NTSB Factual Report

HISTORY OF FLIGHT

On July 8, 2007, at 1602 eastern daylight time, a Mooney M20F, N9180V, was substantially damaged during an aborted landing at Brooks Field (73KY), Brooks, Kentucky. The certificated private pilot and one passenger were fatally injured. Two passengers were killed. Visual meteorological conditions prevailed for the flight that departed Harrisburg-Raleigh Airport (HSB), Harrisburg, Illinois, about 1448 and was destined for Blue Lick Airport (07KY), Louisville, Kentucky. No flight plan was filed for the personal flight conducted under 14 Code of Federal Regulations (CFR) Part 91.

According to a passenger, the pilot attempted to land on runway 6 at 73KY. During the first attempt, the airplane touched down "fast" on the main landing gear and the pilot aborted the landing. The pilot’s wife then said that the person they were going to visit would "never direct them to a place like this" and "we need to go somewhere else." The pilot, who the passenger described as a "quiet person," did not respond. He then joined the traffic pattern for a second attempted landing. During the landing, the passenger believed that the pilot "overshot" and the airplane was near "the middle of the runway when it touched down. "It felt to her as if the runway was full of ruts. The pilot then said, "We are going up."The passenger could see the "treetops" approaching, then heard the engine "rev sharply," and felt the airplane "go up sharply."

According to a witness who observed the airplane as it approached the trees, the nose of the airplane was "pointed at 11 o'clock" assuming the 12 o’clock position would be near vertical, and she could see the bottom of the airplane as it was climbing.

According to a witness who observed the impact sequence, the airplane appeared to impact the ground in what was estimated to be a 15-degree nose down attitude.

PERSONNEL INFORMATION

The pilot, age 57, held a private pilot certificate with ratings for airplane single-engine land and instrument airplane. His most recent Federal Aviation Administration (FAA) third-class medical certificate was issued on June 6, 2007. He reported 1,297 total hours of flight experience on that date. The pilot's logbook was not recovered for review.

AIRCRAFT INFORMATION

According to FAA and maintenance records, the airplane was manufactured in 1969. The airplane's most recent annual inspection was completed on May 4, 2007. At the time of the inspection, the airplane had accrued 4,163.6 total hours of operation.

METEOROLOGICAL INFORMATION

The reported weather at Louisville International Airport (SDF), Louisville, Kentucky, approximately 10 nautical miles north of the accident site, at 1556, included: calm winds, visibility 9 miles, few clouds at 6,500 feet, temperature 32 degrees Celsius, dew point 15 degrees Celsius and an altimeter setting of 29.89 inches of mercury.

AIRPORT INFORMATION

Blue Lick Airport

According to the Airport Facility Directory (AFD), Blue Lick Airport was a private use airport. Permission to use the airport was required prior to landing. It had one runway, 11/29. The runway was turf covered and in good condition. The total length was 2,000 feet long and 100 feet wide. Trees were present 450 feet from the approach end of runway 11 and 1,000 feet from the approach end of runway 29.

Brooks Field

According to the AFD, Brooks Field was also a private use airport. It was located 5.6 nautical miles west-southwest of Blue Lick Airport. It had one runway, 6/24. The runway was turf covered, and in good condition. The total length was 2,150 feet long and 80 feet wide. Trees (20 feet in height) were present on the approach end of runway 6 and trees (50 feet in height) were present 600 feet from the approach end of runway 24.

Examination of the runway revealed that multiple tire marks began 506 feet beyond the runway threshold and continued intermittently on a curved path to a point 1,952 feet down the runway. Measurements revealed that the tire marks correlated to the accident airplane's landing gear geometry. Corn plants, located on the right side of the runway, exhibited damage and pieces of damaged corn plant were found on the runway. Fescue grass at the end of the runway also exhibited damage, along with corn plants located directly off of the departure end.

WRECKAGE AND IMPACT INFORMATION

The wreckage was located in a cornfield approximately 2/3 mile past the departure end of Brooks Field Airport’s runway 6.

Examination of the accident site revealed that multiple corn plants exhibited cut marks consistent with propeller strikes, which correlated to an approximate 54-degree impact angle. Approximately 2 feet east-northeast of the cut corn plants was a ground scar, which correlated to the nose and propeller arc of the airplane. The airplane came to rest inverted, on a magnetic heading of 254 degrees, 41.5 feet east-northeast of that ground scar.

All major components of the airplane were located at the accident site, and no preimpact malfunctions of the engine or airplane were discovered.

The engine and propeller remained partially attached to the airplane. One blade exhibited S-bending and the other blade was curled aft. Both blades exhibited leading edge gouging and chordwise scratching. The crankshaft was rotated by hand and thumb compression was noted on all four cylinders. Continuity of the intake system, exhaust system, valve train, and crankshaft were confirmed. The after-market turbocharger rotated freely by hand and no scoring, deposits, or coking was noted. Operation of the engine driven fuel pump was confirmed. Fuel was present in the engine driven fuel pump, fuel servo, and flow divider. A sample of the fuel obtained from the fuel injection system appeared to be bright, clear, and exhibited no visible contamination. When the fuel sample was applied to a coupon containing water-finding paste, the paste did not change color, indicating that no water was present. All spark plugs were removed, and the electrodes were intact and light gray in color. All four cylinders were examined internally with a lighted borescope, and no anomalies were observed. Both magnetos were rotated and produced spark at all leads. The oil suction screen and oil filter were absent of debris, and oil was noted throughout the engine.

The throttle, propeller, mixture, and turbocharger waste gate controls were in the full forward position. The electric fuel boost pump switch was in the "on" position, and the magneto switch was in the "both" position.

The landing gear was in the "up" position. The left main landing gear wheel well contained multiple pieces of corn plants, and the nose gear wheel well contained pieces of fescue grass. The right wing was separated from the fuselage, and the left wing was attached; however, approximately 4 feet of the left wing outboard of the outer flap panel had separated, and was located 75 feet east-northeast from the main wreckage. The wing flaps were extended approximately 10 degrees, and along with the ailerons exhibited varying degrees of damage.

A 45-degree right hand bend in the aft fuselage, just forward of the empennage, was present, and the vertical stabilizer and rudder panel were bent and crushed beneath the aft fuselage. The vertical stabilizer and left and right horizontal stabilizers remained attached to their fittings. Control continuity was established from the elevator control mechanism to the control wheel pitch actuating mechanism, the rudder pedals to the rudder panel, and from the left and right ailerons to the breaks in the push-pull rods.

MEDICAL AND PATHOLOGICAL INFORMATION

A postmortem examination was performed on the pilot by the State of Kentucky, Office of the Chief Medical Examiner. The cause of death was reported as "multiple blunt force injuries."

Toxicological testing of the pilot was conducted at the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma.

SURVIVAL ASPECTS

Examination of the installed restraint system revealed that all four seats were equipped with seatbelts, but no shoulder harnesses were installed. Further examination of the restraint system revealed that the left rear seatbelt spring loaded clasp had become unhooked from its seatbelt mounting bar, which resulted in the occupant being unrestrained by the seatbelt during the impact sequence.

TESTS AND RESEARCH

During interviews with a friend whom the pilot was going to visit within the Louisville area, it was discovered that the friend had made arrangements with the airport manager at Blue Lick Airport for the pilot to utilize the private field. The friend however, when speaking with the pilot by telephone inadvertently referred to the airport as "Brooks Field."

Global Positioning System (GPS)

During the wreckage examination a handheld GPS was discovered. Data downloaded by the National Transportation Safety Board Vehicle Recorders Laboratory revealed that the accident airplane took off from HSB at approximately 1448. The airplane climbed to a cruising altitude of 10,000 feet GPS altitude, which it achieved at about 1515. About 45 minutes later, the airplane began to descend to about 1,500 feet, which it achieved just before crossing over the Ohio River at about 1551. At a point just south of 73KY, the airplane turned north and descended to a low of 612 feet, at a point adjacent to the runway. The airplane then climbed back up to 1,500 feet while turning onto a left-hand closed traffic pattern. It then aligned once again with the runway axis. While on the final approach leg of the traffic pattern, the airplane descended to a low of 508 feet, which it achieved at 1601:41, at a point about 3,700 feet from the location of the final GPS update. The airplane then began to climb to an altitude of 639 feet, before descending to 592 feet at the location of the last GPS update. The last computed GPS groundspeed was 73 mph.

Weight And Performance Information

A review of billing information for the trip revealed that the airplane had been refueled in Harrisburg with 30.78 gallons of fuel.

Examination of the wreckage revealed that in addition to the 4 occupants, 163 pounds of baggage and miscellaneous items were also onboard.

According to the airplane manufacturer, the maximum gross weight was 2,740 pounds. According to weight and balance information discovered in the wreckage, the empty weight of the airplane was 1,750 pounds.

Estimated weight calculations performed by Safety Board investigators revealed that with the combination of fuel onboard, passengers, and baggage, the airplane would have departed HSB at a gross weight of approximately 2,763 pounds (or 2,962 pounds with full fuel). Weight on arrival at 73KY would have been approximately 2,690 pounds (or 2,890 pounds with full fuel prior to flight).

According to the Owners Manual for the accident airplane, on a "hard surface runway" with "zero wind," with wing flaps full down, at an indicated airspeed at 80 mph, and "power off," the distance to land over a 50-foot obstacle at 2,740 pounds, was 1,879 feet.

Seatbelt Attach Fittings

The accident airplane’s restraint system was equipped with spring-loaded clasp-type attach fittings. Examination of the fittings revealed that a hole was provided in the fitting for insertion of a cotter pin that would lock the gate in the closed position. No cotter pins were discovered in any of the installed seatbelt attach fittings.

According to the airplane manufacturer, the seatbelt assemblies were manufactured in compliance to FAA Technical Standard Order TSO-22 and were purchased "as a whole" from an approved vendor. Cotter pins were installed during assembly at the factory until the late 1980's, when the airplane manufacturer began to use seatbelts with anchors that had a continuous loop. They later switched to an inflatable restraint system.

Guidance in the maintenance manual relative to the seatbelt removal and replacement, was to "reverse as removed," meaning to reinstall it in the sequence it was removed. According to the airplane manufacturer, if a cotter pin was there originally, it should be replaced.

Previous Seatbelt Attach Fitting Problems

The FAA had received reports indicating that during two accidents involving transport category airplanes, several passengers’ seatbelts had released from the seat attachments (i.e., the seatbelts remained buckled but had become unhooked at their attachment fittings to the seat). The absence of damage to the hook end of the seatbelts and the "D-ring" type seatbelt attachment fittings suggested that in each case, the fitting aligned with the opening in the hook end of the seatbelt, and the seatbelt then became detached from the "D-ring" type seatbelt attachment fittings.

The FAA became concerned as detachment of a seatbelt from the "D-ring" type seatbelt attachment fitting could result in injury to the seat occupant during an accident, turbulence, or a hard landing.

During the investigation, one repeatable method of demonstrating the seatbelt detachment was discovered. When the hook end of the seatbelt is near the seatbelt fastener that attaches the fitting to the seat, the seatbelt hook end can become aligned such that the hook end is contacting two points on the "D-ring" fitting. In this configuration, the spring keeper on the hook end of the seatbelt would be in alignment with the upper portion of the "D-ring" type attachment fitting. Detachment would then occur when an out-of-plane load was applied to the hook end of the seatbelt by the seatbelt webbing. As the seatbelt attempted to align the hook end of the seatbelt with the load, the spring keeper would become depressed and the seatbelt would detach from the fitting.

As a result, on December 22, 2003, the FAA released a Special Airworthiness Information Bulletin (SAIB NM-04-37), to alert owners and operators of 79 models of transport category airplanes with passenger seats equipped with "D-ring" type seatbelt attachment fittings that had the potential of inadvertently releasing the seatbelts attached to them.

On August 28, 2006, a Raytheon Aircraft Company Hawker 800XP being operated under the provisions of 14 CFR Part 91K, was involved in a midair collision (LAX06FA277A).

During the examination of the accident airplane, it was noted that the seatbelt attach points for two seats were not secured. Interviews with passengers revealed that one passenger was in seat No. 7, with his lapbelt buckled, when the midair collision occurred. The first officer had informed the passengers that they were going to make a gear-up landing and everyone was to secure their seatbelts. The passenger in seat No. 7 tightened his lapbelt and the inboard attachment end came out from between the seat cushions. He jumped up from seat No. 7, sat down in seat No. 5 and buckled the lapbelt. When he went to tighten that belt, the inboard attachment end came out from between the seat cushions. He then grabbed onto the attached portion, leaned over, and held on.

On September 8, 2006, the operator issued a Maintenance Information Bulletin calling for a fleet inspection of the lapbelts. On September 20, 2006, the operator provided an update indicating that though they had not found any additional loose belts, they did find 14 instances on 4 different airplanes where the seatbelt attach keepers were bent or distorted to varying degrees. This information was forwarded to the airplane manufacturer and the seatbelt manufacturer.

During October 2006, the airplane manufacturer issued a Safety Communique to all owners, operators, Raytheon Aviation Centers, chief pilots, directors of operations, directors of maintenance, all Raytheon Aircraft Authorized Service Centers, international distributors, and dealers, regarding the inspection and maintenance of lapbelts for all Hawker Series 800, 800XP, 850XP, and 1000 airplanes.

In February 2007, they issued a Mandatory Service Bulletin calling for the inspection of the lapbelt attachments and modification of the lapbelt attach shackles and updated their 300-hour inspection to specifically include the passenger seat safety belts, and to "check seatbelt attachment hook and safety clip for distortion and security."

ADDI

NTSB Probable Cause

The pilot's failure to maintain aircraft control during the aborted landing. Contributing to the accident was the exceedance of the airplane's maximum gross weight, and the pilot's inadequate preflight planning.