Saturday, December 14, 2019

Loss of Engine Power (Total): Beech A36TC Bonanza, N136RM; fatal accident occurred August 12, 2018 near Whiteman Airport (KWHP), Los Angeles, California

Scott Frazier Watson 


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

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; Van Nuys, California
Textron Aviation; Wichita, Kansas
Continental Motors; Mobile, Alabama

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/136RM




Location: Sylmar, CA
Accident Number: WPR18FA219
Date & Time: 08/12/2018, 1345 PDT
Registration: N136RM
Aircraft: Beech A36TC
Aircraft Damage: Substantial
Defining Event: Loss of engine power (total)
Injuries: 1 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal

On August 12, 2018, about 1345 Pacific daylight time, a Beech A36TC airplane, N136RM, impacted terrain near Sylmar, California, after declaring an emergency while approaching Whiteman Airport (WHP), Los Angeles, California. The private pilot was fatally injured and the airplane sustained substantial damage. The airplane was registered to the pilot, who was operating it 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 originated from Placerville Airport, (PVF), Placerville, California, about 1200 and was destined for WHP.

Review of Federal Aviation Administration (FAA) air traffic control transcripts revealed that, as the pilot was descending through 3,700 ft, and just after being instructed to contact the WHP tower controller, he made a mayday call. The pilot reported that the airplane was descending and that he was looking for a place to land. He stated that he was unable to make WHP because he had "no throttle, no engine at all."

Witnesses reported that they saw the airplane flying southbound about 30 to 40 ft above the interstate when it turned east and descended below terrain into a nearby field.



Pilot Information

Certificate: Private
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: Yes
Medical Certification: Class 3 Without Waivers/Limitations
Last FAA Medical Exam: 09/14/2016
Occupational Pilot: No
Last Flight Review or Equivalent: 08/03/2016
Flight Time:  (Estimated) 478 hours (Total, all aircraft), 148 hours (Total, this make and model), 441 hours (Pilot In Command, all aircraft)



Aircraft and Owner/Operator Information

Aircraft Make: Beech
Registration: N136RM
Model/Series: A36TC
Aircraft Category: Airplane
Year of Manufacture: 1980
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: EA97
Landing Gear Type: Retractable - Tricycle
Seats: 4
Date/Type of Last Inspection: 09/15/2017, Annual
Certified Max Gross Wt.:
Time Since Last Inspection: 52 Hours
Engines: 1 Reciprocating
Airframe Total Time: 3870.66 Hours at time of accident
Engine Manufacturer: Continental Motors
ELT: Installed, activated, did not aid in locating accident
Engine Model/Series: TSIO-520-UB
Registered Owner: On file
Rated Power: 300
Operator: On file
Operating Certificate(s) Held: None



Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: VNY, 802 ft msl
Distance from Accident Site: 6 Nautical Miles
Observation Time: 1351 PDT
Direction from Accident Site: 190°
Lowest Cloud Condition: Clear
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 8 knots /
Turbulence Type Forecast/Actual: None / None
Wind Direction: 140°
Turbulence Severity Forecast/Actual: N/A / N/A
Altimeter Setting: 29.95 inches Hg
Temperature/Dew Point: 32°C / 12°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Placerville, CA (PVF)
Type of Flight Plan Filed: VFR
Destination: Whiteman, CA (WHP)
Type of Clearance: VFR Flight Following
Departure Time: 1200 PDT
Type of Airspace:

Airport Information

Airport: Whiteman Airport (WHP)
Runway Surface Type: N/A
Airport Elevation: 1003 ft
Runway Surface Condition: Dry; Vegetation
Runway Used: N/A
IFR Approach: None
Runway Length/Width:
VFR Approach/Landing: Forced Landing



Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None 
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Fatal
Latitude, Longitude: 34.295556, -118.469167 

The airplane came to rest in a field east of and adjacent to the interstate. The first identified point of impact was a strip of disturbed dirt with a fragment of grey paint. About halfway through the length of the disturbed dirt strip and to the right of the strip of dirt, was a paralleling disturbed strip of dirt, followed by a large disturbed area and the nose landing gear strut. Next, there was an approximate 80-ft section of mostly undisturbed grass with pieces of plexiglass, the left wingtip, and nose gear landing door scattered throughout the area. The main wreckage was located at the end of the debris path. The forward fuselage was heavily damaged; the airplane's engine, firewall, and instrument panel were fractured from the right side of the fuselage and bent to the left of the airplane; and the engine came to rest upside down. The front seats were exposed, and the remaining cabin area was mostly intact. The left wing was bent aft at the root and fractured midspan. The outboard section was bent aft underneath the inboard section and came to rest with the leading edge facing aft. The aft fuselage and empennage were mostly intact and undamaged. The right wing was mostly whole; however, the rear spar was fractured at the root and the forward portion of the wing was bent downward.

Examination of the airframe revealed flight control continuity throughout the airframe. The flaps were in the retracted position, and the landing gear was in the extended position. About 12 gallons of fuel was removed from the right wing, and fuel was observed exiting the breached left main fuel tank during the recovery process. The fuel selector faceplate was fracture separated. The fuel selector was removed from the airframe and air was blown through the selector; it was positioned to the left main fuel tank.

The engine remained mostly intact; the spark plugs were removed and exhibited normal operating signatures. The engine was rotated by hand and continuity was noted to the aft cylinders; in addition, the magnetos' distributor gears rotated. Borescope examination of the engine revealed normal operating signatures. The engine was prepared for shipment to the manufacturer for further examination.

Due to impact-related damage, the engine could not be test run. A teardown examination of the engine revealed no pre-accident anomalies that would have precluded the production of rated power. The crankshaft was fractured aft of the propeller flange. The spark plugs, cylinders, and piston heads were removed and exhibited normal operating signatures. The turbocharger was removed and no scoring was noted on the impeller housing. The fuel pump sustained impact damage and could not be tested; all internal components exhibited normal operating wear signatures. The crankcase was split and the crankshaft, camshaft, piston arms, and journals were oily and did not exhibit abnormal or thermal signatures. The magnetos were removed and operated normally when installed onto a test bench. Both the throttle body/fuel metering unit and the fuel manifold operated when installed onto test benches. 

Medical And Pathological Information

The Department of Medical Examiner-Coroner, Los Angeles, California, performed an autopsy of the pilot and determined the cause of death to be blunt trauma.

The FAA Forensic Sciences Laboratory performed forensic toxicology on specimens from the pilot with positive results for fexofenadine, losartan, and azacyclonol, none of which are considered a hazard to flight safety.

Loss of Control in Flight: Cessna 172L Skyhawk, N7239Q; fatal accident occurred June 22, 2018 near Diamondhead Airport (66Y), Hancock County, Mississippi

View of Main Wreckage as Found - Federal Aviation Administration


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

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; Jackson, Mississippi
Textron Aviation; Wichita, Kansas
Lycoming Engines; 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/N7239Q



Location: Diamondhead, MS
Accident Number: ERA18FA174
Date & Time: 06/22/2018, 0659 CDT
Registration: N7239Q
Aircraft: CESSNA 172
Aircraft Damage: Destroyed
Defining Event: Loss of control in flight
Injuries: 1 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal

On June 22, 2018, at 0659 central daylight time, a Cessna 172L, N7239Q, was destroyed when it collided with trees, powerlines, and terrain during the initial climb after takeoff from Diamondhead Airport, Diamondhead, Mississippi. The student pilot was fatally injured. The airplane was owned by the student's flight instructor, who was the operator of the Title 14 Code of Federal Regulations Part 91 solo instructional flight. Visual meteorological conditions prevailed at the time of the accident, and no flight plan was filed.

According to the student pilot's flight instructor, the purpose of the flight was to conduct solo traffic pattern work at the airport. The student pilot was to conduct full-stop landings and taxi back to the approach end of the runway before initiating the next takeoff. The flight instructor also stated that the student pilot was "not supposed to perform" touch-and-go landings.

A police detective saw the airplane while he was traveling westbound on the interstate near the departure end of runway 36. He said that the airplane appeared over the interstate, just above treetop height, traveling "slowly" northbound.

The witness used a model airplane to show that, as the accident airplane crossed the roadway, the nose pitched up from a level attitude. Once the airplane was across the interstate and above the trees on the north side, the nose gradually pitched down as the airplane rolled and turned to the left until it was out of view below the trees. The witness stated that his car was directly abeam the airplane at that time and that he saw smoke above the trees when he was about 1/2 mile past the accident site. The witness stated that he used the radio in his car to contact police dispatch about the accident. The accident was reported to 911 at 0659:03.

Radar data obtained from the Federal Aviation Administration (FAA) depicted that the airplane was first detected on radar at 0628:28 then completed four left-hand traffic patterns. The last radar return was at 0658:24, near the end of the fourth approach; the airplane was at an altitude of 225 ft mean sea level (msl) and was 1,100 ft from the approach end of the runway. No further radar targets were associated with the accident airplane.



Pilot Information

Certificate: Student
Age: 69, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: 3-point
Instrument Rating(s): None
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 3 With Waivers/Limitations
Last FAA Medical Exam: 09/01/2017
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time: 169 hours (Total, all aircraft), 169 hours (Total, this make and model)

The student pilot was issued an FAA third-class medical and student pilot certificate in September 2017. A review of his logbook revealed that he had accrued 169.1 total hours of flight experience. His first solo endorsement was dated June 12, 2018, after he had accrued 164.9 hours of flight experience.



Aircraft and Owner/Operator Information

Aircraft Make: CESSNA
Registration: N7239Q
Model/Series: 172 L
Aircraft Category: Airplane
Year of Manufacture:
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 17260539
Landing Gear Type: Tricycle
Seats: 4
Date/Type of Last Inspection: 10/01/2017, Annual
Certified Max Gross Wt.: 2299 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 4898 Hours as of last inspection
Engine Manufacturer: Lycoming
ELT: Installed, not activated
Engine Model/Series: O-320-E2D
Registered Owner: On file
Rated Power: 160 hp
Operator: On file
Operating Certificate(s) Held: None

According to FAA records, the accident airplane was manufactured in 1972. Its most recent annual inspection was completed on October 1, 2017, at 4,8984 total aircraft hours.

The Cessna 172 owner's manual stated the following about wing flap settings:

Normal and obstacle clearance take-offs are performed with wing flaps up. The use of 10° flaps will shorten the ground run approximately 10%, but this advantage is lost in the climb to a 50-foot obstacle. Therefore, the use of 10° flaps is reserved for minimum ground runs or for take-off from soft or rough fields. If 10° of flaps are used for minimum ground runs, it is preferable to leave them extended rather than retract them in the climb to the obstacle. In this case, use an obstacle clearance speed of 65 MPH. As soon as the obstacle is cleared, the flaps may be retracted as the airplane accelerates to the normal flaps-up climb speed of 80 to 90 MPH.

During a high altitude take-off in hot weather where climb would be marginal with 10° flaps, it is recommended that the flaps not be used for take- off. Flap settings of 30 ° to 40 are not recommended at any time for take-off.



Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KHSA, 23 ft msl
Distance from Accident Site: 3 Nautical Miles
Observation Time: 1150 UTC
Direction from Accident Site: 270°
Lowest Cloud Condition: Clear
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: Calm /
Turbulence Type Forecast/Actual:
Wind Direction:
Turbulence Severity Forecast/Actual:
Altimeter Setting: 29.93 inches Hg
Temperature/Dew Point: 24°C / 24°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Diamondhead, MS (66Y)
Type of Flight Plan Filed: None
Destination: Diamondhead, MS (66Y)
Type of Clearance: None
Departure Time: 0659 CDT
Type of Airspace: Class G

At 0650, the weather recorded at Stennis International Airport, Kiln, Mississippi, which is 3 miles west of the accident site, reported clear skies and calm winds. The temperature was 24°C, the dew point was 24°C, and the altimeter setting was 29.93 inches of mercury.

The calculated density altitude at the time of the accident was 1,100 ft.


View of Angularly Cut Tree Trunk Sections at Site - Federal Aviation Administration

View of Left Wing Leading Edge as Found - Federal Aviation Administration

Airport Information

Airport: DIAMONDHEAD (66Y)
Runway Surface Type: Asphalt
Airport Elevation: 14 ft
Runway Surface Condition: Dry
Runway Used: 36
IFR Approach: None
Runway Length/Width: 3800 ft / 75 ft
VFR Approach/Landing: Traffic Pattern

Diamondhead Airport was at 14 ft elevation and positioned between Interstate 10 and Cutoff Bayou. Runway 36/18 was 3,800 ft long and 75 ft wide. Runway 36 ended immediately prior to Interstate 10, which was a four-lane divided highway oriented east-west.


View of Angular Cut to Fractured Tree Trunk at Site - Federal Aviation Administration

View of Engine after Recovery - Lycoming

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: 30.369167, -89.390556

The wreckage was examined at the site, and all major components were accounted for at the scene. The wreckage path was oriented along a magnetic heading of about 210° and was about 75 ft in length. The airplane came to rest upright and was oriented along a 098° magnetic heading. Several pieces of angularly cut wood, some of which were greater than 8 inches in diameter, were scattered around the airplane.

The cockpit, cabin area, right wing, and the empennage were consumed by a postcrash fire. The left wing displayed uniform crushing along the leading edge. Striation marks and tearing along the leading edge, consistent with contact with a wire, were visible. The tail section showed thermal damage but was mostly intact.

The engine was exposed, the propeller remained attached, and each displayed significant thermal damage. The right magneto and oil filter were separated from the engine, and the left magneto remained secure in its mounts.

The engine was rotated by hand through the vacuum pump pad. Continuity was confirmed through the accessory section to the valve train and power train. Thumb suction and compression were observed at all cylinders except for the No. 2 cylinder. The No. 2 cylinder intake valve appeared not fully seated. The cylinder was removed and checked for leaks with water. Water drained from the intake port with only valve-spring tension applied to the valve stem. The valve was "staked" using a mallet, and, when water was again poured into the interior of the cylinder, no liquid was observed draining out of the intake port. Coking on the intake valve stem was consistent with the valve in an open position while exposed to the postimpact fire.

Flight control continuity was confirmed from the cockpit area to the flight control surfaces or their associated hardware and attachment points. The flap actuator jackscrew was intact and measured in its as-found condition. Measurement of the exposed threads corresponded with a full-flap, 40° extension setting. 


View of Flap Actuator as Found - Federal Aviation Administration

Medical And Pathological Information

The Mississippi State Medical Examiner's Office, Pearl, Mississippi, performed a pathological examination of the pilot and determined his cause of death as blunt force injuries with thermal injuries.

Toxicology testing performed at the FAA's Forensic Sciences Laboratory found that the pilot's specimens tested negative for drugs and ethanol.

Loss of Control in Flight: North Wing Pulse 10 Meter, N62073; fatal accident occurred June 02, 2018 at Mountain Home Air Force Base (KMUO), Elmore County, Idaho

Dan Buchanan

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

Additional Participating Entity:
Federal Aviation Administration / Flight Standards District Office; Boise, Idaho 

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/N62073


Location: Mountain Home, ID
Accident Number: WPR18LA163
Date & Time: 06/02/2018, 1338 MDT
Registration: N62073
Aircraft: NORTH WING Pulse
Aircraft Damage: Substantial
Defining Event: Loss of control in flight
Injuries: 1 Fatal
Flight Conducted Under: Part 91: General Aviation - Air Race/Show 

On June 2, 2018, about 1338 mountain daylight time, an experimental, amateur-built North Wing Pulse 10M hang glider, N62073, collided with the ground while participating in an airshow at Mountain Home Air Force Base (KMUO), Mountain Home, Idaho. The commercial pilot sustained fatal injuries and the hang glider sustained substantial damage. The hang glider was registered to and operated by the pilot as a Title 14 Code of Federal Regulations Part 91 flight. Visual meteorological conditions prevailed, and no flight plan was filed for the local flight, which departed KMUO about 1332.

The premise of the pilot's airshow routine was a comedy act in which he would simulate inadvertently flying the hang glider into an active airshow, interrupting another airplane that was performing an aerobatic routine. The plan was for the hang glider, which was equipped with smoke canisters and a series of trailing streamers, to be towed past show center while the aerobatic airplane made a series of close passes, eventually cutting the streamers. Throughout the routine, the rehearsed radio interactions between the hang glider pilot, aerobatic pilot, and the show announcer were transmitted over the public address system.

During a typical airshow, the hang glider was launched by a moving tow-launch system composed of a winch trailer pulled by a truck. The truck and trailer then travelled back and forth down the runway spinning out the tow line while the winch operator maintained line tension as the hang glider climbed to the desired altitude (usually 1,500 ft). The pilot typically released the line once the truck had turned around after the third pass. The pilot would then begin to perform a series of gliding maneuvers down to the ground, while the line, which was equipped with a parachute, was rewound back into the winch spool as it descended.

Most of the accident sequence was recorded on a security camera located on the KMUO control tower in the center of the airport, about 2,100 ft south of runway 12/30, and directly across from show center. Footage from the camera was provided by the United States Air Force (USAF).

On the day of the accident, the performance began and progressed uneventfully until the end of the truck and winch trailer's second runway pass. After being given the all-clear by the hang glider pilot, the truck and winch trailer turned around as planned and began to accelerate along runway 12 in anticipation of the pilot releasing the line. (See figure 1.) The winch operator stated that, a few seconds after the turn, he looked up and noticed that the hang glider was about 500 ft below the altitude at which he would typically expect to see it. The hang glider then performed an aggressive turning maneuver (see figure 2) and descended another 500 ft. The winch operator then released the winch pressure to supply the hang glider with more slack and prevent it from being impeded by line tension. The hang glider then entered a climb, rolled to the left, descended, and impacted the ground in a nose-down attitude. (See figures 3 and 4.)


Figure 1. Hang glider (red circle) and tow truck (green circle) beginning the final pass along runway 12

Figure 2. Hang glider performing aggressive turning maneuver

Figure 3. Hang glider rolling left

Figure 4. Hang glider striking the ground

Multiple witnesses recounted a similar sequence of events, stating that the maneuvers after the second pass were completely unconventional and not part of the routine. The airshow coordinator (air boss), who had seen the routine performed many times before, stated that the performance appeared to be going well and the streamers were cut during the second lap as planned. However, during the final turn, the hang glider was a little lower than normal and it performed a sudden circling maneuver, which he described as a "pinwheel." He commented to one of the crew that something was not right. The hang glider appeared to stabilize and descend, and then performed another pinwheel maneuver before it impacted the ground in a nose-down attitude. A witness saw the hang glider suddenly pitch up before the impact, and based on his experience, assumed that it had encountered a strong wind.

Neither the air boss nor the winch operator saw the line parachute deploy, and when the winch operator arrived at the accident site, the parachute and line were in the immediate vicinity of the main wreckage, appearing to have detached on impact. Multiple airshow attendees reported to news media that the tow line was cut by the aerobatic airplane during the routine, however, examination revealed that the line was intact and undamaged.

Pilot Information

Certificate: Commercial
Age: 62, Male
Airplane Rating(s): None 
Seat Occupied: Single
Other Aircraft Rating(s): Glider
Restraint Used:
Instrument Rating(s): None
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 3 Unknown
Last FAA Medical Exam: 03/18/1996
Occupational Pilot: Yes
Last Flight Review or Equivalent:
Flight Time:  (Estimated) 2000 hours (Total, all aircraft), 1500 hours (Total, this make and model) 

The 62-year-old pilot had broken his neck in a hang-gliding accident in 1981 and had been a C7 quadriplegic, paralyzed from the shoulders down, since then. He was issued a commercial pilot certificate with a glider rating in February 1996, with limitations for "aero tow" and "hand controls" only.

Federal Aviation Administration (FAA) records indicated that the pilot had undergone an FAA medical examination in March 1996, and subsequently was scheduled for a medical flight test in May of that year, but it was not clear if he completed the test or if a medical certificate was ultimately issued.

FAA regulations do not require the pilot of a hang glider to hold a pilot or medical certificate. 

Aircraft and Owner/Operator Information

Aircraft Make: NORTH WING
Registration: N62073
Model/Series: Pulse 10M
Aircraft Category: Weight-Shift
Year of Manufacture: 1995
Amateur Built:Yes 
Airworthiness Certificate: Experimental
Serial Number: 53201
Landing Gear Type: Tandem
Seats: 1
Date/Type of Last Inspection:  Unknown
Certified Max Gross Wt.: 269 lbs
Time Since Last Inspection:
Engines: 0
Airframe Total Time:
Engine Manufacturer:
ELT: Not installed
Engine Model/Series:
Registered Owner: On file
Rated Power:
Operator: On file
Operating Certificate(s) Held: None 

The hang glider was composed of a North Wing Pulse 10M wing and a Moyes Delta Gliders Contour model harness. The system was configured with a "softpack" style BRS Aerospace aircraft parachute rescue system mounted to the harness.

The harness was connected to the tow line using a two-point strap, which incorporated a barrel-type quick release on the right side next to the pilot's chest. Operation of the quick release would have required pulling the barrel toward the harness while the strap was still under tension. The strap was connected to the tow line with a weak link, and a small parachute was connected to the end of the tow line.

The winch system included a spool of ultra-high molecular weight polyethylene cord (tow line), which was driven by an electrical motor. The speed of the spool during the towing process was maintained by a hydraulically-controlled automotive disk brake system, the pressure of which was governed by the tow operator.  

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KMUO, 2996 ft msl
Distance from Accident Site: 1 Nautical Miles
Observation Time: 1938 UTC
Direction from Accident Site: 22°
Lowest Cloud Condition: Clear
Visibility:  4 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 5 knots /
Turbulence Type Forecast/Actual:
Wind Direction: 40°
Turbulence Severity Forecast/Actual:
Altimeter Setting: 30.25 inches Hg
Temperature/Dew Point: 24°C / 1°C
Precipitation and Obscuration: Moderate - Haze; No Obscuration; No Precipitation
Departure Point: Mountain Home, ID (MUO)
Type of Flight Plan Filed: None
Destination: Mountain Home, ID (MUO)
Type of Clearance: None
Departure Time: 1332 MDT
Type of Airspace: Class D 

A ground pyrotechnic display was scheduled to begin as the show opened, with more pyrotechnics progressively ignited during the day in coordination with approaching aircraft to simulate bombing runs. However, according to the air boss, due to a shift in wind direction, fire from the initial display landed in the other pyrotechnic staging area. Therefore, the decision was made to expend the entire remaining pyrotechnic load in a controlled manner rather than risk it igniting by accident. The subsequent controlled explosion at 1115 started a grass fire on the airfield, and the show was put on hold while the fire was extinguished. During that period the control tower was evacuated, but by 1132, fire command advised that the show could resume. Fire crews continued to extinguish flare-ups and monitor the area for hotspots, and by 1333, 5 minutes before the accident, one of the engines on the field reported that all the fires had been extinguished.

Two witnesses provided statements regarding the weather conditions over the area at the time of the accident. The first was a working volunteer who was also a hang glider pilot, and the second was a pilot who had just been flying a P-51 Mustang in the airshow, and was located immediately east of the accident site, and still in his airplane. Both witnesses described seeing dust devils over the area before and immediately after the accident.

The first witness, who was located about show center, indicated that before the accident pilot started his routine, he observed a dust devil to the west of the runway in a location past the air traffic control tower. He identified that the dust devil had a well-defined vortex and extended to about 200 ft above the ground. He stated that only a small amount of dust outlined the vortex's shape, and that he pointed out the dust devil to a friend who also witnessed the event.

The second witness saw several large dust devils over the airport area during the accident period. He indicated that the winds were light and variable until the pyrotechnic display and related fire started, after which strong vertical wind flows followed. Immediately after the accident, he noticed a dust devil to the south of his position travel across the audience. He described it as a large "lumbering" dust devil with a diameter of 40 to 80 ft that extended from 300 to 1,000 ft high. He noticed it blowing dust and disturbing papers, and people in the audience were holding their hats due to the sudden winds. He was able to observe the dust devil for about 5 to 10 minutes before he lost sight of it. Based on the movement and location of the dust devil, he extrapolated that it was likely over the area of the accident at the time of the event.

The air boss stated that at no time during the show did he see any dust devils, and it was not until the next day that he was told they were present.

Synoptic Conditions

The northwest section of the National Weather Service (NWS) Surface Analysis Chart for 1200 MDT on June 2, 2018, depicted two high pressure systems over Idaho and western Wyoming at 1028- and 1030-hectopascals (hPa) respectively, dominating over the area with a weak pressure gradient. No other significant boundaries were identified over the area.

The station models surrounding the accident site depicted clear skies and temperatures in the 70º F range with surface wind from the east to northeast at 5 knots or less.

A review of the NWS Boise (KCBX) WSR-88D radar imagery surrounding the period did not detect any significant meteorological echoes or boundaries over the area.

Surface Observations

KMUO, located at an elevation of 2,996 ft mean sea level, had an automated weather observation system which was supplemented by Air Force weather observers.

The automated observation issued at 1258 indicated a 2-minute average wind from 070º at 4 knots, 10 miles or more visibility, skies clear, temperature of 73ºF, dew point of 34ºF, and an altimeter setting of 30.27 inches of mercury (Hg). The remarks included that drizzle was reported within the hour, which was likely from water spray used by the fire department to extinguish the grass fire after the pyrotechnics display.

A review of the 1-minute observations indicated that the 2-minute average winds were 7 knots or less between 1307 and 1344; at the time of the accident, winds were reported from 040º at 4 knots. The 1-minute observations also showed a significant variation in visibility during the period, with visibility at and below 5 miles or in haze (most likely smoke) between 1313 and 1344, with visibility decreasing below 3 miles between 1316 and 1325.

A special observation made by a weather observer was issued at 1349. At that time, the wind was reported from 230º at 3 knots; visibility was 10 miles or more with a few clouds less than 100 ft above ground level. The temperature was 75ºF, and the altimeter setting was 30.25 inches Hg. The remarks section noted the presence of smoke.

Video

The NTSB received five videos of the accident sequence taken by airshow attendees. These videos, along with the KMUO tower video, were reviewed for any additional meteorological information such as wind or dust devil activity.

All the videos depicted clear skies over the area with visibility generally unrestricted in the vicinity of the accident site. Several of the videos confirmed lower visibility in haze or smoke to the north-northwest through the northeast. At least three videos captured a dust devil, which extended vertically several hundred feet high on the field and south of the control tower.

The KMUO tower video revealed that as the hang glider began its first pass to the southeast after takeoff, the smoke from smoldering grass was moving to the southeast as well. About two minutes 30 seconds later, as the hang glider came back for its second pass the smoke stopped and then began to change direction, drifting northwest. About that time, a USAF F-22 Raptor was on the ramp, adjacent to show center with its exhaust facing the runway almost directly adjacent and below the hang glider's location. The F-22 then began to move forward and turn north to taxi along the adjacent ramp as the hang glider routine progressed.

Several of the videos captured the hang glider become airborne after impacting the ground and move a short distance south. After impact, the smoke from the hang gliders smoke canisters appeared to drift to the south, in the same direction as dust generated by approaching Aircraft Rescue and Firefighting (ARFF) trucks. At the same time, smoke from smoldering grass about 750 ft southwest appeared to be drifting north. A few minutes later, while the ARFF personnel were attending to the wreckage, the smoke from the hang glider began to drift vertically and toward the northwest.

After the accident occurred, the KMUO tower video captured multiple ARFF vehicles approaching from different directions on the field. Dust from vehicles approaching the accident site from the northwest moved in a northwest direction, while dust from vehicles approaching from the south moved in a southeast direction. As the first ARFF truck arrived at the accident site, its dust appeared to be pulled directly upward into a column shape.

Dust Devils

According to the American Meteorological Society, a dust devil is defined as, "a well-developed dust whirl; a small but vigorous whirlwind, usually of short duration, rendered visible by dust, sand, and debris picked up from the ground."

Accordingly, wind speed ranges from an average of 40 knots and can exceed 50 knots in intense dust devils, which can be occasionally strong enough to cause minor structural damage. Diameters range from about 10 ft to greater than 100 ft; their average height is about 600 ft, but a few have been observed as high as 3,000 ft or more. Although the vertical velocity is predominantly upward, the flow along the axis of large dust devils may be downward. Large dust devils may also contain secondary vortices. Dust devils are best developed on a hot, calm afternoon with clear skies, in a dry region when intense surface heating causes a very steep lapse rate of temperature in the lowest 3,000 ft of the atmosphere. In the United States, dust devils have been reported in every state but are most frequently reported in the deserts and flat terrain of the southwest.

The atmospheric conditions that commonly increase the likelihood of dust devil formation include flat barren terrain, clear skies, calm to light winds under 10 knots, and surface air temperatures over 90°F. Since dust devils are associated with intense solar heating, the maximum occurrence typically occurs between 1300 and 1400 local, at the time of maximum soil temperatures and the convective heat flux.

The creation of eddies of sufficient magnitude have also been documented to trigger dust devil formation due to the increase in relative vorticity. Such eddies could come from hot aircraft exhaust, local grass fires, or from emergency response vehicles.

According to the United States Parachute Association, dust devils are also considered major hazards among skydivers and paragliding pilots, as they can cause a parachute or a glider to collapse with little to no warning at altitudes considered too low to cut away, and contribute to the serious injury or death of many parachutists.

A complete meteorology report, along with videos, witness locations, and statements is available in the public docket.

Airport Information

Airport: MOUNTAIN HOME AFB (MUO)
Runway Surface Type: Asphalt
Airport Elevation: 2996 ft
Runway Surface Condition: Dry
Runway Used: 12
IFR Approach: None
Runway Length/Width: 13510 ft / 200 ft
VFR Approach/Landing: None 

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Fatal
Latitude, Longitude: 43.041667, -115.871667 

The hang glider came to rest about 250 ft southwest of the right edge of runway 12, perpendicular to show -center and about midway down the runway.

The primary airframe structure, including the king post, keel beam, and leading edge tubes were intact. The bridles and support cables were intact and remained connected at their respective fittings. With the exception of scratches and serrations at the nose, the sail was intact and remained attached to both the left and right leading edge tubes and all ribs.

The damage appeared to be impact-related and focused at the forward end of the wing structure at the nose plate junction assembly. Similar bending damage was present on the downtubes leading to the crossbar assembly, and both plastic main wheels had shattered.

The harness remained attached to the slider bar through the main suspension strap. The tilt rope loop was intact at the top of the harness and continuous around the pulley to the adjustable tilt cleat. The right side of the towing strap remained attached to the harness; the left side had been detached from the harness by first responders. The tow line quick-release tube was in the locked (unreleased) position. Examination of the quick-release mechanism revealed that it could be activated normally by hand.

There were no indications that the pilot had deployed the BRS parachute or released the tow line.

Both the spool and brake system of the winch operated when tested.

Examination did not reveal any anomalies with the airframe that would have precluded normal operation. Refer to the airframe examination report included in the public docket for further details. 

Medical And Pathological Information

According to the autopsy performed at the request of the Elmore County Coroner's Office, Mountain Home, Idaho, the pilot's cause of death was traumatic blunt force injuries. Mild coronary artery disease was also found.

Toxicology testing performed by the FAA Forensic Sciences Laboratory did not identify any tested-for substances.

The pilot's personal medical records indicated that, during the week before the accident, he had visited an orthopedic specialist for an evaluation after several months of significantly decreased range of motion and limited function of his left shoulder that made it harder for him to operate his wheelchair. The diagnosis was primarily arthritis, and they discussed a future joint replacement, but no definitive treatment was performed.

According to the winch operator, who helped the pilot with day-to-day operations, the pilot had longstanding issues with mobility in his left shoulder, which was progressively deteriorating. As such, the pilot was finding it harder to perform basic tasks such as showering or getting in and out of his truck, and the winch operator had been helping him more with physical tasks. Although the last practice flight occurred 2 days before the accident, the pilot had decided to curtail future flights due to the pain he endured getting in and out of the harness and in order to reduce wear and tear on his shoulder.

The pilot stated to the winch operator that his goal was to get through the 2018 show season and decide the future of the operation at the end of the year.

Additional Information

The winch operator and pilot had driven to Idaho from Dayton, Nevada, a few days before the accident. The pilot had been scheduled to perform at the airshow the day before the accident but had cancelled due to strong wind conditions. They were staying in a local hotel, and the pilot went to bed about midnight the night before the accident, which was his normal routine. On the day of the accident, they departed for the airport at 0650, and the airshow briefing started at 0800.

The winch operator stated that the briefing was routine, and the pilot, driver, and himself met with the air boss and announcer. The group then drove the flight line, established show center, checked the wind, and discussed the various launch, turn, and release points. They arrived back at the hangar at 0930, and then did a "meet and greet" with the attendees. The pilot seemed in good spirits and wanted to watch the upcoming pyrotechnics show.

About 1215, the pilot performed his preflight checks. He carried a water bottle and was drinking from it throughout the morning. Once the check was complete, the group assisted the pilot with getting into the hang glider, and about 1300, they drove to the taxiway, where they waited for the previous act to finish. The winch operator stated that the time the pilot spent in the harness was not excessively long and was typical for most airshows.

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: https://app.ntsb.gov/pdf 


Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms


http://registry.faa.gov/N213EJ


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

General

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
Destination:
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.