LAX98FA039

NTSB accident investigation · Mooney M20 · Big Bear, CA · November 15, 1997

Accident · FatalField investigationFinal report
Date
November 15, 1997, 06:59 local (14:59 UTC)
Place
Big Bear, CA
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Initial climb
Aircraft
N5231BMooney M20
Weather
Instrument (IMC) · Day
Status
Completed · report April 20, 1999
Report
Approved by Office Director
FAA report
19971115032989A
Case key
29925

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

VFR flight by the pilot into instrument meteorological conditions (VMC), which led to spatial disorientation, loss of aircraft control, and an uncontrolled descent into terrain. Related factors were: the adverse weather conditions, the pilot's lack of instrument experience, overconfidence of the pilot in his personal ability, and possible pilot distraction due to an unlatched baggage door, which was not properly secured during preflight.

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.

In flight encounter with weatherTakeoff - initial climb
Weather condition - low ceilingFactor
Weather condition - fogFactor
Terrain condition - mountainous/hilly
Vfr flight into imc - performedPilot in commandCause
Overconfidence in personal abilityPilot in commandFactor
Loss of control - in flightTakeoff - initial climb
Aircraft preflight - inadequatePilot in commandFactor
Door,cargo/baggage - unlatchedFactor
Diverted attentionPilot in commandFactor
Flight/nav instruments,attitude indicator - other
Aircraft control - not maintainedPilot in commandCause
Spatial disorientationPilot in commandCause
Lack of total experiencePilot in command
Lack of total instrument timePilot in commandFactor
In flight collision with terrain/waterDescent - uncontrolled
Seat belt - not usedPilot in command

Analysis

The non-instrument rated pilot performed a preflight inspection, and taxied east to the approach end of runway 26, where he made an engine run-up. Weather at the airport was reported to be 200 feet overcast, visibility 3/4 mile with fog, and the wind calm. Witnesses indicated that to the east, they observed blue sky and the rising sun, while to the west and south, they observed low clouds and restricted visibility. The pilot elected to takeoff west on runway 26. Witnesses indicated that after takeoff, the airplane climbed into the clouds, and within 60 seconds, it descended from the clouds in a steep left bank. The airplane crashed on a mountainside, 0.8 miles from the airport, while in a nose low and steep left bank attitude. Impact occurred at an elevation of about 6,850 feet; elevation of the airport was 6,748 feet. The accident occurred 10 days after the pilot was issued a private pilot certificate. Examination of the wreckage revealed evidence of oil leakage in an aft direction on the airplane's belly and on the engine's exterior. Also, a puddle of oil was found on the hangar floor, below where the engine would have been, while the airplane was parked. However, no evidence of oil starvation, overheat distress signatures, or loss of engine power were found. The attitude indicator had a history of precession. The baggage compartment door of the airplane and the pilot's lap belt were found unlatched. No maintenance logs were located. The pilot's former flight instructor (CFI) reported that the pilot had 'tinkered' with the engine to stop oil leakage. Also, the CFI characterized the pilot as being an aggressive student.

Factual narrative

History of flight

On November 15, 1997, at 0659 hours Pacific standard time, a Mooney M20, N5231B, operated by the pilot, was destroyed upon descending into upsloping mountainous terrain near the uncontrolled Big Bear City Airport, Big Bear, California. The pilot and passenger were fatally injured during the personal flight. Instrument meteorological conditions existed, and no flight plan was filed by the non-instrument rated private pilot. The flight was originating at the time of the accident.

The airplane was based at the Corona Airport, Corona, California. At 1958, on November 14, the airplane was serviced with 12.3 gallons of 80/87 octane aviation fuel. The airplane's total fuel quantity was not determined. Thereafter, the airplane departed Corona, and arrived at the Big Bear City Airport at an undetermined time.

According to management personnel at Aero Haven, the sole refueler at the Big Bear City Airport, no fuel was pumped into the accident airplane on November 14 or 15. Airport management personnel reported that the airplane was parked overnight at the airport. A taxicab driver reported delivering the pilot and passenger to the airplane at 0645 on November 15.

A witness at the airport reported observing the pilot perform a preflight inspection of the airplane, and then taxi to the approach end of runway 26 where an engine run-up was performed. Thereafter, the airplane was observed to make a normal takeoff and climbout. The witness lost visual contact with the airplane as it climbed into the clouds which were based approximately 200 feet above ground level.

An additional witness, who was located south of the airport, reported observing the airplane descending in a southwesterly direction out of the clouds. The airplane appeared to be in a nose high pitch attitude and, as it turned left, its bank angle increased to about 90 degrees. This witness further reported that he observed the airplane's nose drop, and then the airplane descended until impacting trees.

Both witnesses reported hearing the airplane's engine operate continuously for the entire duration of its flight, which they estimated lasted about 60 seconds. Neither witness reported hearing any backfiring or sputtering sounds.

Personnel information

A review of the pilot's flight record logbook and Federal Aviation Administration (FAA) records revealed that on November 5, 1997, the pilot was issued a private pilot certificate. Thereafter, he made five flights in the accident airplane. The pilot had previously flown to the Big Bear City Airport on five occasions.

The certified flight instructor (CFI) who recommended the pilot for the private pilot flight check characterized the pilot as being an aggressive student who demonstrated "Type A" personality characteristics. He also reported that when he would advise the pilot to perform a task, the student would comply with his instructions, but would thereafter exceed the instructions by performing unauthorized flights and/or maneuvers.

Aircraft information

According to the FAA, on August 21, 1997, the pilot purchased N5231B and applied for registration as President of E. C. Pacific, Inc., Las Vegas, Nevada. The pilot's wife reported to the National Transportation Safety Board that her husband was the owner of the accident airplane, and the airplane was hangared at the Corona Airport.

An examination of the Corona hangar revealed the presence of puddles of oil on the floor. The largest puddle was located in an area consistent with where the engine of the airplane would be located while parked. According to the CFI who recommended the pilot for his private pilot flight check, the hangar floor was repainted 2 or 3 weeks prior to the accident. The oil on the hangar floor was recently deposited there by the accident airplane's engine. The pilot was aware that the engine was leaking oil, and the pilot had "tinkered" with the engine in an effort at stopping the leak.

Regarding other mechanical problems, the CFI reported that the airplane's artificial horizon was not functioning properly. It was "lazy" in that it tended to lag behind the airplane. The CFI indicated that he would provide a statement describing this phenomena. (No statement has been received.) The CFI stated that he had never observed the airplane's maintenance logs.

Regarding evidence of the airplane's last annual inspection, the previous owner reported that he last paid for an annual inspection in March 1993. He indicated that the new owner had purchased the airplane through Midwest Executive Aviation, an aircraft broker.

The airplane broker reported that prior to selling the airplane the prospective purchaser (the accident pilot) had paid for a pre-purchase inspection, and then an annual inspection. Both inspections were accomplished by Don's Aviation, Lee's Summit, MO. The aircraft broker provided copies of payments made by the pilot to Don's Aviation for the annual inspection, and a copy of Don's Aviation invoice indicating that it had performed an annual inspection.

Additionally, a CFI who was associated with Midwest Executive, and who initially flew with the pilot to familiarize him with the airplane, reported that the annual inspection had been performed by Don's Aviation. However, on November 20, 1997, personnel from Don's Aviation reported to the Safety Board that its firm had not performed an annual inspection on the accident airplane.

No airplane maintenance logbooks have been located. The airplane inspection and flight time data contained in this report are estimated and based upon sales and flight records provided by the FAA, the pilot's wife, and Midwest Executive Aircraft, Inc.

Meteorological information

An automatic weather observing system (AWOS) is located at the Big Bear City Airport. At 0640, 0700 and 0720, the AWOS recorded an overcast sky condition with the base of the clouds at 200 feet above ground level. At 0700, the visibility was recorded at 0.75 miles, the wind was calm, and the temperature was 20 degrees Fahrenheit.

According to airport management personnel, the pilot's airplane had been parked overnight about 500 feet west of the AWOS sensor. Two witnesses reported observing blue sky and the rising sun to the east of the airport. Witnesses also reported observing low clouds to the south and west of the airport.

Communication

None of the witnesses nor airport personnel reported hearing any radio communications from the airplane.

Wreckage and impact information

The accident site coordinates are approximately 34 degrees 15.50 minutes north latitude, by 116 degrees 52.15 minutes west longitude. The estimated terrain elevation at the accident site is 6,850 feet mean sea level.

From an examination of the accident site and airplane wreckage, and from witness statements, the airplane was found to have descended into trees and terrain while in a nose low and steep left bank attitude. The bank angle was described by witnesses as being about 90 degrees.

The initial point of impact (IPI) occurred with estimated 75-foot-tall trees. The airplane's severed left flap was found suspended from tree branches at this location. The approximate distance and direction from the Big Bear City Airport to the crash site is 0.8 nautical miles and 233 degrees (magnetic).

The left wing was found broken into two pieces which were separated from the main wreckage. The severed 5 1/2-foot-long outboard and 9-foot-long inboard portions of the left wing were located within several yards of the base of the IPI tree. Additional splintered portions of airplane structure were located along an east-southeasterly track of 117 degrees.

The main airplane wreckage was located approximately 90 feet from the IPI. The airplane was found pointed in a westerly direction (270 degrees), and was resting on its left side in an approximate 120-degree left bank

Aircraft

Registration
N5231B
Reported as
Mooney M20
Category
Airplane
Serial number
1094
Airframe hours
2,300
Engine
Lycoming O-320-3, 150 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Operator
John A. Marshall
Registered owner
E. C. Pacific, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
Annual · August 20, 1997 · 92 hours before
Departed
L35
Airport
L35 · Big Bear City, runway 26, 5,850 × 75 ft, asphalt

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
47
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
96 total · 92 in this make and model · 56 as pilot in command · 96 in the last 90 days · 32 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Day
Wind
Calm
Visibility
0.75 statute miles
Lowest ceiling
200 ft overcast
Temperature
19 °F, dew point 18 °F
Altimeter
30.00 inHg
Observed at
L35, 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.