Sunday, April 28, 2019

Mooney M20J 201, operated as a Title 14 Code of Federal Regulations Part 91 personal flight, N643RJ: Fatal accident occurred March 28, 2017 near Monroe County Airport (M40), Aberdeen, Mississippi

Richard Arlin Justice

John K. Nuesch

The National Transportation Safety Board traveled to the scene of this accident

Additional Participating Entities:

Federal Aviation Administration Flight Standards District Office; Jackson, Mississippi
Lycoming; Williamsport, Pennsylvania 

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.gov/N643RJ




Location: Aberdeen, MS
Accident Number: ERA17FA139
Date & Time: 03/28/2017, 0615 CDT
Registration: N643RJ
Aircraft: MOONEY M20J
Aircraft Damage: Substantial
Defining Event: Loss of visual reference
Injuries: 2 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal 

HISTORY OF FLIGHT

On March 28, 2017, at 0615 central daylight time, a Mooney M20J, N643RJ, collided with trees and terrain shortly after takeoff from Monroe County Airport (M40), Aberdeen, Mississippi. The airline transport pilot and one passenger were fatally injured, and the airplane was substantially damaged. The airplane was owned by the pilot who was operating it as a Title 14 Code of Federal Regulations Part 91 personal flight. Night visual meteorological conditions prevailed near the accident site at the time of the accident, and an instrument flight rules flight plan was filed for the flight, which was destined to Bruce Campbell Field Airport (MBO), Madison, Mississippi.

The pilot and his passenger departed M40 about 0614 for the 1-hour flight to MBO, which was located about 130 miles to the southwest. GPS data indicated that, after departing runway 18, the airplane climbed and performed a slight left turn to a heading of about 178° magnetic at 417 ft mean sea level (msl) while still over airport property. The airplane then made a climbing right turn to a heading of 233° (approximately consistent with a direct heading toward MBO) and reached a maximum altitude of about 600 ft msl before entering a right turning descent. The airplane continued its descending turn until it impacted trees and terrain on a heading of about 318° about 2,500 ft west of the departure end of the runway.

Video and audio from the airport security system showed dark night conditions at the time of the accident. It did not capture the airplane during takeoff due to the light and weather conditions; however, audio recorded the sound of the engine on the takeoff roll, during the initial climb, and throughout the accident sequence. The sound of the engine remained constant throughout the takeoff until the sound of impact.

Review of radar data from Columbus Air Force Base (CBM), Columbus, Mississippi, located 15 miles south of M40, revealed four targets correlated with the accident airplane. The first target indicated that the airplane was flying south at 400 ft msl at a groundspeed of 70 knots. The next two targets indicated that the airplane climbed to 600 ft msl at 70 knots, and the last target corresponded with a descending right turn at 500 ft msl.

Richard Arlin Justice

PERSONNEL INFORMATION

According to Federal Aviation Administration (FAA) airman records, the pilot, age 73, held an airline transport pilot certificate with ratings for airplane single- and multi-engine land, airplane single-engine sea, and glider. In addition, he held a flight instructor certificate with ratings for airplane single- and multi-engine and instrument airplane. In addition, he held type ratings in the CE-500, LR-60, and LR-Jet. The pilot reported civil flight experience that included 24,800 hours total time and 120 hours in the previous 6 months as of his most recent FAA medical examination on March 9, 2017. His most recent flight review was completed on July 5, 2016.

AIRCRAFT INFORMATION

The airplane was manufactured in 1980 and had a normal category airworthiness certificate. It was a single-engine, low-wing, four-place airplane powered by a 200-horsepower, fuel injected, four-cylinder Lycoming engine equipped with a two-blade constant-speed propeller. The airframe and engine had accumulated 2,873 hours total time and 908 hours since major overhaul. The most recent annual inspection was completed on March 23, 2017. The accident flight was the airplane's first flight since the inspection; according to the logbook, the engine was test run following the inspection and no discrepancies were noted.

METEOROLOGICAL INFORMATION

The closest reporting station to the accident site was CBM. The special weather observation at CBM at 0603 included wind from 150° at 4 knots, 8 miles visibility, a broken cloud ceiling at 1,800 ft above ground level (agl), overcast clouds at 2,400 ft agl, temperature 18°C, dew point 18°C, and altimeter setting of 29.93 inches of mercury. The light conditions at the time of the accident were dark; the beginning of civil twilight was at 0622 and sunrise was at 0647, about 7 minutes and 30 minutes, respectively, after takeoff.

AIRPORT INFORMATION

M40 was classified by the FAA as a public airport. It was located 4 miles northeast of Aberdeen, Mississippi. The airport elevation was 225.8 ft msl, and the asphalt runway was configured in a 18/36 orientation. The runway was 4,999 ft long by 75 ft wide. The airport was surrounded by sparsely populated and heavily wooded terrain south and west of the airport.

WRECKAGE AND IMPACT INFORMATION

The wreckage was located 2,500 ft west-southwest of the departure end of runway 18 in heavily wooded terrain. The wreckage path was oriented on a heading of about 318° and was about 400 ft long (Figure 1).


Figure 1 shows wreckage path direction and thumbnail view of airport in relation to accident site.

All major components of the airplane were located at the accident site. There was no evidence of pre- or postimpact fire. Examination of the wreckage revealed that the airplane impacted the tops of trees in a right-wing-low attitude. The right wing was separated and was the first large piece of wreckage located at the initial point of impact. Trees near the impact site were cut progressively lower as the airplane continued forward. Both wings and the entire empennage were separated from the airframe. The fuselage and cockpit area came to rest inverted against several trees in a left 45°-nose-down attitude with the engine partially buried in the ground. The engine remained attached to the engine mount and firewall. The propeller spinner was crushed and torn. The propeller hub and one propeller blade remained attached to the engine crankshaft flange. The opposing blade separated from the hub and was located about 50 ft beyond the main wreckage. The separated blade exhibited twisting, s-bending, and chordwise abrasion and the propeller tip was bent aft about 30°. The propeller blade that remained attached to the hub was free to rotate in the hub and was bent aft about 30° about 18 inches outboard of the hub. The propeller tip was curled, and the blade exhibited chordwise abrasion.

Multiple branches along the wreckage path between 3 and 5 inches in diameter displayed cuts consistent with propeller contact.

The engine was removed from the airframe, suspended from a lift, and partially disassembled to facilitate examination. The engine crankshaft was turned manually; internal continuity was confirmed. Compression and suction were observed on all cylinders and valve action was correct. The interiors of the cylinders were examined using a lighted borescope and no anomalies were noted. Oil was observed in the engine and the engine appeared well lubricated. The oil suction screen and filter were undamaged and contained no foreign material.

The propeller governor remained attached to the engine and no damage was noted. It was removed and rotated freely by hand. The governor control arm was observed in the maximum rpm position. The cockpit propeller control was observed in a full-forward position.

The fuel injector servo remained attached to the engine. The mixture control arm shaft was separated. The arm remained attached to the mixture control cable. The servo regulator section was partially disassembled and no damage was noted to the rubber diaphragms. The regulator cover brass plug was secure. The fuel inlet screen was absent of debris. The flow divider remained attached to the engine and no damage was noted on the unit. It was partially disassembled, and no damage noted to the rubber diaphragm. The flow divider body passages were unobstructed. The engine was equipped with GAMI injector fuel injector nozzles; they were unobstructed.

The engine-driven fuel pump remained attached to the engine and no damage was noted externally or internally. Aviation fuel was observed in the fuel hoses from the engine-driven fuel pump to the flow divider and in the engine-driven fuel pump, the fuel injector servo, and the flow divider.

The dual magnetos remained attached to the engine and showed no signs of damage. The magnetos were rotated and produced sparks from all ignition towers. The spark plugs were removed; the electrodes exhibited normal wear and color when compared to a Champion inspection chart. The sparkplug electrodes were undamaged. The electrodes of the Nos. 2 and 4 cylinder top and bottom sparkplugs were oil-soaked, consistent with the orientation of the engine at the accident site. The alternator remained attached to the engine and no damage was noted.

The vacuum pump remained attached to the engine and no damage was noted. The pump was removed and produced air at the outlet port when rotated by hand. It was partially disassembled and no damage was noted to the drive assembly. The carbon rotor and vanes were removed and were intact.

Flight control continuity was confirmed by tracing the control tubes and push-pull rods from the fuselage to their respective locations to the left wing, right wing, and empennage. The control rods exhibited bending and breakage consistent with overload. The right wing was severely fragmented. The left wing separated and exhibited compression and buckling, but the left aileron remained attached and moved freely through control tube pushrod input and the bell crank was functional. The empennage was severely deformed and fragmented and was wrapped around a tree. The elevators and rudder remained partially attached and the elevator trim jackscrew showed 7 threads, consistent with a takeoff trim setting.

The instrument panel exhibited impact damage. The magneto switch was located in the "both" position. The standby vacuum pump was in the off position. The master switch was in the on position. The pilot's primary flight instruments appeared undamaged. The attitude indicator was removed and examined and showed no anomalies. The throttle and propeller controls were both in the full-forward position and the mixture control was about 1/2 inch from full-forward. The landing gear switch was in the up position.

Data obtained from a JPI engine monitor indicated that the engine was operating throughout the flight without anomaly.

MEDICAL AND PATHOLOGICAL INFORMATION

The Mississippi State Medical Examiner's Office, Pearl, Mississippi, performed an autopsy of the pilot. The cause of death was blunt force injuries and the manner of death was accident. The autopsy noted an enlarged heart, weighing 480 grams (average for a 234-pound man is 403 grams with a range of 305 to 531 gm), and moderate coronary atherosclerosis with 50% stenosis in the left anterior descending coronary artery. There were no other signs of natural disease.

The FAA's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicology testing on specimens of the pilot. Testing identified amlodipine, metoprolol, and yohimbine in liver and subclavian blood. Amlodipine and metoprolol are both blood pressure medications and are not considered impairing. Yohimbine is extracted from tree bark and is available in the US in a variety of supplements. Testing was negative for carbon monoxide and ethanol.

ADDITIONAL INFORMATION

Weight and Balance

Review of the pilot's operating manual for the accident airplane make and model revealed that the airplane's maximum gross takeoff weight was 2,740 lbs. The left front seat pilot weighed about 240 lbs. The passenger weighed 235 lbs and was occupying the right rear seat. About 50 gallons (300 lbs) of fuel was on board, and about 20 lbs of personal effects were gathered from the scene. The calculated weight and balance revealed that the accident takeoff weight was about 2,620 lbs, which was 120 lbs below the maximum takeoff weight; the center of gravity was within limits.

Spatial Disorientation

The FAA Airplane Flying Handbook (FAA-H-8083-3) described some hazards associated with flying when visual references, such as the ground or horizon, are obscured:

The vestibular sense (motion sensing by the inner ear) in particular tends to confuse the pilot. Because of inertia, the sensory areas of the inner ear cannot detect slight changes in the attitude of the airplane, nor can they accurately sense attitude changes that occur at a uniform rate over a period of time. On the other hand, false sensations are often generated; leading the pilot to believe the attitude of the airplane has changed when in fact, it has not. These false sensations result in the pilot experiencing spatial disorientation.

Pilot Information

Certificate: Airline Transport; Flight Instructor; Commercial
Age: 73, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land; Single-engine Sea
Seat Occupied: Left
Other Aircraft Rating(s): Glider
Restraint Used: 3-point
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): Airplane Multi-engine; Airplane Single-engine; Instrument Airplane
Toxicology Performed: Yes
Medical Certification: Class 2 With Waivers/Limitations
Last FAA Medical Exam: 03/09/2017
Occupational Pilot: No
Last Flight Review or Equivalent: 07/05/2016
Flight Time: (Estimated) 24800 hours (Total, all aircraft) 

Aircraft and Owner/Operator Information

Aircraft Make: MOONEY
Registration: N643RJ
Model/Series: M20J
Aircraft Category: Airplane
Year of Manufacture:
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 24-1003
Landing Gear Type: Retractable - Tricycle
Seats: 4
Date/Type of Last Inspection: 03/23/2017, Annual
Certified Max Gross Wt.: 2740 lbs
Time Since Last Inspection: 0 Hours
Engines: 1 Reciprocating
Airframe Total Time: 2873 Hours as of last inspection
Engine Manufacturer: LYCOMING
ELT: C91  installed, activated, aided in locating accident
Engine Model/Series: IO-360-A3B6D
Registered Owner: On file
Rated Power: 200 hp
Operator: On file
Operating Certificate(s) Held: None 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Night/Dark
Observation Facility, Elevation: CBM, 225 ft msl
Distance from Accident Site: 15 Nautical Miles
Observation Time: 1103 UTC
Direction from Accident Site: 180°
Lowest Cloud Condition:
Visibility:  8 Miles
Lowest Ceiling: Broken / 1800 ft agl
Visibility (RVR):
Wind Speed/Gusts: 4 knots /
Turbulence Type Forecast/Actual: /
Wind Direction: 150°
Turbulence Severity Forecast/Actual: /
Altimeter Setting: 29.93 inches Hg
Temperature/Dew Point: 18°C / 18°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: ABERDEEN, MS (M40)
Type of Flight Plan Filed: IFR
Destination: MADISON, MS (MBO)
Type of Clearance: IFR
Departure Time: 0614 CDT
Type of Airspace: Class G

Airport Information

Airport: MONROE COUNTY (M40)
Runway Surface Type: Asphalt
Airport Elevation: 225 ft
Runway Surface Condition: Dry
Runway Used: 18
IFR Approach: None
Runway Length/Width: 4999 ft / 75 ft
VFR Approach/Landing: None

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Substantial
Passenger Injuries: 1 Fatal
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 2 Fatal
Latitude, Longitude: 33.865278, -88.498889

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