Aviation Accident Summaries

Aviation Accident Summary WPR20FA015

American Falls, ID, USA

Aircraft #1

N201BJ

Mooney M20J

Analysis

The pilot departed on a visual flight rules cross-country flight. GPS data revealed the airplane deviated from its previously established on-course heading after about 2 hours and established a direct course to a closer airport. The airplane began a descent about 30 minutes later that continued until the end of the recorded data. The airplane began a 180° turn away from a populated area and impacted terrain about 3.5 miles from the airport. A witness, located about 2 miles from the accident site, reported that she observed an airplane flying at a low altitude that turned and went “straight down.” During the last moments of the flight, the pilot turned 180° to avoid a populated area. This placed the airplane over farmland with a highway, about 450 ft to the left, and parallel to the airplane’s flightpath. It is likely that the pilot continued the left turn to land on the highway but allowed the airplane to slow down and exceed the critical angle of attack, resulting in an aerodynamic stall and spin at an altitude too low for recovery. Ground scars at the accident site were also consistent with the airplane impacting in a near-vertical attitude. Recorded engine data revealed consistent operation of the engine throughout the flight until about 2 minutes prior to the loss of data, when the data indicated a total loss of engine power. Postaccident examination of the two main fuel tanks and the two auxiliary fuel tanks revealed no visible fuel remained, along with no hydraulic deformation of the forward wall of the main tanks. The recorded engine data also showed that 12.8 gallons of fuel remained in the airplane; however, it is likely the pilot input an incorrect amount of usable fuel in the engine monitoring device and believed that he had sufficient fuel to reach his destination. It was not possible to determine the amount of fuel onboard at takeoff. Fuel was not available at the departure airport. Toxicology testing of the pilot’s specimens detected the presence of Tetrahydrocannabinol, the psychoactive component of marijuana, at levels considered impairing. It is likely the pilot was impaired by his use of marijuana and made a series of errors including, poor fuel planning, and inability to successfully manage a forced landing following a total loss of engine power due to fuel exhaustion. It is likely impairing effects from his use of marijuana on the day of the flight contributed to this accident.

Factual Information

HISTORY OF FLIGHTOn October 25, 2019, about 1200 mountain daylight time, a Mooney M20J, N201BJ, was substantially damaged when it was involved in an accident near American Falls, Idaho. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. A witness, who was driving about 2 miles from the accident site, reported that she observed an airplane flying at a low altitude, “barely above the treetops”. She stated that the airplane turned and then went straight down. Download from an onboard GPS unit revealed that the airplane departed the Dinsmore Airport (D63), Dinsmore, California, about 0711 Pacific daylight time, and travelled southeast for about 5 miles, then turned left to a heading of about 070° magnetic, consistent with a direct course to Boire Field Airport (ASH), Nashua, New Hampshire. The airplane climbed to about 11,800 ft and accelerated to about 175 knots ground speed. The airplane maintained that altitude, heading, and ground speed for about 430 miles. About 0923 the airplane diverged to the southeast and followed a track consistent with a direct course to American Falls Airport (U01), American Falls, Idaho. About 33 minutes later, the airplane began to descend. By 1008:44, the airplane had descended to 5,160 ft (760 ft above ground level [agl]) was about 3.5 miles from U01, and turned left 180°, opposite the location of a populated area. (See Figure 1). The last GPS data point was recorded at 1009:23 about 310 ft agl, 82 knots, and about 0.3 mile east of the accident site, and about 3.5 miles short of U01. A highway was located about 450 ft east of the accident site (see figure). Figure. Capture of the 180° turn. Data recovered from an engine data monitor (EDM) revealed engine performance parameters for the accident flight. The data revealed consistent operation for the engine throughout the takeoff, climb, enroute-cruise, and descent phases. During the last 2 minutes of the flight, all cylinder head temperatures reduced in value from about 315°C to about 184°C, and the exhaust gas temperatures reduced in value from about 1,400°C to about 245°C. During the same 2 minutes, the manifold pressure increased from 19 to 25.5 inches of mercury. The recorded engine oil pressure and engine speed revealed consistent operation until about 1 minute before the end of the recorded data, when the oil pressure dropped from 62 pounds per square inch (psi) to 0 psi, and engine speed dropped from 1,311 rpm to 1 rpm The recorded fuel flow revealed that for the first 20 minutes, the fuel flow rate varied from 2.4 gallons per hour to a 24.8 gallons per hour, consistent with startup, taxi and climb out, then remained about 13 gallons per hour for the remainder of the flight, except for the last 2 minutes, where the fuel flow dropped to 0 gallons per hour. At the end of the accident flight the EDM reported that 12.8 gallons of fuel remained on board. According to the Pilot’s Guide “For EDM fuel calculations to be accurate, it is mandatory that you inform the EDM of the correct amount of usable fuel onboard the aircraft… Do not rely on fuel flow instruments to determine fuel levels in tanks.” WRECKAGE AND IMPACT INFORMATIONThe airplane came to rest on a flat sandy area on a heading of about 321° magnetic. The debris field was contained in an area of about 120 ft by 45 ft and consisted mostly of small items from the cabin. All major components were accounted for near the fuselage. The right wing had separated and came to rest against the right side of the fuselage. Most damage to the right wing was concentrated near the wing tip, which displayed heavy crushing from the leading edge aft. A long gouge in the soil was present about 20 ft north of the fuselage, and the right composite wingtip was located adjacent to the gouge, consistent with a right-wing low impact. The propeller separated from the engine and remained partially buried, spinner first, in the soil. The propeller blades were in the feathered position. The propeller governor control arm was in the feathered position. The right-wing contact with the ground and the deposited propeller were consistent with a near vertical impact. The fuselage damage was concentrated at the engine cowling and cabin area and displayed upward and aft crush marks. The vertical stabilizer remained intact and was bent to the left about mid-span. The left horizontal stabilizer and left elevator remained attached to the empennage and were partially buried in the soil. The right horizontal stabilizer and elevator displayed damage at the area where the right wing came to rest on it. The flap actuator was about 2.5 inches extended, which is consistent with flaps full up. The landing gear was in the retracted position. The landing gear handle was in the down position with the handle bent towards down. Postaccident examination revealed no visible fuel in any of the four tanks, and no evidence of hydraulic deformation to the forward tank walls. All fuel caps were secured, with soft and pliable seals. Examination of the airframe and engine revealed no mechanical malfunctions or failures that would have precluded normal operation. ADDITIONAL INFORMATIONThe Pilot’s User’s Manual for the JPI-830 EDM states in part, “Prior to engine start you inform the EDM Fuel Flow Option of the known quantity of fuel onboard, it subsequently tracks all fuel delivered to the engine.” And “IMPORTANT: For EDM fuel calculations to be accurate, it is mandatory that you inform the EDM of the correct amount of usable fuel onboard the aircraft and confirm proper operation of the fuel flow transducer prior to and during flight. Do not rely on fuel flow instruments to determine fuel levels in tanks. Refer to original fuel flow instrumentation for primary fuel management information.” The FAA approved Airplane Flight Manual Supplement for N201BJ states in part: “Engine failure after liftoff and during climb. If the engine does not start, pull the propeller lever all the way-out holding pressure and the propeller will go into feather to extend your glide. Then proceed to POWER OFF LANDING procedures page 3-6.” MEDICAL AND PATHOLOGICAL INFORMATIONTesting performed on femoral blood as part of the autopsy identified Delta-9-tetrahydrocannibinol (THC, the primary psychoactive compound in marijuana) at 8.7 ng/ml; its inactive metabolite Delta-9-Carboxy-THC at 20 ng/ml and its active metabolite 11-Hydroxy-Delta-9-THC at 1.0 ng/ml. Toxicology testing performed by the FAA’s Forensic Sciences Laboratory on cavity blood identified 24.1 ng/ml of the parent compound, Delta-9-THC; 18.3 ng/ml of the inactive Delta-9-Carboxy-THC and trace amounts of 11-Hydroxy-Delta-9-THC (<1.0 ng/ml). All three analytes were also identified in urine. A backpack was recovered from the cockpit of the airplane. It contained three small containers of a substance confirmed to be marijuana, and smoking paraphernalia.

Probable Cause and Findings

The pilot’s failure to ensure adequate fuel onboard and his subsequent failure to maintain airspeed while maneuvering which resulted in an aerodynamic stall following a total loss of engine power due to fuel exhaustion. Contributing to the accident was the pilot’s impairment due to his use of marijuana.

 

Source: NTSB Aviation Accident Database

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