Saturday, December 14, 2019

Loss of Control in Flight: Mooney M20E, N213EJ; fatal accident occurred March 26, 2018 at Marina Municipal Airport (KOAR), Monterey County, California

Gordon Leroy Holley
April 20, 1932 ~ March 26, 2018 (age 85)

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

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; San Jose, California
Lycoming Engines; Williamsport, Pennsylvania
Mooney Aircraft; Kerrville, Texas

Aviation Accident Factual Report - National Transportation Safety Board: 

Investigation Docket - National Transportation Safety Board:

Location: Marina, CA
Accident Number: WPR18FA112
Date & Time: 03/26/2018, 1053 PDT
Registration: N213EJ
Aircraft: MOONEY M20E
Aircraft Damage: Destroyed
Defining Event: Loss of control in flight
Injuries: 1 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal

On March 26, 2018, about 1053 Pacific daylight time, a Mooney M20E airplane, N213EJ, was destroyed when it impacted terrain shortly after takeoff from runway 29 at Marina Municipal Airport (OAR), Marina, California. The private pilot was fatally injured. The airplane was registered to and operated by the pilot as a Title 14 Code of Federal Regulations Part 91 personal flight. Visual meteorological conditions prevailed, and no flight plan was filed for the flight, which had originated from Watsonville Municipal Airport (WVI), Watsonville, California.

The pilot kept his airplane in a hangar at WVI. According to WVI operations personnel, the pilot parked his car just outside the airport operations office about 0954 and came into the office to request a fuel top off for his airplane, which was in his hangar. The operations supervisor noticed that the pilot's ability to walk had significantly deteriorated since he last saw the pilot a few months prior, but that the pilot appeared to be in good spirits. The airplane was subsequently serviced with 25.4 gallons of fuel. A WVI surveillance camera recorded the airplane taking runway 20 for departure at 1035:54.

The airplane landed at OAR, which is located about 15 miles south of WVI. No radio communications to or from the airplane were recorded at WVI, en route, or OAR. No witnesses were identified who could provide information about the pilot's activities at OAR in the minutes preceding the accident, including whether the accident takeoff was part of a touch-and-go landing, or was preceded by a full-stop landing. However, two witnesses observed the takeoff before the accident.

One witness at OAR, who was located about midfield, reported that he saw the accident airplane lift off, and stated that the landing gear retracted immediately after the airplane became airborne. That witness and another witness reported that they saw the airplane begin an unusually steep climb in an unusually high nose-up attitude. The airplane then pitched over to an approximately level attitude and began to yaw to the left. During that nose-left yaw, the nose and left wing dropped, and the airplane began a spin.

The airplane spun to the ground, and a fire erupted immediately.

A surveillance camera was mounted on a building near the southwest corner of the airport about 1,500 ft west of the accident location. The airplane entered the camera field of view near the upper frame edge appeared to be on a descending flight path on a heading of about 160°in an approximate 15° nose down pitch attitude The airplane continued to yaw left, the pitch attitude continued to decrease, and the trajectory became increasingly steep. By the time the airplane was about 3 airplane lengths above the ground, the nose-down pitch attitude was nearly vertical, the top of the airplane was facing the runway 11 threshold, and the trajectory appeared to be near vertical. The airplane impacted the ground in a near-vertical nose-down attitude, and a fire began immediately. The vertical distance from the top of the image frame to the impact point was about 10 airplane lengths, or about 230 ft. The elapsed time from the first image of the airplane to impact was about 3.5 seconds.

Because the climb was not captured, climb speed or climb angle information could be obtained from the imagery. 

Pilot Information

Certificate: Private
Age: 85, 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: Yes
Medical Certification: BasicMed Unknown
Last FAA Medical Exam:
Occupational Pilot: No
Last Flight Review or Equivalent: 
Flight Time:  2650 hours (Total, all aircraft), 14 hours (Last 90 days, all aircraft), 3 hours (Last 30 days, all aircraft)

Federal Aviation Administration (FAA) records indicated that the pilot, age 85, held a private pilot certificate with an instrument-airplane rating. Review of the pilot's logbook revealed that he had a total flight experience of about 2,650 hours. He ceased flying in mid-2014 due to a family illness and resumed in August 2017. The logbook indicated that he had accrued about 22.6 hours since then, all of which were in the accident airplane. The first 8.1 of those hours were dual instruction with a flight instructor, including a flight review on November 22, 2017.

The flight instructor owned and operated a Mooney M20E similar to the accident airplane, and the pilot was referred to the instructor by their common maintenance facility.

Between August 25 and November 22, the instructor flew with the pilot a total of 8 times and then conducted and endorsed the pilot's flight review. All flights were in the accident airplane, and all originated at WVI.

The instructor noted that, at first, the pilot was "rusty" but that he regained his proficiency in the airplane. At some point early in the re-currency training, the pilot had difficulty extending the landing gear, but he did eventually master that procedure. The pilot preferred to not conduct touch-and-go landings, and when flying with the instructor, the pilot always preferred full-stop landings with a taxi back for takeoff. The instructor stated that the pilot's "go-arounds were well-managed."

Aircraft and Owner/Operator Information

Aircraft Make: MOONEY
Registration: N213EJ
Model/Series: M20E NO SERIES
Aircraft Category: Airplane
Year of Manufacture: 1965
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 939
Landing Gear Type: Retractable - Tricycle
Seats: 4
Date/Type of Last Inspection: 09/22/2017, Annual
Certified Max Gross Wt.: 2575 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 3518 Hours as of last inspection
Engine Manufacturer: LYCOMING
ELT: Installed
Engine Model/Series: IO 360 SER
Registered Owner: On file
Rated Power: 200 hp
Operator: On file
Operating Certificate(s) Held: None


The airplane was manufactured in 1965 and was equipped with a Lycoming IO-360 series engine. The pilot purchased the airplane in 1990 and had kept it hangared at WVI since 1999. Maintenance records indicated that the most recent annual inspection was completed on September 22, 2017. As of that date, the airplane had a total time (TT) in service of about 3,517 hours, and the engine had a TT of about 792 hours.

The airplane was not approved for intentional spins.

Landing Gear

The M20E has a manual landing gear retraction/extension system activated by a large lever (sometimes referred to as a "Johnson bar") located between the two front seats. The lever pivots about 90° at a point on the floor below the instrument panel. The motion of the lever is through an arc parallel to the longitudinal axis of the airplane. When the lever is up/vertical, the landing gear is extended; when lever is down/horizontal, the landing gear is retracted. Gear retraction requires the lever to be pivoted aft and down; gear extension is accomplished via the opposite motion. The lever has a locking button and a slide collar for activation and locking for both the gear-extended and gear-retracted positions.

Pitch Trim and Flaps

The pitch trim is manually controlled and actuated by a handwheel on the cockpit floor between the two front seats. The wheel rotates in the vertical plane parallel to the airplane longitudinal axis. Rotation of the trim wheel operates a chain that operates a jackscrew that changes the angle of incidence of the empennage, and concurrently actuates the pitch trim position indicator. The pitch trim position indicator is located on a central subpanel that is below the primary instrument panel. The pitch trim position indicator is situated above the flap position indicator.

The hydraulic flaps are manually controlled and actuated. Flap extension is a two-step process; first, the flap lever is set to the desired flap position, and then the flaps are extended by manually pumping the flap handle. Flap retraction is commanded via the flap lever and actuated by springs and airloads; the pilot does not need to pump the flap handle. The flap position indicator is on the central subpanel just below the pitch trim position indicator. Both the trim and flap indicator systems used mechanically driven pointers moving relative to fixed scales.

Takeoffs in the airplane are typically conducted with half flaps, and landings are typically conducted with full flaps. In flight, flap extension results in an airplane-nose-down (AND) moment, which requires airplane-nose-up (ANU) trim to reduce or alleviate control forces. With landing flaps extended, the airplane typically requires significant ANU trim. Go-arounds, therefore, require significant AND re-trimming to reduce or alleviate adverse ANU control forces.

Takeoff and Stall Speeds

According to the manufacturer's owner's manual (OM), takeoff is accomplished by applying back pressure on the yoke "at about 65-75 mph airspeed." The airplane will adopt a nose-high attitude until back pressure is released. Best angle climb speed is 94 mph, and best rate of climb speed is 113 mph at sea level. Once airborne and placed in the proper pitch attitude, the airplane will accelerate rapidly to a speed well above the liftoff speed.

The OM lists the zero-bank stall speeds for the zero, half, and full flap positions as 67, 64, and 57 mph, respectively.

Pilot Seat Fore-Aft Position

The pilot's seat was mounted on rollers that rode on two longitudinal rails or tracks on the floor to provide for adjustment in longitudinal position. The design enabled the pilot to select a position and lock the seat in that position via a retractable, spring-loaded pin on the seat assembly that fit into one of several holes in the seat tracks. Several factors, including seat pin and/or track hole wear, improper adjustment, debris, damage, or mispositioning by the pilot could result in improper or incomplete pin engagement, which in turn could result in seat slippage (travel) during airplane maneuvers. In such cases, acceleration forces on takeoff could result in uncommanded and unexpected aft seat travel.

According to a Mooney representative, if the seat were to come unlatched and roll aft in flight, it is possible for it to move fully aft beyond the last track hole until stopped by a pin at the aft end of each seat track. The representative also stated that, during impact, an unlatched seat would travel forward and then either latch in an intermediate position or travel to the forward-most position. 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: MRY, 15 ft msl
Distance from Accident Site: 7 Nautical Miles
Observation Time: 1054 PDT
Direction from Accident Site: 215°
Lowest Cloud Condition: Clear
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 10 knots /
Turbulence Type Forecast/Actual:
Wind Direction: 270°
Turbulence Severity Forecast/Actual:
Altimeter Setting: 30.16 inches Hg
Temperature/Dew Point: 6°C / 4°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Marina, CA (OAR)
Type of Flight Plan Filed: None
Type of Clearance: None
Departure Time: 1035 PDT
Type of Airspace: Unknown

The 1054 automated weather observation at Monterey Regional Airport (MRY), Monterey, California, located 7 miles southwest of OAR, included wind from 110° at 3 knots, visibility 10 miles, clear skies, temperature 6°C, dew point 4°C, and an altimeter setting of 30.16 inches of mercury.

One pilot/witness at OAR reported that the wind at the time of the accident appeared to be from about 260° to 270° at about 10 knots.

Airport Information

Airport: Marina Municipal Airport (OAR)
Runway Surface Type: Asphalt
Airport Elevation: 137 ft
Runway Surface Condition: Dry
Runway Used: 29
IFR Approach: None
Runway Length/Width: 3483 ft / 75 ft
VFR Approach/Landing: Unknown

OAR was situated at an elevation of 137 ft mean sea level and was equipped with a single paved runway designated 11/29. The runway measured 3,843 ft by 75 ft. OAR was not equipped with an air traffic control tower. 

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: N/A
Aircraft Fire: On-Ground
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Fatal
Latitude, Longitude: 36.675556, -121.756944 (est)

The airplane impacted and came to rest just southwest of the intersection of runway 29 and taxiway C, offset about 300 ft from the runway centerline. The impact site was located on a flat grassy area between the runway and a parallel taxiway. The only ground scars were a small crater from the propeller and engine, and two shallow impressions from the two wing leading edges. The upright wreckage was primarily confined to an area slightly larger than the length and wingspan of the airplane.

The wreckage was documented on scene and in additional detail after recovery. Significant portions of the cockpit and cabin and their contents were heavily damaged or consumed by fire. No evidence of any large or heavy baggage or other cabin contents was observed. The wings and the steel-frame fuselage structure exhibited substantial impact crush damage. The outboard wing sections and the empennage were not significantly damaged by the fire. All major components were accounted for on scene.

Both wings bore full-span leading edge crush damage in the aft direction. All flight control panels/surfaces remained attached to their respective primary structures. The ailerons, elevators, and rudder were intact. The left flap was impact damaged and slightly fire damaged. The right flap was partially consumed by fire.

Flight control continuity in all 3 axes, including pitch trim, was confirmed between the respective aerodynamic surfaces and their cockpit controls. The airplane was equipped with an aftermarket deployable spoiler assembly on each wing; both the left and right spoiler panel sets were found in their retracted positions.

The pitch trim was found set to the takeoff position. The flap setting at impact could not be determined. The landing gear was found in the retracted position.

Although impact and fire damage precluded a complete determination of the pre-accident integrity and functionality of all engine and propeller components, no evidence of pre-impact mechanical deficiencies or failures that would have precluded continued operation was observed.

The outboard seat track for the left (pilot's) forward seat remained partially intact and was examined to determine the possible longitudinal position of the seat during the accident. The track contained seven holes. The seat was found set with the pin in the 5th hole back from the front of the track. 

Medical And Pathological Information

The Monterey County Sheriff's Office, Coroner Division, autopsy report indicated that the cause of death was "multiple blunt force trauma," and that alcohol and drug test results were all negative. Forensic toxicology on specimens from the pilot was performed by the FAA Forensic Sciences Laboratory; results were negative for carbon monoxide, ethanol, and tested-for drugs.

Additional Information

Aerodynamic Stall

The FAA publication H-8083-25A Pilot's Handbook of Aeronautical Knowledge, (PHAK) stated that an aerodynamic stall results from a rapid decrease in lift caused by the separation of airflow from the wing's surface brought on by exceeding the critical angle of attack (AOA). AOA is defined as the acute angle between the chord line of the airfoil and the direction of the relative wind. An aerodynamic stall can occur when the airplane flies too slowly, or when higher wing loads are imposed due to maneuvers such as pull-ups or banked flight.

An airplane can be caused to fly too slowly when the commanded vertical flight path requires more engine power than is available. Both the commanded flight path and the available power can be pilot, design, or circumstantially induced. Circumstantial inducements include mechanical anomalies or failures, and center of gravity location.

Pilot Seat Fore-Aft Position and Adjustment

The investigation was unable to determine which seat position the pilot normally used. The pilot was reported to be about 5 ft 8 inches tall. The Mooney representative was about 6 ft tall; he reported that positioning the seat with the pin in the 5th hole was a "comfortable" position for flying the airplane. The representative also reported that two other Mooney pilots, one who was 6 ft tall and one who was 5 ft 10 inches tall, both used a seat positioned with the pin in the 4th hole.

Gordon Leroy Holley
April 20, 1932 ~ March 26, 2018 (age 85)

Gordon Leroy Holley, better known as Lee Holley passed away suddenly on March 26th, 2018 at the age of 85.

Lee Holley was born in Phoenix, Arizona, on April 20, 1932. Lee was a graduate of Watsonville High School, and following high school, he joined the Navy in 1951. He served as an Aviation Ordnanceman on the USS Bairoko during the Korean War until 1955.

Lee aspired to be a cartoonist, and displayed a love of cartooning at an early age. So upon leaving the Navy, Lee studied at Chouinard Art Institute in Los Angeles.

In 1955 Lee began his professional career as a Warner Bros animator in the Friz Freleng unit and was there from 1955 - 1958. Lee worked on Bugs Bunny, Road Runner, Porky Pig, Speedy Gonzales, Sylvester and Tweety, and Daffy Duck characters. In 1958 he started working for Hank Ketcham on Dennis the Menace.

While working for Hank Ketchum, Lee submitted cartoon ideas to the newspaper syndicates, and in 1960 he finally succeeded in selling a teenage panel to King Features called Ponytail.

Ponytail debuted in 1960 was syndicated in over 300 newspapers worldwide until 1989.

In addition to his career, and love of drawing, Lee had a passion for flying. He loved to fly his own plane, and enjoyed flying over the Monterey Bay. One of his favorite experiences was renting a plane in New Zealand and flying from the North Island to South Island.

No comments:

Post a Comment