NYC07FA130

NTSB accident investigation · Mooney M20J · Canton, MA · June 4, 2007

Accident · FatalField investigationFinal report
Date
June 4, 2007, 10:11 local (14:11 UTC)
Place
Canton, MA
Injuries
1 fatal
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N4126HMooney M20J
Weather
Instrument (IMC) · Day
Status
Completed · report February 28, 2008
Report
Approved by Office Director
Parties
Mooney Aircraft Company, Massachusetts Aeronautics Commission, Lycoming Engines, FAA/FSDO
FAA report
20070604008909A
Case key
65911

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 pilot's failure to maintain airspeed, which resulted in an inadvertent stall and subsequent impact with terrain.

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 flightApproach - faf/outer marker to threshold (ifr)
Airspeed - not maintainedCause
Stall - inadvertentPilot in command
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - swampy

Analysis

The private pilot had owned the airplane and flew it in actual instrument meteorological conditions for many years. The pilot successfully flew a localizer approach, and descended through a cloud layer into visual conditions about 500 feet above ground level. She was in radio contact with air traffic control when the airplane pitched up, then down, and descended rapidly into swampy terrain. During an approximately 45-day period prior to the accident flight, the pilot had experienced problems with the manual and electric pitch trim sticking or exhibiting stiffness when she attempted to move the trim toward the nose up position. The problem was addressed twice by a maintenance repair facility at the pilot's home airport, and once by an avionics repair facility; however, the pilot continued to report problems of trim stiffness. The pilot's husband, who was also a certificated pilot, did not notice any trim problems on a recent long cross-country flight. An examination of the wreckage, including the pitch trim system, did not reveal any preimpact mechanical malfunctions. While the aft pitch trim jackscrew required slightly more force to turn toward the nose up position, verses the nose down position, the aft pitch trim jackscrew moved freely by hand in both directions. In addition, fresh grease was observed on both the forward and aft pitch trim jackscrews. The flaps were found fully extended, and the pitch trim was found in a nose up position, consistent with a normal approach and landing descent.

Factual narrative

History of flight

On June 4, 2007, at 1011 eastern daylight time, a Mooney M20J, N4126H, was substantially damaged when it impacted terrain in Canton, Massachusetts, while on an approach to Norwood Memorial Airport (OWD), Norwood, Massachusetts. The certificated private pilot was fatally injured. Instrument meteorological conditions prevailed for the flight that departed Sky Manor Airport (N40), Pittstown, New Jersey, about 0800. An instrument flight rules (IFR) flight plan was filed for the personal flight conducted under 14 Code of Federal Regulations Part 91.

According to data from the Federal Aviation Administration (FAA), the pilot received a weather briefing and filed an IFR flight plan via Data User Access Terminal (DUATs). The flight proceeded uneventfully to the Norwood, Massachusetts, area. The pilot was in radio contact with Boston Terminal Radar Approach Control (TRACON), and then the Norwood air traffic control tower.

At 0954, the Boston TRACON controller told the pilot to expect the localizer runway 35 approach, with a circle to land on runway 10 at OWD. The pilot acknowledged the transmission, and subsequently advised the controller that she had the current automated terminal information system (ATIS) information, "Lima."

At 1006, the TRACON controller provided a vector of 230 degrees, advised that the airplane was 4 miles from STOGE intersection, instructed the pilot to maintain an altitude of 2,000 feet mean sea level (msl), and issued a clearance for the localizer runway 35 approach, circle to land on runway 10. The pilot acknowledged the clearance.

At 1008, the TRACON controller advised the pilot to contact the OWD control tower. The pilot acknowledged the instructions and complied.

At 1009, the pilot radioed the OWD control tower, provided a position report of 1 mile from STOGE, and requested wind information. The OWD tower controller stated that the winds were from 110 degrees at 12 knots. The controller also told the pilot that runway 35 was available (if she didn't want to perform the circling approach to runway 10). The pilot opted for runway 35, and was cleared to land. The pilot then provided another position report over STOGE.

At 1011, the controller observed the accident airplane descend from a cloud layer. The controller asked the pilot if she had the airport in sight, and the pilot replied that she did. The controller then repeated the landing clearance and provided wind information of 110 degrees at 12 knots. The pilot began to read back the wind information and had stated, "one one zero," when the transmission ceased. No further transmissions were received from the airplane. The controller observed the nose of the airplane pitch up and then down, followed by a rapid descent into terrain.

A review of radar data from Boston TRACON and Providence TRACON revealed that the accident airplane approached OWD from the west. The airplane flew through the localizer course for runway 35, but then corrected and intercepted the localizer course near STOGE. The airplane descended on course, slightly to the left, until the last target was recorded about 2.5 miles from the runway 35 threshold. There was limited or no radar contact with the accident airplane during the last few moments of flight.

A witness was driving on Route 95 South in the area of Norwood, Massachusetts. He lived near the airport, and was familiar with approaching aircraft. The witness observed the accident airplane in level flight, and thought it was very low. He estimated the height of the airplane was between 250 to 300 feet above ground level (agl). The windows in his vehicle were up due to rain, and the witness did not hear any sounds associated with the airplane. The witness further stated that the right wing tipped up, the nose tipped down, and the airplane descended rapidly into a swampy area.

The airplane impacted terrain about one-third mile prior to the runway 35 threshold, and approximately 200 feet right of the extended runway centerline.

Personnel information

The pilot, age 57, held a private pilot certificate, with ratings for airplane single engine land and instrument airplane. Her most recent FAA third class medical certificate was issued on October 2, 2006. At that time, she reported a total flight experience of 1,590 hours. The pilot's husband stated that she had owned the accident airplane for approximately 12 years, and had received her instrument rating prior to purchasing it. The pilot's husband also noted that she frequently flew the accident airplane in actual instrument meteorological conditions (IMC).

The pilot kept an electronic flight log on her computer. According to the log, she had accumulated 1,670.2 total hours of flight experience, of which, 27.9 and 38.7 hours were accumulated during the 30 days and 90 days preceding the accident. Of the total flight experience, about 1,342 hours were in the accident airplane, and 158 hours were in IMC. The pilot had flown 6 hours and 9 hours in IMC during the 30 days and 90 days preceding the accident.

Aircraft information

The airplane was manufactured in 1979. A review of the airplane's logbooks, maintenance invoices, and correspondence between the pilot and a maintenance facility at OWD, her home base, revealed that the airplane's most recent annual inspection was completed on April 5, 2007. At that time, the airplane had accumulated 2,205.5 total hours of operation, and the engine had accumulated 1,799.1 hours of operation since new. The airplane flew about 40 hours from the time of the most recent annual inspection until the accident.

A review of the invoice for the annual inspection revealed, "Elevator Trim Chain Appears Loose. Adjusted Chain As Required IAW The Mooney Maintenance Manual. Operations Checked OK."

Shortly after the annual inspection, the pilot experienced a problem with the electric pitch trim. Specifically, it did not work on one occasion at the end of a flight, and on other occasions, it seemed to have difficulty traveling toward the nose up position. On April 26, 2007, the maintenance facility at her home base diagnosed the problem as a "...Bad Connection At Connector On Wire Harness Side & Adjustment of Clutch On Trim Servo...," and the pilot took the airplane to an avionics repair facility.

On May 2, 2007, the avionics repair facility noted:

"Autopilot Auto And Manual Electric Pitch Trim INOP In Up Direction. Ground tested A/P and trim system. Verified squawk. Found manual trim very stiff in up direction. Gained access to trim servo located in tail. Removed trim servo to shop and bench tested. No trouble found. Motor runs good and slip clutch is set correctly. Found trim system stiffness in up direction to be at fault. Gained access to trim jack screw in tail. Lubed jack screw. No improvement. Customer will have mechanic at home base fix trim stiffness. Closed up access and secured aircraft for flight."

On May 9, 2007, the maintenance facility at the pilot's home base noted:

"Troubleshoot Electric Trim Stiff. Troubleshoot, Check Electric Trim. Lubed Jack Screw And Lubed All Bearings. Operations Checked OK."

From May 9 through May 21, the pilot and her husband flew the accident airplane from Massachusetts, to New Mexico, and back to Massachusetts. The pilot had reported intermittent sticking of the pitch trim during that trip. Her husband was also a certificated pilot, and did not notice any trim problems during that trip.

Meteorological information

The reported weather at OWD, at 0953, was: wind 100 degrees at 11 knots; visibility 2 miles in mist; overcast ceiling at 500 feet; temperature 17 degrees Celsius (C); dew point 61 degrees C; altimeter 29.58 inches of mercury.

Review of a current approach chart for the localizer runway 35 approach at OWD revealed that the minimum descent altitude for a straigh

Aircraft

Registration
N4126H
Reported as
Mooney M20J
Category
Airplane
Serial number
24-0769
Airframe hours
2,206
Engine
Lycoming IO-360, 200 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Registered owner
Agnes E. Imregh
Airworthiness certificate
Standard, Normal
Last inspection
Annual · April 1, 2007 · 40 hours before
Departed
N40 · Pittstown, NJ
Destination
OWD · Norwood, MA
Flight plan
IFR
Airport
OWD · Norwood Memorial Airport, runway 35, 4,008 × 100 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
57
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
July 1, 2006
Seat
Left
Toxicology
Performed
Flight hours
1,672 total · 1,342 in this make and model · 39 in the last 90 days · 28 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Day
Wind
100° at 11 knots
Visibility
2 statute miles
Lowest ceiling
500 ft overcast
Temperature
63 °F, dew point 61 °F
Altimeter
29.85 inHg
Observed at
OWD, 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.

Other investigations on N4126H · 1

Matched to the same aircraft by N-number and date.