NTSB Factual Report

On May 12, 1994, at 0825 hours Pacific daylight time, a Mooney M20K, N231WD, lost control and collided with terrain in a lemon orchard near Ventura, California. The airplane was being operated by the pilot/coowner as a personal flight. The airplane was destroyed by impact forces. The certificated private pilot and private pilot rated passenger received fatal injuries. The flight originated in Camarillo, California, at 0819 hours and was destined for Sedona, Arizona. Instrument meteorological conditions prevailed and a composite IFR/VFR flight plan was filed.

At 0819:09 hours, the right seat pilot contacted the Point Mugu Approach Control after takeoff from Camarillo. The pilot reported climbing through 400 feet mean sea level (msl). At 0819:14 hours, the approach controller instructed the pilot to fly heading 275 degrees and climb and maintain 4,000 feet msl, report when on top of the clouds, and when the pilot desired to cancel the instrument flight rules (IFR) portion of the flight and continue to the destination under visual flight rules (VFR). The pilot then acknowledged the instruction.

At 0821:58 hours, the approach controller advised the pilot the tops of the clouds were last reported to be at 2,500 feet msl. The pilot acknowledged the approach controller's advisory and indicated they would report when they broke out on top. This was the last known communication with the accident airplane.

Radar data was recorded by the Point Mugu Approach Control. The approach control equipment stores the data in a format that permits the information to be displayed on the radar screen (video) in the same manner it appeared to the controller at the time of the accident. The airspace and procedures specialist at the Point Mugu Approach Control manually transcribed the data from the video and produced a video track drawing. The drawing depicts an approximate time, location, and altitude of the recorded data for the accident airplane based on its discrete transponder code.

Review of the drawing indicates radar contact was established with the accident airplane at 0821:05 hours at the departure end of runway 26 at the Camarillo Airport, at an altitude about 300 feet msl. Radar contact was lost about 0824:38 hours at a position approximately 6 nautical miles west-northwest of the airport at 2,300 feet msl.

The last radar target on the accident airplane was at 0825:32 hours. It was a single hit that appeared on the radar screen about 0.5 miles east of the point where the track was lost. The altitude of the last target was 700 feet msl.

Witnesses reported hearing the airplane engine and believed the airplane to be at a low altitude. One witness indicated there was light rain and overcast skies. He observed the airplane descend vertically out of a 500-foot overcast ceiling and collide with the ground in a nose-down attitude.

CREW INFORMATION

FIRST PILOT

The first pilot was found in the right front seat. The first pilot held a private pilot certificate which was issued on May 14, 1989, as the result of obtaining an airplane instrument rating in addition to the single-engine airplane rating.

The first pilot's airman file maintained by the Federal Aviation Administration, in Oklahoma City, Oklahoma, was reviewed by the National Transportation Safety Board investigators. The review disclosed on March 15, 1989, the pilot failed his flight check for an instrument airplane rating. The designated examiner cited poor altitude control while performing instrument flight tasks. The altitude varied from 200 to 600 feet.

The first pilot received an additional 2.5 hours of actual instrument and 5 hours of simulated instrument training from a certified instrument flight instructor. The first pilot then reapplied for the instrument airplane rating on May 14, 1989, and successfully passed the flight check. At the time the first pilot received his airplane instrument rating, his total instrument experience was 52.6 hours of simulated instrument flight and 4.3 hours of actual instrument flight.

According to the first pilot's logbook, his total aeronautical experience consists of about 602 hours, of which 89.8 hours were accrued in actual instrument conditions and 74.4 were accrued in simulated instrument conditions. In the preceding 6 months before the accident, the logbook lists a total of 2.1 actual instrument flight hours and 3.9 hours of simulated instrument flight. The first pilot's logbook indicates the pilot logged seven instrument approaches during the same 6-month period.

Review of the first pilot's logbook revealed that he had flown numerous cross-country flights with the second pilot. Review of the second pilot's logbook revealed that the two would alternate logging pilot-in-command, except in the case where the first pilot would log instrument flight experience. Generally, one pilot would log the flight to a destination and the other pilot would log the return flight.

On March 27, 1994, the two pilots started a 3-day trip from Sedona, Arizona, to Visalia, California, and then to Camarillo, California, and then return to Sedona. On March 27, 1994, the first pilot logged 3 hours of pilot-in-command flight experience from Sedona to Visalia. On March 28, 1994, the second pilot logged 1.4 hours from Visalia to Camarillo, California. On the same day, the first pilot logged 0.6 hours pilot-in-command in actual instrument flight with one instrument approach during the same flight. On March 29, 1994, the second pilot then logged 2.4 hours on the flight from Camarillo to Sedona.

SECOND PILOT

The second pilot was found in the left front seat and held a private pilot certificate which was issued on November 25, 1987, with a single-engine airplane rating.

According to the logbook, her total aeronautical experience consisted of 516.4 hours, of which 8.9 hours were accrued under simulated instrument conditions and 0.8 hours were accrued in actual instrument conditions.

The pilot's airman file, maintained by the Federal Aviation Administration, in Oklahoma City, Oklahoma, was also reviewed by the Safety Board investigators. The review disclosed on November 10, 1987, the pilot failed her flight check for a private pilot single-engine airplane rating. The designated examiner indicated the pilot's application was disapproved, in part, for failing to maintain aircraft control by reference to instruments while under the hood.

According to her logbook, the pilot did not log any simulated or actual instrument flight time since her private pilot certificate was issued in 1987.

AIRCRAFT INFORMATION

The airplane had accumulated a total time in service of 1,128 hours. Examination of the maintenance records revealed that the most recent annual inspection was accomplished on May 12, 1993, about 119 flight hours before the accident.

The airplane was equipped for instrument flight. The primary flight instruments are located in front of the pilot station on the left side of the airplane. There were no flight instruments installed in front of the right seat.

METEOROLOGICAL INFORMATION

The closest official weather observation station is Camarillo Airport, which is located 6 nautical miles east of the accident site. At 0746 hours, a record scheduled surface observation was reporting in part: Sky condition and ceiling partially obscured with cloud bases at 500 feet above the ground. A pilot weather report solicited by the Point Mugu Approach Control indicated the tops of the clouds at 2,500 feet above the ground.

WRECKAGE AND IMPACT INFORMATION

The airplane was found in a nose-down attitude in a lemon orchard. Branches from one of the lemon trees were broken directly above the airplane's point of rest. Both wings were resting on the ground. The nose of the airplane had penetrated the soil to a point where the pilot seat backs were level with ground. The empennage was bent forward over the cabin area.

The airplane nose was excavated from the soil. The propeller spinner was found at a depth of about 4 feet. The propeller remained attached to the crankshaft flange. The crankshaft flange was found separated from the rest of the crankshaft.

Engine and propeller control continuity was established from the engine compartment to the instrument panel controls. Control continuity was also established for the flight controls.

The instrument panel was destroyed. The pilot's attitude indicator was disassembled. The brass rotor in the gyro section exhibited evidence of rotational scoring.

The wing flaps were partially extended. The flap jackscrew was found extended about 2.0 inches. According to the airframe manufacturer, this equates to 10 degrees of panel deflection corresponding to a takeoff position.

The elevator trim jackscrew was found with 0.875 inches of jackscrew extension. According to the airframe manufacturer, this equates to a 1.4-degree deflection of the horizontal stabilizer in a nose-down trim position. The airframe manufacturer also indicated a 0-degree deflection corresponds to the takeoff position.

MEDICAL AND PATHOLOGICAL INFORMATION

Both pilots sustained fatal injuries in the accident and post mortem examinations were conducted by the Ventura County Medical Examiner's Office on May 13, 1994, with specimens retained for toxicological examination.

The findings of the toxicological analysis for both pilots revealed negative results for routine drug and alcohol tests.

TESTS AND RESEARCH

Components of the autopilot system were examined under the supervision of the Federal Aviation Administration on May 19, 1994, at IFR Avionics, Van Nuys, California. The roll servo, the trim servo, and the pitch servo were tested. There was no evidence found indicating the auto pilot system was engaged during the accident sequence. All three units sustained impact damage. The pitch and roll servo clutch torque settings were found about 5 inch/pounds higher than specifications contained in the airplane installation manual. A copy of the manufacturers report detailing the tests is attached to this report.

ADDITIONAL INFORMATION

WRECKAGE RELEASE

The wreckage was released to the representatives of the owner on May 31, 1994.

NTSB Probable Cause

FAILURE OF THE FLIGHT CREW TO MAINTAIN CONTROL OF THE AIRPLANE IN INSTRUMENT METEOROLOGICAL CONDITIONS (IMC), DUE TO SPATIAL DISORIENTATION. A FACTOR RELATED TO THE ACCIDENT WAS: THE FIRST PILOT'S OVERCONFIDENCE IN HIS ABILITY TO ASSURE CONTROL OF THE AIRPLANE FROM THE RIGHT SEAT BY REFERENCE TO THE INSTRUMENTS LOCATED IN FRONT OF THE LEFT SEAT.