Analysis
The commercial pilot was conducting a personal instrument flight rules cross-country flight in day instrument meteorological conditions. As the airplane neared the destination airport, the center air traffic controller working the flight cleared the airplane for an instrument landing system approach, vectored the airplane onto a course to intercept the localizer, and instructed the pilot to contact the airport's air traffic control tower. The pilot established contact with the tower controller and requested radar vectors to intercept the localizer. The tower was not radar-equipped so the tower controller instructed the pilot to change frequencies back to the center air traffic controller for radar vectors. The pilot responded to the instruction, but there were no further radio transmissions from the pilot on the center frequency or the tower frequency. The airplane impacted terrain on a south heading about 5.6 miles north/northeast of runway 18. The wreckage path length, separation of airplane structure, and component damage were consistent with a high-speed, uncontrolled impact with terrain. Examination of the airplane wreckage confirmed flight control continuity, and the propeller displayed signatures consistent with engine power at the time of impact. The attitude indicator gyro exhibited rotational signatures, and the engine-driven vacuum pump exhibited torsional overstress consistent with operation at the time of impact. The wreckage did not display any mechanical anomalies that would have precluded normal airplane operation. An autopsy of the pilot was not performed, and no toxicology samples were available for testing. The pilot's logbook showed that his most recent instrument proficiency check took place about 3 years before the accident and that he did not meet recent instrument flight experience requirements for flight in instrument meteorological conditions.
Probable Cause and Findings
The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's loss of airplane control during an instrument approach. Contributing to the accident was the pilot's lack of instrument flight proficiency.
Findings
Aircraft
Performance/control parameters - Not attained/maintained (Cause)
Personnel issues
Aircraft control - Pilot (Cause)
Recent instrument experience - Pilot (Factor)
Environmental issues
Ceiling/visibility/precip - Effect on operation
Factual Information
History of Flight
Approach-IFR initial approach
Loss of control in flight (Defining event)
Uncontrolled descent
Collision with terr/obj (non-CFIT)
Additional Participating Entity:
Federal Aviation Administration / Flight Standards District Office; Milwaukee, Wisconsin
Aviation Accident Factual Report - National Transportation Safety Board: https://app.ntsb.gov/pdf
Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms
http://registry.faa.govN54PM
Loren Larson, who died in a crash July 28, 2016, stands by the Mooney M20J 201 he flew in an undated photograph from his Facebook page.Accident Number: CEN16FA295
Date & Time: 07/28/2016, 1138 CDT
Registration: N54PM
Aircraft: MOONEY M20J
Aircraft Damage: Destroyed
Defining Event: Loss of control in flight
Injuries: 1 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal
On July 28, 2016, about 1138 central daylight time, a Mooney M20J, N54PM, impacted terrain near Holmen, Wisconsin, while being vectored for an instrument approach to runway 18 at La Crosse Regional Airport (LSE), La Crosse, Wisconsin. The commercial pilot sustained fatal injuries, and the airplane was destroyed by impact forces. The airplane was registered to and operated by the pilot under Title 14 Code of Federal Regulations (CFR) Part 91 as a personal flight that was operating on an instrument flight rules flight plan. Day instrument meteorological conditions prevailed at the time of the accident. The flight originated from Willmar Municipal Airport-John L Rice Field (BDH), Willmar, Minnesota, at 1024 and was destined for LSE.
A friend of the pilot stated that the pilot planned the flight a "few weeks" earlier. The friend reported that the pilot was going to pick him up at LSE and that they were going to fly to Appleton, Wisconsin, to buy tickets for the Oshkosh air show and then fly to Oshkosh, Wisconsin. The friend said that he received a text message from the pilot at 1013 stating that he was ready for takeoff from BDH and would be in the air in about 10 minutes. According to the friend, the flight departed at 1024. He stated that, according to Flightaware, the flight was to land at 1137.
Minneapolis Center provided radar vectors to the pilot for the final approach course for the instrument landing system (ILS) runway 18 approach and then was instructed to contact LSE Air Traffic Control Tower (ATCT). The pilot contacted LSE ATCT and reported that the airplane was over Mindi (Mindi was the locator outer marker for the ILS runway 18 approach and was located 6.6 miles north of runway 18.) The pilot then asked for radar vectors for the localizer. LSE ATCT instructed the pilot to maintain 4,000 feet and to contact Minneapolis Center for radar vectors. The pilot acknowledged the instruction. There were no further radio transmissions from the pilot.
A witness near the accident site stated that he heard the airplane going very fast about 1145 or 1150. He added that the weather was "bad," it was "misting." and the clouds were lower than 700 ft above ground level. He stated that he heard the engine running but could not tell where the engine sound was coming from. The engine then "quit." After the airplane's engine quit, 3 to 4 minutes elapsed and then he heard a "boom."
Loren Ross Larson
Loren worked for the Burlington Northern Santa Fe Railroad as a foreman for the past 36 years. He had a passion for flying, with over 20 years of experience. He served on the Kerkhoven Rescue Squad for 10 years.
Pilot Information
Certificate: Commercial
Age: 55, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used:
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 2 With Waivers/Limitations
Last FAA Medical Exam: 01/01/2016
Occupational Pilot: No
Last Flight Review or Equivalent: 11/29/2015
Flight Time: 1455.5 hours (Total, all aircraft), 1019.8 hours (Total, this make and model), 1376.5 hours (Pilot In Command, all aircraft), 0 hours (Last 90 days, all aircraft), 0 hours (Last 30 days, all aircraft), 1.2 hours (Last 24 hours, all aircraft)
The pilot's logbook showed that his last instrument proficiency check, as specified in 14 CFR Part 61 section 57(d), which included a 1.0 hour biennial flight review, was dated September 7, 2013, and was conducted in the accident airplane. The last filled-in page of the pilot's logbook had flight entries dated from August 1 to May 31 with no year(s) entered; the previous logbook page had its last entry dated July 31, 2014. There was an endorsement at the back of the pilot's logbook for a biennial flight review that was dated November 29, 2015.
Title 14 CFR 61.57(c)(1) states that a person may act as pilot in command under IFR or weather conditions less than the minimums prescribed for VFR only if:
"Within the 6 calendar months preceding the month of the flight, that person performed and logged at least the following tasks and iterations in an airplane, powered-lift, helicopter, or airship, as appropriate, for the instrument rating privileges to be maintained in actual weather conditions, or under simulated conditions using a view-limiting device that involves having performed the following—
(i) Six instrument approaches.
(ii) Holding procedures and tasks.
(iii) Intercepting and tracking courses through the use of navigational electronic systems."
Title 14 CFR 61.57(d) states that "a person who has failed to meet the instrument experience requirements of paragraph (c) for more than six calendar months may reestablish instrument currency only by completing an instrument proficiency check. The instrument proficiency check must consist of the areas of operation and instrument tasks required in the instrument rating practical test standards."
According to the Federal Aviation Administration publication, "Instrument Proficiency Check (IPC) Guidance," regulations for the biennial flight review require a minimum of 1 hour of ground training and 1 hour of flight training. The publication states that, while Part 61.57(d) does not stipulate a minimum time requirement for the IPC, a good rule of thumb is to plan at least 90 minutes of ground time and at least 2 hours of flight time for a solid evaluation of the pilot's instrument flying knowledge and skills. The publication further states that, depending on the pilot's level of instrument experience and currency, the instructor administering the IPC may want to plan on two or more separate sessions to complete an IPC. For pilots with little or no recent instrument flying experience, it is a good idea to schedule an initial session in an appropriate aircraft training device.
Aircraft and Owner/Operator Information
Aircraft Manufacturer: MOONEY
Registration: N54PM
Model/Series: M20J
Aircraft Category: Airplane
Year of Manufacture: 1988
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 24-1677
Landing Gear Type: Retractable - Tricycle
Seats: 4
Date/Type of Last Inspection: 02/04/2016, Annual
Certified Max Gross Wt.: 2740 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 3294 Hours as of last inspection
Engine Manufacturer: Textron Lycoming
ELT: C91 installed, activated, did not aid in locating accident
Engine Model/Series: IO-360-A3B6D
Registered Owner: Pilot
Rated Power: 200 hp
Operator: Pilot
Operating Certificate(s) Held: None
Meteorological Information and Flight Plan
Conditions at Accident Site: Instrument Conditions
Condition of Light: Day
Observation Facility, Elevation: LSE, 656 ft msl
Observation Time: 1053 CDT
Distance from Accident Site: 6 Nautical Miles
Direction from Accident Site: 20°
Lowest Cloud Condition: Clear
Temperature/Dew Point: 21°C / 19°C
Lowest Ceiling: Overcast / 700 ft agl
Visibility: 10 Miles
Wind Speed/Gusts, Direction: 7 knots, 360°
Visibility (RVR):
Altimeter Setting: 29.94 inches Hg
Visibility (RVV):
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Willmar, MN (BDH)
Type of Flight Plan Filed: IFR
Destination: La Crosse, WI (LSE)
Type of Clearance: IFR
Departure Time: 1024 CDT
Type of Airspace:
Airport Information
Airport: La Crosse Regional Airport (LSE)
Runway Surface Type:
Airport Elevation: 656 ft
Runway Surface Condition:
Runway Used: N/A
IFR Approach: ILS
Runway Length/Width:
VFR Approach/Landing: None
Wreckage and Impact Information
Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Fatal
Latitude, Longitude: 43.978889, 91.213611
The accident site was located about 5.6 miles north/northeast of runway 18 at LSE at an elevation of 805 ft msl. The wreckage path was about 800 ft in length and oriented on a north/south heading in a grass/corn field. The fuselage, wings, empennage, control surfaces, engine, and propeller were present along the wreckage path. At the northern edge of the wreckage path about a 35-ft-long by 6- to 10-ft-wide area of corn stalks were cut at an angle of about 45°, sloping down toward the east. The southern edge of the wreckage path contained the engine, which was separated from the airframe. The fuselage was located about 80 ft south of the cut corn stalks and was upright. The left and right wings were located about 6 ft north and 45 ft east of the fuselage, respectively. There was no evidence of soot or fire on the airframe, engine, or terrain.
Examination of the flight controls confirmed flight control continuity from the wing and empennage control surfaces to the cockpit controls through separations of the control system that were consistent with overload. The wing flaps were in the 0° position.
The base of the propeller hub was attached to the engine crankshaft with all the attachment bolts in place. The upper portion of the propeller hub was broken off, and its pieces were located along the wreckage path. The hub fracture surfaces exhibited 45° granular fracture faces consistent with overstress. Both propeller blades were separated from the hub. One propeller blade was buried near corn stalks near the northern edge of the wreckage path, and the other propeller blade was located about 35 ft from the corn stalks. Both propeller blades exhibited leading edge damage and chordwise scratching consistent with propeller rotation/engine power at impact.
The instrument panel was located about 37 ft south from the fuselage. The flight instruments were separated from the panel and were located along the wreckage path. The attitude indicator, which was vacuum driven, was broken apart exposing the gyro casing and gimbals. The gyro was separated from the casing and was not found during recovery of the airplane wreckage. The gyro casing showed circumferential smearing/scoring and was attached to the pitch and roll gimbals.
The engine-driven vacuum pump was attached to the engine accessory section. Removal of the vacuum pump showed that the vacuum pump's drive teeth were intact, but the drive was separated from its opaque plastic coupling, with separation features consistent with torsional overstress. The coupling exhibited counterclockwise witness marks (the drive rotates counterclockwise during engine operation as viewed from the rear of the engine).
The engine did not exhibit any mechanical anomalies that would have precluded engine operation.
Medical And Pathological Information
An autopsy was not performed, and no toxicology samples were available for testing. During the pilot's most recent aviation medical exam, no concerns were reported by the pilot and no significant issues were identified by the aviation medical examiner.
That's based on the analysis of wreckage found at the crash site where pilot Loren Larson, 55, of Kerkhoven, died, according to the final factual report on the accident by the National Transportation Safety Board.
It determined that "loss of control in flight'' was the defining event that caused the crash. The NTSB released its report Jan. 30 after a nearly 1½-year investigation.
Family members have been "watching and waiting'' for the report, Lynn Larson, brother of the victim, told the West Central Tribune. The determination of "loss of control in flight'' left him perplexed. His brother had over 20 years of experience as a pilot, he said.
Loren Larson had departed solo from the Willmar Municipal Airport in a rented Mooney airplane at 10:24 a.m. CDT. He was planning to land in La Crosse to pick up a friend. They were to fly to Appleton, Wisconsin, to buy tickets and then fly to the Oshkosh air show.
Due to cloud cover, Larson was going to make an instrument approach at the La Crosse airport. Instead, his plane impacted a cornfield at 11:38 a.m. CDT, about 5.6 miles northeast of the runway at the La Crosse Airport.
A witness told investigators that the weather was "bad,'' according to the accident report. It was misting at the time and clouds were lower than 700 feet above ground level.
The witness heard the plane's engine running, but could not tell where the sound was coming from. "The engine then quit." After the airplane's engine quit, three to four minutes elapsed and then he heard a boom,'' stated the report.
Larson had made radio contact with the La Crosse Regional Airport and had requested vector coordinates to make an instrument approach.
A transcript of the radio transmissions between the pilot and controllers indicates that an air traffic controller in La Crosse had instructed Larson to maintain his altitude at 4,000 feet. He provided Larson with the radio frequency to the Minneapolis Air Route Traffic Control Center. The Minneapolis Center had the plane on radar and was to provide the vector coordinates to Larson for the approach to Runway 18 at La Crosse.
Larson confirmed the radio frequency for contacting Minneapolis with the La Crosse Airport controller. He did not repeat the controller's order to maintain a 4,000-foot altitude.
Larson's radio transmission confirming the radio frequency was recorded at 16:38:23 Universal Time Coordinated, or moments before the crash is believed to have occurred.
Radio transmissions continued between the La Crosse and Minneapolis controllers, who were not aware of the crash until an emergency locator signal was received.
The Minneapolis Center told La Crosse that it had cleared Larson for the approach, but had not heard back from him. " ... We asked him if he had any issues. He said no. So I was just wondering if he had said anything to you about having any issues,'' stated the Minneapolis controller to La Crosse.
Repeated attempts by the La Crosse controller to contact Larson following this exchange did not produce a response.
The accident report indicated that Larson had previous training for making an instrument approach, but it was dated. The report stated that he should have completed a proficiency check within the previous six months of the flight, but had not.
An 800-foot-long wreckage path, running north and south, was found at the accident site. At the northern edge of the wreckage path, an area of corn stalks — measuring about 35 feet long and 6 to 10 feet wide — was cut an an angle of about 45 degrees, sloping to the east.
There was no evidence of soot or fire on the airframe, engine or terrain. The left and right wings were located away from the plane's body. The wing flaps were in the 0-degree position.
Damage to the propellers was consistent with rotation and engine power at impact, the report stated. The engine did not exhibit any mechanical anomalies that would have precluded engine operation, according to the report.
The plane's instrument panel was located about 37 feet from the fuselage. The attitude indicator was broken apart and its gyro was not found.
An autopsy was not performed and no toxicology samples were available for testing. Larson's most recent aviation medical exam had found no health concerns.
Original article can be found here ➤ http://www.wctrib.com
14 CFR Part 91: General Aviation
Accident occurred Thursday, July 28, 2016 in Holmen, WI
Aircraft: MOONEY M20P, registration: N54PM
Injuries: 1 Fatal.
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 either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.
On July 28, 2016, about 1138 central daylight time, a Mooney M20P, N54PM, impacted terrain near Holmen, Wisconsin during an instrument landing system approach runway 18 at La Crosse Regional Airport (LSE), La Crosse, Wisconsin. The airplane was destroyed by impact forces. The commercial instrument rated pilot sustained fatal injuries. The airplane was registered to and operated by the pilot under 14 Code of Federal Regulations Part 91 as a personal flight that was on an instrument flight rules flight plan. Instrument meteorological conditions prevailed about the time of the accident. The flight originated from Willmar Municipal Airport-John L Rice Field (BDH), Willmar, Minnesota and was destined to LSE.
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