LAX98FA199

NTSB accident investigation · Mooney M20R · Van Nuys, CA · June 16, 1998

Accident · FatalField investigationFinal report
Date
June 16, 1998, 05:14 local (12:14 UTC)
Place
Van Nuys, CA
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N130RBMooney M20R
Weather
Instrument (IMC) · Dawn
Status
Completed · report June 22, 2000
Report
Approved by Office Director
FAA report
19980616013659A
Case key
29955

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 non-instrument rated pilot's intentional VFR flight into instrument meteorological conditions. Factors were the low ceiling, drizzle, and fog.

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 - to cruise
Light condition - dawn
Weather condition - drizzle/mistFactor
Weather condition - low ceilingFactor
Weather condition - fogFactor
Vfr flight into imc - intentionalPilot in commandCause
Aircraft control - not maintainedPilot in commandCause
In flight collision with terrain/waterDescent - uncontrolled

Analysis

The non-instrument rated private pilot departed at dawn for a 1,300-mile cross country flight. There was no FAA record of the pilot obtaining a preflight weather briefing. The weather at the departure airport was a ceiling of 900 feet overcast with visibility 3 miles in fog and light drizzle. Radar data indicated a right climbing turn to 2,200 feet, then an abrupt maneuver followed by a rapid descent into a residential area. The airplane's gross weight was exceeded by an estimated 165 pounds. The airplane was equipped for instrument flight, including an autopilot; however, the pilot had no known instrument flight training. Post-accident airframe and engine examinations failed to find evidence of mechanical failures.

Factual narrative

History of flight

On June 16, 1998, about 0514 hours Pacific daylight time, a Mooney M20R, N130RB, operated under 14 CFR Part 91 by the pilot was destroyed during collision with a residence at Van Nuys, California. The pilot and passenger both received fatal injuries. Instrument meteorological conditions prevailed and no flight plan was filed. According to airport police at 0512, the aircraft departed from runway 16R without radio transmission.

The air traffic control tower was closed at the time of the departure. Radar data obtained from the airport noise abatement program indicated a right climbing turn to about 2,200 feet msl, followed by a rapid descent into a residential area. The Federal Aviation Administration (FAA) Burbank Approach radar recording system was down for maintenance at the time of the accident.

According to a family member, the pilot was en route to a Minneapolis, Minnesota, for an appointment at the Mayo Clinic.

Personnel information

The private pilot was rated for airplane single engine land in visual flight conditions. The pilot was not instrument rated and had no known instrument flight training. The pilot's flight logbook was not recovered. At the pilot's last third-class flight physical dated April 4, 1997, he reported a total flight time of 4,100 hours. The pilot had recently purchased the accident aircraft and attended Flight Safety International to meet the VFR requirements of his insurance company.

On January 21, 1998, the pilot completed a Mooney Pilot Initial Training Program. The training started on January 19, 1998, and consisted of ground school and briefing on the Mooney aircraft and systems, with 5.5 hours of VFR flight maneuvers. The pilot's file folder listed 4,000 total flight hours with 3,900 as pilot-in-command and 3,600 in a Mooney.

Aircraft information

According to the aircraft logbook, the new aircraft certification occurred on April 30, 1997. The same log entry states that the next annual inspection was due April 30, 1998. Delivery of the aircraft to the owner/pilot occurred on May 20, 1997. The first and last logbook entry, other than the factory entries, occurred on April 29, 1998, at 39.6 total flight hours. That entry was for the installation of extended range fuel tanks. Weight and balance figures were computed after the fuel tank installation. The new useful load limit for fuel, baggage, pilot, and passengers is 1,020 pounds.

FAA certificated aircraft operating under 14 CFR Part 91 (General Operating and Flight Rules) are required to have an annual inspection every 12 calendar months.

The auxiliary fuel tank installation adds an additional 29 gallons of usable fuel to the existing 89 gallons for a total of 118 gallons. According to the installer, an additional 12 gallons can be added using the proper refueling technique and allowing the fuel to balance or transfer. The fuel load at the time of departure could not be determined.

During the auxiliary fuel tank installation and according to the airframe logbook, the proprietor of the company noted that the aircraft was out of annual inspection/license. He stated that he informed the owner pilot of this condition. The owner/pilot told him that he was going to have Dugosh Aircraft Service Company, Inc., of Kerrville, Texas, perform the annual inspection. A copy of the proprietor's statement is attached.

Dugosh Aircraft Service Company, Inc. was contacted regarding an appointment for an annual inspection. According to Dugosh, the inspection was scheduled by the owner/pilot for October 13, 1998, after the annual Mooney owner/pilots convention (MAPA) scheduled for October 8, 9, and 10, 1998. A copy of the Dugosh representative's statement is attached.

Meteorological information

Aviation weather information "AIRMET SIERRA" was valid for the time of the accident for California and coastal waters. The Airmet reported in part: occasional ceilings below 1,000 feet, and visibility below 3 miles and mist. The cloud tops were reported about 3,000 feet msl.

At 0509, the Van Nuys Automated Surface Observation System (ASOS) was reporting: wind 130 degrees at 6 knots; visibility 3 miles in mist; sky condition 900 feet overcast; temperature 61 degrees Fahrenheit; dew point 57 degrees Fahrenheit; and altimeter 29.82 inHg.

About 0600, an airport witness provided a weather observation of sky condition approximately 400 overcast and visibility was about 2.5 miles.

A Safety Board meteorological factual report is attached. There was no Federal Aviation Administration (FAA) record of a preflight weather briefing.

Airport information

The Van Nuys Airport traffic is controlled by an FAA Air Traffic Control Tower operating between 0600 and 2245. During the tower operation the airspace is class "D" controlled. During the hours of closure the airspace is class "G" uncontrolled, up to but not including 3,000 feet agl. Above that, 3,000 to 4,800 msl, it becomes the Burbank class "C" airspace, all under the Los Angeles mode "C" veil.

Wreckage and impact information

The wreckage was examined on scene inside a two-story home in a residential area of Van Nuys. It was located at ground level below the floor of a dining room area. The aircraft had penetrated the roof and two floors.

On July 7, 1998, the Safety Board conducted a detailed examination of the aircraft and engine. During the examination it was determined that the landing gear and the flaps were in the retracted position at the time of the accident.

A postaccident fire consumed some of the aircraft and home structure. Radio, autopilot components, and instruments were fire and impact damaged. Control continuity was established where possible. The fuel selector was on the right fuel tank. Altimeter barometric pressure was set at 29.92 inHg. The horizontal situation indicator (King KCS-55A HSI) heading bug was indicating 056 degrees; Omni bearing selector and heading were indicating 350 degrees. The instrument pressure was indicating 6 inches. There was no gyro rotor scoring information available.

Baggage items located inside the aircraft were examined. Clothes, shoes, food, fruit, candy, tools, aircraft battery, oil filter, several quarts of oil, two medical oxygen bottles (DOT 3AL2015M44824M4002), the installed aircraft oxygen bottle, a breathing machine, water, books, and maps were among the items. The weight of the baggage was estimated to be in excess of 100 pounds.

A measurement was taken from the safety hinge of the horizontal stabilizer and was given to the Mooney Aircraft Company Engineering Department. They reported that the measurement equated to a -4.05 degree (leading edge down) angle of attack of the horizontal stabilizer.

Medical and pathological information

On June 17, 1998, the Los Angeles County Medical Examiner performed an autopsy on the pilot. The cause of death was listed as multiple blunt force trauma. During the course of the autopsy the FAA Civil Aeromedical Institute in Oklahoma City, Oklahoma City obtained samples for toxicological analysis. The results of the analysis were negative for carbon monoxide, cyanide, volatiles, and drugs.

According to the medical examiner's autopsy report, in his opinion: "Because the decedent's injuries are of a type expected to cause instantaneous death, I cannot tell whether or not he was alive at the time of the impact. The body hemorrhages of injury are absolutely minimal and far out of proportion to the degree of skeletal and organ disruption. The complete absence of intra-cranial hemorrhage is noteworthy in this regard. The decedent had an enlarged heart and had experienced recent symptoms that could have been cardiac. Thus, a sudden cardiac death in flight is a possibility that would be consistent with all the findings. However, it cannot be diagnosed from the autopsy findings."

The pilot was known to hav

Aircraft

Registration
N130RB
Reported as
Mooney M20R
Category
Airplane
Serial number
29-0114
Engine
Continental IO-550--G, 280 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Operator
Reiner Bey
Registered owner
Reiner Bey
Airworthiness certificate
Standard, Normal
Last inspection
Annual · April 30, 1997
Departed
VNY · CA
Destination
MSP · Minneapolis, MN
Airport
VNY · Van Nuys, runway 16R, 8,001 × 150 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
65
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
4,100 total

Weather

Conditions
Instrument (IMC) · Dawn
Wind
130° at 6 knots
Visibility
3 statute miles
Lowest ceiling
900 ft overcast
Temperature
61 °F, dew point 57 °F
Altimeter
29.00 inHg
Observed at
VNY, 2 nm away

Docket · 25

The files NTSB released with the investigation on June 2, 1999, on NTSB’s docket system: statements, records, photos and specialists’ reports. 4.7 MB in all.

Supplement AItem 1 · .PDF · 176 KBSupplement BItem 2 · .PDF · 248 KBSupplement KItem 3 · .PDF · 285 KBSupplement SItem 4 · .PDF · 47 KBMeteorology 5 - Factual Report of Group ChairmanItem 5 · .PDF · 1.9 MBWitness StatementsItem 6 · .PDF · 120 KBFAA Radar InformationItem 7 · .PDF · 75 KBVan Nuys Airport Noise Abate ProgramItem 8 · .PDF · 197 KBAircraft Logbook InformationItem 9 · .PDF · 295 KBDugosh Aircraft Service Company InformationItem 10 · .PDF · 70 KBMooney Aircraft Corporation InformationItem 11 · .PDF · 447 KBFlight Safety InformationItem 12 · .PDF · 40 KBRequest for Information ResponseItem 13 · .PDF · 62 KBVan Nuys Airport Police ReportItem 14 · .PDF · 118 KBStatement of Party Representatives to NTSB InvestigationItem 15 · .PDF · 146 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 16 · .PDF · 58 KBToxicological ReportItem 17 · .PDF · 52 KBPhoto 1 : Instrument panel examination pictureItem 18 · .PDF · 58 KBPhoto 2 : The King KCS - 55A Horizontal Situation Indicator (HSI) InstrumentItem 19 · .PDF · 56 KBPhoto 3 : A view of the throttle,mixture,and propeller controls in the full forward positionItem 20 · .PDF · 52 KBPhoto 4 : A view of the fuel control in the full open positionItem 21 · .PDF · 32 KBPhoto 5 : A view of the engine driven fuel pump in the full open positionItem 22 · .PDF · 49 KBPhoto 6 : Measuring of the horizontal stabilizer trim positionItem 23 · .PDF · 40 KBPhoto 7 : The installed aircraft oxygen bottle on the right and two medical emergency bottles on the leftItem 24 · .PDF · 48 KBPhoto 8 : A typical view of an inspection panel with screw paint unbrokenItem 25 · .PDF · 36 KB

FAA reports on this event · 1

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