MIA08FA094
MIA08FA094

HISTORY OF FLIGHT

On April 27, 2008, about 1019 eastern daylight time, a Mooney Airplane Company, Inc., M20M, N429RM, registered to RKJ Aero LLC, experienced an in-flight loss of control shortly after takeoff from Chesterfield County Airport (FCI), and crashed into a house located in Midlothian, Virginia. Instrument meteorological conditions prevailed at the time and an instrument flight rules (IFR) flight plan was filed for the 14 Code of Federal Regulations (CFR) Part 91 personal flight from FCI to Franklin Municipal-John Beverly Rose Airport (FKN), Franklin, Virginia. The airplane was destroyed by impact and a postcrash fire, and the certificated private pilot and pilot-rated passenger were killed. The house was destroyed by impact and the postcrash fire, and the sole person in the house sustained serious injuries due to burns. The flight originated about 1016, from FCI.

An employee of a fixed base operator (FBO), at the departure airport, reported the airplane remained on their ramp with the engine running for approximately 15 minutes. The airplane then taxied to runway 33 and remained at the approach end of the runway for approximately 15 minutes. Another employee of the same FBO reported she did not hear any radio calls on the common traffic advisory frequency (CTAF) from the pilot announcing his departure, but she became busy with work duties and people that arrived at the FBO about that time.

According to a transcription of communications with Potomac Terminal Radar Approach Control (TRACON), at 1007:46, an occupant of the airplane established contact with the James River Flight Data (JRVFD) Position and advised the controller that they were on the ground at FCI requesting IFR clearance to FKN. The JRVFD controller advised the pilot that the flight was cleared to FKN via direct Harcum VORTAC, then direct FKN. He was also advised to maintain 2,000 feet mean sea level (msl), expect 5,000 feet msl 10 minutes after takeoff, the departure frequency was 134.7 MHz, and the discrete transponder code was 5321. An occupant of the airplane correctly read back the IFR clearance and the JRVFD controller instructed the pilot to advise when the flight was ready to depart. An occupant replied that they were currently number one to takeoff from runway 33. At 1009:08, the Potomac TRACON JRVFD controller advised the pilot that the flight was released for departure and to enter controlled airspace heading 180 degrees. An occupant of the airplane read back the heading information.

The employee of the FBO, who witnessed the airplane taxiing out, further reported that during takeoff, when the airplane was abeam the windsock, it was below the tree-line. While airborne, the airplane continued past the departure end of the runway, where he lost sight of the airplane after entering clouds. It was not raining at the time of departure, but it was cloudy. He did not recall whether the landing gear retracted and did not recall seating positions of the occupants before departure.

According to the NTSB Air Traffic Control (ATC) Radar Study, the first radar target associated with the accident airplane was at 1016:03; the airplane at that time was located near the departure end of runway 33 at 300 feet msl. The flight continued on the runway heading until approximately 1017:04, and climbed to approximately 1,100 feet msl. At that time the flight was near Jacobs Road. The airplane then turned left, flying in a west-northwesterly direction and climbed to approximately 1,300 feet msl, until approximately 1017:22. At that time the flight turned right flying in a northwesterly direction. The flight continued in the northwesterly heading, climbing to approximately 1,800 feet msl, until 1017:50, while over Hull Street Road (U.S. Route 360), the airplane then turned left. The airplane continued in the left turn until 1018:17. During the left turn the airplane descended initially to 1,600 feet msl, then climbed back to 1,800 feet msl. The airplane remained at approximately 1,800 feet msl, but turned right, flying first in a westerly direction, then turned left flying in a west-southwesterly direction until 1018:27. At that time, the airplane began a right descending turn, losing 1,000 feet of altitude in an approximate 10 second period, with a corresponding ground speed increase from approximately 140 knots to 170 knots. The last radar target, which occurred at 1018:40, depicted the airplane to be at 600 feet msl, and was located near the accident site. A non-correlated radar target was located west of the last radar target.

One witness, located near the accident site, reported to a Federal Aviation Administration (FAA) inspector, that he observed the airplane flying beneath the cloud bases. The airplane flew in a southerly direction at an estimated 50 to 60 feet above ground level (agl), in a wings level, slow descent. He saw a large part separate, then heard engine sound decrease. He noticed the propeller turning slowly, then lost sight of the airplane.

A second witness reported hearing the engine “stalled” and tried to restart, while a third witness reported that at the time of the accident there was light drizzle. The witness heard an airplane approaching from the northwest and reported the noise increased enough to get his attention. He observed the airplane, which appeared to be silver in color, and noticed the right side of the airplane while it was descending at about a 45-degree angle. The engine sounded “wide open” and there was no sputtering; the engine roar was constant. He correlated it to a “kamikaze type dive.” He did not see any sign of a recovery from the nose-low descent, and it disappeared from his view. A second or two later, he heard the impact and his wife dialed 911. He did not see anything separate from the airplane. It was not “listing to either side and was right side up. I could not see the pilot or passenger.”

A fourth witness reported that at the time of the accident, he was in his driveway and heard a noise from above. It sounded to him like the engine was “missing and sputtering.” He looked in the direction of the noise and saw the airplane coming across the trees, moving southward across Woodsong Drive at a rapid rate of speed. The airplane was descending at about a 45-degree angle, and it was not pitching or rolling. The airplane impacted on Woodsong Drive. He drove to the scene right away and saw other neighbors circling the house, trying to gain entrance, but it was evident they could not enter due to the heavy smoke and flames.

At 1019:26, a controller with the Potomac TRACON Flatrock (FLTRK) Position advised on the departure frequency, “november four two nine romeo mike potomac departure low altitude alert climb and maintain two thousand immediately.” There was no recorded response from the pilot and there was no recorded communication from the accident pilot while airborne with Potomac TRACON.

The airplane crashed into a house located in a residential area during daylight conditions. The crash site was located approximately 400 feet south-southeast from the last correlated radar target.

PERSONNEL INFORMATION

The pilot, age 40, held a private pilot certificate with ratings for airplane single-engine land and instrument airplane, issued on February 3, 2007 and April 7, 2007, respectively. He also held a third-class medical certificate, with no limitations, issued on December 18, 2006.

A review of his pilot logbook, which was found in the wreckage and was heat damaged, revealed that no carry forward flight time was listed on the first page of logged flights. The “From” date indicated December 16th, with the year not legible. He logged a total time of approximately 332 hours, of which approximately 271 hours were as pilot-in-command (PIC). Since obtaining his instrument rating on April 7, 2007, he logged approximately 23 hours actual instrument flight time, of which 19 hours were logged as PIC.

The right front seat occupant, age 72, was the holder of a commercial pilot certificate with airplane single and multiengine land, instrument airplane, and rotorcraft helicopter ratings, last issued on September 1, 1977. He was last issued a 2nd class medical certificate on January 6, 1979.

AIRCRAFT INFORMATION

The airplane was type certificated in accordance with Civil Airworthiness Regulation (CAR) 3 for structures, and 14 CFR Part 23 for the engine and electrical systems. A review of CAR 3.339 titled, “Flap Interconnection” indicates that the motion of the flaps on opposite sides of the plane of symmetry shall be synchronized by a mechanical interconnection.

The airplane was manufactured in July 2000, by Mooney Airplane Company, Inc., as model M20M, and was designated serial number 27-0301. It was powered by a Lycoming TIO-540-AF1B, 270-horsepower engine and equipped with a McCauley three-bladed constant speed propeller. The airplane was equipped with two electrically controlled and actuated Precise Flight speedbrakes, one installed in each wing. The airplane was also equipped with one electrically controlled and actuated flap in each wing. The flap actuation system consists of an actuator that connects to a bellcrank, which is secured to a single jackshaft. The single jackshaft operates the left and right flaps.

The copilot’s side of the instrument panel did not contain any flight or engine instruments. Although the exact airplane total time at the time of the accident was not determined, the airplane total time 5 days before the accident was recorded to be 732.7 hours.

A review of the airplane Pilot’s Operating Handbook and FAA Approved Flight Manual (POH/AFM), with respect to the Precise Flight speedbrakes, revealed that in the unlikely event that one speedbrake “cartridge” deploys while the other remains retracted, a maximum of 10 percent of corrective aileron travel and 5 pounds of rudder pressure are required for coordinated flight from stall speed through Velocity never exceed speed (Vne).

The pilot’s wife reported that her husband knew before arrival on April 25th, to the Essex County Airport (CDW), Caldwell, New Jersey, that there was an issue of a “sticking flap,” but her husband had been told by a non vested partner that the airplane was safe to fly. When they arrived at CDW, the pilot’s wife “…flipped a switch for the flaps while her husband was behind the plane.” The pilot’s wife further reported that her husband called a Mooney Service Center located on the airport, and a mechanic was sent to inspect the airplane. The mechanic, who was familiar with Mooney type airplanes, reported observing the flaps being operationally cycled “a few [times]” and did not report hearing any abnormal sounds. The mechanic did not perform an inspection and no work order was prepared. The pilot’s wife reported the mechanic informed them that the airplane was safe to fly, though the maintenance records did not reflect any written discrepancy or corrective action related to the flaps. The airplane was flown that same day to FCI, arriving uneventfully; no maintenance was performed to the airplane while at FCI.

Review of the maintenance records revealed the airplane was last inspected in accordance with an annual inspection on November 16, 2007. The owner of an Authorized Mooney Aircraft Service facility that had worked on the airplane numerous times, reported they did inspect the flap system of the airplane on February 4, 2008. The entry on the work order pertaining to the flaps indicates, “check flap actuator circuit breaker pops occasionally. Check limit switches OK. Lube System. Unable to duplicate, cycled flaps numerous times.”

Mooney personnel reported that with one flap fully extended and the opposite flap fully retracted, the asymmetric flap extension results in a slow roll, and the airplane is controllable with 1/3 aileron input and comfortable control forces.

METEOROLOGICAL INFORMATION

The PIC stated in an e-mail to his certified flight instructor on April 24, 2008, that if the weather was bad on Saturday or Sunday, he would not utilize the airplane.

There was no record of any preflight weather briefing with Lockheed Martin Automated Flight Service Station.

An employee of an FBO, where the airplane was parked, reported seeing the pilot and also the pilot-rated passenger check the automated weather observing system (AWOS) screen at their FBO before departure. The employee advised the pilot-rated passenger that the wind was from 010 degrees at 7 knots, and an overcast ceiling at 800 feet existed. She also reported seeing the pilot check the WSI computer. The pilot-rated passenger advised her that they were flying to FKN for the purpose of performing approaches. Neither occupant expressed to her any concern regarding the weather conditions.

A surface observation weather report, taken at the departure airport (FCI) at 1019, indicates the wind was from 360 degrees at 4 knots, the visibility was 10 statute miles, overcast clouds existed at 800 feet, the temperature and dew point were 17 and 13 degrees Celsius respectively, and the altimeter setting was 30.15 inches of Mercury.

COMMUNICATIONS

There was no recorded two-way communication with Potomac TRACON FLTRK position; there was no reported communication equipment discrepancy with Potomac TRACON at the time of the accident.

AIRPORT INFORMATION

The Chesterfield County Airport (FCI), located in Richmond, Virginia, has one asphalt
runway designated 15/33. The runway is 5,500 feet long and 100 feet wide. The CTAF is monitored by an FBO, but is not recorded.

The departure end of runway 33 is located at 37 degrees 24.738 minutes North latitude
and 077 degrees 31.846 minutes West longitude.

WRECKAGE AND IMPACT INFORMATION

The airplane crashed in a residential area; the crash site was located approximately 311 degrees and 3.8 nautical miles straight line distance and direction from the departure end of runway 33. The airplane crashed into a wood framed house, which was destroyed by impact and a postcrash fire.

The lower fuselage panel was located in one piece approximately 600 feet northwest from the crash site. Inspection of the panel revealed no fire or soot damage; normal in-service grease and oil was noted. The forward right corner of the panel had a diagonal oriented crease, and a crease parallel to the forward and aft edges was located nearly midspan. Marks consistent with spacing from the rudder spring were noted near the left aft edge of the panel. Nearly all the holes in the panel exhibited fastener pull through. Pieces of the left rear window were located on the ground between the location of the lower fuselage panel and the crash site. The pieces were found in an area of approximately 150 feet wide and 250 feet long. Cursory examination of the 28 pieces revealed no evidence of soot. The pieces were recovered and retained for further examination by the NTSB Materials Laboratory.

Examination of the accident site revealed ground scars before the house, oriented on a magnetic heading of 130 degrees. The ground scars were attributed to the engine impact and right wing contact. The right aileron counterweight was located in the right wing ground scar. The airplane was fragmented and destroyed by impact and postcrash fire. All components necessary to sustain flight were accounted for at the accident site. The landing gear was retracted as evidence by the actuator positions of the left and right main landing gears. The flap position could not be determined as the flap actuator and flap actuator jackscrew were not located. Examination of the left and right wings revealed both speedbrakes were separated. The left speedbrake was found in the retracted position; impact and fire damage was noted to the speedbrake. Examination of the blades of the left speedbrake revealed no evidence of appreciable damage to either panel. The right speedbrake was found in the partially deployed position. Examination of the right speedbrake revealed one end of the frame was separated and not located while the same end of the frame was displaced up. Inspection of the panels of the right speedbrake revealed no evidence of impact signatures indicating either panel was deployed or partially deployed at the point of ground contact. The motor of the right speedbrake was separated and not located. The elevator and rudder flight control push/pull tubes were fragmented, but remained connected at the aft bellcrank. The rudder counterweight and the right elevator counterweight were not recovered. The left aileron push/pull tube was fractured at the wing root area, while the outer portion of the tube had a portion of aileron bellcrank attached. The short aileron push/pull tube was separated and not recovered. The threaded portion at the bellcrank exhibited overload features. The right aileron push/pull rod was separated at both ends, but accounted for. It was crushed flat in areas along its length. The short aileron push/pull tube was separated and not recovered. Examination of the manual trim wheel assembly and the empennage jackscrew revealed both indicated approximately takeoff trim setting. The engine was found separated from the airframe and the propeller hub remained secured to the engine; one propeller blade remained secured to the propeller hub. The remaining two blades were recovered from the impact site.

Examination of the cockpit and cabin revealed extensive impact and fire damage. Components of the cockpit that were identifiable included the ignition switch, compass, altimeter, and attitude indicator. Examination of the attitude indicator revealed impact and fire damage. Disassembly of the unit revealed light rotational scoring of the rotor and rotor housing. The cabin and baggage doors were located at the accident site. Both doors exhibited impact and fire damage. The cabin door was compressed longitudinally, and the forward pin position of the baggage door was consistent with extension at impact. Components consisting of a digital camera, a Hewlett-Packard (HP) iPAQ, and an electronic engine/environmental recording/display from the airplane were recovered either from the wreckage or in close proximity to the main wreckage and retained for further investigation by NTSB.

Examination of the engine revealed extensive impact and fire damage, which precluded operational testing. Rotation of the crankshaft by hand revealed crankshaft, camshaft, and valve train continuity to the non-damaged valve train components. Suction was noted in all cylinders during hand rotation. Borescope inspection of all cylinders revealed normal combustion signatures. Removal of the accessory case revealed the internal timing was correct, and the crankshaft gear was secure. Inspection of the engine lubrication system revealed no evidence of preimpact failure or malfunction. Examination of the ignition system revealed both magnetos were impact and fire damaged, which precluded operational testing. The spark plugs from cylinder Nos. 2 through 6 exhibited light gray color and moderate electrode wear with normal gap settings. Both spark plugs from the No. 1 cylinder were damaged. The vanes of the turbocharger were damaged and soil was found within the compressor. The controller and bypass valve were impact separated and the valve was separated from the actuator and found in the closed position; impact damaged precluded movement of the bypass valve. Impact damage to the servo fuel injector was noted and the throttle plate was found in the full open position. Examination of the fuel injector manifold revealed thermal damage to the diaphragm; the piston was seized inside the housing. The engine driven fuel pump was impact and fire damaged; the lower body remained attached to the accessory case, and the drive spline shaft was not failed. Examination of the engine-driven vacuum pump revealed the drive coupling was thermally damaged. The interior surface of the center body exhibited rotational score marks.

Examination of the propeller revealed the blade that remained secured to the propeller hub exhibited torsional bending; the blade was free to rotate in the hub. The second propeller blade, which was separated from the propeller hub, was bent aft and approximately 12 inches of the blade tip was sheared off. The third propeller blade, which was also separated from the propeller hub, exhibited forward and aft bending and leading edge tip damage.

MEDICAL AND PATHOLOGICAL INFORMATION

Postmortem examinations of the pilot and pilot-rated passenger were performed by the Office of the Chief Medical Examiner, Richmond, Virginia. The cause of death for the pilot was listed as “Massive blunt force trauma,” while the cause of death for the passenger was listed as “Corporal fragmentation due to massive blunt force trauma.”

Forensic toxicology was performed on specimens of the pilot by the FAA Bioaeronautical Sciences Research Laboratory (CAMI), Oklahoma City, Oklahoma. The toxicology report indicated the results were negative for volatiles and tested drugs. Testing for carbon monoxide and cyanide was not performed.

Forensic toxicology was performed on specimens of the passenger by CAMI and also the Commonwealth of Virginia Department of Forensic Science. The toxicology report by CAMI indicated the results were also negative for volatiles and tested drugs. Testing for carbon monoxide and cyanide was not performed. The toxicology report from the Commonwealth of Virginia Department of Forensic Science indicated the result was positive in the submitted muscle specimen for carbon monoxide (less than 7 percent saturation). The remainder of the test results was negative.

TESTS AND RESEARCH

Inspection of the digital camera, HP iPAQ, and also the electronic engine/environmental recording/display by the NTSB Vehicle Recorders Division revealed no images on the SD digital camera card, or on the HP iPAQ SD storage card. Inspection of the electronic engine/environmental recording/display revealed two identical integrated circuits that are not capable of any storage of information.

Examination of the left rear window pieces was performed by the NTSB Materials Laboratory, located in Washington, DC. Eleven pieces were measured for thickness, which ranged from a minimum of 0.167 inch to a maximum of 0.209 inch, with a mean of 0.193 inch. The specification is 0.187 inch plus or minus 0.030 inch. The primary fractures in the window emanated from an origin at the bottom edge of the window, approximately 20 inches aft of the forward edge. Patterns on the fracture surfaces indicate that the cracking initiated under overstress conditions at the corner between the exterior window surface and the bottom edge of the window within the window frame. Fracture surfaces close to the origin exhibited features consistent with crazing and fracture initiation on multiple planes with subsequent coalescence into a single fracture. The fracture surfaces away from the origin generally exhibited evidence of rapid fracture. None of the fractures in the window propagated along the edges of the window frame.

The pilot flew the airplane on April 25, 2008, from CDW to FCI. After landing, the pilot requested both tanks be filled. The airplane was fueled the same day; a total of 31.0 gallons of 100 low lead (100LL) fuel were added. The airplane was not operated between the arrival flight and the accident flight. The fuel facility did not report any problems by owners or pilots of other airplanes fueled from the same source.

According to the airplane Type Certificate Data Sheet, the airplane’s usable fuel capacity is 89.0 gallons, and the maximum takeoff weight limitation is 3,368 pounds. A review of the airplane’s POH/AFM located in the wreckage revealed the latest weight and balance was dated February 28, 2007. The empty weight and empty weight moment were indicated to be 2,454.0 pounds and 110800.3, respectively, and the empty weight center of gravity (CG) was 45.2 inches aft of datum. The POH/AFM further indicated that the calibrated weight for 100LL is 5.82 pounds per gallon.

Weight and balance calculations were performed using the latest airplane empty weight (2,454.0 pounds), the weights of the pilot and passenger per their last medical certificates (180 and 165 pounds respectively), and the weight of usable fuel (approximately 518 pounds). The airplane weight and CG at the moment of engine start were estimated to be approximately 3,317 pounds and 45.15 inches aft of datum. The calculation included placement of the pilot and co-pilot’s seats at the aft most positions. At approximately 3,317 pounds, the forward and aft CG limits are approximately 44.7 and 51.0 inches aft of datum, respectively.

According to the NTSB Recorded Radar and Performance Study, after takeoff the airplane flew in a northwesterly direction and about 100 seconds later began to turn left about (100 degrees) and then turned right as the flight leveled at an altitude of about 1,800 feet. During the right turn the performance calculations showed the bank angle and turn rate increased beyond the standard rates and angles, and the load factor reached close to maximum limits. The data then showed the flight descend at greater than 6,000 feet-per-minute and at a large negative pitch angle.

ADDITIONAL INFORMATION

Spatial disorientation is an inaccurate awareness of attitude and/or direction of motion relative to the surface of the earth. In instrument meteorological conditions, it can occur because the human vestibular and somatosensory systems provide misleading information during maneuvering flight. This misleading information prompts illusions of motion (or lack of motion) that can be very compelling, especially if the flight instruments are not continuously monitored.

There are many forms of vestibular illusions. One is known as the “post-roll illusion.” When an airplane’s rolling motion is stopped after many seconds, the pilot may feel as if the airplane has begun to roll in the opposite direction. Another form is the “graveyard spiral illusion.” After becoming established in a spiral turn with a relatively constant angular velocity, a pilot will begin to lose the sensation of being in the turn, and will experience a feeling of turning in the opposite direction during recovery.

Any pilot can experience vestibular illusions during maneuvering flight. In fact, false perceptions of attitude and/or motion are inevitable when a pilot is distracted from monitoring the flight instruments in instrument meteorological conditions. When illusions of roll or bank occur, an instrument-rated pilot will normally regain accurate orientation after returning his or her attention to the flight instruments. In rare instances, however, these illusions may prompt the pilot to make inappropriate control inputs that increase the angle of bank, placing the airplane in a spiral dive.

The appropriate steps for recovering from a spiral dive are to (1) level the wings and (2) pull back on the control column. These actions are taught to all instrument-rated pilots during flight training. The order of the recovery actions is important, because pulling back on the control column before leveling the wings will only tighten the turn and increase the load factor. This will tend to intensify vestibular illusions during subsequent attempts to stop the turn and it will increase the risk of airframe overstress during attempts to pull out of the dive.

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