NTSB Factual Report

HISTORY OF FLIGHT

On September 6, 2004, approximately 1010 mountain daylight time, a Mooney M20D, N1907Y, piloted by a private pilot, was destroyed when it impacted terrain during takeoff at Stevens Field, Pagosa Springs, Colorado. Visual meteorological conditions prevailed at the time of the accident. The personal flight was being conducted under the provisions of Title 14 CFR Part 91. No flight plan had been filed. The pilot was fatally injured. The flight was originating at the time of the accident, and was en route to Durango, Colorado (DRO).

The following is based on witness interviews and written statements: The pilot and his wife had visited the Pagosa Springs area in July 2004. When he got ready to return home in Lake Havasu, Arizona, the pilot made several takeoff attempts, but aborted each one. Airport personnel said that when he came into the office, he appeared thoroughly shaken by the experience. He told employees he would not take off from the airport until runway construction had been completed and entire length of the runway was made available. He then told a mechanic that there was a shimmy in the nose wheel steering.

While the mechanic inspected the airplane, the pilot approached a local flight instructor and asked him for his advice on how to take off from the airport. After questioning by the instructor, the pilot said he didn't know how to make a short-field takeoff, and that he had forgotten how to compute density altitude. When asked to produce the aircraft's operating limitations and weight and balance documents, the pilot couldn't find them. The mechanic returned and told the pilot that the steering linkage was missing, the nose gear assembly was "severely worn," and repairs would have to be made. The pilot left the airplane at Pagosa Springs and contracted with the flight instructor to deliver it to Lake Havasu after the repairs had been made.

The first attempt to deliver the airplane was on August 11, 2004. During the preflight inspection, the instructor discovered the right fuel tank was leaking and the VOR (Very high frequency Omnidirectional Radio range) receivers did not work. The tank was stripped and resealed. When told of the delay, the pilot told the instructor that he was aware of the malfunctioning VOR receivers, but suggested that the instructor use a hand-held GPS (Global Positioning System) receiver for navigation.

The next day, August 12, the instructor and mechanic conducted high-speed taxi tests in the airplane. The instructor said he was surprised when he entered the cockpit: The magnetic compass was dangling by a few wires underneath the instrument panel instead of being mounted on the windshield center post, the airspeed indicator was twisted about 60 degrees in the instrument panel, and there were numerous 9-volt and AA batteries on the rear floor and in the door pockets. Taxi tests were satisfactory and indicated the nose wheel steering had been repaired. According to Wind Dancer Aviation Services Work Order No. 3490, a rebuilt nose wheel assembly and shimmy dampner were installed.

The second attempt to deliver the airplane was on August 14, 2004. During the preflight inspection, the instructor noticed the right fuel tank was still leaking slightly. Delivery was postponed until repairs could be made.

The third attempt to deliver the airplane was on September 5, 2004. It had rained the day before. During the preflight inspection, the instructor drained more than a quart of water from the left tank sump. He found the fuel cap O-rings were "severely cracked and worn." The instructor continued draining the sumps until no water appeared. Upon entering the airplane, he discovered the battery was dead. A tug was used to jumpstart the battery. After starting the engine, the instructor received a traffic advisory and taxied to the run-up area where he made pre-takeoff checks. He also turned on the landing light "for safety." Shortly thereafter, he noticed the communication radios were not operating. He decided to cancel the flight and taxied back to the ramp. When he turned the landing light off, the communication radios came back on. He tried making radio contact with the fixed base operator but not successful.

After securing the airplane, the instructor went home and called the pilot. The pilot was upset. When told of the communication difficulties, the pilot replied, "Well, don't you have a hand-held radio you can use?" The pilot then decided to drive a rental car to Pagosa Springs and ferry the airplane home. He and his wife arrived in Pagosa Springs on September 5. He intended to fly the airplane to Durango and meet his wife, who would drive the car to the rental agency for drop-off. They would then continue home.

Several witnesses watched the takeoff and saw the accident. The fixed base operator wrote: "…it appeared the aircraft left the runway. I then saw a puff of dirt on the left side of the runway, after which the aircraft flipped into the air and came down on its nose and top." Another witness, the mechanic who had worked on the airplane, wrote: "I saw him get airborne but he was only 20-50 feet high and then there was a slight puff of dust and I could tell he was to the left of the runway. He then was at a high angle of attack and I could see the belly of his plane. His left wing dropped and he settled back to the ground and he flipped tail over and instantly exploded." Although witnesses were unsure if the pilot had started his takeoff roll from the runway threshold or from the displaced threshold, they agreed that the takeoff roll appeared normal and that the engine sounded like it was developing full power.

PERSONNEL INFORMATION

The 76-year-old private pilot held airplane single-engine land and instrument ratings. His third class airman medical certificate, dated August 14, 2003, contained no restrictions or limitations. The pilot's logbook was found in the wreckage but, due to fire damage, no useful information was recovered. According to his application for this medical certification, he estimated he had accumulated 2,600 total flight hours, of which 42 hours were accrued in the last six months.

AIRCRAFT INFORMATION

N1905Y, a model M20D (s/n 202) was manufactured by the Mooney Aircraft Corporation, Kerrville, Texas, in 1964. It was powered by a Lycoming O-360-A1D engine (s/n RL-30590-36A), rated at 180 horsepower), driving a Hartzell all-metal, 2-blade, constant-speed propeller (s/n F7666A). The aircraft maintenance records were found in the wreckage but, due to fire damage, no useful information was recovered. A copy of the work order was obtained from Wind Dancer Aviation and is attached as an EXHIBIT.

METEOROLOGICAL INFORMATION

The following pertinent METARs (Aviation Routine Weather Reports) were both recorded at 0953 at Wolf Creek Pass (CPW) and Durango-La Plata County Airport (DRO), located 22 miles north-northeast and 43 miles west-southwest of Stevens Field, respectively:

CPW: Wind, 170 degrees at 7 knots, gusting to 15 knots; visibility, 10 statute miles (or greater); sky condition, clear; temperature, 8 degrees C.; dew point, -1 degree C.; altimeter setting, 30.62 inches of mercury.

DRO: Wind, calm; visibility, 10 statute miles (or greater); sky condition, clear; temperature, 14 degrees C.; dew point, 7 degrees C.; altimeter setting, 30.37 inches of mercury.

AERODROME INFORMATION

Stevens Field (2V1) is located 3 miles northwest of Pagosa Springs at an elevation of 7,700 feet msl (mean sea level). It has one asphalt runway: 01-19/9,000 feet x 75 feet. At the time of the accident, only 3,900 feet was available (the other 5,100 feet was closed for reconstruction). An additional 660 feet of displaced threshold was available for takeoffs. While driving the useable portion of runway, the surface felt rough and uneven.

WRECKAGE AND IMPACT INFORMATION

The on-scene investigation commenced and terminated on September 7 and 8, 2004, respectively. The runway and aircraft path were marked off using a recently calibrated rolatape measuring wheel.

It is not known where the pilot began his takeoff roll. Measurements were taken from the beginning of the displaced threshold. The displaced threshold was 600 feet long. At a point 1,528 feet from the displaced threshold, three distinct tire tracks, similar in width to a Mooney M20D landing gear, angled off the runway and into the grass at an angle of approximately 10 degrees. Numerous intermittent marks --- similar to a landing gear touching down and tailskid strikes --- continued across the ground and terminated at the main body of wreckage. At the 1,688-foot point, a runway edge light had been struck and was shattered. Some 1,247 feet beyond, the airplane struck a 600-pound concrete block, knocking it 22 feet from where it was positioned. The airplane came to rest inverted 1,283 feet beyond the point of runway excursion and 240 feet left of the 75-foot wide runway's centerline. It was 2,211 from the runway threshold, and 2,811 feet from the displaced threshold (see Airport Photo and Wreckage Diagram in EXHIBITS).

The cockpit and cabin were completely fire-gutted. Although the manual landing gear handle (J-bar) appeared to be in the stowed position, further examination revealed that the landing gear was down. The flaps were up. Both propeller blades remained attached to the hub, the hub remained attached to the flange, and the flange remained attached to the crankshaft. One blade, however, was bent at the shank 30 degrees opposite the direction of rotation. The outer half portion of the blade had snapped off. It was found in a ditch about 50 feet away. It was bent forward in the direction of rotation. Examination of the fracture surfaces revealed a failure pattern consistent with overload. The other blade was curled aft at the tip.

MEDICAL AND PATHOLOGICAL INFORMATION

According to the autopsy report, the cause of death was "inhalation of combustion products." The pathologist wrote, "This man does not have fatal blunt force injuries. The presence of soot in the airway indicates breathing after the fire started, but consciousness cannot be determined. The spinal fracture and cord injury would have prevented him from exiting the aircraft had he been conscious. The multifocal severe coronary atherosclerosis could have resulted in a cardiac event precipitating the crash, but this must be considered speculative.

According to the FAA Civil Aeromedical Institute's toxicology report, 12 percent carbon monoxide and 0.218 (ug/ml, ug/g) diphenhydramine were detected in the blood.

TESTS AND RESEARCH

On September 29, 2004, the engine was disassembled and examined at the facilities of Beegles Aircraft Service, Greeley, Colorado. No anomalies were noted.

ADDITIONAL INFORMATION

In addition to the Federal Aviation Administration, parties to the investigation included Textron Lycoming.

The wreckage was released to the insurance adjuster on September 29, 2004, at the conclusion of the engine examination.

NTSB Probable Cause

the pilot's inadequate preflight planning and his failure to maintain directional control. Contributing factors were the pilot's failure to abort the takeoff, and the rough and uneven runway surface.