Accident Details
Probable Cause and Findings
The pilot’s exceedance of the airplane’s critical angle of attack during a climbing turn during a go-around, which resulted in an aerodynamic stall and loss of control.
Aircraft Information
Registered Owner (Current)
Analysis
On November 21, 2023, at 1748 central standard time, a Mooney M20C airplane, N1204X, was destroyed when it was involved in an accident near Plano, Texas. The pilot was fatally injured, and one person on the ground sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.
The airplane departed from Eagle Roost Airpark (27AZ), Aguila, Arizona. According to the pilot’s friend, the purpose of the flight was for the pilot to travel to Plano, Texas, to visit family and friends.
According to Air Traffic Control (ATC) data, the pilot was inbound to Air Park–Dallas (F69) and advised the Addison ATC tower controller that it may be too dark, and he might have to divert to Addison Airport (ADS) Dallas, Texas. The airplane overflew F69, and the controller informed the pilot that the airport was 1 mile behind him. The pilot turned back towards F69, reported the field in sight, and asked for a wind check. The controller stated the wind at ADS was from 320 degrees at 12 kts gusting to 18 kts and offered a transfer of communication to the F69 Common Traffic Advisory Frequency; however, the pilot elected to remain on the controller’s frequency. The pilot aligned with runway 34 at F69 and initiated a go-around over the runway. The controller queried the pilot if he was going around but did not receive a response. ATC data indicated the airplane was 0.5 miles northwest of F69 at 900 ft and 60 kts when radar contact was lost.
Multiple witnesses reported seeing the airplane attempt to land on runway 34 and subsequently perform a go-around. During the go-around, witnesses observed the airplane’s left wing dip perpendicular to the ground and enter a near-vertical descent. Several surveillance cameras also captured the attempted landing, go-around, climb, wing dip, and descent toward terrain.
The airplane impacted a shopping center parking lot about 0.25 miles west of the departure end of the runway. A post-impact fire ensued and spread to an unoccupied vehicle. The airplane was destroyed by the fire.
The main wreckage came to rest inverted. The engine separated from the fuselage and was embedded about 2 ft into the ground with the propeller just north of the main wreckage. Both wings remained attached to the fuselage and exhibited leading edge accordion crush damage consistent with a nose-low impact. Black rubber transfer and broken pavement, consistent with the landing gear being extended, were located on the pavement at the accident site.
A postaccident examination revealed that the entire engine exhibited damage consistent with impact. Cylinder No. 1 was impact-separated. The fuel inlet screen was clean. The carburetor was impact-separated. The brass carburetor floats moved freely and exhibited hydraulic deformation. The engine crankshaft could not be rotated due to impact damage. A borescope was used on cylinder Nos. 2, 3, and 4 with no anomalies noted. The starter was impact-separated and exhibited rotational scoring on the housing consistent with contact with the starter ring gear rotating at impact. The oil suction screen and carburetor inlet screen were clean and clear of debris. The engine-driven fuel pump was impact-damaged and could not be tested. The magnetos were found attached to the accessory section with thermal damage and could not be functionally tested. The elevator trim position was found to be between a takeoff and nose-up position. The propeller and hub assembly was impact-separated from the crankshaft aft of the propeller flange. Both propeller blades were located with the engine. One blade tip was impact-separated. Both blades showed rotational scoring, and one blade was bent aft and showed leading edge damage. The propeller governor mount was fractured but remained attached to the accessory case. The propeller governor rotated by hand.
Instruments capable of recording engine data were sent to the NTSB recorders laboratory; however, all internal electronic components were damaged, and no non-volatile memory was recovered. The Electronics International R-1, which records the last flight time, peak rpm and a limited history of rpm values, revealed that the last recorded flight was 3 hours and 41 minutes in duration, and the peak rpm was 2590 rpm. No timestamps were recorded on the device.
A NTSB video study was conducted based on visual information obtained from a video recorded by a camera installed on a commercial building. The study concluded that the banking airplane transitioned from stable flight at a speed close to the stall speed to flight with a large bank angle and crashed shortly thereafter. Based on video evidence, the pilot appeared to have made control inputs during the landing attempt and go-around.
According to the FAA medical case review, the 87-year-old male pilot’s last aviation medical examination was June 17, 2016. At that examination, the pilot reported a history of high cholesterol and coronary artery disease. He reported taking pravastatin, a prescription medication commonly used to treat high cholesterol and aspirin, an over-the-counter anti-inflammatory medication commonly used to reduce cardiovascular risk. The pilot was issued a third-class medical certificate by Special Issuance, with the limitation that he must wear corrective lenses for distance and have glasses for near vision, and not valid after June 2017. Most recently, the pilot completed a BasicMed course in July 2023 and reported completing a Comprehensive Medical Examination Checklist in June 2021.
According to the FAA medical case review, at previous aviation medical examinations, the pilot had also reported a history of high blood pressure that was noted to be qualified under Conditions Aviation Medical Examiners Can Issue, and bilateral cataract surgeries. In 2002, after complaints of chest pain, the pilot underwent a coronary artery bypass grafting (CABG) surgery for coronary artery disease. Post-operatively, he was treated for a deep vein thrombosis (DVT) with blood thinners. The pilot was denied medical certification in June 2003 for angina (chest pain), coronary artery disease, CABG, and inadequate stress test results. The denial was appealed. In June 2004, the FAA granted the pilot an Authorization for Special Issuance for angina, coronary artery disease, CABG, high blood pressure, and DVT requiring blood thinners. The Special Issuance was renewed multiple times from 2005 to 2016.
The Collin County Office of the Medical Examiner performed the pilot’s autopsy and determined his cause of death was multiple blunt force trauma and his manner of death was accident. Due to the extent of his injuries, the pilot’s autopsy was severely limited for evaluation of natural disease; his brain, heart, and lungs were not available for examination.
The FAA Forensic Sciences Laboratory performed toxicology testing of postmortem specimens of the pilot. Pravastatin, tamsulosin, and terbinafine were detected in muscle and liver tissue. Pravastatin is a prescription medication commonly used to treat high cholesterol. Tamsulosin is a prescription medication commonly used to treat symptoms of enlarged prostate. Terbinafine is an anti-fungal medication available without a prescription in topical form, and by prescription in oral form. Pravastatin, tamsulosin, and terbinafine are not generally considered impairing.
Data Source
Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# CEN24FA042