NTSB Factual Report

HISTORY OF FLIGHT

On February 26, 2012, about 1709 central standard time, a Mooney M20E airplane, N9224M, impacted terrain during initial climb after departure from Stinson Municipal Airport (SSF), San Antonio, Texas. The certified flight instructor (CFI) and the pilot were fatally injured. The airplane was substantially damaged. The airplane was registered to and operated by Niclan Corporation, under the provisions of 14 Code of Federal Regulations Part 91 as a positioning flight. Day visual meteorological conditions prevailed and no flight plan was filed. The flight departed SSF at 1707, and was destined for Gillespie County Airport (T82), Fredericksburg, Texas.

The pilot was cleared for takeoff to the southeast from runway 14 with instructions to turn left to the northeast because of traffic approaching the airport from the south. After takeoff, when the airplane was about 200 feet above ground level (agl), the SSF tower controller noticed the airplane in a right turn and again instructed the pilot to make a left turn to the northeast. An incomplete radio comment from the pilot indicated he was turning back. The controller saw the airplane flying southwest bound at a low altitude and shortly thereafter saw a cloud of black smoke about 1/2 mile south of SSF.

One witness was watching the airplane while it was turning to the right. He saw the wing of the airplane then suddenly roll sharply to the right and the airplane pointed about 45 degrees nose-down and the airplane went into a dive. A second witness heard sputtering, looked up and saw the airplane as it banked to one side and dove toward the ground. A third witness also heard sputtering and then heard the sounds of a crash and an explosion.

Evidence at the scene showed the airplane impacted terrain in a nose-down attitude and came to rest inverted. There was a postimpact explosion and fire.

PERSONNEL INFORMATION

Certified Flight Instructor

The CFI, age 63, held an airline transport pilot certificate with airplane single and multiengine land, airplane single engine sea, glider, and instrument airplane ratings. He held a type rating for CE-500. In addition, he held a flight instructor certificate with airplane single and multiengine, glider, and instrument airplane privileges. He was issued a second class airman medical certificate, with limitations, on February 3, 2012.

The CFI's pilot logbook was not available for examination; however on his most recent medical certificate application he reported that he had logged 20,825 hours of total flight experience; with about 120 of those hours in the previous six months. No other records of the CFI's flight experience were available. For most of the time following his retirement from military service the CFI had been working full-time as a flight instructor, with most of that activity at SSF. The CFI was known to usually fly from the right cockpit seat any time there was another pilot in the cockpit, who would be flying from the left cockpit seat.

Pilot

The pilot, age 54, held a private pilot certificate with a rating for airplane single land. He was issued a third class airman medical certificate, with limitations, on September 17, 2010.

The damaged parts of the pilot's logbook that were found in the wreckage showed that he had 209.1 hours of total flight experience in airplane single engine land. 127.5 of those hours were in complex airplanes, and about 110 hours were logged as flight instruction received. There was no evidence that the pilot had ever before flown an airplane with a turbocharged engine.

The pilot, who was a law enforcement officer, had recently been receiving that flight instruction from the CFI in order to earn his instrument airplane rating and a commercial pilot certificate. Of the most recent 45 flights in the logbook, 29 of the flights were logged as flight instruction received from the CFI. Most of those flights were in a similar Mooney M20C and included the pilot's most recent flight review which was completed on June 6, 2011.

AIRCRAFT INFORMATION

The four-seat, low-wing, retractable landing gear, single engine airplane, serial number (s/n) 1183, was manufactured in 1966. It was equipped with a 200-horsepower Lycoming model IO-360-A1A engine, serial number L-2509-51A, which drove an MT-Propeller, model MTV-12-B/180-59B, 3-blade wood composite propeller.

The engine had been modified with a turbo-normalizer system manufactured by M-20 Turbos, Inc., which was installed on July 21, 2009, under FAA Supplemental Type Certificate Number SE01643AT and SA01642AT.

The airplane had been modified by the installation of a redesigned pilot's and co-pilot's instrument panel equipped with a Garmin G500 dual screen Primary Flight Display (PFD) and Multifunction Display (MFD); Aspen EFD 1000 Pro Flight Display; Avidyne WSI AV300 Datalink Receiver; J.P. Instruments EDM-930, Engine Data Monitoring System; a back-up electric attitude indicator; and other modifications. The airplane was also equipped with an S-TEC 30 autopilot.

A review of the airframe logbooks and engine logbooks showed that the most recent entry was made on September 1, 2011, with entries certifying that an annual inspection had been completed at 6,343.2 total aircraft hours and 6,343.2 total engine hours since new. The total time since major overhaul for the engine was listed as 980.1 hours. Federal Aviation Administration (FAA) records show the airplane had been registered to the current owner since March 6, 1998.

METEOROLOGICAL INFORMATION

The automated weather observation station at SSF, issued at 1653, reported wind from 170 degrees at 8 knots, visibility of 10 miles, overcast clouds at 3,400 feet above ground level, temperature 17 degrees C, dew point temperature 10 degrees C, with an altimeter setting of 30.04 inches of mercury.

COMMUNICATIONS AND RADAR

At 1653:30, N9224M (voice identified as the pilot) contacted the SSF Federal Contract Tower (FCT) controller and advised he was ready to taxi with information Romeo

At 1653:47, the controller responded

At 1653:51, N9224M (voice identified as the pilot) advised he was VFR and going to T82

At 1653:59, the controller issued taxi instructions to runway 14

At 1654:06, N9224M (voice identified as the pilot) responded he was taxiing to runway 14

At 1654:16, N9224M (voice identified as the CFI) requested flight following, and during the next minute there were several exchanges between the controller and N9224M (voice identified as the CFI)

At 1706:51, N9224M (voice identified as the pilot) advised ready for takeoff runway 14

At 1706:58, the controller instructed N9224M to "turn left northeast bound" and gave clearance for takeoff

At 1707:06, N9224M (voice identified as the pilot) responded he was departing runway 14 and was turning northeast bound

At 1708:46, the controller instructed N9224M " … ah left turn to ah northeast"

At 1708:59, N9224M (voice identified as the pilot) said "mooney nine two two four turning back for ⦠" (there was a change in the sense of urgency noted in the voice of the pilot and the end of the transmission was cut off)

No further communications from N9224M were received.

At 1709:04, the controller said "mooney two four mike traffic a mile southwest of the airport cessna entering right downwind"

FAA Air Traffic Control radar showed at total of four returns from N9224M. The first two radar returns at 1708:32 and 1708:41 had altitude data at 800 feet. The last two returns at 1708:46 and 1708:55 had no altitude data.

WRECKAGE AND IMPACT INFORMATION

The airplane impacted in a flat unimproved field. The debris trail from the main crater led on a direction of 330 degrees for 57 feet to the main wreckage. The wreckage came to rest in an inverted position with the nose of the airplane oriented to about 360 degrees. All major components of the airplane were observed at the accident scene.

The initial impact ground scars were 44 feet wide from tip to tip and showed the airplane impacted terrain in a partially inverted mostly nose down attitude with the end of the right wing oriented to about 190 degrees and broken pieces of green glass in the area corresponding to the impact with the right wing tip. The ground scar corresponding to the end of the left wing was oriented to about 010 degrees. The main crater corresponding to the impact from the propeller was deeper than the other portions of the ground scars and contained portions of a broken propeller blade.

The engine was separated from the engine mounts and came to rest upright. All three of the wood composite propeller blades were separated from the hub and were found at the scene. Two of the propeller blades displayed chordwise smearing and impact gouging on the leading edges, the third propeller blade was fragmented into smaller pieces which prevented examination of the blade faces.

The non-steel parts of the fuselage were almost completely consumed by fire. The right wing was observed inverted with impact compression damage all along the leading edge. About three feet of the outermost leading edge was crushed aft at about a 20 degree angle. The left wing was separated from the fuselage and had flipped to an upright position with similar impact compression damage all along the leading edge. Both ailerons remained attached to their hinge points and the flaps were still attached or partially attached to the trailing edges of both wings. Both fuel caps were observed still attached.

The empennage and about 5 feet of the tail cone were resting on its right side with the left horizontal stabilizer pointing up nearly vertical. The vertical stabilizer was nearly parallel to the ground. The right horizontal stabilizer was bent up and inboard, nearly parallel to the vertical stabilizer. The elevator and rudder remained attached at their hinge points and the empennage remained attached to the tail cone. There was a compression bending crease at about a 45 degrees angle across the left side of the tail cone forward of the tail cone aft bulkhead. The elevator trim tab was observed to be near a cruise trim setting.

The right main landing gear was in the retracted position in the right wing with part of the middle gear door still attached. The left main landing gear and the nose wheel were broken and separated.

Aileron control continuity was confirmed from the cockpit to the right aileron where the pushrods were impact broken and separated from the bellcrank and aileron. Aileron control continuity was also confirmed from the cockpit to the left aileron. Rudder and elevator control continuity were confirmed from the control surfaces to the tail cone, but could not be confirmed to the cockpit due to the impact and fire damage. All control surface counterweights were observed at the scene.

The main cabin door was located beneath debris near the right wing root and all locking pins were in the extended position. Two AMSAFE Aviation Inflatable Restraint system inflator bottles were observed in the wreckage. Due to fire and heat damage it could not be determined whether or not they may have discharged at impact.

The postaccident examination of the airframe revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation.

After documentation at the scene, the engine was removed and examined separately. The engine exhibited impact damage and exposure to heat and fire. The propeller hub remained attached to the flange on the crankshaft. The magnetos and ignition harness were fire damaged and could not be tested. The oil sump was breached by fire. All of the rear accessories were damaged and partially consumed by fire. The valve covers and the top sparkplugs were removed. The spark plugs appeared clean and had a very clean bead blasted appearance. The gaps on the fine wire electrodes were observed pushed closed on the top number two and top number three spark plugs.

The crankshaft was rotated by hand and thumb compression was established on all cylinders. Engine drive train continuity was confirmed throughout. The cylinders were borescope inspected and signs of detonation were noted with a bead blasted clean appearance. The number one and number three cylinders were removed to facilitate photos of the cylinder heads and pistons. Three of the fuel injectors were removed; one injector was captured by molten material. One injector was found free of debris, and the other two were blocked by what appeared to be carbonized oil from exposure to heat. The fuel flow divider was opened and no anomalies were noted, other than heat damage to the diaphragm. The fuel servo showed signs of heat deformation and the servo inlet screen was captured by molten material. The oil pickup screen was found free of debris.

The turbo-normalizer system was examined. The turbocharger was deformed by heat and the impeller was seized with molten aluminum. The absolute pressure relief valve (pop-off valve) was also heat damaged and could not be moved. The turbocharger housing and pipe clamps were intact.

MEDICAL AND PATHOLOGICAL INFORMATION

Certified Flight Instructor

An autopsy was performed on the CFI by the Bexar County Office of the Medical Examiner in San Antonio, Texas. The cause of death was listed as multiple traumatic injuries.

Forensic toxicology was performed on specimens from the CFI by the Federal Aviation Administration (FAA), Aeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma.

The toxicology report stated: NO CARBON MONOXIDE detected in Blood; NO CYANIDE detected in Blood; NO ETHANOL detected in Urine.

The following additional findings were noted:

Amlodipine detected in Urine

Amlodipine detected in Blood

Azacyclonol detected in Urine

Azacyclonol NOT detected in Blood

Fexofenadine detected in Urine

Fexofenadine detected in Blood

Paroxetine detected in Urine

Paroxetine NOT detected in Blood

0.116 (ug/mL, ug/g) Tramadol detected in Blood

Tramadol detected in Urine

The National Transportation Safety Board (NTSB) Chief Medical Officer reviewed the factual report narrative, the autopsy report, the toxicology results, the CFI's FAA airman medical certification file, and the CFI's personal medical records.

FAA records showed the CFI was first issued an airman medical certificate in 1987. In 1990 he reported a hospital admission for "hypertitis" and having previously had a negative evaluation for hematuria. On that visit, a heart murmur was detected but the pilot reported it had previously been evaluated. On a FAA airman medical certificate application in 1993 he denied taking any medications and reported having previously had surgery on a knee and shoulder. He was granted a first class medical certificate, limited by the need to wear corrective lenses. In 1997 he reported to the FAA that he had had his tonsils removed but in 1998 he recorded the procedure as a "UPPP" which stands for uvulopalatopharyngoplasty. This is a surgical procedure performed on the posterior parts of the throat to limit snoring, usually on patients diagnosed with sleep apnea. There is no record of any further evaluation by the FAA and the CFI did not report a diagnosis of sleep apnea.

In 2006, the CFI reported treatment for hypertension and after he supplied additional information about his cardiovascular condition, he was issued a second class airman medical certificate. The CFI continued to be medically certificated and his last FAA airman medical exam was performed on February 2, 2012. At that time he reported taking Lotrel for his hypertension (a combination medication containing amlodipine and benazepril). His blood pressure was measured at 129/78.

The toxicology testing revealed amlodipine in urine and cavity blood; fexofenadine (a non-sedating antihistamine marketed under the trade name Allegra) in urine and blood and its metabolite azacyclonol in urine; paroxetine (an antidepressant marketed under the trade name Paxil) in urine but not in blood; and tramadol (an opioid pain medication marketed under the trade name Ultram) in urine and in cavity blood at 0.116ug/ml.

A review of the CFI's personal medical records revealed the following diagnoses: sleep apnea, (treated with surgery in 1996 but

NTSB Probable Cause

The pilot's inadvertent overboost of the turbocharged engine during initial climb, which resulted in detonation and a partial loss of engine power followed by the pilot's failure to maintain airspeed and the instructor's delayed remedial action, which resulted in an aerodynamic stall. Contributing to the accident was the instructor's improper judgment in acting as a pilot with disqualifying medical conditions and while taking impairing medications.