Avalon, CA, USA
N201EN
MOONEY M20J
The airplane was taking off from an airport on top of a mountain, at 1,602 feet mean sea level, on a runway surrounded on three sides by cliff-like precipitous drop-offs. Shortly after liftoff the airplane began to wobble and perform in an unstable manner, making contact again with the runway at about 2/3 of its length. The airplane then veered left off the runway, traveling through a gravel infield area in a nose-high attitude with the main landing gear still on the ground. The airplane continued through the gravel before veering back onto the runway surface just before the pavement ended and the terrain dropped away steeply at the departure end. The airplane descended into the valley and collided with downward sloping terrain. The airplane was destroyed by postimpact fire. The uphill slope of the first 2/3 of the runway made it appear much shorter than it actually was. No obvious preimpact anomalies were noted with the airframe. The engine intake valve cam lobes exhibited wear that could have resulted in a reduction of engine power, but this reduction would have occurred progressively over an extended period of time prior to the accident. It was unclear whether a reduction in engine power could have significantly affected the airplane's performance. The gross weight could not be determined with certainty; however, the airplane was loaded on the inbound trip with the same amount of passengers and baggage as the accident flight, and fueling facilities did not exist at the accident airport. The autopsy results were consistent with a cardiac event suffered by the pilot at some point around the time of the accident, but the pilot had not reported any symptoms and was actively controlling the aircraft and speaking with the surviving passenger during the accident sequence.
HISTORY OF FLIGHT On October 20, 2008, about 1315 Pacific daylight time, a Mooney M20J, N201EN, collided with descending terrain during takeoff from runway 22 at the Catalina Airport, Avalon, California. The certificated private pilot was operating the airplane under the provisions of 14 Code of Federal Regulations Part 91. The private pilot and two passengers were killed; one passenger sustained serious injuries. The airplane was destroyed by post impact fire. Visual meteorological conditions prevailed and no flight plan was filed. The personal flight departed Catalina with a planned destination of Corona Municipal Airport, Corona, California. Visual meteorological conditions prevailed, and no flight plan had been filed. The passenger reported that the outbound flight departed from John Wayne-Orange County Airport, Santa Ana, California, on October 17, 2009, about 1430. He did not notice anything unusual about the takeoff roll, but noted that the runway was longer than Catalina. He further stated that the flight to Catalina was uneventful. The pilot and passengers then remained in the Catalina area for the next 3 days. The passenger reported that during the trip the pilot appeared in good spirits, and did not appear to be suffering from any medical ailments. For the accident flight, he reported the ground roll to be slower and "labored" when compared to the flight to Catalina, and that the airplane seemed to be, "going and going" on the runway surface. The airplane then took off and immediately began to "wobble." About the runway midpoint he sensed the airplane begin to slow down, and then accelerate. As they approached the end of the runway he observed the pilot pulling back on the control yoke and reported that the pilot then stated, "I'm sorry." The passenger then looked forward as the airplane descended beyond the runway bluff and towards the lower terrain. His next recollection was of being outside the airplane, which was now engulfed in flames. The passenger reported that the pilot did not appear to be incapacitated at any time during the flight. He further stated that there were no obstructions on the runway, and no birds or wildlife interfered with the takeoff. A witness to the accident was located on a road below, and to the northwest of the runway 22 departure bluff. Prior to witnessing the accident, he looked up and observed an airplane takeoff. He then observed the accident airplane depart, but this time further to the left of the runway centerline. As the airplane departed the bluff it began to bank to the right and dive out of his view. He observed dust and fire erupt in the valley below. He did not observe smoke trailing from the airplane during the sequence, and reported that the engine appeared to be running at a high engine speed. PERSONNEL INFORMATION A review of Federal Aviation Administration (FAA) airman records revealed that the 74-year-old pilot held a private pilot certificate with ratings for airplane single-engine land, and instrument airplane. He held a third-class medical certificate issued on February 27, 2007, with limitations that the pilot must wear corrective lenses. An examination of the pilot's flight logbook revealed that the last flight time entry was on September 15, 2007. At that time the pilot reported a total of 1,348 hours flight experience, 27 hours of which were flown in the accident airplane. His most recent documented flight experience at Catalina airport occurred on December 18, 1983. A witness at Corona airport stated that he observed the pilot flying the accident airplane between 30 and 40 times during the 18 months preceding the accident. AIRCRAFT INFORMATION The four-seat, low-wing, retractable-gear airplane, was manufactured in 1977. It was powered by a four-cylinder, fuel-injected, Textron Lycoming IO-360 200-hp engine, and equipped with a McCauley two blade, constant-speed propeller. Maintenance records indicated that an annual inspection was completed on June 20, 2008, at a recorded tachometer time of 3,478 hours. At the time of the annual inspection, the engine had accumulated a total time in service of 3,476 hours. The engine had accrued 743 flight hours since the most recent major overhaul, which was performed in March 1997. The maintenance logbooks revealed that from November 2004 to January 2006, the engine accumulated 23 hours of flight time, and the engine oil and filter were changed one time. For the remaining period until February 2007, the engine accumulated 20 hours of flight time, and received one engine oil and filter change. Fire damage prevented observation of the tachometer time at the accident site. Weight and Balance The weight and balance sheet for the airplane revealed a basic empty weight of 1,795.34 pounds, and a useful load of 944.66 pounds. According to the Pilot Operating Handbook (POH) applicable to the accident airplane, the total usable fuel capacity was 64 gallons. Fueling records revealed that the airplane was last serviced with the addition of 27 gallons of 100LL octane aviation fuel at Corona Municipal Airport on October 17, 2008, at 1337. The total weight of the front seat occupants was 387 pounds, and 255 pounds for the rear seat occupants. The surviving passenger, who was located in the forward right seat, reported that three duffel bags and three hanging clothes bags were loaded into the aft baggage area of the airplane. The airplane was loaded with the same baggage as on the outbound flight. He estimated the total weight of the baggage to be about 160 to 200 pounds, and that they needed to, "cram" the bags into the aft of the airplane. The NTSB investigator-in-charge weighed the remnants of partially burned baggage at the accident site. The baggage was recovered from the aft of the airplane, behind the rear seats, and weighed approximately 80 pounds. The POH applicable to the accident airplane, states that the maximum allowable weight in the baggage compartment is 120 pounds. Performance The POH states that with the airplane loaded to its maximum gross weight, and for weather conditions at the time of the accident, departing on a level runway, the takeoff ground roll distance would be about 1,050 feet. METEOROLOGICAL INFORMATION An aviation routine weather report for Catalina airport was issued at 1251. It stated: winds from 260 degrees at 5 knots; visibility 10 miles; clear skies; temperature 18 degrees C; dew point -2 degrees C; altimeter 30.10 inches of mercury. AIRPORT INFORMATION The FAA Airport/Facilities Directory (AFD), Southwest US, indicated that Catalina airport runway 22 was 3,000 feet long and 60 feet wide. Runway 22 slopes up 1.8 percent for the first 2,000 feet, with the remaining surface level. The runway surface was composed of asphalt. The airport remarks section further stated: 'Pilots cannot see aircraft on opposite ends of runway due to gradient. Rwy 04-22 surface rough with numerous potholes and soft spots. Potholes and loose fragments on runway. Rwy 04-22 safety area both ends, 1600'+ dropoffs to sea.' Catalina airport was not equipped with fueling facilities. The AFD noted that John Wayne Airport has two asphalt surface runways, with lengths of 5,701 and 2,887 feet, respectively. Both runways exhibit a 0.4 percent uphill gradient to the south. WRECKAGE AND IMPACT INFORMATION Two sets of tire marks, and a 20-foot-long paint transfer mark were noted on the runway surface at the runway crest, about 2,100 feet beyond the beginning of runway 22. The tire marks matched the dimensions of the main landing gear (MLG) of the airplane, with the dimension of the paint transfer corresponding to the location of the right wing tip. The tire marks continued off to the left edge of the runway surface, and onto an adjacent infield gravel area for an additional 800 feet before traversing to the right and back onto the left edge of the runway. The MLG tire marks continued straddling the runway edge and the infield area for the remaining 200 feet of the runway before ending in soft soil at a point where the terrain dropped away. A 20-foot-long impression with dimensions corresponding to the nose wheel was observed in the gravel area about the 2,540-foot mark. A similar impression was additionally noted with the MLG in the soft soil area at the runway drop off. No other impressions corresponding to the nose wheel were observed. The first identified debris was the left wing tip and aileron, located at the base of a tree 700 feet beyond, and 150 feet below the runway. The tree exhibited multiple freshly broken limbs at approximately the 15-foot level. The debris path, which consisted of clear sections of plastic, continued on a heading of 250 degrees magnetic to the main wreckage, located 190 feet beyond the left wing tip. The airplane came to rest in a ravine on a heading of 330 degrees magnetic, approximately 180 feet below the departure end of runway 22. The airplane remained largely intact; the cabin area and inboard wing sections were consumed by fire. The underside of the right wing tip, and the outboard trailing edge of the right aileron exhibited scrape marks. The paint colors in the scraped areas resembled the color of paint chips located in the transfer mark on the runway surface. The left flap, and right elevator were folded under their respective wing surfaces. The right wing sustained upward leading edge crush damage along its entire length. The left wing exhibited a circular indentation, the diameter of which was consistent with that of a tree trunk located at the initial impact point. According to emergency response personnel, the engine had originally been identified with the main wreckage, but rolled approximately 25 feet forward of its initial resting point during firefighting efforts. All major sections of airplane were accounted for at the accident site. Airframe Control continuity was confirmed for all control surfaces through to the center cabin area. Impact and fire damage precluded confirmation of control surface continuity through to the cockpit controls. The elevator moving tail trim jack screw was extended 7/8 inch, which the Mooney representative stated corresponded to a takeoff trim setting. Fire damage prevented determination of the flap position setting. Examination of the remaining airframe and flight control system components revealed no obvious evidence of preimpact mechanical malfunction. Engine The engine was damaged by fire and attached to the engine mount, which had become separated from the firewall. The single drive dual magneto and mechanical fuel pump were completely consumed by fire. The accessory case was thermally damaged and remnants of the fuel pump were observed on the casing. Safety wire was noted in the fuel pump attach bolts. The propeller governor was consumed by fire. The spark plugs were removed and examined. The spark plug electrodes remained mechanically undamaged, dark gray in color, and oil soaked. The spark plugs displayed wear signatures consistent with normal operation referencing the Champion Aviation Spark Plugs Check-A-Plug form AV-27. Examination of the fuel injectors revealed that their passages were clear. The fuel injector servo was fractured at its mounting flanges and separated from the intake manifold; the mixture and throttle control linkages were observed attached to their respective control arms. The fuel divider was internally inspected and its diaphragm appeared intact. Drive train continuity was confirmed through to the accessory case by rotation of the propeller hub. All valves lifted in the appropriate order, and thumb compression was obtained on all cylinders. Residual oil was observed within the rocker cover areas and in the oil sump. Cylinders number two and four were removed to allow for internal engine examination. The camshaft was intact, and each of the shared intake valve cam lobes exhibited scoring and wear signatures. The Lycoming representative stated that the lifting peaks of the shared cam lobes were worn to about 75 percent of their original size, and that this could result in an undetermined reduction in engine power. One propeller blade exhibited an s-shaped bend with twist from root to tip; the other propeller blade was bent aft at the root. MEDICAL AND PATHOLOGICAL INFORMATION Autopsies were conducted by the Los Angeles County Department of the Coroner. The cause of death for both rear seat occupants was reported as the combined effects of blunt force and thermal injuries. The cause of death for the pilot was reported as the combined effects of blunt force and thermal injuries. The autopsy report also noted "severe coronary atherosclerosis" with "almost complete occlusion by a thrombus of the left anterior descending coronary artery." The pilot's most recent application for a third-class airman medical certificate indicated "No" in response to "Do You Currently Use Any Medication," to all items under "Medical History," and to "Visits to Health Professionals Within the Last 3 Years." The pilot reported his occupation as a physician. Toxicological tests on specimens from the pilot were performed by the FAA Civil Aeromedical Institute. Analysis revealed no findings for carbon monoxide or cyanide. The results were negative for all screened drug substances and ingested alcohol. Refer to the attached toxicology report for specific test parameters and results.
The pilot's failure to maintain aircraft control during takeoff for undetermined reasons. Contributing to the accident was the pilot's failure to abort the takeoff while sufficient runway remained to stop.
Source: NTSB Aviation Accident Database
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