NTSB Factual Report

HISTORY OF FLIGHT

On November 15, 1997, at 0659 hours Pacific standard time, a Mooney M20, N5231B, operated by the pilot, was destroyed upon descending into upsloping mountainous terrain near the uncontrolled Big Bear City Airport, Big Bear, California. The pilot and passenger were fatally injured during the personal flight. Instrument meteorological conditions existed, and no flight plan was filed by the non-instrument rated private pilot. The flight was originating at the time of the accident.

The airplane was based at the Corona Airport, Corona, California. At 1958, on November 14, the airplane was serviced with 12.3 gallons of 80/87 octane aviation fuel. The airplane's total fuel quantity was not determined. Thereafter, the airplane departed Corona, and arrived at the Big Bear City Airport at an undetermined time.

According to management personnel at Aero Haven, the sole refueler at the Big Bear City Airport, no fuel was pumped into the accident airplane on November 14 or 15. Airport management personnel reported that the airplane was parked overnight at the airport. A taxicab driver reported delivering the pilot and passenger to the airplane at 0645 on November 15.

A witness at the airport reported observing the pilot perform a preflight inspection of the airplane, and then taxi to the approach end of runway 26 where an engine run-up was performed. Thereafter, the airplane was observed to make a normal takeoff and climbout. The witness lost visual contact with the airplane as it climbed into the clouds which were based approximately 200 feet above ground level.

An additional witness, who was located south of the airport, reported observing the airplane descending in a southwesterly direction out of the clouds. The airplane appeared to be in a nose high pitch attitude and, as it turned left, its bank angle increased to about 90 degrees. This witness further reported that he observed the airplane's nose drop, and then the airplane descended until impacting trees.

Both witnesses reported hearing the airplane's engine operate continuously for the entire duration of its flight, which they estimated lasted about 60 seconds. Neither witness reported hearing any backfiring or sputtering sounds.

PERSONNEL INFORMATION

A review of the pilot's flight record logbook and Federal Aviation Administration (FAA) records revealed that on November 5, 1997, the pilot was issued a private pilot certificate. Thereafter, he made five flights in the accident airplane. The pilot had previously flown to the Big Bear City Airport on five occasions.

The certified flight instructor (CFI) who recommended the pilot for the private pilot flight check characterized the pilot as being an aggressive student who demonstrated "Type A" personality characteristics. He also reported that when he would advise the pilot to perform a task, the student would comply with his instructions, but would thereafter exceed the instructions by performing unauthorized flights and/or maneuvers.

AIRPLANE INFORMATION

According to the FAA, on August 21, 1997, the pilot purchased N5231B and applied for registration as President of E. C. Pacific, Inc., Las Vegas, Nevada. The pilot's wife reported to the National Transportation Safety Board that her husband was the owner of the accident airplane, and the airplane was hangared at the Corona Airport.

An examination of the Corona hangar revealed the presence of puddles of oil on the floor. The largest puddle was located in an area consistent with where the engine of the airplane would be located while parked. According to the CFI who recommended the pilot for his private pilot flight check, the hangar floor was repainted 2 or 3 weeks prior to the accident. The oil on the hangar floor was recently deposited there by the accident airplane's engine. The pilot was aware that the engine was leaking oil, and the pilot had "tinkered" with the engine in an effort at stopping the leak.

Regarding other mechanical problems, the CFI reported that the airplane's artificial horizon was not functioning properly. It was "lazy" in that it tended to lag behind the airplane. The CFI indicated that he would provide a statement describing this phenomena. (No statement has been received.) The CFI stated that he had never observed the airplane's maintenance logs.

Regarding evidence of the airplane's last annual inspection, the previous owner reported that he last paid for an annual inspection in March 1993. He indicated that the new owner had purchased the airplane through Midwest Executive Aviation, an aircraft broker.

The airplane broker reported that prior to selling the airplane the prospective purchaser (the accident pilot) had paid for a pre-purchase inspection, and then an annual inspection. Both inspections were accomplished by Don's Aviation, Lee's Summit, MO. The aircraft broker provided copies of payments made by the pilot to Don's Aviation for the annual inspection, and a copy of Don's Aviation invoice indicating that it had performed an annual inspection.

Additionally, a CFI who was associated with Midwest Executive, and who initially flew with the pilot to familiarize him with the airplane, reported that the annual inspection had been performed by Don's Aviation. However, on November 20, 1997, personnel from Don's Aviation reported to the Safety Board that its firm had not performed an annual inspection on the accident airplane.

No airplane maintenance logbooks have been located. The airplane inspection and flight time data contained in this report are estimated and based upon sales and flight records provided by the FAA, the pilot's wife, and Midwest Executive Aircraft, Inc.

METEOROLOGICAL INFORMATION

An automatic weather observing system (AWOS) is located at the Big Bear City Airport. At 0640, 0700 and 0720, the AWOS recorded an overcast sky condition with the base of the clouds at 200 feet above ground level. At 0700, the visibility was recorded at 0.75 miles, the wind was calm, and the temperature was 20 degrees Fahrenheit.

According to airport management personnel, the pilot's airplane had been parked overnight about 500 feet west of the AWOS sensor. Two witnesses reported observing blue sky and the rising sun to the east of the airport. Witnesses also reported observing low clouds to the south and west of the airport.

COMMUNICATION

None of the witnesses nor airport personnel reported hearing any radio communications from the airplane.

WRECKAGE AND IMPACT INFORMATION

The accident site coordinates are approximately 34 degrees 15.50 minutes north latitude, by 116 degrees 52.15 minutes west longitude. The estimated terrain elevation at the accident site is 6,850 feet mean sea level.

From an examination of the accident site and airplane wreckage, and from witness statements, the airplane was found to have descended into trees and terrain while in a nose low and steep left bank attitude. The bank angle was described by witnesses as being about 90 degrees.

The initial point of impact (IPI) occurred with estimated 75-foot-tall trees. The airplane's severed left flap was found suspended from tree branches at this location. The approximate distance and direction from the Big Bear City Airport to the crash site is 0.8 nautical miles and 233 degrees (magnetic).

The left wing was found broken into two pieces which were separated from the main wreckage. The severed 5 1/2-foot-long outboard and 9-foot-long inboard portions of the left wing were located within several yards of the base of the IPI tree. Additional splintered portions of airplane structure were located along an east-southeasterly track of 117 degrees.

The main airplane wreckage was located approximately 90 feet from the IPI. The airplane was found pointed in a westerly direction (270 degrees), and was resting on its left side in an approximate 120-degree left bank (see photographs).

The cockpit was observed crushed in an aft direction and was destroyed. The elevator and rudder assemblies were observed attached to the empennage which had remained attached to the fuselage and inboard portion of the right wing. The outboard portion of the right wing was located adjacent to the main wreckage. The ailerons were found attached to the wings.

The continuity of the push-pull tube control system was confirmed between the flight control surfaces and the center section of the impact damaged fuselage. The propeller, which was observed torsionally twisted, leading edge gouged, and chordwise scratched, was found attached to the crankshaft mounting flange.

Fuel was observed in the main fuel line between the fuel selector valve and the engine. Oil was observed trailing in an aft direction covering the airplane's belly (see photographs). No oil residue was observed on the front windshield. There was no evidence of fire.

The baggage door was observed in the open and unlocked position. The latching mechanism was found functional. Neither of the two door locking pins, nor their respective engagement receptacles in the fuselage, appeared damaged. The crush pattern in the metal of the partially bent door and the over-travel deformation to its upper hinge did not match adjacent damage signatures in the surrounding fuselage structure.

SURVIVAL FACTORS

SEAT BELT USAGE.

The coroner reported that the left seated pilot was found ejected from the cockpit area. An examination of the pilot's lap belt webbing material was performed, and no evidence of strain was found. The male and female ends of the metal buckle were not found connected, and they appeared undamaged.

The passenger was found in the front, right seat, and was secured by a lap belt. An examination of the lap belt webbing material revealed evidence of strain marks. The buckle was found closed.

The right side (female end) of the pilot's lap belt was found secured to the male end of the passenger's belt.

EMERGENCY LOCATOR TRANSMITTER (ELT).

The ELT was found in the baggage compartment, and it was not found secured to the airplane structure with tie down straps or brackets. The bottom of the ELT box had a Velcro-like material glued to it. To ascertain the preimpact location of the ELT, the antenna cable to which it was connected was stretched out, and the ELT was placed on the carpeted floor of the baggage compartment. Slight depression marks were observed in the left side of the baggage compartment's carpet which matched the shape of the rectangular ELT box.

The ELT activation switch was observed in the "ARM" position. No emergency radio signal transmission was evident. The ELT was subsequently examined and tested. The FAA reported it functioned in accordance with specifications.

MEDICAL AND PATHOLOGICAL INFORMATION

On November 17, 1997, an autopsy on the pilot was performed by the San Bernardino County Coroner's Office, San Bernardino, California. Results of the FAA's toxicology tests were negative for ethyl alcohol and all screened drugs.

TESTS AND RESEARCH

Engine and Accessory Examination.

Spark was observed from all eight spark plug leads during hand rotation of the magnetos' drive gears. The impulse coupler on the left magneto was found intact and functional. The spark plugs were visually examined, and the engine participant opined that the plugs appeared serviceable.

No evidence of metal contamination was observed in the oil filter canister or in the propeller governor's oil screen. Fuel was observed in the engine driven fuel pump, and in the main fuel line connected to the bottom of the fuel selector valve. The fuel screen in the bowl was devoid of contamination.

The vacuum pump's drive gear and vanes were found intact. The impact damaged artificial horizon case was located and was devoid of the gyro.

Engine valve and gear train continuity was established during manual rotation of the crankshaft through 720 degrees of arc. Thumb compression was felt in all four cylinders during the rotation.

As the crankshaft was rotated, residual oil pumped out of the engine. No evidence of oil starvation was found. The source of the engine/accessory oil leak was not identified. At the conclusion of the examination, the participant indicated that no evidence of any preimpact mechanical failure was found in any examined rotating or reciprocating component.

ADDITIONAL INFORMATION

The airplane wreckage was released to the pilot's wife on November 19, 1997. No parts were retained.

NTSB Probable Cause

VFR flight by the pilot into instrument meteorological conditions (VMC), which led to spatial disorientation, loss of aircraft control, and an uncontrolled descent into terrain. Related factors were: the adverse weather conditions, the pilot's lack of instrument experience, overconfidence of the pilot in his personal ability, and possible pilot distraction due to an unlatched baggage door, which was not properly secured during preflight.