Friday, February 03, 2017

Mooney M20C Ranger, N9149V: Accident occurred February 02, 2017 in Ellendale, Steele County, Minnesota













Aviation Accident Final Report - National Transportation Safety Board 

The National Transportation Safety Board did not travel to the scene of this accident. 

Additional Participating Entity:
Federal Aviation Administration / Flight Standards District Office; Minneapolis, Minnesota 
Lycoming; Williamsport, Pennsylvania 

Investigation Docket - National Transportation Safety Board:


Location: Ellendale, Minnesota 
Accident Number: CEN17LA101
Date & Time: February 2, 2017, 19:55 Local
Registration: N9149V
Aircraft: Mooney M20C 
Aircraft Damage: Substantial
Defining Event: Miscellaneous/other 
Injuries: 1 Serious
Flight Conducted Under: Part 91: General aviation

Analysis

The accident occurred during the commercial pilot's third flight of the day in the accident airplane. The pilot reported that he used the airplane's heater throughout the day. The pilot reported having a headache and experiencing "butterflies" in his stomach during the end of first flight. The headache subsided after the flight, and he felt fine during the second flight, but the headache returned after he landed. Before the third flight, the pilot expedited his time on the ground because he was concerned about getting the engine started in the cold weather. The pilot started the engine and sat in the airplane while he filed his flight plan and got organized for the flight. The pilot added that, while taxiing to the runway, he still had the headache, and he experienced another episode of "butterflies." He stated that the symptoms were more intense at that time than they had been in the morning but that they subsided by time he reached the runway, and he felt "good" but became "hyper focused." He performed an engine run-up and repeated the takeoff checklist three or four times until the controller asked if he was ready to take off, which "snapped" him out of repeating the takeoff checklist. The pilot was in the airplane with the engine running for about 12 minutes before takeoff.

The pilot remembered being cleared to a heading of 240° and setting the autopilot heading bug before taking off. He stated that, while climbing out, he experienced another case of the "butterflies." He added that he began a turn and activated the autopilot during the turn. The last thing he remembered was being cleared to 6,000 ft on a heading of 240°. After the pilot attempted to check in twice with departure control (he was still on the tower control frequency), air traffic controllers repeatedly attempted to contact the pilot without success. Radar data showed that the airplane climbed higher than 12,000 ft and was off course. The airplane continued to fly until it ran out of fuel and crashed in an open field. The pilot was not conscious until after the airplane impacted the field. He stated he was very confused and had loud ringing in his ears at this point. The pilot freed his legs from the wreckage and exited the airplane. He stated he was very weak and had difficulty with his balance and ability to walk as he made his way to a nearby house.

A postaccident examination revealed that the both fuel tanks were empty. The cabin heat was found on, and the cabin vent control was found off. The exhaust muffler had several cracks, one of which contained soot/exhaust deposits on the fractured surfaces, indicating it existed before impact. The crack would have allowed exhaust gases to enter the cockpit/cabin. The pilot reported that the airplane was not equipped with a carbon monoxide (CO) detector. A review of maintenance records showed that a new exhaust system was installed on the airplane on January 25, 2007, at a tachometer time of 2,343 hours. The last annual inspection was conducted on February 2, 2016, at a tachometer time of 2998.0 hours. The tachometer time at the time of the accident was 3,081 hours.

The pilot's CO level, when tested over 4 1/2 hours after the accident, was 13.8%. Given the half-life of CO in the blood stream over 4 to 5 hours while breathing ambient air, the pilot's CO level at the time of the accident was at least 28% and likely significantly higher because oxygen was administered in varying amounts during the first few hours of his postaccident medical care. The pilot's high CO level led to his incapacitation due to CO poisoning and the airplane's continued flight until it ran out of fuel and impacted terrain.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's incapacitation from carbon monoxide poisoning in flight due to cracks in the exhaust muffler, which resulted in the airplane's continued flight until it ran out of fuel and its subsequent collision with terrain.

Findings

Aircraft (general) - Fatigue/wear/corrosion
Personnel issues Carbon monoxide - Pilot

Factual Information

On February 2, 2017, about 1955 central standard time, N9149V, a Mooney M20C, collided with a field in Ellendale, Minnesota, after the pilot became incapacitated during the flight. The pilot was seriously injured and the airplane was substantially damaged. The airplane was registered to and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a business flight. Visual meteorological conditions prevailed and an instrument flight rules flight plan was filed. The flight originated from the Duluth International Airport (DLH), Duluth, Minnesota, at 1808, with an intended destination of the Winona Municipal Airport (ONA), Winona, Minnesota.

Earlier on the day of the accident the pilot flew the airplane from ONA to Thunder Bay (CYQT), Ontario (CYQT). The weather was cold so he had the airplane heater on for the entire trip. The pilot stated he had a slight headache during the last 10 to 15 minutes of the 2 hour 30-minute flight. After landing, while in the fixed base operator, the headache remained and he felt "butterflies" in his stomach
which he likened to a feeling of anxiety. The pilot attributed his headache to not having any caffeine in the morning and having possibly picked up an illness from a family member and he attributed the anxiety to his concern about following proper customs procedures.

The pilot stated the headache continued during the morning until he drank coffee which seemed to help. The pilot had the airplane preheated and departed CYQT about 1600 for the 1 hour 20-minute flight to DLH. The pilot reported he did not have a headache during the flight, but the headache returned after he landed at DLH. The pilot expedited his time on the ground at DLH because he was concerned about getting the engine started in the cold weather. He stated he started the airplane and sat in it while he filed his flight plan and "took my time getting the cockpit organized for the flight." The pilot received his IFR clearance to fly as filed to ONA at 6,000 ft above mean sea level (msl) and to expect a clearance to 9,000 ft msl, 10 minutes after takeoff. The pilot read back the clearance and requested to taxi.

The pilot still had a headache and experienced another episode of "butterflies" while taxiing to the runway. He stated the symptoms were more intense than they were in the morning. He stated the symptoms subsided by time he reached the runway, and he felt "good" but became "hyper focused." He performed an engine runup and performed the takeoff checklist 3 or 4 times and repeatedly checked the
avionics and instruments, which was not his normal routine. The airport tower controller asked him if he was ready to takeoff, which he stated "snapped" him out of repeating the takeoff checklist. Air traffic control (ATC) recordings show the pilot was in the airplane with it running for at least 12 minutes prior to taking off.

The pilot stated he remembers being cleared to a heading of 240° and setting the autopilot heading bug prior to taking off. While climbing out, he experienced another case of the "butterflies". He stated he began the turn and activated the autopilot during the turn. The last thing he remembers is being cleared to 6,000 ft msl on a heading of 240°. ATC transcripts recordings show the pilot communicated with ATC for the first four minutes of the flight. About three minutes after takeoff, the DLH tower controller instructed the pilot to contact departure control. The pilot acknowledged the instruction and attempted to check in with departure control while still on the tower control frequency. The controller informed the pilot that he was still on the tower frequency. At 1812:18, the pilot once again attempted to contact departure control without having changed the frequency. This was the last communication from the pilot.

Both the DLH controller and controllers in the Minneapolis Air Route Traffic Center made numerous attempts to contact the pilot, including having other pilots attempt to make radio contact. Radar data showed the airplane flew a ground track of 190 to 200 degrees at altitudes that exceeded 12,000 ft msl. The last radar contact was at 1952:47 at an altitude of 2,300 ft msl about 1 mile north-northeast of the accident site, which was about 80 miles west of ONA.

The pilot remained unresponsive until after the airplane impacted a field in a relatively level attitude.The pilot recalled waking up and thinking that he fell asleep for a few minutes. He stated he keyed the microphone to let air traffic control know that he was alright and noticed that the windscreen was "clear." He reached his hand out the hole in the windscreen which is when he realized that he was no longer flying. He stated he was very confused and had loud ringing in his ears at this point. The pilot freed his legs from the wreckage and he exited the airplane. He stated he was very weak and had difficulty with his balance and ability to walk. The pilot eventually made his way to a house about 500 ft from the accident site. It is unknown how long the pilot was unconscious after the impact. However, the last radar contact was at 1955 and the 911 call from the house was placed at 2107.

A postaccident examination of the airplane revealed that both the left and right fuel tanks were empty. The cabin heat control was full out (on) and the cabin vent control was full in (off). The exhaust muffler contained several cracks, one of which contained soot/exhaust deposits on the fractured surfaces. The inside of the exhaust shroud contained sooting as did the scat tubing leading from the muffler. The pilot reported he had the heater "full-on" during all three of the flights on the day of the accident and he did
not have a CO detector in the airplane.

A review of maintenance records showed a new exhaust system was installed on the airplane on January 25, 2007, at a tachometer time of 2,343 hours. The last annual inspection was conducted February 2, 2016, at a tachometer time of 2998.0 hours. The tachometer time at the time of the accident was 3,081 hours.

The pilot provided his postaccident medical records for the National Transportation Safety Board (NTSB). The NTSB Chief Medical Officer reviewed the records and reported the pilot was treated for injuries sustained during the accident and for frostbite. At 0018, on the morning following the accident, the pilot's blood was drawn for tests which included carbon monoxide (CO) levels. At that time, the CO level was 13.8%.

Carbon monoxide is an odorless, tasteless, colorless, nonirritating gas formed by hydrocarbon combustion. CO binds to hemoglobin with much greater affinity than oxygen, forming carboxyhemoglobin; elevated levels result in impaired oxygen transport and utilization. Nonsmokers may normally have up to 3% carboxyhemoglobin in their blood; heavy smokers may have levels of 10 to 15%. The pilot was a nonsmoker.

The degree of carboxyhemoglobinemia is primarily related to the relative amounts of CO and oxygen in the environment and the duration of exposure. Once exposure to the CO decreases or ends, oxygen molecules batter the receptor and slowly knock the CO off so it can be exhaled. This process is more efficient when there are more oxygen molecules in the blood. The half-life (the time it takes to get rid of ½ the CO) of CO with a patient breathing ambient air at sea level (21% oxygen) is about 4 – 5 hours; once the person is breathing high flow oxygen, the half-life of CO drops to about 90 minutes. Given the half-life of 4 – 5 hours while breathing ambient air, the pilot's CO level at the time of the accident was at least 28% and most likely significantly higher because oxygen was administered in varying amounts during the first few hours of his postaccident medical care.

History of Flight

Enroute Miscellaneous/other (Defining event)
Uncontrolled descent Collision with terr/obj (non-CFIT)

Pilot Information

Certificate: Commercial; Flight instructor 
Age: 39,Male
Airplane Rating(s): Single-engine land
Seat Occupied: Left
Other Aircraft Rating(s): None 
Restraint Used: 3-point
Instrument Rating(s): Airplane 
Second Pilot Present: No
Instructor Rating(s): Airplane single-engine 
Toxicology Performed: No
Medical Certification: Class 3 Without waivers/limitations
Last FAA Medical Exam: August 30, 2016
Occupational Pilot: No 
Last Flight Review or Equivalent:
Flight Time: 2108 hours (Total, all aircraft), 680 hours (Total, this make and model), 2138 hours (Pilot In Command, all aircraft), 20 hours (Last 90 days, all aircraft), 11 hours (Last 30 days, all aircraft), 4 hours (Last 24 hours, all aircraft)

Aircraft and Owner/Operator Information

Aircraft Make: Mooney
Registration: N9149V
Model/Series: M20C 
Aircraft Category: Airplane
Year of Manufacture: 1969
Amateur Built:
Airworthiness Certificate: Normal 
Serial Number: 690026
Landing Gear Type: Retractable - Tricycle Seats: 4
Date/Type of Last Inspection: February 2, 2016 Annual 
Certified Max Gross Wt.: 2575 lbs
Time Since Last Inspection: 83 Hrs 
Engines: 1 Reciprocating
Airframe Total Time: 3081 Hrs at time of accident
Engine Manufacturer: LYCOMING
ELT: Installed, not activated 
Engine Model/Series: O&VO-360 SER
Registered Owner: 
Rated Power: 0 Horsepower
Operator: On file 
Operating Certificate(s) Held: None

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual (VMC)
Condition of Light: Night
Observation Facility, Elevation: KAEL,1261 ft msl
Distance from Accident Site: 15 Nautical Miles
Observation Time: 19:55 Local
Direction from Accident Site: 184°
Lowest Cloud Condition: Clear
Visibility: 10 miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 6 knots / 
Turbulence Type Forecast/Actual:  /
Wind Direction: 300°
Turbulence Severity Forecast/Actual:  /
Altimeter Setting: 30.37 inches Hg
Temperature/Dew Point: -10°C / -16°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Duluth, MN (DLH)
Type of Flight Plan Filed: IFR
Destination: Winona, MN (ONA ) 
Type of Clearance: IFR
Departure Time: 18:08 Local
Type of Airspace: Class D;Class E;Class G

Wreckage and Impact Information

Crew Injuries: 1 Serious
Aircraft Damage: Substantial
Passenger Injuries:
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Serious
Latitude, Longitude: 43.898056,-93.348609





If you don’t believe in God, guardian angels, miracles and fate you may think twice about the airplane crash that took place north of Beaver Lake on Thursday night, February 2.

Daniel Johnathan Bass, 39, who works in the area of metal fabrication, filed a flight plan and left the Duluth airport at 6:10 on Thursday night.  It is thought that he headed his Mooney M20C Ranger on a direct flight, south bound for home, to Winona.

Bass has experienced many hours of flying time, and once in the air it is thought that he had put his plane on automatic pilot.

The Federal Aviation Administration later that evening reported the plane missing when it disappeared from radar.  Somehow the plane got about 85 miles off course from what should have been a straight-line flight.

Cynthia Crabtree, who lives a little bit north of Beaver Lake, had been sitting in her sunroom that night, when she heard a noise and assumed a large portion of an oak tree on the farm had come down.  Then, about 9:00, she heard a banging sound on the outside of her home, as well as a cry for help. 

She went to investigate but was concerned about opening the door as she was home alone.  She looked out the window and discovered a man with blood on his face standing outside her home.

Cynthia happens to be a nurse and felt a need to help the man. She asked him to come into her home and immediately called 911. She said it didn’t take long before help arrived, probably because there had already been people out looking for the missing plane.

Cynthia did what she could to help the injured pilot, and was pleased to find that though his speech was impaired he was alert and responsive.

Following the initial review of Bass’ medical condition, he asked if he could call his wife as she would have been expecting him home.  He was also concerned about his plane.

Bass told Cynthia that it may have taken him about 20-30 minutes or more to free himself from the plane, which had crashed just west of 72nd Avenue SW.  Once he got his bearings in the dark, he started walking toward the light he had seen in the area, which he later learned was the Crabtree farm.  It was later determined that Daniel had walked about 500 yards looking for someone to help him.

When the plane crashed, the windshield shattered, and Bass hit his head on the dash. He was transported to St. Marys’ Hospital in Rochester by a North Memorial helicopter and remained in the hospital for a few days following the accident. 

Bass sustained a broken jaw as a result of the plane crash and had to undergo surgery to repair the break before he was released from the hospital. 

Several local sheriff’s departments, Steele, Waseca and Freeborn, the Minnesota Highway Patrol, local ambulance and EMTs, members of the fire department, and others assisted at the scene.  Chuck Crabtree said he was surprised to see about 20 emergency vehicles in the area when he returned home that night. 

Once word was released that there was a plane missing, people from the area commented they had heard planes flying low over the area, something they felt was a bit unusual for this time of the year, especially at night.   People may have first heard the plane that had gotten off course, as well as the aircraft that had been sent out to look for the missing plane. 

The plane came down in an area that is owned by Evelyn Lee and Chuck and Cynthia Crabtree and came to rest in a northwesterly direction on a snowbank a short distance from a grove of trees on the north side of the Crabtree farm.  Bass was fortunate that the plane came down in an area that was clear of trees and buildings.

The Federal Aviation Administration and the NTSB were called in to investigate the plane crash.  Following the initial investigation, the plane, which sustained substantial damage, was disassembled into sections and loaded unto trailers and all the debris from the accident was cleared from the scene.

It is unknown how long it will take to determine the cause of the plane crash.  It can take months for the National Transportation Safety Board to complete their investigation and anything less is pure speculation.

Bass’s brother, who lives in the Twin Cities area, visited the site of the crash the following day and expressed his appreciation to the Crabtrees for their help.  He also said that his brother planned to come back for a visit with them sometime in the future, which would allow him to thank them personally for all the help that they had offered him.



On Sunday afternoon, a beautiful bouquet of flowers and a brief note were delivered to Cynthia, which brought tears to her eyes.  The note said, “Thank you so much for everything.  I am doing well, better every day. Looking forward to seeing you again. I will be more cleaned up and will drive there to visit you. Yours truly, Dan and Deanna Bass.”

We are glad to report Bass was able to walk away from his accident and thankful for the many people from our southern Minnesota area who offered him their assistance when he so desperately needed it.  

It has been said before and I am sure it will be said again, “Any landing one can walk away from is a good one.”


Source:  http://www.newrichlandstar.com




ELLENDALE — A plane crash Thursday outside Ellendale put to the test the old saying that any landing one can walk away from is a good one.

According to a National Transportation Safety Board spokesperson, a single-engine Mooney M20M aircraft took off from Duluth at about 6:10 p.m. and disappeared from radar at about 7:50 p.m. The Federal Aviation Administration reported the plane missing to the Rice-Steele Dispatch Center at about 8:15 p.m., according to Steele County officials.

But it was not until about 9:10 p.m. that the plane and pilot — identified by the Steele County Sheriff’s Office as Daniel Bass, 39, of Winona — were located, after Cynthia Crabtree of rural Ellendale heard a noise outside her home.

“I was just sitting in the sun room, and I heard this bang on the siding of the house, and I heard, ‘Help me!’” she said. “So I looked out the window, and there he was looking at me. I saw his face was all full of blood, so I brought him into the house and called the ambulance.”

The plane had come down in a field just west of 72nd Avenue Southwest and north of Beaver Lake, and Crabtree’s was the closest home. Crabtree said she had heard a noise at about 8 p.m. that she had thought at the time was a falling tree, but it was not clear when exactly the crash occurred, or what transpired between the crash and the pilot arriving at her home.

Crabtree said the pilot, who was taken from the scene by a North Memorial helicopter, seemed alert and responsive after reaching her home.

“He was talking the whole time and wanted me to call his wife, let her know he was OK,” she said.

Sgt. Gary Okins of the Steele County Sheriff’s Office said the flight path filed for was from Duluth to Winona, but the plane “went off course” and ended up in the field north of Ellendale. Bass was flown to Rochester for treatment and remained in St. Marys Hospital on the Mayo Clinic campus as of Friday afternoon, Okins said. FAA records show the plane (identified as an M20C model) is registered to Bass.

The pilot’s wife, Deanna Bass, told the Pioneer Press that her husband may have been affected by carbon monoxide fumes during the flight. She described his injuries as non-life-threatening.

A spokesperson for St. Marys reported his condition Friday afternoon as fair.

Both NTSB and the FAA are investigating the crash, which the FAA said caused substantial damage to the plane. The FAA spokesperson said his agency’s investigation will take several weeks at minimum, while the NTSB said a preliminary report could be finished in about a week.

The Steele, Waseca and Freeborn County Sheriff’s offices; Minnesota State Patrol; and Ellendale Fire and Ambulance assisted at the scene. Officials continue to ask the public to avoid the immediate area.


Source:   http://www.albertleatribune.com



STEELE COUNTY, Minn. – The Federal Aviation Administration continues to investigate a small plane crash in a field just west of Ellendale.

After crashing on Thursday night, the pilot, 39 year old Daniel Bass, was able to walk to a nearby home to get help. That home belongs to Chuck and Cynthia Crabtree. Cynthia was home at the time.

“I was sitting in my chair and I heard some noise outside, like something banging on the wall. And I got up and I looked out the window, and i heard ‘Please help me’,” said Cynthia.

Seeing that the man was injured, she let him into her home. He told her that he crashed his plane into the nearby field.

“He was more concerned about his wife. He said ‘Please call my wife and let her know I’m ok.’ But I said first I had to call 911 and get the ambulance out here,” Cynthia said.

As Cynthia reflects on the scary scene that happened so close to her home, she’s grateful that she was in the right place at the right time.

“I just thought about all the things that he went through and how God was with him and protected him. It’s a miracle that he walked away from that airplane.

Bass was eventually airlifted to North Memorial Hospital in the Twin Cities. His condition is unknown, but the Crabtrees’ were told he had to have surgery on his jaw.

Bass told Cynthia that he ran out of fuel and that’s why the plane crashed. The FAA is still investigating to determine the official cause.

Source:  http://kimt.com


UPDATE: According to the Steele County Sheriff’s Office, the pilot of the plane has been airlifted to North Memorial Hospital. Their condition is unknown at this time. Before being transported, the pilot was able to walk to a nearby residence to seek help. 

The small plane was reported missing by the Federal Aviation Administration at 8:15 p.m. Thursday.  It was located west of Ellendale near 72nd avenue and Beaver Lake. 

The Federal Aviation Administration and Steele County Sheriff’s Office are being assisted by the Minnesota State Patrol, Waseca County Sheriff’s Office, Freeborn County Sheriff’s Office, Ellendale Fire Department and Ellendale Ambulance.

The public is asked to avoid the immediate area.

ELLENDALE, Minn. –  According to the Steele County Sheriff’s Office a small plane has crashed in rural Ellendale near Beaver Lake. Officials are on the scene and they are asking the public to stay away from the area.

Witnesses on the scene say they heard a plane flying over their homes Thursday evening.  

Responders are still on the scene as of 10:15 Thursday night.

Source:   http://kimt.com


The Steele County Sheriff's Office says the pilot of a small plane that crashed in rural Ellendale was able to walk away from the crash, but was airlifted to the hospital.

At about 8:15 p.m., the sheriff's office says the Federal Aviation Administration reported a missing plane. That plane was located just west of Ellendale.

The scene is being handled by the Federal Aviation Administration, and secured by the Steele County Sheriff's Office with assistance from the Minnesota State Patrol, Waseca County Sheriff's Office, Freeborn County Sheriff's Office, Ellendale Fire Department and Ellendale Ambulance.

The condition of the pilot is currently unknown.

Source:  http://www.kaaltv.com


ELLENDALE — Steele County first responders were called Thursday evening to a reported small plane crash in rural Ellendale. 

County officials sent out an email alert at 9:49 p.m., saying that the Steele County Sheriff’s Office was on the scene and asking the public to stay away from the area.

No further information was available at press time.

Source:   http://www.southernminn.com

NTSB Identification: CEN17LA101 
14 CFR Part 91: General Aviation
Accident occurred Thursday, February 02, 2017 in Ellendale, MN
Probable Cause Approval Date: 09/06/2017
Aircraft: MOONEY M20C, registration: N9149V
Injuries: 1 Serious.

NTSB investigators may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.

The accident occurred during the commercial pilot’s third flight of the day in the accident airplane. The pilot reported that he used the airplane’s heater throughout the day. The pilot reported having a headache and experiencing “butterflies” in his stomach during the end of first flight. The headache subsided after the flight, and he felt fine during the second flight, but the headache returned after he landed. Before the third flight, the pilot expedited his time on the ground because he was concerned about getting the engine started in the cold weather. The pilot started the engine and sat in the airplane while he filed his flight plan and got organized for the flight. The pilot added that, while taxiing to the runway, he still had the headache, and he experienced another episode of “butterflies.” He stated that the symptoms were more intense at that time than they had been in the morning but that they subsided by time he reached the runway, and he felt “good” but became “hyper focused.” He performed an engine run-up and repeated the takeoff checklist three or four times until the controller asked if he was ready to take off, which “snapped” him out of repeating the takeoff checklist. The pilot was in the airplane with the engine running for about 12 minutes before takeoff.

The pilot remembered being cleared to a heading of 240° and setting the autopilot heading bug before taking off. He stated that, while climbing out, he experienced another case of the “butterflies.” He added that he began a turn and activated the autopilot during the turn. The last thing he remembered was being cleared to 6,000 ft on a heading of 240°. After the pilot attempted to check in twice with departure control (he was still on the tower control frequency), air traffic controllers repeatedly attempted to contact the pilot without success. Radar data showed that the airplane climbed higher than 12,000 ft and was off course. The airplane continued to fly until it ran out of fuel and crashed in an open field. The pilot was not conscious until after the airplane impacted the field. He stated he was very confused and had loud ringing in his ears at this point. The pilot freed his legs from the wreckage and exited the airplane. He stated he was very weak and had difficulty with his balance and ability to walk as he made his way to a nearby house.

A postaccident examination revealed that the both fuel tanks were empty. The cabin heat was found on, and the cabin vent control was found off. The exhaust muffler had several cracks, one of which contained soot/exhaust deposits on the fractured surfaces, indicating it existed before impact. The crack would have allowed exhaust gases to enter the cockpit/cabin. The pilot reported that the airplane was not equipped with a carbon monoxide (CO) detector. A review of maintenance records showed that a new exhaust system was installed on the airplane on January 25, 2007, at a tachometer time of 2,343 hours. The last annual inspection was conducted on February 2, 2016, at a tachometer time of 2998.0 hours. The tachometer time at the time of the accident was 3,081 hours.

The pilot’s CO level, when tested over 4 1/2 hours after the accident, was 13.8%. Given the half-life of CO in the blood stream over 4 to 5 hours while breathing ambient air, the pilot’s CO level at the time of the accident was at least 28% and likely significantly higher because oxygen was administered in varying amounts during the first few hours of his postaccident medical care. The pilot’s high CO level led to his incapacitation due to CO poisoning and the airplane’s continued flight until it ran out of fuel and impacted terrain.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The pilot’s incapacitation from carbon monoxide poisoning in flight due to cracks in the exhaust muffler, which resulted in the airplane’s continued flight until it ran out of fuel and its subsequent collision with terrain.

On February 2, 2017, about 1955 central standard time, N9149V, a Mooney M20C, collided with a field in Ellendale, Minnesota, after the pilot became incapacitated during the flight. The pilot was seriously injured and the airplane was substantially damaged. The airplane was registered to and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a business flight. Visual meteorological conditions prevailed and an instrument flight rules flight plan was filed. The flight originated from the Duluth International Airport (DLH), Duluth, Minnesota, at 1808, with an intended destination of the Winona Municipal Airport (ONA), Winona, Minnesota.

Earlier on the day of the accident the pilot flew the airplane from ONA to Thunder Bay (CYQT), Ontario (CYQT). The weather was cold so he had the airplane heater on for the entire trip. The pilot stated he had a slight headache during the last 10 to 15 minutes of the 2 hour 30-minute flight. After landing, while in the fixed base operator, the headache remained and he felt "butterflies" in his stomach which he likened to a feeling of anxiety. The pilot attributed his headache to not having any caffeine in the morning and having possibly picked up an illness from a family member and he attributed the anxiety to his concern about following proper customs procedures.

The pilot stated the headache continued during the morning until he drank coffee which seemed to help. The pilot had the airplane preheated and departed CYQT about 1600 for the 1 hour 20-minute flight to DLH. The pilot reported he did not have a headache during the flight, but the headache returned after he landed at DLH. The pilot expedited his time on the ground at DLH because he was concerned about getting the engine started in the cold weather. He stated he started the airplane and sat in it while he filed his flight plan and "took my time getting the cockpit organized for the flight." The pilot received his IFR clearance to fly as filed to ONA at 6,000 ft above mean sea level (msl) and to expect a clearance to 9,000 ft msl, 10 minutes after takeoff. The pilot read back the clearance and requested to taxi.

The pilot still had a headache and experienced another episode of "butterflies" while taxiing to the runway. He stated the symptoms were more intense than they were in the morning. He stated the symptoms subsided by time he reached the runway, and he felt "good" but became "hyper focused." He performed an engine runup and performed the takeoff checklist 3 or 4 times and repeatedly checked the avionics and instruments, which was not his normal routine. The airport tower controller asked him if he was ready to takeoff, which he stated "snapped" him out of repeating the takeoff checklist. Air traffic control (ATC) recordings show the pilot was in the airplane with it running for at least 12 minutes prior to taking off.

The pilot stated he remembers being cleared to a heading of 240° and setting the autopilot heading bug prior to taking off. While climbing out, he experienced another case of the "butterflies". He stated he began the turn and activated the autopilot during the turn. The last thing he remembers is being cleared to 6,000 ft msl on a heading of 240°. ATC transcripts recordings show the pilot communicated with ATC for the first four minutes of the flight. About three minutes after takeoff, the DLH tower controller instructed the pilot to contact departure control. The pilot acknowledged the instruction and attempted to check in with departure control while still on the tower control frequency. The controller informed the pilot that he was still on the tower frequency. At 1812:18, the pilot once again attempted to contact departure control without having changed the frequency. This was the last communication from the pilot.

Both the DLH controller and controllers in the Minneapolis Air Route Traffic Center made numerous attempts to contact the pilot, including having other pilots attempt to make radio contact. Radar data showed the airplane flew a ground track of 190 to 200 degrees at altitudes that exceeded 12,000 ft msl. The last radar contact was at 1952:47 at an altitude of 2,300 ft msl about 1 mile north-northeast of the accident site, which was about 80 miles west of ONA.

The pilot remained unresponsive until after the airplane impacted a field in a relatively level attitude. The pilot recalled waking up and thinking that he fell asleep for a few minutes. He stated he keyed the microphone to let air traffic control know that he was alright and noticed that the windscreen was "clear." He reached his hand out the hole in the windscreen which is when he realized that he was no longer flying. He stated he was very confused and had loud ringing in his ears at this point. The pilot freed his legs from the wreckage and he exited the airplane. He stated he was very weak and had difficulty with his balance and ability to walk. The pilot eventually made his way to a house about 500 ft from the accident site. It is unknown how long the pilot was unconscious after the impact. However, the last radar contact was at 1955 and the 911 call from the house was placed at 2107.

A postaccident examination of the airplane revealed that both the left and right fuel tanks were empty. The cabin heat control was full out (on) and the cabin vent control was full in (off). The exhaust muffler contained several cracks, one of which contained soot/exhaust deposits on the fractured surfaces. The inside of the exhaust shroud contained sooting as did the scat tubing leading from the muffler. The pilot reported he had the heater "full-on" during all three of the flights on the day of the accident and he did not have a CO detector in the airplane.

A review of maintenance records showed a new exhaust system was installed on the airplane on January 25, 2007, at a tachometer time of 2,343 hours. The last annual inspection was conducted February 2, 2016, at a tachometer time of 2998.0 hours. The tachometer time at the time of the accident was 3,081 hours.

The pilot provided his postaccident medical records for the National Transportation Safety Board (NTSB). The NTSB Chief Medical Officer reviewed the records and reported the pilot was treated for injuries sustained during the accident and for frostbite. At 0018, on the morning following the accident, the pilot's blood was drawn for tests which included carbon monoxide (CO) levels. At that time, the CO level was 13.8%.

Carbon monoxide is an odorless, tasteless, colorless, nonirritating gas formed by hydrocarbon combustion. CO binds to hemoglobin with much greater affinity than oxygen, forming carboxyhemoglobin; elevated levels result in impaired oxygen transport and utilization. Nonsmokers may normally have up to 3% carboxyhemoglobin in their blood; heavy smokers may have levels of 10 to 15%. The pilot was a nonsmoker.

The degree of carboxyhemoglobinemia is primarily related to the relative amounts of CO and oxygen in the environment and the duration of exposure. Once exposure to the CO decreases or ends, oxygen molecules batter the receptor and slowly knock the CO off so it can be exhaled. This process is more efficient when there are more oxygen molecules in the blood. The half-life (the time it takes to get rid of ½ the CO) of CO with a patient breathing ambient air at sea level (21% oxygen) is about 4 – 5 hours; once the person is breathing high flow oxygen, the half-life of CO drops to about 90 minutes. Given the half-life of 4 – 5 hours while breathing ambient air, the pilot's CO level at the time of the accident was at least 28% and most likely significantly higher because oxygen was administered in varying amounts during the first few hours of his postaccident medical care.

The National Transportation Safety Board did not travel to the scene of this accident. 

Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Minneapolis, Minneapolis
Lycoming; Williamsport, Pennsylvania 

NTSB Identification: CEN17LA101 
14 CFR Part 91: General Aviation
Accident occurred Thursday, February 02, 2017 in Ellendale, MN
Aircraft: MOONEY M20C, registration: N9149V
Injuries: 1 Serious.

NTSB investigators may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.

On February 2, 2017, about 1955 central standard time, N9149V, a Mooney M20C, collided with a field in Ellendale, Minnesota, after the pilot became incapacitated during the flight. The pilot was seriously injured and the airplane was substantially damaged. The airplane was registered to and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a business flight. Visual meteorological conditions prevailed and an instrument flight rules flight plan was filed. The flight originated from the Duluth International Airport (DLH), Duluth, Minnesota, at 1808, with an intended destination of the Winona Municipal Airport (ONA), Winona, Minnesota.

Earlier on the day of the accident the pilot flew the airplane from ONA to Thunder Bay (CYQT), Ontario (CYQT). The weather was cold so he had the airplane heater on for the entire trip. The pilot stated he had a slight headache during the last 10 to 15 minutes of the 2 hour 30-minute flight. After landing, while in the fixed base operator, the headache remained and he felt "butterflies" in his stomach which he likened to a feeling of anxiety. The pilot attributed his headache to not having any caffeine in the morning and having possibly picked up an illness from a family member and he attributed the anxiety to his concern about following proper customs procedures.

The pilot stated the headache continued during the morning until he drank coffee which seemed to help. The pilot had the airplane preheated and departed CYQT about 1600 for the 1 hour 20-minute flight to DLH. The pilot reported he did not have a headache during the flight, but the headache returned after he landed at DLH. The pilot expedited his time on the ground at DLH because he was concerned about getting the engine started in the cold weather. He stated he started the airplane and sat in it while he filed his flight plan and "took my time getting the cockpit organized for the flight." The pilot received his IFR clearance to fly as filed to ONA at 6,000 ft above mean sea level (msl) and to expect a clearance to 9,000 ft msl, 10 minutes after takeoff. The pilot read back the clearance and requested to taxi.

The pilot still had a headache and experienced another episode of "butterflies" while taxiing to the runway. He stated the symptoms were more intense than they were in the morning. He stated the symptoms subsided by time he reached the runway, and he felt "good" but became "hyper focused." He performed an engine runup and performed the takeoff checklist 3 or 4 times and repeatedly checked the avionics and instruments, which was not his normal routine. The airport tower controller asked him if he was ready to takeoff, which he stated "snapped" him out of repeating the takeoff checklist. Air traffic control (ATC) recordings show the pilot was in the airplane with it running for at least 12 minutes prior to taking off.

The pilot stated he remembers being cleared to a heading of 240° and setting the autopilot heading bug prior to taking off. While climbing out, he experienced another case of the "butterflies". He stated he began the turn and activated the autopilot during the turn. The last thing he remembers is being cleared to 6,000 ft msl on a heading of 240°. ATC transcripts recordings show the pilot communicated with ATC for the first four minutes of the flight. About three minutes after takeoff, the DLH tower controller instructed the pilot to contact departure control. The pilot acknowledged the instruction and attempted to check in with departure control while still on the tower control frequency. The controller informed the pilot that he was still on the tower frequency. At 1812:18, the pilot once again attempted to contact departure control without having changed the frequency. This was the last communication from the pilot.

Both the DLH controller and controllers in the Minneapolis Air Route Traffic Center made numerous attempts to contact the pilot, including having other pilots attempt to make radio contact. Radar data showed the airplane flew a ground track of 190 to 200 degrees at altitudes that exceeded 12,000 ft msl. The last radar contact was at 1952:47 at an altitude of 2,300 ft msl about 1 mile north-northeast of the accident site, which was about 80 miles west of ONA.

The pilot remained unresponsive until after the airplane impacted a field in a relatively level attitude. The pilot recalled waking up and thinking that he fell asleep for a few minutes. He stated he keyed the microphone to let air traffic control know that he was alright and noticed that the windscreen was "clear." He reached his hand out the hole in the windscreen which is when he realized that he was no longer flying. He stated he was very confused and had loud ringing in his ears at this point. The pilot freed his legs from the wreckage and he exited the airplane. He stated he was very weak and had difficulty with his balance and ability to walk. The pilot eventually made his way to a house about 500 ft from the accident site. It is unknown how long the pilot was unconscious after the impact. However, the last radar contact was at 1955 and the 911 call from the house was placed at 2107.

A postaccident examination of the airplane revealed that both the left and right fuel tanks were empty. The cabin heat control was full out (on) and the cabin vent control was full in (off). The exhaust muffler contained several cracks, one of which contained soot/exhaust deposits on the fractured surfaces. The inside of the exhaust shroud contained sooting as did the scat tubing leading from the muffler. The pilot reported he had the heater "full-on" during all three of the flights on the day of the accident and he did not have a CO detector in the airplane.

A review of maintenance records showed a new exhaust system was installed on the airplane on January 25, 2007, at a tachometer time of 2,343 hours. The last annual inspection was conducted February 2, 2016, at a tachometer time of 2998.0 hours. The tachometer time at the time of the accident was 3,081 hours.

The pilot provided his postaccident medical records for the National Transportation Safety Board (NTSB). The NTSB Chief Medical Officer reviewed the records and reported the pilot was treated for injuries sustained during the accident and for frostbite. At 0018, on the morning following the accident, the pilot's blood was drawn for tests which included carbon monoxide (CO) levels. At that time, the CO level was 13.8%.

Carbon monoxide is an odorless, tasteless, colorless, nonirritating gas formed by hydrocarbon combustion. CO binds to hemoglobin with much greater affinity than oxygen, forming carboxyhemoglobin; elevated levels result in impaired oxygen transport and utilization. Nonsmokers may normally have up to 3% carboxyhemoglobin in their blood; heavy smokers may have levels of 10 to 15%. The pilot was a nonsmoker.

The degree of carboxyhemoglobinemia is primarily related to the relative amounts of CO and oxygen in the environment and the duration of exposure. Once exposure to the CO decreases or ends, oxygen molecules batter the receptor and slowly knock the CO off so it can be exhaled. This process is more efficient when there are more oxygen molecules in the blood. The half-life (the time it takes to get rid of ½ the CO) of CO with a patient breathing ambient air at sea level (21% oxygen) is about 4 – 5 hours; once the person is breathing high flow oxygen, the half-life of CO drops to about 90 minutes. Given the half-life of 4 – 5 hours while breathing ambient air, the pilot's CO level at the time of the accident was at least 28% and most likely significantly higher because oxygen was administered in varying amounts during the first few hours of his postaccident medical care.

The National Transportation Safety Board did not travel to the scene of this accident. 

NTSB Identification: CEN17LA101
14 CFR Part 91: General Aviation
Accident occurred Thursday, February 02, 2017 in Ellendale, MN
Aircraft: MOONEY M20C, registration: N9149V
Injuries: 1 Serious.

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.

On February 2, 2017, at 1950 central standard time, N9149V, a Mooney M20C, collided with a field in Ellendale, Minnesota, following a pilot incapacitation. The pilot was seriously injured. The airplane was substantially damaged. The aircraft was registered to and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a business flight. Visual meteorological conditions prevailed and an instrument flight rules flight plan was filed. The flight originated from the Duluth International Airport (DLH), Duluth, Minnesota, with an intended destination of the Winona Municipal Airport (ONA), Winona, Minnesota.

1 comment:

  1. incredible this guy survived the CO poisoning, much less the crash. lucky man indeed

    ReplyDelete