CEN12FA170
CEN12FA170

HISTORY OF FLIGHT

On February 26, 2012, about 1709 central standard time, a Mooney M20E airplane, N9224M, impacted terrain during initial climb after departure from Stinson Municipal Airport (SSF), San Antonio, Texas. The certified flight instructor (CFI) and the pilot were fatally injured. The airplane was substantially damaged. The airplane was registered to and operated by Niclan Corporation, under the provisions of 14 Code of Federal Regulations Part 91 as a positioning flight. Day visual meteorological conditions prevailed and no flight plan was filed. The flight departed SSF at 1707, and was destined for Gillespie County Airport (T82), Fredericksburg, Texas.

The pilot was cleared for takeoff to the southeast from runway 14 with instructions to turn left to the northeast because of traffic approaching the airport from the south. After takeoff, when the airplane was about 200 feet above ground level (agl), the SSF tower controller noticed the airplane in a right turn and again instructed the pilot to make a left turn to the northeast. An incomplete radio comment from the pilot indicated he was turning back. The controller saw the airplane flying southwest bound at a low altitude and shortly thereafter saw a cloud of black smoke about 1/2 mile south of SSF.

One witness was watching the airplane while it was turning to the right. He saw the wing of the airplane then suddenly roll sharply to the right and the airplane pointed about 45 degrees nose-down and the airplane went into a dive. A second witness heard sputtering, looked up and saw the airplane as it banked to one side and dove toward the ground. A third witness also heard sputtering and then heard the sounds of a crash and an explosion.

Evidence at the scene showed the airplane impacted terrain in a nose-down attitude and came to rest inverted. There was a postimpact explosion and fire.

PERSONNEL INFORMATION

Certified Flight Instructor

The CFI, age 63, held an airline transport pilot certificate with airplane single and multiengine land, airplane single engine sea, glider, and instrument airplane ratings. He held a type rating for CE-500. In addition, he held a flight instructor certificate with airplane single and multiengine, glider, and instrument airplane privileges. He was issued a second class airman medical certificate, with limitations, on February 3, 2012.

The CFI's pilot logbook was not available for examination; however on his most recent medical certificate application he reported that he had logged 20,825 hours of total flight experience; with about 120 of those hours in the previous six months. No other records of the CFI's flight experience were available. For most of the time following his retirement from military service the CFI had been working full-time as a flight instructor, with most of that activity at SSF. The CFI was known to usually fly from the right cockpit seat any time there was another pilot in the cockpit, who would be flying from the left cockpit seat.

Pilot

The pilot, age 54, held a private pilot certificate with a rating for airplane single land. He was issued a third class airman medical certificate, with limitations, on September 17, 2010.

The damaged parts of the pilot's logbook that were found in the wreckage showed that he had 209.1 hours of total flight experience in airplane single engine land. 127.5 of those hours were in complex airplanes, and about 110 hours were logged as flight instruction received. There was no evidence that the pilot had ever before flown an airplane with a turbocharged engine.

The pilot, who was a law enforcement officer, had recently been receiving that flight instruction from the CFI in order to earn his instrument airplane rating and a commercial pilot certificate. Of the most recent 45 flights in the logbook, 29 of the flights were logged as flight instruction received from the CFI. Most of those flights were in a similar Mooney M20C and included the pilot's most recent flight review which was completed on June 6, 2011.

AIRCRAFT INFORMATION

The four-seat, low-wing, retractable landing gear, single engine airplane, serial number (s/n) 1183, was manufactured in 1966. It was equipped with a 200-horsepower Lycoming model IO-360-A1A engine, serial number L-2509-51A, which drove an MT-Propeller, model MTV-12-B/180-59B, 3-blade wood composite propeller.

The engine had been modified with a turbo-normalizer system manufactured by M-20 Turbos, Inc., which was installed on July 21, 2009, under FAA Supplemental Type Certificate Number SE01643AT and SA01642AT.

The airplane had been modified by the installation of a redesigned pilot's and co-pilot's instrument panel equipped with a Garmin G500 dual screen Primary Flight Display (PFD) and Multifunction Display (MFD); Aspen EFD 1000 Pro Flight Display; Avidyne WSI AV300 Datalink Receiver; J.P. Instruments EDM-930, Engine Data Monitoring System; a back-up electric attitude indicator; and other modifications. The airplane was also equipped with an S-TEC 30 autopilot.

A review of the airframe logbooks and engine logbooks showed that the most recent entry was made on September 1, 2011, with entries certifying that an annual inspection had been completed at 6,343.2 total aircraft hours and 6,343.2 total engine hours since new. The total time since major overhaul for the engine was listed as 980.1 hours. Federal Aviation Administration (FAA) records show the airplane had been registered to the current owner since March 6, 1998.

METEOROLOGICAL INFORMATION

The automated weather observation station at SSF, issued at 1653, reported wind from 170 degrees at 8 knots, visibility of 10 miles, overcast clouds at 3,400 feet above ground level, temperature 17 degrees C, dew point temperature 10 degrees C, with an altimeter setting of 30.04 inches of mercury.

COMMUNICATIONS AND RADAR

At 1653:30, N9224M (voice identified as the pilot) contacted the SSF Federal Contract Tower (FCT) controller and advised he was ready to taxi with information Romeo

At 1653:47, the controller responded

At 1653:51, N9224M (voice identified as the pilot) advised he was VFR and going to T82

At 1653:59, the controller issued taxi instructions to runway 14

At 1654:06, N9224M (voice identified as the pilot) responded he was taxiing to runway 14

At 1654:16, N9224M (voice identified as the CFI) requested flight following, and during the next minute there were several exchanges between the controller and N9224M (voice identified as the CFI)

At 1706:51, N9224M (voice identified as the pilot) advised ready for takeoff runway 14

At 1706:58, the controller instructed N9224M to "turn left northeast bound" and gave clearance for takeoff

At 1707:06, N9224M (voice identified as the pilot) responded he was departing runway 14 and was turning northeast bound

At 1708:46, the controller instructed N9224M " … ah left turn to ah northeast"

At 1708:59, N9224M (voice identified as the pilot) said "mooney nine two two four turning back for ⦠" (there was a change in the sense of urgency noted in the voice of the pilot and the end of the transmission was cut off)

No further communications from N9224M were received.

At 1709:04, the controller said "mooney two four mike traffic a mile southwest of the airport cessna entering right downwind"

FAA Air Traffic Control radar showed at total of four returns from N9224M. The first two radar returns at 1708:32 and 1708:41 had altitude data at 800 feet. The last two returns at 1708:46 and 1708:55 had no altitude data.

WRECKAGE AND IMPACT INFORMATION

The airplane impacted in a flat unimproved field. The debris trail from the main crater led on a direction of 330 degrees for 57 feet to the main wreckage. The wreckage came to rest in an inverted position with the nose of the airplane oriented to about 360 degrees. All major components of the airplane were observed at the accident scene.

The initial impact ground scars were 44 feet wide from tip to tip and showed the airplane impacted terrain in a partially inverted mostly nose down attitude with the end of the right wing oriented to about 190 degrees and broken pieces of green glass in the area corresponding to the impact with the right wing tip. The ground scar corresponding to the end of the left wing was oriented to about 010 degrees. The main crater corresponding to the impact from the propeller was deeper than the other portions of the ground scars and contained portions of a broken propeller blade.

The engine was separated from the engine mounts and came to rest upright. All three of the wood composite propeller blades were separated from the hub and were found at the scene. Two of the propeller blades displayed chordwise smearing and impact gouging on the leading edges, the third propeller blade was fragmented into smaller pieces which prevented examination of the blade faces.

The non-steel parts of the fuselage were almost completely consumed by fire. The right wing was observed inverted with impact compression damage all along the leading edge. About three feet of the outermost leading edge was crushed aft at about a 20 degree angle. The left wing was separated from the fuselage and had flipped to an upright position with similar impact compression damage all along the leading edge. Both ailerons remained attached to their hinge points and the flaps were still attached or partially attached to the trailing edges of both wings. Both fuel caps were observed still attached.

The empennage and about 5 feet of the tail cone were resting on its right side with the left horizontal stabilizer pointing up nearly vertical. The vertical stabilizer was nearly parallel to the ground. The right horizontal stabilizer was bent up and inboard, nearly parallel to the vertical stabilizer. The elevator and rudder remained attached at their hinge points and the empennage remained attached to the tail cone. There was a compression bending crease at about a 45 degrees angle across the left side of the tail cone forward of the tail cone aft bulkhead. The elevator trim tab was observed to be near a cruise trim setting.

The right main landing gear was in the retracted position in the right wing with part of the middle gear door still attached. The left main landing gear and the nose wheel were broken and separated.

Aileron control continuity was confirmed from the cockpit to the right aileron where the pushrods were impact broken and separated from the bellcrank and aileron. Aileron control continuity was also confirmed from the cockpit to the left aileron. Rudder and elevator control continuity were confirmed from the control surfaces to the tail cone, but could not be confirmed to the cockpit due to the impact and fire damage. All control surface counterweights were observed at the scene.

The main cabin door was located beneath debris near the right wing root and all locking pins were in the extended position. Two AMSAFE Aviation Inflatable Restraint system inflator bottles were observed in the wreckage. Due to fire and heat damage it could not be determined whether or not they may have discharged at impact.

The postaccident examination of the airframe revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation.

After documentation at the scene, the engine was removed and examined separately. The engine exhibited impact damage and exposure to heat and fire. The propeller hub remained attached to the flange on the crankshaft. The magnetos and ignition harness were fire damaged and could not be tested. The oil sump was breached by fire. All of the rear accessories were damaged and partially consumed by fire. The valve covers and the top sparkplugs were removed. The spark plugs appeared clean and had a very clean bead blasted appearance. The gaps on the fine wire electrodes were observed pushed closed on the top number two and top number three spark plugs.

The crankshaft was rotated by hand and thumb compression was established on all cylinders. Engine drive train continuity was confirmed throughout. The cylinders were borescope inspected and signs of detonation were noted with a bead blasted clean appearance. The number one and number three cylinders were removed to facilitate photos of the cylinder heads and pistons. Three of the fuel injectors were removed; one injector was captured by molten material. One injector was found free of debris, and the other two were blocked by what appeared to be carbonized oil from exposure to heat. The fuel flow divider was opened and no anomalies were noted, other than heat damage to the diaphragm. The fuel servo showed signs of heat deformation and the servo inlet screen was captured by molten material. The oil pickup screen was found free of debris.

The turbo-normalizer system was examined. The turbocharger was deformed by heat and the impeller was seized with molten aluminum. The absolute pressure relief valve (pop-off valve) was also heat damaged and could not be moved. The turbocharger housing and pipe clamps were intact.

MEDICAL AND PATHOLOGICAL INFORMATION

Certified Flight Instructor

An autopsy was performed on the CFI by the Bexar County Office of the Medical Examiner in San Antonio, Texas. The cause of death was listed as multiple traumatic injuries.

Forensic toxicology was performed on specimens from the CFI by the Federal Aviation Administration (FAA), Aeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma.

The toxicology report stated: NO CARBON MONOXIDE detected in Blood; NO CYANIDE detected in Blood; NO ETHANOL detected in Urine.

The following additional findings were noted:

Amlodipine detected in Urine
Amlodipine detected in Blood
Azacyclonol detected in Urine
Azacyclonol NOT detected in Blood
Fexofenadine detected in Urine
Fexofenadine detected in Blood
Paroxetine detected in Urine
Paroxetine NOT detected in Blood
0.116 (ug/mL, ug/g) Tramadol detected in Blood
Tramadol detected in Urine

The National Transportation Safety Board (NTSB) Chief Medical Officer reviewed the factual report narrative, the autopsy report, the toxicology results, the CFI's FAA airman medical certification file, and the CFI's personal medical records.

FAA records showed the CFI was first issued an airman medical certificate in 1987. In 1990 he reported a hospital admission for "hypertitis" and having previously had a negative evaluation for hematuria. On that visit, a heart murmur was detected but the pilot reported it had previously been evaluated. On a FAA airman medical certificate application in 1993 he denied taking any medications and reported having previously had surgery on a knee and shoulder. He was granted a first class medical certificate, limited by the need to wear corrective lenses. In 1997 he reported to the FAA that he had had his tonsils removed but in 1998 he recorded the procedure as a "UPPP" which stands for uvulopalatopharyngoplasty. This is a surgical procedure performed on the posterior parts of the throat to limit snoring, usually on patients diagnosed with sleep apnea. There is no record of any further evaluation by the FAA and the CFI did not report a diagnosis of sleep apnea.

In 2006, the CFI reported treatment for hypertension and after he supplied additional information about his cardiovascular condition, he was issued a second class airman medical certificate. The CFI continued to be medically certificated and his last FAA airman medical exam was performed on February 2, 2012. At that time he reported taking Lotrel for his hypertension (a combination medication containing amlodipine and benazepril). His blood pressure was measured at 129/78.

The toxicology testing revealed amlodipine in urine and cavity blood; fexofenadine (a non-sedating antihistamine marketed under the trade name Allegra) in urine and blood and its metabolite azacyclonol in urine; paroxetine (an antidepressant marketed under the trade name Paxil) in urine but not in blood; and tramadol (an opioid pain medication marketed under the trade name Ultram) in urine and in cavity blood at 0.116ug/ml.

A review of the CFI's personal medical records revealed the following diagnoses: sleep apnea, (treated with surgery in 1996 but reportedly requiring the use of a CPAP machine), nasal allergies, hypertension, gout, chronic joint pain, esophageal reflux, prostatism, depression, and anxiety.

The medical records demonstrate the most current prescriptions prior to the accident for tamulosin (used to improve urine flow in men with prostatism, marketed under the trade name Flomax), tramadol (a opioid pain medication that is a schedule II controlled substance and is marketed under the trade name Ultram), meloxicam (a non-steroidal anti-inflammatory analgesic, marketed under the trade name Mobic), esomeprazole (heartburn medication marketed under the trade name Nexium), allopurinol (increases the excretion of uric acid and is used to prevent attacks of gout, marketed under the trade name Zyloprim), finasteride (used to improve urine flow in men with prostatism, marketed under the trade name Proscar), and paroxetine (an antidepressant marketed under the trade name Paxil).

The CFI's personal medical records showed he had been treated with tramadol once or twice daily since at least 2009 but continued to report chronic pain. In addition, in May, 2011, the CFI reported feeling depressed and was prescribed sertraline (an antidepressant marketed under the trade name Zoloft). In August 2011, the prescription was switched from sertraline to paroxetine (Paxil). His personal medical records showed the CFI had been intermittently treated with paroxetine at least as early as 2007. In September, 2011, the CFI reported to his primary care doctor that his depression was incompletely treated and that he was having trouble concentrating. He requested and received an increase in his paroxetine dosing. Although the CFI visited his primary care doctor, his urologist, and a rheumatologist in the ensuing months, there is no record of that any of his physicians addressed the status of his depression after September, 2011.

Pilot

An autopsy was performed on the pilot by the Bexar County Office of the Medical Examiner in San Antonio, Texas. The cause of death was listed as massive traumatic injuries.

Forensic toxicology was performed on specimens from the pilot by the FAA, Aeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma.

The toxicology report stated: NO CARBON MONOXIDE detected in Blood; NO CYANIDE detected in Blood; NO ETHANOL detected in Urine. The following additional findings were noted: NO DRUGS listed above detected in Urine.

The NTSB Chief Medical Officer reviewed the factual report narrative, the autopsy report, the toxicology results, and the pilot's FAA airman medical certification file.

FAA records showed the pilot was first issued an FAA airman medical certificate in 1977. He was continuously certified through 1983, then again in 1991. He did not report any medical problems or medications on any of those airman medical certificate applications. He reapplied for medical certification in 2010, when he reported hypertension and high cholesterol with the use of lisinopril (a blood pressure medication marketed under the trade name Prinivil) and simvastatin (a cholesterol lowering agent marketed under the trade name Zocor). The pilot's most recent third class airman medical certificate was granted on September 17, 2010. The autopsy found no significant natural disease was identified by the pathologist.

TESTS AND RESEARCH

Several impact damage and fire damaged items which may have contained non-volatile memory (NVM) were removed from the wreckage and were examined at the NTSB vehicle recorder division in Washington, D.C. The items examined included a: Garmin GTS 800 Traffic Advisory System; Garmin G500 dual screen PFD and MFD; Garmin GNS430 GPS/Nav/Comm unit; JPI EDM-930 engine data monitor, Apple iPhone, and a Digital Camera.
No data was recovered from any of the units examined.

ADDITIONAL INFORMATION

According to the FAA Pilot Handbook of Aeronautical Knowledge, page 6-14: "On most modern turbocharged engines, the position of the waste gate is governed by a pressure-sensing control mechanism (which is) is automatically positioned to produce the desired MAP simply by changing the position of the throttle control. Other turbocharging system designs use a separate manual control to position the waste gate. With manual control, the manifold pressure gauge must be closely monitored to determine when the desired MAP has been achieved. Manual systems … require special operating considerations … it is possible to produce a manifold pressure that exceeds the engine's limitations. (an overboost in pressure) may produce severe detonation ... To help prevent overboosting, advance the throttle cautiously to prevent exceeding the maximum manifold pressure limits."

According to the FAA Pilot Handbook of Aeronautical Knowledge, page 6-19: "Detonation is an uncontrolled, explosive ignition of the fuel/air mixture within the cylinder's combustion chamber. It causes excessive temperatures and pressures which, if not corrected, can quickly lead to failure of the piston, cylinder, or valves. In less severe cases, detonation causes engine overheating, roughness, or loss of power … Preignition occurs when the fuel/air mixture ignites prior to the engine's normal ignition event. Premature burning is usually caused by a residual hot spot in the combustion chamber, often created by a small carbon deposit on a spark plug, a cracked spark plug insulator, or other damage in the cylinder that causes a part to heat sufficiently to ignite the fuel/air charge. Preignition causes the engine to lose power, and produces high operating temperature. As with detonation, preignition may also cause severe engine damage, because the expanding gases exert excessive pressure on the piston while still on its compression stroke. Detonation and preignition often occur simultaneously and one may cause the other. "

According to the FAA Airframe & Powerplant Mechanics Powerplant Handbook; AC 65-12A, Chapter 10: "Unless detonation is heavy, there is no cockpit evidence of its presence. Light to medium detonation may not cause noticeable roughness, observable cylinder head or oil temperature increase, or loss of power. However, when an engine has experienced detonation, we see evidence of it at teardown as indicated by dished piston heads, collapsed valve heads, broken ring lands or eroded portions of valves, pistons and cylinder heads. Severe detonation can cause a rough-running engine and high cylinder head temperature.'

"According to the Champion Aerospace Aviation Service Manual; AV6-4, page 10: "The affect of (detonation) will sometimes damage spark plug electrodes or crack the insulator core nose."

The FAA's Aeronautical Information Manual, Chapter 8, contains the following instructions regarding fitness for flight: "CAUTION- The CFRs prohibit a pilot who possesses a current medical certificate from performing crewmember duties while the pilot has a known medical condition or increase of a known medical condition that would make the pilot unable to meet the standards for the medical certificate." In addition: pilots are prohibited from "performing crewmember duties while using any medication that affects the faculties in any way contrary to safety."

According to 49 C.F.R. 61.53, Prohibition on operations during medical deficiency ; "no person … may act as … pilot in command, or in any other capacity as a required pilot flight crewmember, while that person: (1) Knows or has reason to know of any medical condition that would make the person unable to meet the requirements for the medical certificate necessary for the pilot operation; or (2) Is taking medication or receiving other treatment for a medical condition that results in the person being unable to meet the requirements for the medical certificate necessary for the pilot operation."

The manager of the fixed base operator (FBO) provided records showing they had refueled the airplane about 1125 on the morning of the day of the accident. The main tanks of the airplane had been "topped-off" with 19.3 gallons of 100LL aviation gasoline from the FBO's 100LL avgas fuel truck (Truck #2). He also reported that immediately following the accident the FBO had stopped fuel sales and quarantined the truck. The manager took fuel samples from the truck and performed a "white bucket test". He reported that the fuel was the correct blue color and was clear and bright. He also performed a "white paper test" and the fuel evaporated in about 30 seconds with no residue or stain. Both tests showed that the fuel had no contamination from water, or foreign particles. During both tests the smell and feel of the fuel showed that there was not contamination from jet fuel or diesel fuel. The manager reported that the FBO lifted the quarantine after the satisfactory fuel quality tests were completed. On the next day the manager repeated the "white bucket test" and the "white paper test" under the direct supervision of an FAA inspector. Those fuel quality tests were also satisfactory.

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