NTSB Factual Report

HISTORY OF FLIGHT

On May 3, 1999, at 1451 mountain daylight time, a Mooney M20E, N5594Q, was destroyed during a forced landing near Cedar City Regional Airport, Cedar City, Utah. The instrument rated commercial pilot, the instrument rated private pilot passenger, and the non-pilot passenger were all fatally injured. The airplane was being operated by the pilot under Title 14 CFR Part 91. Instrument meteorological conditions prevailed for the personal cross-country flight which originated from Boulder, Colorado, with a stop in Nucla, Colorado (total airborne time was approximately 4 hours and 57 minutes). The pilot was on an IFR clearance at the time of the accident.

According to FAA records, the pilot and the pilot certificated passenger each contacted Direct User Access Terminal System (DUATS) five separate times to receive weather reports and file a visual flight rules (VFR) flight plan for the flight. The Denver Automated Flight Service Station (AFSS) records indicate the pilot departed Boulder Municipal Airport at 0908, and requested that his flight plan be activated.

The next transmission from the pilot was at 1015, as N5594Q was passing through Monarch Pass. The FAA controller advised the pilot that VFR flight was not recommended due to mountain obscuration, icing, and turbulence.

FAA records indicate that at 1122 the pilot telephoned Denver AFSS saying that he had landed at Nucla, Colorado, due to weather, and would they close his VFR flight plan. A witness at Hopkins Field at Nucla, Colorado, reported that the pilot approached her and wanted to purchase fuel for his airplane. She responded saying that the airport manager had the fuel pump key, and he was in Cortez for the day. She said that N5594Q departed Nucla at 1207. Her general comment about the weather conditions was "it sure was a crappy day to fly."

Salt Lake City (SLC) Air Route Traffic Control Center (ARTCC) reported that at 1316 the pilot called them requesting an IFR clearance, and said that his location was 13 nautical miles (nm) northeast of Hanksville VOR at 8,500 feet. SLC ARTCC requested that he climb higher for radar pickup. At 1324, SLC ARTCC identified N5594Q 13 nm south of Hanksville, and recommended that the pilot check his equipment. SLC ARTCC then cleared the pilot to "the Cedar City airport via victor eight Bryce Canyon victor two ninety three Cedar City, climb and maintain one four thousand."

FAA records indicate that at 1431, the pilot called SLC ARTCC and said "we're going to have to declare minimum fuel here sir." SLC ARTCC cleared N5594Q for an instrument approach to the Cedar City airport, and advised him to change to Cedar City's advisory frequency.

Radar data indicates that N5594Q flew towards the Instrument Landing System (ILS) initial approach fix, but then flew northward towards Velde (see attached instrument procedure chart). He then turned southwest, paralleling the inbound course of the ILS. At 1443, the pilot radioed Cedar City radio inflight saying "declaring emergency zero fuel, we believe we're in gliding range of the Cedar City airport and we are currently on the two two six radial inbound [radar data indicates that he was actually on the 046 radial]." He further stated that his engine had stopped, and that he was having difficulty receiving a VOR signal.

The pilot reported that "we've just got the engine back, it might have been an ice problem on the intakes." FAA data indicates that was where the last radar return was received for N5594Q (030 degrees from the airport for 10 nm, and 9,000 feet mean sea level (msl)). At 1450, the pilot said that he "does not have the ILS, we're circling low, uh, we're having problems because of ice on our antenna, we think we have." Although the pilot did not say if the engine was running during the final minute of flight, physical evidence at the accident site suggested that it was not running. No emergency locator transmitter signal was received. An Air Force helicopter located the downed airplane at 1608.

PERSONNEL INFORMATION

The pilot began flying in 1991, and had acquired his commercial pilots license and instrument rating for both single engine land and multiengine land flight operations. During this time period, he had accumulated approximately 835 hours of flight experience of which approximately 481 hours was in make and model (N5594Q). The pilot's logbook indicates that the 7 months 14 days prior to the day of the accident, he had flown 5 times for 4.2 hours. His pilot's logbook further indicates that on April 21, 1999, he flew 1.5 hours dual with a flight instructor, and received an endorsement for an Instrument Competency Check (ICC). His pilot's logbook indicates that he had 16 hours of Instrument Meteorological Conditions (IMC) flight experience in approximately 8 years of flying.

AIRCRAFT INFORMATION

The airplane was a single engine, propeller-driven, four seat airplane, which was manufactured by Mooney Aircraft Corporation in 1965. It was certificated for a maximum gross weight of 2,575 pounds. The airplane was powered by a Textron Lycoming IO-360-A1A, four cylinder, reciprocating, horizontally opposed, direct drive, fuel injected engine which had a maximum takeoff rating of 200 horsepower. At the time of the accident, the aircraft records and the pilot's personal flight logbook (to include the flight time on the day of the accident) indicated that the airframe had accumulated approximately 5,886.5 hours. The airplane's maintenance logbooks indicate that N5594Q received its last annual inspection on April 21, 1999.

The airplane had two main fuel tanks which held a total of 52.6 gallons, of which 52 gallons were usable. Fuel records at Boulder Municipal Airport indicate that N5594Q was "topped off" with 13.6 gallons of fuel on May 2, 1999. The airplane's engine manufacturer's operating manual states that fuel consumption would be the following:

1. 2700 RPM 16.66 gal/hr. 2. 75% power 12.0 gal/hr. 3. 65% power 9.3 gal/hr. 4. 55% power 8.5 gal/hr.

An engineer from Mooney Aircraft Corporation said that engine performance data indicates that start engine ramp fuel, takeoff, and climb from 5,000 feet msl to 10,000 feet msl would be consume approximately 3.5 gallons of fuel. The same performance profile to 14,000 feet would require 7.5 gallons of fuel.

Due to the multiple variables effecting fuel consumption, the exact fuel required for this flight could not be determined. The pilot bought this airplane in the summer of 1993. On Sept 5, 1994, he flew from Roseburg, Oregon, to Boulder, Colorado, (833.5 nm) nonstop in 6.2 hours of flight time. Several pilots questioned about Mooney Aircraft flight endurance said that they will not plan a flight longer than 4.5 hours.

METEOROLOGICAL INFORMATION

The weather at Cedar City at 1453 was: wind 310 degrees for 14 knots, visibility 6 statute miles (sm), rain, mist, 1900 feet overcast ceilings, temperature 36 degrees F., dew point 32 degrees F., and altimeter 29.59 inches of mercury. The weather at Cedar City at 1527 was: wind 300 degrees for 15 knots gusting to 22 knots, visibility 2 sm, light snow, mist, 2/10 cloud coverage at 800 feet, 1700 feet overcast ceilings, temperature 34 degrees F., dew point 30 degrees F., and altimeter 29.60 inches of mercury.

An FAA Inspector, who was driving southwest bound on I-15, approximately 7,000 feet south of the impact point, at the time of the accident, reported mist, light rain mixed with light snow, and visibility estimated to be 5 car lengths. Another FAA employee, standing on the ramp at the Cedar City Regional airport, reported that the weather northeast of the field was "crappy to the ground; it was snow showers to the ground." He said the weather started approximately 5 to 6 miles out from the airport.

The NTSB's meteorology group chairman stated that weather data suggests that N5594Q encountered head winds, at 14,000 feet msl, across Colorado and Southern New Mexico, of 35 to 45 knots. He further stated that N5594Q was in solid IMC for the last 30 minutes of flight. These weather conditions would include possible light-moderate snow/rain showers and light to moderate turbulence. The Iron County Sheriff reported hearing thunder during the local snow showers.

Cedar City FSS had received some pilot reports which indicated light to moderate rime icing in clouds above 9,000 feet msl. The NTSB's meteorologist said that analysis of the upper air data revealed that the height of the freezing level was likely between 8,000 and 9,000 feet msl in the Cedar City area at the time of the accident. The pilot never reported seeing any ice on his airplane.

AERODROME INFORMATION

The Cedar City Regional airport (elevation 5,623 feet) is not serviced with a control tower; there is an AFSS on the airport which provides airport advisories. The minimum radar vectoring altitude by SLC ARTCC for the Cedar City's northeast quadrant is 8,500 feet msl.

WRECKAGE AND IMPACT INFORMATION

The airplane was found on a rocky hill side (elevation 5,770 feet, N37 degrees 48.18 minutes, W112 degrees 59.09 minutes) covered with sagebrush. It was on the up sloping (approximately 20 degrees to the north) side of a ravine located approximately 029 degrees from the Cedar City Regional Airport at approximately 7.5 nm.

A ground scar 18 inches long, which contained green lens fragments, extended on a 345 to 350 degree orientation. Twenty feet further was a circular ground scar which measured 8 by 4 feet, and 23 feet further was the main fuselage. The fuselage was found on its left side with both wings structurally separated (electrical wires, push tubes, and fuel lines remain attached), and the empennage was twisted right and up. The fuselage was oriented on a 080 to 090 degree direction.

The bottom of the fuselage, from the forward engine area aft approximately 10 feet, was crushed upward and back (see photograph of crush line on the engine's manifold) into the cabin area. All the flight controls were accounted for, but impact damage prevented determining push tube continuity or the flaps position. The landing gear was found in the up position, which was verified by the J-bar's down location. All cockpit switches and instrumentation were destroyed except for the heading indicator (which read 358 degrees) and the engine's RPM gauge (which read 1,700 RPM). The engine throttle was found approximately 2 inches out and bent down, the mixture control was found full in, and the propeller control was found full in. Both control yokes were identified and were found intact.

All of the airplane's major components were accounted for at the accident site. The engine's crankshaft was rotated by hand, and thumb compression was observed on all cylinders. Valve continuity was visually confirmed on the engine, and all accessory gears rotated. The oil sump was completely broken off, and was found in numerous pieces. The fuel injected flow divider cap was opened, and "residual fuel" was found inside. One propeller blade was found separated from its hub, covered with chordwise striations, and twisted in an "S" type manner. The other blade remained attached to the hub, with no apparent chordwise striations, and its tip was bent aft.

The right wing fuel tank was found torn open, and there was no evidence that fuel had been present at impact (no discolored stains or wilted vegetation around it). The left wing fuel tank was found intact with no fuel in it. The first rescuers on scene reported the absence of any fuel or the smell of fuel vapors.

The airplane contained a portable oxygen unit which had a maximum gauge indication of 3,000 psi. The unit was found with 2,100 psi reading on the gauge and two uncoiled hoses with nose-type gas dispensers.

No preimpact engine or airframe anomalies, which may or may not have affected the airplane's performance, were identified.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was performed on the pilot by Dr. Edward A. Leis, a forensic pathologist with the State of Utah's Department of Health, Office of the Medical Examiner, Salt Lake City, Utah, on May 4, 1999.

Toxicology tests were performed on the pilot by the FAA's Civil Aeromedical Institute (CAMI) in Oklahoma City, Oklahoma. According to CAMI's report (#9900088001), the pilot's carbon monoxide test was not performed. Cyanide, volatiles, and drug tests were completed with negative results.

TESTS AND RESEARCH

An engineer with Mooney Aircraft Corporation stated that if icing were to occur on an airplane, it would show up first on the lower edge of the center front wind screen. He said that the whole front wind screen would be covered with ice before engine alternate intake air would be required (which will operate automatically if required). Another engineer with Mooney Aircraft Corporation reported that Very High Frequency Omnidirectional Radio Range (VOR) signal (108 to 117.95 megahertz) reception by the airplane's antenna element would not be affected by ice build-up on it (see attached letter). The airplane was not certificated for flight into known icing conditions.

A test pilot with Mooney Aircraft Corporation said that if an airplane were to exhaust its fuel during flight and the pilot were to glide at the recommended airspeed, the propeller would windmill between 1600 to 1700 revolutions per minute (RPM). An engineer with the company which manufactured the airplane's attitude indicator said that sufficient vacuum is produced by a 1500 RPM windmilling engine to drive an attitude indicator.

ADDITIONAL DATA

The airplane, including all components and logbooks, was released to a representative of the owner's insurance company on January 25, 2000.

NTSB Probable Cause

The pilot's inadequate fuel consumption calculations. Factors were the loss of engine power due to fuel exhaustion and the obscuring weather conditions.