N1148V – Mooney International M20K – 2004-03-17 NTSB Accident Report

HISTORY OF FLIGHT

On March 16, 2004, about 1703 Pacific standard time, a Mooney M20K, N1148V, descended into a single family residence about 0.5 nautical miles south-southeast (122 degrees, magnetic) of the Santa Monica Municipal Airport (SMO), in Los Angeles, California. Impact forces and fire destroyed the airplane and a portion of the private residence. The two private pilots in the airplane were fatally injured. The male pilot in the left front seat held an instrument rating. The female passenger in the right front seat was not instrument-rated. Neither the sole occupant in the residence nor anyone else on the ground was injured. The male pilot was the registered co-owner of the airplane. Instrument meteorological conditions prevailed, and an instrument flight plan was in effect at the time of the accident. The personal flight was performed under the provisions of 14 CFR Part 91, and it originated from the Mammoth Yosemite (uncontrolled) Airport, near Mammoth Lakes, California, at an undetermined time before 1538.

A friend of the pilot reported to the National Transportation Safety Board investigator that he believed the purpose of the accident flight was to return home following a brief vacation in the Mammoth area where the accident pilot and his wife (the passenger-pilot) had been skiing.

According to the Federal Aviation Administration (FAA), after takeoff the male pilot contacted the Oakland, California, Air Route Traffic Control Center (ARTCC) at 1538. The pilot requested an instrument flight rules (IFR) clearance to SMO. The pilot had previously filed an IFR flight plan for the flight.

The controller radar identified the airplane and issued the requested clearance. The flight proceeded without mishap during its en route phase, and all communications were normal.

Approaching the Los Angeles basin area, the pilot was handed off to a radar controller at the Southern California Terminal Radar Approach Control facility (SCT). At 1643, the SCT controller asked the pilot if he had received SMO's automatic terminal information service (ATIS) "Information Yankee." At 1644, the pilot responded to SCT that he had received "Information Yankee."

The SCT controller provided a clearance for the pilot to proceed toward SMO, and to descend to 4,300 feet mean sea level (msl). The pilot acknowledged the clearance.

At 1655, the SCT controller, after noticing that the airplane's altitude was 4,100 feet and that it was descending to 3,600 feet, reminded the pilot that the assigned altitude was 4,300 feet. The controller told the pilot "you need a clearance prior to making a change of altitude." The pilot replied "I misunderstood," and the airplane's altitude increased.

At 1657:24, SCT issued the pilot an instrument approach clearance to perform the VOR runway 21 instrument approach into SMO. The pilot acknowledged the clearance and proceeded inbound on the approach.

According to the FAA's recorded radar data, about 1659, the airplane flew past the Bevey Intersection (final approach fix) at 2,500 feet, as indicated by the airplane's Mode C altitude reporting transponder. Thereafter, the airplane continued descending while proceeding toward the airport.

As the airplane passed the Culve Intersection (step down fix) it was about 0.3 miles left (south) of the prescribed course.

At 1701:05, the SMO tower controller, who was observing the accident airplane approach the airport on the control tower's digital bright radar indicator (DBrite), transmitted to the pilot "...you appear to be left of course, verify correcting to the right." No reply was recorded from the pilot.

At 1701:36, the SCT controller advised the SMO tower controller to "...watch this guy he is all over."

About 1702:06, when the airplane was approximately 0.4 miles east of the approach end of runway 21 and at 700 feet, the pilot advised the controller that he was "going around." This location was also about 1,000 feet northwest of the crash site. Thereafter, no recorded radar evidence was found of the airplane departing the area.

At 1702:26, the airplane was approximately 900 feet southeast of the crash site at an elevation of 500 feet. About the time of the last radar return, at 1703:08, the airplane was approximately 400 feet north-northwest of the crash site.

The radar data indicates that during the airplane's last (approximate) 1.5 minutes of flight its flight path was consistent with the airplane making two left 360-degree turns within 1/4-mile of a point 0.5 miles southeast of runway 21's threshold. During this time a SMO controller broadcast to the airplane "...if you can hear, fly the published missed approach procedure."

Several witnesses reported hearing and/or seeing the airplane flying below the clouds. In part, the auditory witnesses indicated the airplane's sound gave them the impression that the airplane was circling over the area. Several of these witnesses indicated that the engine revved up as it was descending and then the engine sound completely stopped just before the impact.

The eyewitness reported that the airplane was turning with a steep angle of bank as it descended. One of the eyewitnesses reported that the airplane's bank angle increased from 30 to 60 degrees just before the crash. Another eyewitness reported that the bank angle increased over 60 degrees just before the crash. No witness reported observing fire or smoke trailing from the airplane.

PERSONNEL INFORMATION

Pilot, Left Seat.

The occupant in the left front seat held a private pilot certificate with an instrument rating. He received the pilot certificate in 1982 and the instrument rating in 1984.

A family friend, who co-owned the accident airplane, verbally opined to the Safety Board investigator that the accident pilot had only flown their airplane a couple of times during the past several months. Moreover, the accident pilot would probably not have rented another airplane while their airplane was being repaired. The friend also stated that he believed the pilot was familiar with the airplane's global positioning satellite navigation receiver and the autopilot.

On October 17, 2003, the pilot reported to a representative of the Mooney Aircraft Pilot's Association that his total pilot flight time was 1,897 hours. Also, his total Mooney flying experience was 797 hours, and he had a total of 238 hours of instrument flying experience (all models of airplanes).

According to the pilot's medical records on file in the FAA's Aerospace Medical Certification Division, when the pilot last was last issued an aviation medical certificate on November 14, 2003, he reported that his total flying experience was about 1,600 hours. Also, he had flown about 30 hours during the preceding 6 months.

On a preceding application for an aviation medical certificate, dated November 29, 2001, the pilot had reported that his total flying experience was about 1,520 hours, and he had flown about 60 hours during the preceding 6 months.

In an aviation insurance application dated January 15, 2004, the pilot reported that he had flown 60 hours during the previous 12 months. His total flying experience in the model of accident airplane was 842 hours. The pilot's total flying time in retractable gear airplanes was 1,542 hours.

According to a document filed with the co-owner's aviation insurance company, the pilot satisfactorily completed a flight review in the accident airplane on March 6, 2004. The pilot's indicated total flying experience was 1,550 hours. He had 900 hours in the model of accident airplane

Partially destroyed records found in the burned accident airplane indicated that on March 6, 2004, a person with the initials "PT" flew the airplane for 1.2 hours. On March 8, 2004, a person with the same initials flew the airplane for 1.6 hours. (The letters "PT" correspond to the accident pilot's first and last name.)

Instrument Currency Requirements.

FAA regulations (14 CFR Part 61.57(c)) prescribe the flying currency that a pilot must have in order to operate an airplane under instrument flight rules. In pertinent part, the regulations indicate that no person may act as pilot-in-command in weather conditions less than the minimums prescribed for visual flight rules unless, within the preceding 6 calendar months, that person has performed and logged under actual or simulated instrument conditions (1) at least six instrument approaches, (2) holding procedures; and (3) intercepting and tracking courses through the use of navigation systems.

Acquaintances of the pilot reported that the pilot typically kept his personal flight record logbook in the airplane when he flew. The airplane's cockpit and baggage compartment were totally destroyed by fire. No logbook was found. The Safety Board investigator was not able to document the accident pilot's instrument currency for the accident flight.

Documentation of the pilot's instrument currency was received from the co-owner of the airplane, and from a certified flight instructor (CFI) who flew with the accident pilot a few weeks prior to the crash.

The co-owner reported that he had flown with the accident pilot in August and October 2003, and about 2 weeks before the accident. The co-owner, who is instrument-rated, stated that their flights had been performed under visual conditions, and no simulated instrument flying had been performed.

The CFI who conducted the flight review of the accident pilot on March 6, 2004, reported that he had the pilot perform a 180-degree turn while flying solely by reference to flight instruments. The maneuver was performed in accordance with private pilot standards. The length of the flight under the hood lasted about 2 minutes. The remainder of the flight was performed under visual conditions. No practice instrument approaches were performed. The pilot passed the flight review.

Passenger-Pilot, Right Seat.

The occupant in the right front seat held a private pilot certificate that was obtained in 1999. According to FAA records, when she last applied for and was issued a third-class aviation medical certificate in September 2000, her total flying experience was 120 hours.

Regarding the pilot's currency, no logbook was found. The flight instructor who provided the pilot with her primary flight training verbally reported to the Safety Board investigator that she had not rented airplanes from his flight school in several years.

A family friend verbally reported to the Safety Board investigator that, to the best of his knowledge, the pilot's wife had not flown any airplane in several years. The friend doubted that the wife had been flying the accident airplane because she had not been checked out in it, and most likely she was not current.

AIRCRAFT INFORMATION

The airplane was equipped with a Garmin GNS430 global positioning satellite receiver with a moving map display, which was certificated for use in instrument meteorological conditions. The airplane's autopilot was coupled to its flight director system, and the autopilot was capable of providing electric pitch, roll, and altitude control commands.

The airplane had undergone maintenance between October 3, 2003 and March 3, 2004. During this period the airplane had not been flown. The maintenance resulted, in part, from a hard landing and propeller strike event. In addition to repairs related to this event, additional maintenance was accomplished involving components associated with the airplane's malfunctioning King KCS 55A system. Following the maintenance, the airplane was tested and returned to service.

The co-owner of the airplane verbally reported to the Safety Board investigator that he believed all instruments and systems in the airplane were functioning normally when the accident pilot departed for the round trip flight between SMO and Mammoth. The co-owner stated that the airplane had just been repaired.

METEOROLOGICAL INFORMATION

Pilot Briefings.

At 0713, the pilot called the Riverside Automated Flight Service Station (AFSS) and obtained an outlook pilot weather briefing for an instrument flight rules (IFR) flight from Mammoth to SMO. Thereafter, he filed an IFR flight plan for the flight.

At 1419, the pilot again called the Riverside AFSS. At this time he obtained an abbreviated pilot weather briefing for the IFR flight from Mammoth to SMO.

Weather Conditions, Official Reports.

In pertinent part, the following weather conditions were recorded at SMO:

Time Visibility Sky Condition; Temperature/Dew Point

1621* 1 mile Mist, indefinite ceiling 400 feet above ground level (agl); 15/13 degrees Celsius

1629 1 mile Mist, indefinite ceiling 400 feet agl; 14/13 degrees C

1640 1/2-mile Fog, vertical visibility 400 feet agl; 14/13 degrees C

1651** 1/2-mile Fog, overcast ceiling 200 feet agl; 14/13 degrees C

1710 1/2-mile Mist, overcast ceiling 200 feet agl; 14/13 degrees C

1751 1/4-mile Fog, overcast ceiling 200 feet agl; 14/13 degrees C

*The 1621 weather was broadcast over SMO's ATIS as "Information Yankee."

**When the ATIS was next updated, the 1651 weather was broadcast over the ATIS as "Information Zulu."

Weather Conditions, Witness Reports.

According to ground and airborne witnesses, a layer of low elevation clouds covered the ground inland from the Pacific coast shore line to at least 2 miles east of SMO. Ground-based witnesses located in the vicinity of the accident site reported that no blue sky was visible through the fog bank.

The Safety Board investigator noted that, about the time of the accident, the sky condition about 10 miles east of Santa Monica was mostly clear. The layer of coastal fog observed in the Santa Monica area was moving inland (eastward).

AIDS TO NAVIGATION

To assist pilots in locating and descending to the runway, visual lighting aids were installed at the airport in addition to a radio navigation aid.

Visual Navigation Aids.

At SMO, runway 21 is equipped with a visual glideslope indicator, known as a precision approach path indicator (PAPI). Also installed are runway end identifier lights (REIL).

The FAA airways facilities aircraft accident representative reported that both the PAPI and the REIL are normally operating during daytime hours. Also, the FAA did not have any indication that these facilities were not operating normally at the time of the accident.

Radio Navigation Aids.

An airport-based very high frequency omnidirectional range (VOR) is collocated with distance measuring equipment (DME) at SMO. These aids to navigation are located near the departure end of runway 21. The VOR is without voice on its frequency.

According to the FAA, all electronic aids to navigation pertinent to the airplane's approach into SMO were functioning normally at the time of the flight.

AIRPORT AND INSTRUMENT APPROACH INFORMATION

SMO's elevation is 175 feet msl. Runway 21 is 4,987 feet long by 150 feet wide, and it has an asphalt surface.

The airport is equipped with an automated surface observing system (ASOS). The installed limited aviation weather reporting station (LAWRS) reports cloud height, weather, obstructions to vision, temperature and dew point, surface wind, altimeter and pertinent remarks.

The FAA published a VOR/GPS-A instrument approach procedure (IAP) to the airport. For the accident airplane's circling approach, the minimum descent altitude (with identification at the Culve intersection) is 680 feet msl. The minimum visibility for landing is 1 statute mile. No straight-in landing procedure is published.

WRECKAGE AND IMPACT INFORMATION

The main wreckage was found beneath the demolished roof of an impact and fire-damaged single-family one story residence, about 34 degrees 00.89 minutes north latitude by 118 degrees 26.25 minutes west longitude. The on-scene examination of the accident site and airplane wreckage revealed the south wall of the residence and a parked automobile were also destroyed by fire. Homes circumferentially located around the main impact site did not sustain impact damage.

The airplane's propeller, engine assembly, and the forward cockpit area were found on a northerly heading (about 340 degrees, magnetic) in the kitchen area of the residence, at ground level. The wings and aft empennage were found a few yards south and east of the kitchen. The approximate roof elevation at the initial point of impact is 200 feet msl.

Evidence was observed indicating the entire airframe (from wing tip to wing tip and from the propeller spinner to the tailcone) was present at the main wreckage site. The engine was found displaced in an aft direction into the firewall. The entire span of the left wing's leading edge was crushed in an aft direction.

No evidence was observed of a preimpact fire. Snow skies were found in the airplane wreckage.

MEDICAL AND PATHOLOGICAL INFORMATION

Pilot, Left Seat.

During the 1980s, the pilot was diagnosed as having coronary artery disease (CAD). He experienced an acute myocardial infarction in 1989. During the 1990s, he was diagnosed with other ailments and received medical treatment. By 2000, the pilot's CAD had progressed, and the FAA did not renew its authorization for special issuance of an airman medical certificate because of "objective evidence of ongoing coronary artery disease and myocardial ischemia by coronary catheterization and radionuclide scintigraphy." The pilot underwent coronary artery bypass grafting.

Thereafter, the pilot underwent a series of examinations and tests. In February 2002, the FAA's manager, Aeromedical Certification Division, Civil Aeromedical Institute, issued the pilot a letter stating, in part, that he had reviewed information submitted by the pilot in support of his request for an airman medical certificate. The manager stated that "the medical evidence reveals a history of myocardial infarction and coronary artery disease requiring percutaneous transluminal coronary angioplasty and coronary artery bypass graft surgery. You are ineligible for third-class medical certification ....However, based on the complete review of the available medical evidence, I have determined that you may be granted authorization for special issuance of the enclosed third-class airman medical certificate...." The certificate was issued with an expiration date of November 30, 2002.

The FAA's airman's medical records indicate that the pilot's most recent third-class aviation medical certificate was issued on November 14, 2003. It bore the limitation that the pilot must wear corrective lenses for near and distant vision.

Autopsy Findings.

On March 19, 2004, an autopsy was performed on the pilot by the Los Angeles County Coroner's Department. In part, the coroner reported observing evidence of the previous surgical intervention with bilateral saphenous vein-type grafts. In the autopsy report, the coroner reported "...one of the saphenous vein grafts appears to be patent. The other saphenous vein graft appears to be partially occluded along its proximal length and is approximately 80 percent eccentric atherosclerotic narrowing. The native coronary arteries show marked atherosclerosis, calcification and hardening, and show greater than 90 percent eccentric atherosclerotic narrowing." Following the coroner's review of the autopsy findings, he opined that the pilot died of multiple blunt force traumatic injuries.

Toxicological tests were performed on specimens from the pilot by the coroner and the FAA's Bioaeronautical Sciences Research Laboratory. No evidence of screened drugs or ethanol was detected.

Pilot (Passenger) Right Seat.

The pilot-passenger's last aviation medical certificate was issued in 2000 with the limitation that she wear corrective lenses. No evidence of physical ailments was reported.

Toxicological tests were performed on specimens from the pilot-passenger by the FAA. No evidence of screened drugs or ethanol was detected.

TESTS AND RESEARCH

Maintenance Records Review.

At the direction of the Safety Board investigator, FAA personnel reviewed the airplane's maintenance records for the 24-month period preceding the accident. In summary, the FAA reported that the airplane's pitot/static system and transponder tests were completed in July 2002. The airplane received its last annual inspection in July 2003. The engine was overhauled in February 2004. All records concerning the airworthiness of the airplane were found in compliance with applicable regulations, and no discrepancies were noted.

Engine, Accessory and Propeller Wreckage Examinations.

The entire exterior of the engine was observed charred. Components including the throttle body, oil cooler, vacuum pump, magnetos, starter, oil filter adapter and the alternator either had been broken off or were deformed. The vacuum pump coupling was found melted. The crankshaft was found fractured forward of the oil seal, and the fracture surface exhibited 45-degree facets. The top spark plugs exhibited "nominal electrode erosion" according to the Continental Engine participant. All rocker arms and piston domes were intact and exhibited thermal damage. All gears in the accessory section were also found intact. The participant reported that no evidence of preimpact damage was found.

The propeller governor incurred both thermal and mechanical damage. The three propeller blades were found attached to the hub assembly. They exhibited leading edge nicks. The spinner was torsionally deformed in a direction opposite that of crankshaft rotation.

Airframe Examination.

All of the airplane's flight control surfaces were located at the impact site, with the exception of the right horizontal stabilizer, right elevator, and the upper portion of the rudder assembly, which were mostly consumed by the post impact ground fire. The fire destroyed the cockpit, fuselage, and most of the instruments including the installed global positioning satellite receiver with its moving map indicator. The landing gear was found in the extended (down) position.

The throttle was found in the closed position. The propeller control was full forward. The mixture was in the midrange position.

Instrument Examination and Settings.

The glass covering the impact and fire damaged King KCS 55A Pictorial Navigation Indicator (PNI) was removed and the indicator face was photographed and examined. This instrument, with the related slaved compass and associated instruments, provides the pilot with a visual display of the airplane's heading and position in relation to a desired course. The PNI was fire damaged and could not be functionally tested. A visual examination of the PNI revealed the following:

1. The "NAV" warning flag was displayed. The "HDG" warning flag was not displayed. According to the component's manufacturer, these flags become visible under normal operating conditions when electric power is off.

2. The Compass Card indicated the airplane's magnetic heading was about 267 degrees.

3. The Selected Course Pointer (commonly referred to as the omni bearing selector or "OBS") indicated the desired VOR course was set to 210 degrees.

4. The VOR Deviation Bar (commonly referred to as the course deviation indicator or "CDI") was at full right deflection, or about 5 dots. Note, this indicates the airplane was left of the 210-degree inbound course. Note, when tuned to a VOR frequency, each dot represents 2 degrees of course deviation.

5. The Heading Select Bug, which is used to select the desired flight heading, was set to 212 degrees.

6. The To-From Indicator was not visible.

See the King KCS 55A Compass System "Pilot's Guide," included as an exhibit to this report, for additional information about this instrument.

Because of the impact and fire damage, no determination could be made regarding whether the airplane's navigation equipment had been set to the GPS approach or to the VOR tracking mode at the time of the accident. Similarly, no determination could be made regarding whether the flying pilot was hand flying the airplane or was in the flight director (autopilot) mode. Unless a pilot overrides the autopilot, bank angle is limited to 25 degrees maximum in the flight director mode, according to personnel at Kim Davidson Aviation, Inc., the FAA certificated repair station which last performed maintenance on the airplane at SMO.

Weather Reporting and Dissemination Requirements.

FAA Order 7900.5, entitled "Surface Weather Observing," states, in part, that all weather reports "...shall be given local dissemination. When reports are corrected, the corrected report shall be given the same dissemination as the report being corrected."

Additionally, special observations "...shall be completed and transmitted as soon as possible..." after conditions meeting the special criteria are observed or detected. In pertinent part, the observer shall take, record and disseminate a special observation when the "visibility as reported in the body of the report decreased to less than...1 mile...or the lowest standard instrument approach procedure minimum as published in the U.S. Terminal Procedures."

Issuance of Safety Alerts and Operating Procedures.

FAA Order 7110.65, entitled "Air Traffic Control" states, in part, that a controller's duty priority is to "give first priority to separating aircraft and issuing safety alerts...." The safety alert is to be issued to an aircraft once the controller observes and recognizes a situation wherein the aircraft is in unsafe proximity to terrain, obstacles, or other aircraft. The controller "...must remain vigilant for such situations...."

The FAA Order also requires that controllers maintain an ATIS message that reflects the most current arrival information and make a new recording upon receipt of any new official weather. Controllers shall ensure that pilots receive the most current pertinent information and ask the pilot to confirm receipt of the current ATIS information if the pilot does not initially state the appropriate ATIS code.

Instrument Approach Procedure.

The minimum descent altitude (MDA) for the airplane, with identification at the Culve Intersection, is listed on the SMO VOR or GPS-A instrument approach procedure charts as 680 feet msl. The minimum visibility for landing is listed as 1 mile.

Flight Track.

A review of the FAA's recorded radar data indicates that throughout the duration of the airplane's approach toward SMO, it was continuously tracking left (south) of the prescribed inbound course. For additional details regarding the track and the air traffic controllers' handling of the accident airplane, see the Safety Board's "Air Traffic Control Factual Report."

ADDITIONAL INFORMATION

The airplane wreckage was released to the owners' assigned insurance adjuster on April 1, 2004. No parts were retained.