MIA08FA094

NTSB accident investigation · Mooney M20M · Midlothian, VA · April 27, 2008

Accident · FatalField investigationFinal report
Date
April 27, 2008, 10:19 local (14:19 UTC)
Place
Midlothian, VA
Injuries
2 fatal, 1 serious; on the ground: 1 serious
Damage
Destroyed
Phase of flight
Maneuvering
Aircraft
N429RMMooney M20M
Defining event
Maneuvering: Loss of control in flight
Weather
Instrument (IMC) · Day
Status
Completed · report August 12, 2010
Report
Approved by Office Director
Parties
Mooney Airplane Compay, Inc., Textron Lycoming, FAA/FSDO
FAA report
20080427832529A
Case key
67889

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The pilot’s improper control inputs resulting from spatial disorientation.

Findings · 1

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The instrument-rated private pilot departed with an instrument flight rules clearance and encountered instrument meteorological conditions shortly after takeoff. He did not establish contact with air traffic control at any time during the flight, nor did he enter controlled airspace on the assigned heading of 180 degrees. According to the NTSB Air Traffic Control (ATC) Radar Study, the flight climbed to approximately 1,800 feet msl, and continued in a direction northwest of the departure airport while turning left, right, and then left with slight changes in altitude. The airplane then began a right descending turn with the bank angle and turn rate increasing beyond the standard rates and angles, and the load factor reached close to maximum limits. At some point near the end of the flight, during the right descending turn, the lower fuselage panel separated and the left rear window separated. The airplane impacted the ground then a house and both were destroyed by impact and postcrash fire.

The pilot's wife reported a previous concern with a stuck flap. Although the impact and fire destroyed sections of the flight control push/pull tubes and components of the flap system, changes in direction to the left and right were consistent with the pilot controlling the airplane. Examination of the wreckage, including the flight control, flap, and speedbrake systems, did not reveal any preimpact mechanical malfunctions. Additionally, Mooney Flight Test personnel reported that the airplane is controllable with one flap fully extended and the other flap fully retracted. No evidence of preimpact failure or malfunction was noted to the engine or engine accessories.

Risk factors for spatial disorientation were present at the time of the accident, including instrument meteorological conditions and maneuvering flight. The airplane’s sequence of turns during the departure and its subsequent spiral dive were conducive to vestibular illusions. Analysis of the radar data in the airplane performance study showed evidence of a flight path and associated increased g-loading that were consistent with the effects of spatial disorientation.

Factual narrative

History of flight

On April 27, 2008, about 1019 eastern daylight time, a Mooney Airplane Company, Inc., M20M, N429RM, registered to RKJ Aero LLC, experienced an in-flight loss of control shortly after takeoff from Chesterfield County Airport (FCI), and crashed into a house located in Midlothian, Virginia. Instrument meteorological conditions prevailed at the time and an instrument flight rules (IFR) flight plan was filed for the 14 Code of Federal Regulations (CFR) Part 91 personal flight from FCI to Franklin Municipal-John Beverly Rose Airport (FKN), Franklin, Virginia. The airplane was destroyed by impact and a postcrash fire, and the certificated private pilot and pilot-rated passenger were killed. The house was destroyed by impact and the postcrash fire, and the sole person in the house sustained serious injuries due to burns. The flight originated about 1016, from FCI.

An employee of a fixed base operator (FBO), at the departure airport, reported the airplane remained on their ramp with the engine running for approximately 15 minutes. The airplane then taxied to runway 33 and remained at the approach end of the runway for approximately 15 minutes. Another employee of the same FBO reported she did not hear any radio calls on the common traffic advisory frequency (CTAF) from the pilot announcing his departure, but she became busy with work duties and people that arrived at the FBO about that time.

According to a transcription of communications with Potomac Terminal Radar Approach Control (TRACON), at 1007:46, an occupant of the airplane established contact with the James River Flight Data (JRVFD) Position and advised the controller that they were on the ground at FCI requesting IFR clearance to FKN. The JRVFD controller advised the pilot that the flight was cleared to FKN via direct Harcum VORTAC, then direct FKN. He was also advised to maintain 2,000 feet mean sea level (msl), expect 5,000 feet msl 10 minutes after takeoff, the departure frequency was 134.7 MHz, and the discrete transponder code was 5321. An occupant of the airplane correctly read back the IFR clearance and the JRVFD controller instructed the pilot to advise when the flight was ready to depart. An occupant replied that they were currently number one to takeoff from runway 33. At 1009:08, the Potomac TRACON JRVFD controller advised the pilot that the flight was released for departure and to enter controlled airspace heading 180 degrees. An occupant of the airplane read back the heading information.

The employee of the FBO, who witnessed the airplane taxiing out, further reported that during takeoff, when the airplane was abeam the windsock, it was below the tree-line. While airborne, the airplane continued past the departure end of the runway, where he lost sight of the airplane after entering clouds. It was not raining at the time of departure, but it was cloudy. He did not recall whether the landing gear retracted and did not recall seating positions of the occupants before departure.

According to the NTSB Air Traffic Control (ATC) Radar Study, the first radar target associated with the accident airplane was at 1016:03; the airplane at that time was located near the departure end of runway 33 at 300 feet msl. The flight continued on the runway heading until approximately 1017:04, and climbed to approximately 1,100 feet msl. At that time the flight was near Jacobs Road. The airplane then turned left, flying in a west-northwesterly direction and climbed to approximately 1,300 feet msl, until approximately 1017:22. At that time the flight turned right flying in a northwesterly direction. The flight continued in the northwesterly heading, climbing to approximately 1,800 feet msl, until 1017:50, while over Hull Street Road (U.S. Route 360), the airplane then turned left. The airplane continued in the left turn until 1018:17. During the left turn the airplane descended initially to 1,600 feet msl, then climbed back to 1,800 feet msl. The airplane remained at approximately 1,800 feet msl, but turned right, flying first in a westerly direction, then turned left flying in a west-southwesterly direction until 1018:27. At that time, the airplane began a right descending turn, losing 1,000 feet of altitude in an approximate 10 second period, with a corresponding ground speed increase from approximately 140 knots to 170 knots. The last radar target, which occurred at 1018:40, depicted the airplane to be at 600 feet msl, and was located near the accident site. A non-correlated radar target was located west of the last radar target.

One witness, located near the accident site, reported to a Federal Aviation Administration (FAA) inspector, that he observed the airplane flying beneath the cloud bases. The airplane flew in a southerly direction at an estimated 50 to 60 feet above ground level (agl), in a wings level, slow descent. He saw a large part separate, then heard engine sound decrease. He noticed the propeller turning slowly, then lost sight of the airplane.

A second witness reported hearing the engine “stalled” and tried to restart, while a third witness reported that at the time of the accident there was light drizzle. The witness heard an airplane approaching from the northwest and reported the noise increased enough to get his attention. He observed the airplane, which appeared to be silver in color, and noticed the right side of the airplane while it was descending at about a 45-degree angle. The engine sounded “wide open” and there was no sputtering; the engine roar was constant. He correlated it to a “kamikaze type dive.” He did not see any sign of a recovery from the nose-low descent, and it disappeared from his view. A second or two later, he heard the impact and his wife dialed 911. He did not see anything separate from the airplane. It was not “listing to either side and was right side up. I could not see the pilot or passenger.”

A fourth witness reported that at the time of the accident, he was in his driveway and heard a noise from above. It sounded to him like the engine was “missing and sputtering.” He looked in the direction of the noise and saw the airplane coming across the trees, moving southward across Woodsong Drive at a rapid rate of speed. The airplane was descending at about a 45-degree angle, and it was not pitching or rolling. The airplane impacted on Woodsong Drive. He drove to the scene right away and saw other neighbors circling the house, trying to gain entrance, but it was evident they could not enter due to the heavy smoke and flames.

At 1019:26, a controller with the Potomac TRACON Flatrock (FLTRK) Position advised on the departure frequency, “november four two nine romeo mike potomac departure low altitude alert climb and maintain two thousand immediately.” There was no recorded response from the pilot and there was no recorded communication from the accident pilot while airborne with Potomac TRACON.

The airplane crashed into a house located in a residential area during daylight conditions. The crash site was located approximately 400 feet south-southeast from the last correlated radar target.

Personnel information

The pilot, age 40, held a private pilot certificate with ratings for airplane single-engine land and instrument airplane, issued on February 3, 2007 and April 7, 2007, respectively. He also held a third-class medical certificate, with no limitations, issued on December 18, 2006.

A review of his pilot logbook, which was found in the wreckage and was heat damaged, revealed that no carry forward flight time was listed on the first page of logged flights. The “From” date indicated December 16th, with the year not legible. He logged a total time of approximately 332 hours, of which approximately 271 hours were as pilot-in-command (PIC). Since obtaining his instrument rating on April 7, 2007, he logged approximately 23 hours actual instrument flight time, of which 19 hours were log

Aircraft

Registration
N429RM
Reported as
Mooney M20M
Category
Airplane
Serial number
27-0301
Airframe hours
491
Engine
Lycoming TIO-540-AF1B, 270 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Operator
Joseph A. Grana III
Registered owner
Rkj Aero LLC
Airworthiness certificate
Standard, Normal
Last inspection
Annual · November 16, 2007
Departed
FCI · Midlothian, VA
Destination
FKN · Franklin, VA
Flight plan
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
40
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Without waivers/limitations
Last flight review
April 7, 2007
Seat
Left
Toxicology
Performed
Flight hours
332 total · 271 as pilot in command · 0 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Day
Wind
360° at 4 knots
Visibility
10 statute miles
Lowest ceiling
800 ft overcast
Temperature
63 °F, dew point 55 °F
Altimeter
30.14 inHg
Observed at
FCI

Docket · 37

The files NTSB released with the investigation on January 29, 2010, on NTSB’s docket system: statements, records, photos and specialists’ reports. 12.7 MB in all.

ATC 3 - Potomac TRACON Radar Data RIC ASR-9Item 1 · ZIP · 2.5 MBATC 3 - Radar StudyItem 2 · .PDF · 1.7 MBAircraft Performance 13 - Study of Group ChairmanItem 3 · .PDF · 486 KBMaterials Laboratory Factual Report 08-123, Examination of left hand rear windowItem 4 · .PDF · 221 KBRecord of NTSB ConversationsItem 5 · .PDF · 254 KBWitness StatementsItem 6 · .PDF · 301 KBWeather Reports and RecordsItem 7 · .PDF · 45 KBTranscript of Radio CommunicationsItem 8 · .PDF · 622 KBWeight and BalanceItem 9 · .PDF · 732 KBExcerpts from Aircraft LogbookItem 10 · .PDF · 1.1 MBFueling InformationItem 11 · .PDF · 315 KBFlight PlanItem 12 · .PDF · 47 KBExcerpt from Airplane Type Certificate Data SheetItem 13 · .PDF · 53 KBExcerpts from Pilot's Operating Handbook and FAA Approved Airplane Flight ManualItem 14 · .PDF · 351 KBATC Personnel StatementsItem 15 · .PDF · 258 KBWork OrderItem 16 · .PDF · 82 KBLetter from Mooney Regarding Airplane Controllability.Item 17 · .PDF · 22 KBDocument from Mooney Airplane CorporationItem 18 · .PDF · 79 KBLetter from Pilot's Wife Concerning FlapsItem 19 · .PDF · 88 KBStatement from C & W Aero Services, Inc.Item 20 · .PDF · 26 KBE-mail from CSC DUATS about Weather BriefingItem 21 · .PDF · 17 KBE-mail Concerning WeatherItem 22 · .PDF · 43 KBExcerpts from Maintenance RecordsItem 23 · .PDF · 910 KBToxicology Report-PilotItem 24 · .PDF · 60 KBToxicology Reports-PassengerItem 25 · .PDF · 92 KBStatement of Party Representatives to NTSB InvestigationItem 26 · .PDF · 63 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 27 · .PDF · 178 KBPhoto 1: NTSB Digital Picture. View Showing the Separated Lower Fuselage PanelItem 28 · .PDF · 181 KBPhoto 2: NTSB Digital Picture. View Showing the Accident Site.Item 29 · .PDF · 292 KBPhoto 3: NTSB Digital Picture. Another View of the Accident Site.Item 30 · .PDF · 269 KBPhoto 4: NTSB Digital Picture. Another View of the Accident Site.Item 31 · .PDF · 184 KBPhoto 5: NTSB Digital Picture. View of the Engine Being Recovered from the Accident Site.Item 32 · .PDF · 306 KBPhoto 6: NTSB Digital Picture. View of the Wreckage Layout.Item 33 · .PDF · 185 KBPhoto 7: NTSB Digital Picture. View of the Rotor from the Attitude Gyro. Note the Scoring.Item 34 · .PDF · 155 KBPhoto 8: NTSB Digital Picture. View of the Left Speedbrake.Item 35 · .PDF · 154 KBPhoto 9: NTSB Digital Picture. View of the Right Speedbrake.Item 36 · .PDF · 144 KBPhoto 10: NTSB Digital Picture. View of the Separated Propeller Blades.Item 37 · .PDF · 165 KB

FAA reports on this event · 1

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