SEA00FA039

NTSB accident investigation · Mooney M20K · Pendleton, OR · January 24, 2000

Accident · FatalField investigationFinal report
Date
January 23, 2000, 18:53 local (Jan 24, 2000, 02:53 UTC)
Place
Pendleton, OR
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Initial climb
Aircraft
N251BDMooney M20K
Weather
Instrument (IMC) · Night/dark
Status
Completed · report February 23, 2001
Report
Approved by Office Director
FAA report
20000123006639A
Case key
48550

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 adequately remove ice and snow from the airplane. A contributing factor was the pilot's inability to maintain control during climb due to degradation of the airplane's aerodynamic performance.

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 flightTakeoff - initial climb
Ice/frost removal from aircraft - inadequatePilot in commandCause
Aircraft control - not maintainedPilot in commandFactor
In flight collision with terrain/waterDescent - uncontrolled

Analysis

After landing to refuel, the pilot made an inadequate effort to remove airframe ice and snow, which had accumulated while on the ground before departing for his final destination. A witness (refueler) observed that about a half inch of somewhat moist snow had accumulated on the wings of the airplane prior to the time he fueled the airplane, necessitating brushing snow away from the fuel caps. The witness (refueler) stated that after wiping the snow off, there was still a covering of rough ice on the upper surface of the wing. During the fueling, he noticed that none of the ice on the wing had melted (ambient temperature at the time of the accident was minus 1 degree Celsius). The witness (refueler) also reported that after refueling the airplane, he looked at the right wing leading edge and pointed out some rough ice behind the area that the pilot had cleared, both on top and bottom of the wing. The pilot had rubbed his hand over the rough area, commenting that there wasn't enough ice to make any difference, before attempting his takeoff. The airplane crashed within two miles of the airport. The pilot's last radio communication received was that he was 'going down.' Post-crash examination of the engine revealed no evidence of pre-impact malfunction.

Factual narrative

History of flight

On January 23, 2000, at 1853 Pacific standard time, a Mooney M20K, N251BD, was destroyed when it collided with terrain approximately 1.5 miles from the end of runway 29, shortly after takeoff from Pendleton, Oregon. The private pilot and his passenger were fatally injured. The airplane had been cleared for takeoff approximately two minutes before the pilot declared a "Mayday." Instrument meteorological conditions prevailed, and the pilot had received an Instrument Flight Rules (IFR) clearance to climb to ten thousand feet mean sea level (MSL) en route to Eugene, Oregon. The airplane burned after impact. The emergency locator beacon (ELT) assisted in the location of the wreckage.

The pilot had departed Billings, Montana, earlier in the day on a Visual Flight Rules (VFR) flight plan, with a destination of Creswell, Oregon. While en route, he had picked up an IFR clearance, and had closed his VFR flight plan. He had elected to land at Pendleton while en route. During approach to Pendleton, he had advised that he was encountering icing conditions, and had requested that after-hours refueling be made available. After landing, he had parked on the ramp and his airplane was refueled ("topped off") with 36.6 gallons of 100 octane low-lead aviation gasoline.

The pilot borrowed a 2" x 6" wheel chock from the refueler and - according to the refueler - "...started pounding the leading edges of the wings and vertical stabilizer. After finishing the vertical stabilizer, he [the pilot] made the comment that his airplane was now deiced." The refueler, who was a highly experienced general aviation commercial pilot, did not specifically observe the pilot knocking the ice off the leading edge of the horizontal stabilizer.

During an interview by investigators, the refueler stated that about a half inch of somewhat moist snow had accumulated on the wings of the airplane prior to the time he fueled the airplane, necessitating brushing snow away from the fuel caps. He stated that after wiping the snow off, there was still a covering of rough ice on the upper surface of the wing. During the fueling, he noticed that none of the ice on the wing had melted (ambient temperature at the time of the accident was minus 1 degree Celsius).

In a written statement, the refueler stated, "after refueling, I looked at the right wing leading edge and pointed out some rough ice behind the area that he [the pilot] had cleared, both on top and bottom of the wing. Rubbing his hand over the rough area, he commented that there wasn't enough ice to make any difference."

"He then paid for the fuel, requesting a cash receipt. I went to the office to complete a receipt and then returned to the aircraft. I did not leave my vehicle and did not observe whether or not any additional snow or ice had been removed from the wing. The aircraft departed immediately. I observed the aircraft taking off about 1/3 of the way down the runway. It appeared and sounded normal."

The air traffic controller observed the airplane using most of the 5,581-foot runway during its takeoff roll. After losing sight of the airplane, and issuing a hand-off to contact departure control, he heard the pilot radio "Mayday, mayday, two five one bravo delta going down." There were no further communications with the airplane.

The wreckage was located in rolling terrain about 1.5 miles west-northwest of the departure end of the runway.

Meteorological information

The most recent weather sequence, at 1856 local, reported winds of 350 degrees at 3 knots, visibility 1 statute mile with light snow and mist, a broken cloud layer at 700 feet, 1,500 foot overcast, temperature and dew point of minus 1 degree Celsius, altimeter 30.04 inches Mercury, and tower reporting visibility of two miles.

Communications

Contract tower personnel at Pendleton air traffic control tower stated that the pilot called for an IFR clearance at 1848, taxi clearance at 1849, and called ready for departure at 1851. The controller logged the departure as 1855 from runway 29, IFR to Eugene.

Wreckage and impact information

The wreckage was located in an open field at N45 degrees 42.85 minutes, W118 degrees 52.66 minutes, approximately 8,150 feet from the departure end of runway 29, and slightly to the right of the extended centerline. At the time of inspection by investigators, the surface was muddy, with several inches of snow. The wreckage was oriented on a heading of 175 degrees on the centerline of the fuselage, from tail to nose. A ground impact scar, of about 40 feet overall length, and oriented on a heading of 016 degrees toward the main wreckage, was observed. The right-hand wing tip was located next to the ground scar, furthest from the main wreckage. The inboard section of the right wing, followed by the outboard section of the right wing, were located between the main wreckage and the ground impact scar. The right landing gear was found retracted in the wheel well, and the right flap was up.

The cockpit area, forward of the trailing edge of the wing, was consumed by fire, and it was still smoldering at the time of the onsite investigation. The tailcone, aft of the cabin area, exhibited extensive wrinkling. The empennage surfaces were intact; the elevator was resting in the down position, and the rudder was neutral. Control continuity of the rudder and elevator was established to the aft portion of the cabin

The vacuum pump was disassembled; its rotor was fractured, its vanes were intact. The coupling was consumed by fire.

One blade of the two-bladed propeller was exposed; the other was embedded in the surface. The exposed blade exhibited leading edge gouges and scratches running diagonally across the face. The blade was bent aft in a gentle arc.

Medical and pathological information

SallyAnn G. Clausen, M.D., conducted the post-mortem examination of the pilot at the facilities of Burns Mortuary, 336 SW Dorion, Pendleton, Oregon, on Jan 24, 2000. The FAA's Toxicology Accident and Research Laboratory, Oklahoma City, Oklahoma conducted toxicological evaluation of samples from the pilot. The findings were reported as negative (refer to attached TOX report).

Tests and research

The engine was disassembled and inspected at the facilities of Teledyne Continental, Mobile, Alabama, on August 23, 2000. There was no evidence of pre-impact malfunction noted during the examination.

Additional data

The wreckage, except for the engine, was released to the insurance adjuster, as owner's representative, on March 9, 2000. The engine was released to the insurance adjuster on August 29, 2000 (refer to attached NTSB Form 6120.15).

Aircraft

Registration
N251BD
Reported as
Mooney M20K
Category
Airplane
Serial number
25-0364
Engine
Continental TSIO-360-LB1, 200 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Operator
Heine, Doug L.
Registered owner
Bd Air, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
Annual · September 9, 1999
Departed
PDT · Pendelton, OR
Destination
EUG · Eugene, OR
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
48
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Valid Medical--no waivers/lim.
Seat
Left
Toxicology
Performed
Flight hours
3,900 total

Weather

Conditions
Instrument (IMC) · Night/dark
Wind
350° at 3 knots
Visibility
1 statute miles
Lowest ceiling
700 ft broken
Temperature
30 °F, dew point 30 °F
Altimeter
30.00 inHg
Observed at
PDT, 2 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.