NTSB Factual Report

HISTORY OF FLIGHT

On November 20, 2007, at 1655 eastern standard time, a Mooney M20K, N252DD, was destroyed when it impacted terrain in Maine, New York shortly after takeoff from Greater Binghamton Airport (BGM), Binghamton, New York. The certificated private pilot was fatally injured. Instrument meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan was filed for the personal flight destined for Albany International Airport (ALB), Albany, New York. The flight was conducted under 14 Code of Federal Regulations Part 91.

According to witness statements, after taking on fuel, the pilot taxied to the end of runway 34 and was observed to takeoff, level off over the runway, accelerate, and then climb up into an indefinite ceiling.

According to Federal Aviation Administration (FAA)air traffic control voice recordings, the pilot was issued a clearance to turn right on course and was then cleared for takeoff. After his departure, a frequency change was issued, and the change was acknowledged by the pilot. The pilot however, was never heard to check in on the new frequency.

According to FAA provided radar data, The airplane was airborne for approximately 19-seconds and was lost from radar approximately 3/4 of a mile northeast of the airport. Peak recorded altitude was 2000 feet above mean sea level, which was 364 feet above the airport elevation.

The accident occurred during the hours of dusk. The wreckage was located at 42 degrees, 13.726 minutes north latitude, 75 degrees, and 58.727 minutes west longitude, at an elevation of 1,370 feet msl.

PERSONNEL INFORMATION

According to FAA records, the pilot held a private pilot certificate with ratings for airplane single-engine-land, and instrument airplane. He reported 1,500 total hours of flight experience on his most recent application for a Federal Aviation Administration (FAA) third-class medical certificate, dated September 17, 2007.

AIRCRAFT INFORMATION

According to FAA records, the airplane was manufactured in 1979. According to sales records, at the time of the accident, the airplane had accrued 1,919 total hours of operation. The engine had been remanufactured, and had accrued 411 hours of operation.

METEOROLOGICAL INFORMATION

A weather observation taken about 2 minutes before the accident, included; wind at 280 degrees at 3 knots, visibility 1/4 mile in fog, ceiling indefinite at 100 feet, temperature 6 degrees Celsius (C), dew point 6 degrees C, and an altimeter setting of 30.03 inches of mercury.

AIRPORT INFORMATION

According to the Airport Facility Directory, BGM was a public use airport. It had two runways, oriented in a 16/34, and 10/28 configuration. Runway 34 was grooved asphalt, in good condition. It was 7,100 feet long by 150 feet wide. The runway had precision markings that were in good condition. It was equipped with high intensity runway edge lights, a precision approach path indicator, a medium intensity approach lighting system with runway alignment indicator lights, and an ILS.

WRECKAGE AND IMPACT INFORMATION

The airplane came to rest in a wooded area on a magnetic heading of 118 degrees, 4,549 feet north-northeast of the departure end of runway 34, and 199 feet in elevation below it.

Multiple areas of burned underbrush along with the smell of fuel, was evident at the accident site. The debris path was 275 feet long and oriented on a magnetic heading of 118 degrees. The initial impact point was a tree strike located approximately 9-feet above ground level at the western edge of the debris field. All major components of the airplane were accounted for at the accident site.

Examination of the wreckage revealed no evidence of any preimpact malfunctions, structural failures, or in-flight fire, and the landing gear was in the retracted position prior to the impact.

The wreckage displayed heavy crush, fragmentation, and compression damage, and the engine had been separated from its mounts. The remains of the right wing were found near the beginning of the wreckage path, wrapped around a tree, with portions of the right aileron lying nearby. Approximately 20-feet further, portions of the pilot’s seat assembly were located resting against the base of tree in close proximity to the right flap, empennage, aft fuselage, left flap, left wing, and aileron.

Examination of the remains of the aft fuselage and empennage revealed that the empennage was almost completely separated from the aft fuselage. It was found inverted, with a portion of the upper rudder separated from its mounting location, and both elevators stripped from the horizontal stabilizer.

No preimpact failures or malfunctions of the primary or secondary flight controls were identified. Examination of the flight control system revealed impact damage and multiple fractures of the push-pull tubes that made up the system. The breaks in the flight control system were consistent with overload, and control continuity was confirmed from the ailerons, elevators, and rudder to the cockpit area. Continuity could not be established to the control yokes or rudder pedals due to fragmentation and crush damage. The wing flaps were found to be in the up (0-degree) position and both speed brakes were stowed.

Examination of the remains of the cockpit revealed that the cockpit had been fragmented, with evidence that the engine and firewall had been displaced into the pilot's instrument panel. Multiple portions of the forward fuselage, cockpit instruments, avionics, and seat assemblies were strewn throughout the debris path. Further examination of the remains of the instrument panel revealed that the mixture control was in the full rich position, the propeller control was set to high RPM, and both gyro assemblies from the vacuum driven flight command indicator (attitude indicator) and electric standby horizon exhibited rotational scoring.

The airplane was equipped with a 3-blade propeller. Examination of the propeller blades revealed impact damage, chordwise scratching, leading edge gouging and S-bending. All of the propeller blades remained attached to their hubs, however the pitch mechanism was broken internally.

The engine was discovered near the end of the debris path were it had come to rest inverted. Examination of the engine revealed no evidence of any preimpact malfunctions. The sump had been sheared off the bottom of the case and fragmented, however, oil was present internally and was also present in the rocker boxes. The vacuum pumps and magnetos had separated from their respective mounts and the two magnetos as well as one recovered vacuum pump, exhibited impact damage. Internal examination of the recovered vacuum pump revealed that the blades were intact. Examination of both magnetos revealed that they were functional and both produced spark at all towers. The intake and exhaust systems were compromised and both exhibited multiple breaks, fragmentation, and missing tubing. The turbocharger exhibited impact damage and would not rotate, however, during visual examination of the impeller, evidence of rotational scoring was evident. The crankshaft was rotated by hand through the accessory pad, and no binding was noted. Thumb compression was obtained on all cylinders, with the exception of the No.1 cylinder, which exhibited damage to its exhaust pushrod, and No.5 cylinder, which exhibited impact damage and was missing a portion of its rocker box section. All sparkplugs were removed for examination. Their electrodes were light gray in color, with the exception of the top and bottom spark plugs of the No. 5 cylinder, which exhibited oil residue.

Examination of the fuel system revealed that all fuel filler caps were closed and latched. The No. 2, 4, and 6, fuel injectors were intact. The no. 1, 3, and 5 injectors were separated from their respective mounting locations and exhibited impact damage.Visual examination of the No. 2, 4, and 6 fuel injectors revealed, that they were clear and exhibited no preimpact damage. Fuel samples obtained from both the fuel truck which was used to fuel the airplane as well as the engine's fuel injection system appeared to be bright, clear, and exhibited no visible contamination. When the fuel samples were applied to coupons containing water-finding paste, the paste did not change color, indicating that water was not present.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was performed on the pilot at Lourdes Hospital, Binghamton, New York on behalf of the Broome County Coroner.

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

The pilot's forensic toxicology report revealed:

“>> OMEPRAZOLE present in URINE

>> OMEPRAZOLE NOT detected in Blood

>> RANITIDINE present in URINE

>> RANITIDINE detected in Blood”

TESTS AND RESEARCH

According to the pilot’s spouse, he was working for a company in the Syracuse and Binghamton area and was traveling "a lot back and forth" from their home in Michigan and had been experiencing “acid reflux.” He was taking "Prilosec," at the time of the accident.

On Sunday, November 18, 2007, she dropped the pilot off at Detroit Metropolitan Wayne County Airport (DTW), Detroit, Michigan so he could take a commercial flight to Syracuse Hancock International Airport (SYR), Syracuse, New York to pick up the accident airplane at a certified repair station where it was undergoing maintenance.

On the day of the accident the pilot was going to meet her at a fixed base operation at ALB so they could spend the Thanksgiving holiday with family members.

Repair Station Information

According to maintenance personnel, the repair station had regularly maintained the airplane over the last several years. However, the pilot had relocated to Michigan and the airplane had not been at the facility for over a year.

The pilot had been using the airplane extensively for business travel. In Early October 2007 while conducting business in the central New York area, he once again brought the airplane in for maintenance. At that time, he complained of a problem with the speed brakes. The system was inspected, cleaned, and the return springs were reinstalled. The repair station also ordered new return springs so they would be available for installation when the airplane returned.

The pilot also complained of a recurring problem in which the autopilot would not track while in heading mode. According to the repair station, the airplane had experienced this problem for several years, and on multiple occasions, they had attempted to resolve the issue, but were unsuccessful. After each repair attempt, the pilot would take delivery of the airplane following maintenance and the repair station would not hear from him until months later, at which time he would return and assert that the repair attempt was still unsuccessful.

After the speed brakes were reinstalled during the visit in early October, the airplane was returned to service and the pilot took delivery of the airplane with the intention of returning for additional service when the new springs arrived.

Several days later, the aircraft was returned to the repair facility, the new springs were installed and the autopilot work was initiated. During the inspection, some additional problems were noted including an electrical short or failure of the Directional Gyro (DG) that would cause the DG circuit breaker to trip. The unit was removed and sent out for repair, and the repair station removed and replaced all the wiring between the autopilot and the horizontal situation indicator.

The airplane was at the repair station for approximately 5 weeks while these repairs were being completed. According to maintenance personnel, the pilot was anxious to have the airplane returned to him. He stated that without the use of the airplane he had been forced to fly back and forth to Michigan on the airlines.

The maintenance was completed on Friday, November 16, 2007, but on Sunday, November 18, 2007, the pilot retrieved the airplane without coordinating with the repair station. As a result the repair station was unable to complete a functional test flight prior to the airplane being returned to service.

Engine Performance Monitoring System

During examination of the airplane, it was discovered that the airplane was equipped with a JPI/EGT-701 Engine Performance Monitoring System (EPMS). Download and readout of the EPMS by Safety Board investigators, revealed no preimpact operational anomalies with the engine.

Directional Gyro and Autopilot Testing

On April 22, 2008, the remains of the directional gyro and autopilot system were tested at Honeywell Aerospace under the supervision of an FAA inspector. The examination revealed no preimpact anomalies.

The KG 102A Directional Gyro was damaged from impact forces and the post impact fire. It displayed charring of the frame and electronics. Examination of the gyro assembly revealed that the gyro cup and gyro rotor exhibited rotational scoring.

The KS 177 Pitch Servo was damaged from impact force and the post impact fire however, the capstan would rotate freely, the clutch solenoid plunger would move freely, and continuity testing of the trim micro-switches confirmed that they were functional.

The KS 178 Primary (Roll) servo was impact damaged however, when power was applied to the servo drive motor, the motor would operate. Increasing the voltage would also increase the motor’s speed and it would operate in the opposite direction when polarity was reversed.

The KS 179 Pitch Trim Servo was damaged from impact forces and the post impact fire. The clutch was not engaged and the capstan would rotate freely. Power was applied to the motor but it would not rotate. Examination of the motor and clutch solenoid revealed that, a black colored material consistent with the unit’s plastic cover had been exposed to the post impact fire, had melted and been deposited on the motor and clutch solenoid.

The KC 192 Flight Computer was damaged by impact forces and could not be functionally tested but examination of the AP (autopilot on) bulb revealed that the filament was broken and did not display any stretching.

According to an FAA inspector who in the past had flown with the pilot on functional test flights after the completion of avionics work and on longer flights (including one to Florida), the pilot was not in the habit of engaging the autopilot immediately after takeoff, and would wait to engage the autopilot after reaching a “safe altitude” in the climb.

Somotogravic and G-excess Illusions

According to the FAA’s Aeronautical Information Manual, a Somatogravic illusion can be caused by a rapid acceleration during takeoff. This can create the illusion of being in a nose up attitude. The disoriented pilot will push the aircraft into a nose low, or dive attitude. A rapid deceleration by a quick reduction of the throttles can also have the opposite effect, with the disoriented pilot pulling the aircraft into a nose up, or stall attitude.

In addition, a pilot, after initiating a turn, could be susceptible to a G-excess illusion if looking up and to the inside of the turn, as if looking for the airport, the increased g-loading in the turn may give a pilot the sense that the aircraft is beginning to roll out of the turn, and he may increase roll to compensate.

According to Spatial Orientation in Fundamentals of Aerospace Medicine, Third Edition, "G-induced excessive movement of the pilot’s otolithic membranes causes the pilot to feel an extra amount of head and body tilt, which is interpreted as an underbank of the aircraft when the pilot looks up to the inside of the turn. Correcting for the illusion, the pilot overbanks the aircraft and it descends."

ADDITIONAL INFORMATION

The airframe and engine were released to the pilot’s insurance company on December 19, 2007.

The remains of the directional gyro and autopilot system were released to the pilot’s insurance company on August 6, 2008.

NTSB Probable Cause

The pilot's spatial disorientation, which resulted in a loss of control and subsequent collision with trees.