LAX94FA217

NTSB accident investigation · Mooney M20K · Ventura, CA · May 12, 1994

Accident · FatalField investigationFinal report
Date
May 12, 1994, 08:25 local (15:25 UTC)
Place
Ventura, CA
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N231WDMooney M20K
Weather
Instrument (IMC) · Day
Status
Completed · report August 21, 1995
Report
Approved by Office Director
FAA report
19940512010639A
Case key
28531

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

Failure of the flight crew to maintain control of the airplane in instrument meteorological conditions (IMC), due to spatial disorientation. A factor related to the accident was: the first pilot's overconfidence in his ability to assure control of the airplane from the right seat by reference to the instruments located in front of the left seat.

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 - in flightClimb
Weather condition - low ceiling
Aircraft control - not maintainedFlightcrewCause
Spatial disorientationFlightcrewCause
Overconfidence in personal abilityPilot in commandFactor
In flight collision with terrain/waterDescent - uncontrolled

Analysis

The pilots departed on an IFR flight with clearance to climb to VFR conditions on top. The tops of the clouds were reported at 2500 feet. The person in the right front seat held an instrument rating and was presumed to be the first pilot (PIC). The person in the left front seat was also a pilot, but did not possess an instrument rating. The airplane was equipped with a single set of flight instruments in front of the left seat. According to recorded radar data, the airplane did not reach an altitude where VFR conditions were reported. At about 2300 to 2400 feet MSL, the airplane entered a descent, then radar contact was lost. Witnesses heard and saw the airplane in a steep dive as it descended below the estimated 500-foot overcast. No preimpact mechanical failure or malfunction of the airplane was found.

Factual narrative

On May 12, 1994, at 0825 hours Pacific daylight time, a Mooney M20K, N231WD, lost control and collided with terrain in a lemon orchard near Ventura, California. The airplane was being operated by the pilot/coowner as a personal flight. The airplane was destroyed by impact forces. The certificated private pilot and private pilot rated passenger received fatal injuries. The flight originated in Camarillo, California, at 0819 hours and was destined for Sedona, Arizona. Instrument meteorological conditions prevailed and a composite IFR/VFR flight plan was filed.

At 0819:09 hours, the right seat pilot contacted the Point Mugu Approach Control after takeoff from Camarillo. The pilot reported climbing through 400 feet mean sea level (msl). At 0819:14 hours, the approach controller instructed the pilot to fly heading 275 degrees and climb and maintain 4,000 feet msl, report when on top of the clouds, and when the pilot desired to cancel the instrument flight rules (IFR) portion of the flight and continue to the destination under visual flight rules (VFR). The pilot then acknowledged the instruction.

At 0821:58 hours, the approach controller advised the pilot the tops of the clouds were last reported to be at 2,500 feet msl. The pilot acknowledged the approach controller's advisory and indicated they would report when they broke out on top. This was the last known communication with the accident airplane.

Radar data was recorded by the Point Mugu Approach Control. The approach control equipment stores the data in a format that permits the information to be displayed on the radar screen (video) in the same manner it appeared to the controller at the time of the accident. The airspace and procedures specialist at the Point Mugu Approach Control manually transcribed the data from the video and produced a video track drawing. The drawing depicts an approximate time, location, and altitude of the recorded data for the accident airplane based on its discrete transponder code.

Review of the drawing indicates radar contact was established with the accident airplane at 0821:05 hours at the departure end of runway 26 at the Camarillo Airport, at an altitude about 300 feet msl. Radar contact was lost about 0824:38 hours at a position approximately 6 nautical miles west-northwest of the airport at 2,300 feet msl.

The last radar target on the accident airplane was at 0825:32 hours. It was a single hit that appeared on the radar screen about 0.5 miles east of the point where the track was lost. The altitude of the last target was 700 feet msl.

Witnesses reported hearing the airplane engine and believed the airplane to be at a low altitude. One witness indicated there was light rain and overcast skies. He observed the airplane descend vertically out of a 500-foot overcast ceiling and collide with the ground in a nose-down attitude.

Crew information

First pilot

The first pilot was found in the right front seat. The first pilot held a private pilot certificate which was issued on May 14, 1989, as the result of obtaining an airplane instrument rating in addition to the single-engine airplane rating.

The first pilot's airman file maintained by the Federal Aviation Administration, in Oklahoma City, Oklahoma, was reviewed by the National Transportation Safety Board investigators. The review disclosed on March 15, 1989, the pilot failed his flight check for an instrument airplane rating. The designated examiner cited poor altitude control while performing instrument flight tasks. The altitude varied from 200 to 600 feet.

The first pilot received an additional 2.5 hours of actual instrument and 5 hours of simulated instrument training from a certified instrument flight instructor. The first pilot then reapplied for the instrument airplane rating on May 14, 1989, and successfully passed the flight check. At the time the first pilot received his airplane instrument rating, his total instrument experience was 52.6 hours of simulated instrument flight and 4.3 hours of actual instrument flight.

According to the first pilot's logbook, his total aeronautical experience consists of about 602 hours, of which 89.8 hours were accrued in actual instrument conditions and 74.4 were accrued in simulated instrument conditions. In the preceding 6 months before the accident, the logbook lists a total of 2.1 actual instrument flight hours and 3.9 hours of simulated instrument flight. The first pilot's logbook indicates the pilot logged seven instrument approaches during the same 6-month period.

Review of the first pilot's logbook revealed that he had flown numerous cross-country flights with the second pilot. Review of the second pilot's logbook revealed that the two would alternate logging pilot-in-command, except in the case where the first pilot would log instrument flight experience. Generally, one pilot would log the flight to a destination and the other pilot would log the return flight.

On March 27, 1994, the two pilots started a 3-day trip from Sedona, Arizona, to Visalia, California, and then to Camarillo, California, and then return to Sedona. On March 27, 1994, the first pilot logged 3 hours of pilot-in-command flight experience from Sedona to Visalia. On March 28, 1994, the second pilot logged 1.4 hours from Visalia to Camarillo, California. On the same day, the first pilot logged 0.6 hours pilot-in-command in actual instrument flight with one instrument approach during the same flight. On March 29, 1994, the second pilot then logged 2.4 hours on the flight from Camarillo to Sedona.

Second pilot

The second pilot was found in the left front seat and held a private pilot certificate which was issued on November 25, 1987, with a single-engine airplane rating.

According to the logbook, her total aeronautical experience consisted of 516.4 hours, of which 8.9 hours were accrued under simulated instrument conditions and 0.8 hours were accrued in actual instrument conditions.

The pilot's airman file, maintained by the Federal Aviation Administration, in Oklahoma City, Oklahoma, was also reviewed by the Safety Board investigators. The review disclosed on November 10, 1987, the pilot failed her flight check for a private pilot single-engine airplane rating. The designated examiner indicated the pilot's application was disapproved, in part, for failing to maintain aircraft control by reference to instruments while under the hood.

According to her logbook, the pilot did not log any simulated or actual instrument flight time since her private pilot certificate was issued in 1987.

Aircraft information

The airplane had accumulated a total time in service of 1,128 hours. Examination of the maintenance records revealed that the most recent annual inspection was accomplished on May 12, 1993, about 119 flight hours before the accident.

The airplane was equipped for instrument flight. The primary flight instruments are located in front of the pilot station on the left side of the airplane. There were no flight instruments installed in front of the right seat.

Meteorological information

The closest official weather observation station is Camarillo Airport, which is located 6 nautical miles east of the accident site. At 0746 hours, a record scheduled surface observation was reporting in part: Sky condition and ceiling partially obscured with cloud bases at 500 feet above the ground. A pilot weather report solicited by the Point Mugu Approach Control indicated the tops of the clouds at 2,500 feet above the ground.

Wreckage and impact information

The airplane was found in a nose-down attitude in a lemon orchard. Branches from one of the lemon trees were broken directly above the airplane's point of rest. Both wings were resting on the ground. The nose of the airplane had penetrated the soil to a point where the pilot seat backs were level with ground. The empennage was bent forward o

Aircraft

Registration
N231WD
Reported as
Mooney M20K
Category
Airplane
Serial number
25-0765
Airframe hours
1,128
Engine
Continental TSIO-360-GB, 210 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Registered owner
Reeds, John W
Airworthiness certificate
Standard, Normal
Last inspection
Annual · May 12, 1993 · 119 hours before
Departed
CMA · Camarillo, CA
Destination
SDZ · Sedona, AZ
Flight plan
VFR/IFR

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
65
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Valid Medical--w/ waivers/lim
Seat
Right
Toxicology
Performed
Flight hours
602 total · 490 in this make and model · 553 as pilot in command · 14 in the last 90 days · 3 in the last 30 days

Weather

Conditions
Instrument (IMC) · Day
Wind
250° at 6 knots
Visibility
1 statute miles
Lowest ceiling
500 ft overcast
Temperature
57 °F, dew point 54 °F
Altimeter
29.00 inHg
Observed at
CMA, 6 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.