane making two left 360-degree turns within 1/4-mile of a point 0.5 miles southeast of runway 21's threshold. During this time a SMO controller broadcast to the airplane "...if you can hear, fly the published missed approach procedure." Several witnesses reported hearing and/or seeing the airplane flying below the clouds. In part, the auditory witnesses indicated the airplane's sound gave them the impression that the airplane was circling over the area. Several of these witnesses indicated that the engine revved up as it was descending and then the engine sound completely stopped just before the impact. The eyewitness reported that the airplane was turning with a steep angle of bank as it descended. One of the eyewitnesses reported that the airplane's bank angle increased from 30 to 60 degrees just before the crash. Another eyewitness reported that the bank angle increased over 60 degrees just before the crash. No witness reported observing fire or smoke trailing from the airplane. PERSONNEL INFORMATION Pilot, Left Seat. The occupant in the left front seat held a private pilot certificate with an instrument rating. He received the pilot certificate in 1982 and the instrument rating in 1984. A family friend, who co-owned the accident airplane, verbally opined to the Safety Board investigator that the accident pilot had only flown their airplane a couple of times during the past several months. Moreover, the accident pilot would probably not have rented another airplane while their airplane was being repaired. The friend also stated that he believed the pilot was familiar with the airplane's global positioning satellite navigation receiver and the autopilot. On October 17, 2003, the pilot reported to a representative of the Mooney Aircraft Pilot's Association that his total pilot flight time was 1,897 hours. Also, his total Mooney flying experience was 797 hours, and he had a total of 238 hours of instrument flying experience (all models of airplanes). According to the pilot's medical records on file in the FAA's Aerospace Medical Certification Division, when the pilot last was last issued an aviation medical certificate on November 14, 2003, he reported that his total flying experience was about 1,600 hours. Also, he had flown about 30 hours during the preceding 6 months. On a preceding application for an aviation medical certificate, dated November 29, 2001, the pilot had reported that his total flying experience was about 1,520 hours, and he had flown about 60 hours during the preceding 6 months. In an aviation insurance application dated January 15, 2004, the pilot reported that he had flown 60 hours during the previous 12 months. His total flying experience in the model of accident airplane was 842 hours. The pilot's total flying time in retractable gear airplanes was 1,542 hours. According to a document filed with the co-owner's aviation insurance company, the pilot satisfactorily completed a flight review in the accident airplane on March 6, 2004. The pilot's indicated total flying experience was 1,550 hours. He had 900 hours in the model of accident airplane Partially destroyed records found in the burned accident airplane indicated that on March 6, 2004, a person with the initials "PT" flew the airplane for 1.2 hours. On March 8, 2004, a person with the same initials flew the airplane for 1.6 hours. (The letters "PT" correspond to the accident pilot's firs ## Aircraft - Registration: [N1148V](https://openairdocs.org/deregistered/N1148V-2012-11-15), registration cancelled 2012-11-15, S/N 25-0725, built 1982 (OpenAirDocs) - Reported make and model: Mooney M20K - Registry model: [Mooney M20K](https://openairdocs.org/model/mooney-m20k) (registry code 5870220) (OpenAirDocs) - Registry engine: [Continental TSIO-360 series](https://openairdocs.org/engine/continental-tsio-360-series) (registry code 17019, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 25-0725 - Airframe hours: 2237 - Engines: Continental TSIO-360-GB 210 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Operator: Paul Tobias - Registered owner: Paul Tobias & Harry Kilpatrick - Airworthiness certificate: Standard, Normal - Last inspection: Annual, July 1, 2003, 14 hours before - Departed: MMH, MammothYosemite, CA - Destination: SMO, Santa Monica, CA - Flight plan: IFR - Airport: SMO, Santa Monica, runway 21, 4,987 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 71; injuries: fatal; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; last flight review March 1, 2004; seat: left; toxicology performed; flight hours: 1,550 total, 842 in this make and model, 15 in the last 90 days, 6 in the last 30 days, 2 in the last 24 hours ## Weather - Conditions: Instrument (IMC), Day - Wind: 230° at 6 knots - Visibility: 0.5 statute miles - Lowest ceiling: 200 ft overcast - Temperature: 57 °F, dew point 55 °F - Altimeter: 29.93 inHg - Observed at: SMO, 1 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 20040316003599A](https://openairdocs.org/incident/20040316003599A), Mar 16, 2004: Mooney M20K, Mar Vista, CA, Destroyed, 2 fatal. (-23) On 3/16/2004 Mooney M-20-K impacted a house on final approach to sant monica airports, santa monica CA. Weather reported at time of accident was 1/2 mile… 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.