# NTSB LAX08FA068: Mooney M20C, N591BB, Riverside, CA, February 28, 2008 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: February 27, 2008, 22:07 local (Feb 28, 2008, 06:07 UTC) - Place: Riverside, CA - Coordinates: 33.944721, -117.446662 - Nearby events: https://openairdocs.org/map.md?lat=33.9447&lon=-117.4467&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) - Highest injury: Fatal - Injuries: 3 fatal - Status: Completed, report May 6, 2009 - Report: Approved by Office Director - Parties: Lycoming, Federal Aviation Administration - NTSB case key (mKey): 67592 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX08FA068 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/67592/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=67592 - Page: https://openairdocs.org/ntsb/LAX08FA068 ## Probable cause The pilot's failure to maintain airspeed and aircraft control, resulting in an aerodynamic stall. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: airspeed](https://openairdocs.org/ntsb-findings/01062010): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Mooney M20C, 7 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=5870208), [All aircraft, 1,681 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Mooney M20C, 16 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=5870208), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) (defining event); cases with it: [Mooney M20C, 8 cases](https://openairdocs.org/ntsb-events/241/sequence.md?model=5870208), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md) - [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240); cases with it: [Mooney M20C, 10 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=5870208), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Mooney M20C, 39 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=5870208), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot, who had recently purchased a half share of the airplane, and two passengers were on a local area flight and had stopped at the airport for dinner. The accident occurred as the flight was departing to return to their home airport. A witness reported that once airborne the airplane was "porpoising" up and down as it flew towards him. As the airplane neared the end of the runway, he saw it make a steep climbing left turn. The airplane then rolled inverted and descended towards the ground in a near-vertical nose-down attitude. The airplane impacted a palm tree and a vehicle that was parked on the residential street located just south of the airport. After the airplane impacted the ground, the witness saw an explosion and a fire ball. A postcrash fire largely consumed the wreckage. An examination of the engine showed no discrepancies that would have precluded power from being developed prior to impact. There was no evidence of structural, powerplant, or systems failure. All of the airplane's primary structure and flight controls were accounted for at the accident site. Primary flight control system continuity was established. The fuel selector valve was selected on the left tank. Flaps and landing gear were retracted and the tail trim was measured and found to be set for takeoff. ## Factual narrative HISTORY OF FLIGHT On February 27, 2008, at 2207 Pacific standard time, a Mooney M20C, N591BB, crashed during takeoff from Riverside Municipal Airport (RAL), Riverside, California. The co-owner/pilot was operating the airplane under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The private pilot and two passengers were killed; the airplane was destroyed by impact forces and the post crash fire. The local personal flight was departing at the time, with a planned destination of Corona Municipal Airport (AJO), Corona, California. Visual night meteorological conditions prevailed, and no flight plan had been filed. Interviews with family and friends of the pilot and passengers indicated that the flight departed Corona for a local personal flight. The accident airplane landed at Riverside Airport about 2000. The pilot and passengers intended to eat at the airport restaurant, but the restaurant was closed. The pilot contacted his fiance, who drove to the airport to pick them up for dinner in the local area. After dinner they drove back to the airport, and the pilot and passengers boarded the airplane for the return flight to Corona. The fiance had left the airport prior to the airplane taking off and did not witness the accident. During takeoff a ground witness reported that once airborne the airplane was "porpoising" up and down as it flew towards him. As the airplane neared the end of the runway, he saw it make a steep climbing left turn. The witness stated that the airplane rolled inverted and descended towards the ground in a nose down attitude. The airplane then impacted a palm tree and a vehicle that was parked on a residential street located just south of the airport. After the airplane impacted the ground, the witness saw an explosion and a fire ball. PERSONNEL INFORMATION A review of Federal Aviation Administration (FAA) airman records revealed that the 35-year-old pilot held a private pilot certificate with an airplane single-engine land rating. The pilot held a third-class medical certificate issued on October 14, 2007. It had no limitations or waivers. Investigators were able to examine the pilot's partially damaged logbook. The pilot had an estimated total flight time of about 230 hours, with an estimated 20 hours in the accident make and model. He completed a biennial flight review in February 2007. AIRCRAFT INFORMATION The airplane was a Mooney M20C, serial number 2385. A review of the airplane's logbooks revealed an annual inspection dated February 8, 2008, which reported a total airframe time of 3,811 hours. The tachometer read 489 hours at the last inspection. The inspection was not completed until February 26, 2008, when the post maintenance flight was completed. A Lycoming O-360-A1D, serial number L-5431-36, had been installed on the airplane. Total time recorded on the engine at the last annual inspection was 3,844 hours, and time since major overhaul was 293 hours. The airplane was last fueled to maximum capacity by one of the co-owners about 4 days prior to the accident flight. After the airplane had been refueled, the co-owner reported that the airplane had flown a total of 1.5 hours by the accident pilot prior to the accident. Examination of the maintenance records revealed no unresolved maintenance discrepancies against the airplane prior to departure. METEOROLOGICAL INFORMATION The official weather reporting observation station was located at the Riverside Airport (RAL), .5 nautical miles (nm) north of the accident site. The elevation of the weather observation station was 819 feet mean sea level (msl). An aviation routine weather report (METAR) for RAL was issued at 2153. It stated: winds calm; visibility 10 miles; skies clear; temperature 12 degrees Celsius; dew point 05 degrees Celsius; altimeter 29.92 inches of Mercury. COMMUNICATIONS The pilot was not in communication with air traffic control (ATC) at RAL as the tower was closed. A Riverside police helicopter pilot reported hearing the pilot of a Mooney report on the tower frequency (121.0) that he was taking off from Riverside airport via runway 16 (southbound). A few minutes later they were dispatched to an airplane accident south of the airport. AIRPORT INFORMATION The Airport/Facility Directory, Southwest U. S., indicated that RAL runway 16 was 2,850 feet long and 50 feet wide. The runway surface was asphalt. Riverside airport's main runway, 27/9, was closed per a Notice to Airman (Notam) due to inoperative runway lights. The Notam was issued on February 27, 2008, and canceled on February 28, 2008. WRECKAGE AND IMPACT INFORMATION Investigators examined the wreckage at the accident scene. The airplane had come to rest inverted at the base of a palm tree on the north side curb line of a residential street oriented along a 090-degree magnetic heading. The airplane was mostly consumed by a post impact fire, with the right wing coming to rest on top of an automobile. The impact damage to the palm tree and the street was consistent with the witness statements of the near vertical flight path of the airplane prior to impact. All of the airplane's primary structure and flight controls were accounted for at the accident site. Primary flight control system continuity was established. The engine exhibited no visible evidence of catastrophic mechanical malfunction. The fuel selector valve was selected on the left tank. Flaps and gear appeared to be retracted. The tail trim was measured and was set for takeoff. The airplane was recovered and retained for further examination. MEDICAL AND PATHOLOGICAL INFORMATION The Riverside County Coroner completed an autopsy. The FAA Bioaeronautical Sciences Research Laboratory Forensic Toxicology Research Team, Oklahoma City, Oklahoma, performed toxicological testing of specimens of the pilot. Analysis of the specimens contained no findings for carbon monoxide, volatiles, and tested drugs. The report contained the following findings for Cyanide: 1.56 (ug/ml) detected in blood. TESTS AND RESEARCH Investigators examined the airframe and engine with no mechanical anomalies identified that would have precluded normal operation. ADDITIONAL INFORMATION The accident pilot, a new owner to the airplane partnership, had recently completed the insurance required make and model training. The accident flight was the first flight since the annual had been completed, as well as, the first flight for the accident pilot since attaining the insurance required training. In a written statement by the co-owner, which related that the accident pilot had discussed the weight and balance of his intended flight, and that with full fuel and his passengers he was still within limits of the airplane. No records were recovered showing that the pilot had ever used runway 16 at RAL previously. ## Aircraft - Registration: [N591BB](https://openairdocs.org/deregistered/N591BB-2013-10-29), registration cancelled 2013-10-29, S/N 2385, built 1963 (OpenAirDocs) - Reported make and model: MOONEY M20C - Registry model: [Mooney M20C](https://openairdocs.org/model/mooney-m20c) (registry code 5870208) (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: 2385 - Airframe hours: 3811 - Engines: LYCOMING O-360-A1D 180 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, February 8, 2008, 2 hours before - Departed: RAL, Riverside, CA - Destination: AJO, CORONA, CA - Airport: RAL, Riverside Municipal Airport, runway 16, 2,850 × 50 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 35; injuries: fatal; private; airplane ratings: single-engine land; medical: class 3, without waivers/limitations; last flight review February 1, 2007; seat: left; toxicology performed; flight hours: 268 total, 21 in this make and model ## Weather - Conditions: Visual (VMC), Night - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 61 °F, dew point 39 °F - Altimeter: 29.95 inHg - Observed at: CNO, 9 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 20080227011809A](https://openairdocs.org/incident/20080227011809A), Feb 27, 2008: Mooney M20C, Riverside, CA, Destroyed, 3 fatal. (-23) Shortly after taking off from rwy 16 (2850 x 50), the aircraft turned left in a climbing turn, then rolled inverted, hit a palm tree, and crashed into a… ## Other investigations on N591BB (1) 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. - [NTSB MIA71DLA37](https://openairdocs.org/ntsb/MIA71DLA37), Mar 18, 1971: Mooney M20C (N591BB), Starke, FL, substantial damage ## Docket (13 files) The files NTSB released with the investigation on February 23, 2009, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=67592. 19.2 MB in all. - Witness Statement- Yates (item 1, .PDF, 13 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40308468&FileExtension=.PDF&FileName=Witness%20Statement-%20Yates-Redacted.PDF - Witness Statement- Hernandez (item 2, .PDF, 15 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40308470&FileExtension=.PDF&FileName=Witness%20Statement-%20Hernandez-Redacted.PDF - Witness Statement - Holland (item 3, .PDF, 814 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40308867&FileExtension=.PDF&FileName=Witness%20Statement%20-%20Holland-Redacted.PDF - Airport Diagram- RAL (item 4, .PDF, 133 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40308539&FileExtension=.PDF&FileName=Airport%20Diagram-%20RAL-Master.PDF - PHOTOS (3) - From RAL Rwy 16 to Accident Site (item 5, .PDF, 8.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40308481&FileExtension=.PDF&FileName=PHOTOS%20(3)%20-%20From%20RAL%20Rwy%2016%20to%20Accident%20Site-Master.PDF - PHOTOS (4) - Main Wreckage (item 6, .PDF, 9.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40308483&FileExtension=.PDF&FileName=PHOTOS%20(4)%20-%20Main%20Wreckage-Master.PDF - Lycoming Final Report (item 7, .PDF, 205 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40308540&FileExtension=.PDF&FileName=Lycoming%20Final%20Report-Master.PDF - Toxicological Report (item 8, .PDF, 64 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40376423&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 9, .PDF, 340 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40308544&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 10, .PDF, 55 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40308868&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Aircraft Logbook (item 11, .PDF, 218 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40308546&FileExtension=.PDF&FileName=Aircraft%20Logbook-Redacted.PDF - Annual Invoice/Work Order (item 12, .PDF, 93 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40308869&FileExtension=.PDF&FileName=Annual%20Invoice%2FWork%20Order-Redacted.PDF - Insurance Application (item 13, .PDF, 80 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40308548&FileExtension=.PDF&FileName=Insurance%20Application-Redacted.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.