Aviation Accident Summaries

Aviation Accident Summary ERA11FA095

Dundee, NY, USA

Aircraft #1

N968SM

MOONEY M20R

Analysis

Prior to departing on the night instrument meteorological conditions flight, the pilot obtained a weather briefing that included an airmen's meteorological information for moderate icing conditions below 12,000 feet and two pilot reports, one for light-to-moderate and one for moderate-to-severe icing conditions. The flight progressed toward the destination airport and the pilot was advised by an air traffic controller of pilot reports for moderate and severe icing conditions in the surrounding areas. The airplane intercepted the initial approach fix, turned onto the runway approach course, and began a normal descent through clouds without incident until it veered to the northeast and radar contact was lost. The airplane impacted the ground about 1 mile north-northwest of the last radar target and 8 miles south of the destination airport. No preaccident mechanical malfunctions or failures were found that would have precluded normal operation. Evidence of significant in-flight ice accumulation was observed on the base of a communications antenna mounted on the top of the fuselage and on the upper surface of the inboard two-thirds of the left horizontal stabilizer. At the time of the accident, freezing precipitation, which coated the ground with ice, was present in the vicinity of the accident site. The airplane was not equipped with deicing systems and was not approved for flight into known icing conditions.

Factual Information

HISTORY OF FLIGHT On December 22, 2010, about 1950 eastern standard time, a Mooney M20R, N968SM, operated by a private pilot, was substantially damaged when it impacted terrain in Dundee, New York, while on approach to the Penn Yan Airport (PEO), Penn Yan, New York. The certificated private pilot was fatally injured. Night instrument meteorological conditions prevailed and an instrument flight rules (IFR) flight plan had been filed for the flight that departed Essex County Airport (CDW), Caldwell, New Jersey. The personal flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. The airplane was owned by the pilot, through a limited-liability-company, and was based at CDW. The pilot was employed as an emergency room physician, and was commuting to work, at a hospital in Geneva, New York. According to information obtained from the Federal Aviation Administration (FAA), the airplane departed CDW about 1840 and progressed toward PEO without incident. At 1930:18, the airplane was at an altitude of 8,000 feet mean sea level (msl) when the pilot contacted Elmira Approach Control, and requested the area navigation (RNAV) global position system (GPS) approach to runway 1 at PEO. The pilot was cleared to fly direct to the initial approach fix (IAF), and advised that there were pilot reports for "at least moderate rime ice" from other airplanes operating in the areas around Elmira and Ithaca, New York, at altitudes between 4,000 and 5,500 feet msl, with reports of severe icing towards Elmira, lower to the ground. At 1932:10, the pilot was cleared to descend to 4,100 feet msl, at his discretion. At 1934:53, the pilot was asked to report his flight conditions, and he stated that the airplane was above the clouds at an altitude of 6,000 feet msl. The airplane was cleared for the approach at 1939:14. At 1940:26, the pilot asked for and received a telephone number to cancel his IFR flight plan after landing. At 1943:56, the pilot requested, and was approved to change to the local airport advisory frequency. The pilot acknowledged the frequency change approval at 1944:07. There were no further communications with the airplane. Radar data obtained from the FAA indicated that at the time of the pilot's last communication, the airplane was about 20 miles south-southeast of PEO. The airplane began a descent from 4,100 feet msl at 1947:23, and the last radar target was at 1949:26, about 10 miles south of the airport, at an altitude of 2,600 feet msl. After intercepting the IAF fix, the airplane turned onto the runway 1 approach course and began a descent. During the last minute of the radar data, the airplane was lined-up with the runway 1 approach course descending at rate of about 500 feet per minute, until it veered to the northeast about 45 degrees, before radar contact was lost. The accident site was about 1 mile north-northwest of the last radar target. A witness near the accident site reported that the airplane was low as it passed directly overhead traveling northwest. The airplane was in a bank until it was heading approximately north, and then appeared to descend "straight down." The witness then observed an orange flash and felt an explosion. PERSONNEL INFORMATION The pilot, age 57, held a private pilot certificate, with ratings for airplane single-engine land, and instrument airplane. He reported 2,700 hours of total flight experience on his most recent application for an FAA third-class medical certificate, which was issued on April 30, 2010. Review of the pilot's logbook revealed that at the time of the accident, he had accumulated about 2,775 hours of total flight experience, of which, about 20 and 40 hours were accumulated during the 30 days and 90 days preceding the accident, respectively. In addition, the pilot had accumulated about 25 and 15 hours of night flight experience, and 12 and 5 hours of "actual instrument time" during the 30 and 90 days preceding the accident, respectively. AIRCRAFT INFORMATION The four-seat, low-wing, retractable-gear, all-metal high performance airplane, serial number 29-0348, was manufactured in 2004. It was powered by a Teledyne Continental Motors (TCM) IO-550-G, 280-horsepower engine, equipped with a three-bladed Hartzell propeller assembly. According to FAA records, the pilot initially purchased the airplane during June 2005. Review of maintenance records revealed that the airplane had been operated for about 675 hours since new, and 110 hours since its most recent annual inspection, which was performed on June 9, 2010. The airplane was not equipped with a deicing system. Review of the pilot's operating handbook revealed that the airplane was "NOT APPROVED" for flight into known icing conditions and prohibited from operating in such conditions. METEOROLOGICAL INFORMATION The reported weather at PEO, elevation 990 feet msl, at 1953, was: wind 310 degrees at 10 knots, gusting to 19 knots; visibility 9 statute miles; overcast ceiling at 900 feet; temperature -4 degrees Celsius (C); dew point -6 degrees C; altimeter 29.96 inches of mercury. A witness, who lived near the accident site, reported hearing the sound of an impact about the time of the accident, and noted that "freezing rain" was falling, which coated the ground and surrounding area with ice. The National Weather Service Weather Depiction Chart for 1700 and 2000 depicted marginal visual flight rules to IFR conditions over the region with light continuous snow in the immediate vicinity of the accident site. Geostationary Operational Environmental Satellite number 13 (GOES-13) data indicated an overcast layer of clouds over the accident site, consistent with nimbostratus type clouds, with cloud tops near 6,000 feet. Pilot reports indicated overcast clouds with tops between 4,300 to 6,300 feet with light to moderate, moderate, and one report of moderate to severe icing conditions. At 1924, a Mooney approximately 28 miles east of the accident site reported encountering overcast clouds with a base at 500 feet, with moderate rime icing between 4,000 and 5,500 feet. At 1928, a Cessna Caravan approximately 24 miles south of the accident site reported moderate icing at 5,000 feet. Airmen's meteorological information (AIRMET Sierra) for IFR conditions and mountain obscuration, AIRMET Tango for occasional moderate turbulence below 10,000 feet, and AIRMET Zulu for moderate icing conditions below 12,000 feet were current for the route of flight and over the accident site. The freezing level was identified as the surface. The pilot obtained a computerized direct users access terminal System (DUATS) weather briefing and filed an IFR flight plan about 4 hours prior to the flight. The briefing included an AIRMET for icing, and two pilot reports for Ithaca, New York. One was from the pilot of a De Havilland DHC-8 who reported encountering light to moderate icing below 5,000 feet, and the second was an urgent pilot report from a pilot of a Mitsubishi MU-2, who reported moderate to severe icing at 4,000 feet. Review of a Current Icing Product (CIP) generated by the National Center for Atmospheric Research for 1900 and 2000 were consistent with a high probability of rime type icing below 6,000 feet over the route of flight in northern New Jersey, Pennsylvania, and New York. The 1900 CIP depicted a greater than 70 percent probability of light to moderate rime type icing over the accident site. An FAA inspector, who arrived at the accident site at approximately 2145, reported that he observed evidence of in-flight ice accumulation on the base of a communications antenna mounted on the top of the fuselage, and on the upper surface of the inboard two-thirds of the left horizontal stabilizer. Review of an approach chart for the RNAV (GPS) runway 1 approach at PEO revealed that the descent altitude for a localizer with vertical guidance (LPV) approach was 1,360 feet msl (370 feet above ground level). The minimum visibility requirement was 1.25 mile. WRECKAGE AND IMPACT INFORMATION The airplane was examined at the accident site on December 23 and 24, 2010. The wreckage was then recovered to a storage facility, in Clayton, Delaware, for further examination on December 28 and 29, 2010. All major portions of the airplane were accounted for at the accident site. The airplane impacted terrain about 8 miles south of PEO, at an elevation of approximately 1,320 feet msl. A group of trees were found broken at the 40 to 50-foot level, surrounded by trees that were 50 to 75 feet tall. Several freshly broken tree limbs and trunks up to a diameter of about 10 inches, were found strewn around the broken trees. A debris path oriented on a 015-degree heading extended about 200 feet from the initial tree strikes, to the main wreckage. An impact crater that measured 4 feet wide, 9 feet long, and 14 inches deep, was located about 100 feet north-northeast of the tree strikes. The main wreckage was located about 90 feet north-north east of the impact crater. The main wreckage came to rest on a tree, right-side down about 45 degrees, on a heading of approximately 140 degrees. Both wings were separated. The cockpit, instrument panel and forward portion of the airplane were destroyed. Both wings were separated at their respective roots and located in the debris path. Both wings displayed leading edge deformations consistent with tree strikes. Both fuel tanks were compromised, and there was no evidence of a fuel spill. Fire was observed along the debris path, where the wings came to rest. There was no evidence of fire at or around the main wreckage. The inboard 33 inches of the left horizontal stabilizer remained attached. The right horizontal stabilizer was curled downward about 45 inches from its root on the leading edge, and 31 inches from its root on the trailing edge. The bottom 2 feet of the vertical stabilizer remained attached. The airplane's flight controls were actuated by a series of push-pull tubes. Due to the fragmented nature of the wreckage, flight control continuity could not be confirmed. Measurement of the landing gear, flap, and pitch trim actuator jackscrews corresponded with landing gear down, flaps up, and nose down trim positions; respectively. The engine separated from the airframe and was located approximately 36 feet south of the main wreckage. The propeller assembly remained attached to the crankshaft flange. All three propeller blades exhibited leading and trailing edge damage. One blade was distorted in a "wave" pattern and was missing a portion of the blade tip. The top spark plus were removed from the engine. Their electrodes were intact and gray in color. The propeller was removed and the engine was rotated by hand via the crankshaft flange. Thumb compression was attained on all cylinders, and valve train continuity was confirmed to all cylinders except for the No. 2 cylinder, which sustained impact damage. The mounting flanges on both magnetos were damaged. Both magnetos were removed and produced spark on all towers when rotated by hand. The engine driven fuel pump drive shaft was intact and rotated freely. Internal examination of the engine, utilizing a lighted borescope, did not reveal any preimpact malfunctions. No vacuum pumps were located with the wreckage. An electrically powered attitude indicator was found in the debris path, and disassembled to reveal scoring of the gyro housing and rotor assembly. MEDICAL AND PATHOLOGICAL INFORMATION At the request of the pilot's family, an autopsy was not performed on the pilot; however; specimens were provided to the FAA for toxicology testing. Toxicological testing performed on the pilot by the FAA Bioaeronautical Science Research Laboratory, Oklahoma City, Oklahoma, revealed the following: ">>1.557 (ug/ml, ug/g) Desmethylsertraline detected in Blood (Cavity) >>0.468 (ug/ml, ug/g) Diphenhydramine detected in Blood (Cavity) >>Diphenhydramine detected in Urine >>2.274 (ug/ml, ug/g) Lorazepam detected in Urine >>0.091 (ug/ml, ug/g) Lorazepam detected in Blood (Cavity) >>0.307 (ug/ml, ug/g) Sertraline detected in Blood (Cavity) >>Sertraline detected in Urine. A representative of the pilot's family reported that the pilot had been taking Adavent since 2008 for anxiety, and Zoloft since about 2005 for depression. Review of the pilot's most recent FAA medical certificate application revealed that he had checked "No" to the question, "Do You Currently Use Any Medication (Prescription or Nonprescription.)" ADDITIONAL INFORMATION Astronomical Data Astronomical data obtained from the United States Naval Observatory for the accident site area noted that the end of civil twilight was 1710. At the time of the accident, the Moon was 12 degrees above the horizon on an azimuth of 075 degrees, with 97 percent of the Moon's visible disk illuminated.

Probable Cause and Findings

The pilot's decision to operate in known moderate-to-severe icing conditions, which resulted in a loss of control during approach.

 

Source: NTSB Aviation Accident Database

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