Pilot Debrief

MOONEY M20J near Holmen, WI — 2016-07-28

Final reportCEN16FA295
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Date
2016-07-28
Location
Holmen, WI, USA
Airport
LSE
Aircraft
MOONEY M20J
Registration
N54PM
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Approach

Probable cause

The pilot's loss of airplane control during an instrument approach. Contributing to the accident was the pilot's lack of instrument flight proficiency.

Contributing factors

Contributing to the accident was the pilot's lack of instrument flight proficiency.

NTSB narrative

The commercial pilot was conducting a personal instrument flight rules cross-country flight in day instrument meteorological conditions. As the airplane neared the destination airport, the center air traffic controller working the flight cleared the airplane for an instrument landing system approach, vectored the airplane onto a course to intercept the localizer, and instructed the pilot to contact the airport's air traffic control tower. The pilot established contact with the tower controller and requested radar vectors to intercept the localizer. The tower was not radar-equipped so the tower controller instructed the pilot to change frequencies back to the center air traffic controller for radar vectors. The pilot responded to the instruction, but there were no further radio transmissions from the pilot on the center frequency or the tower frequency. The airplane impacted terrain on a south heading about 5.6 miles north/northeast of runway 18. The wreckage path length, separation of airplane structure, and component damage were consistent with a high-speed, uncontrolled impact with terrain. Examination of the airplane wreckage confirmed flight control continuity, and the propeller displayed signatures consistent with engine power at the time of impact. The attitude indicator gyro exhibited rotational signatures, and the engine-driven vacuum pump exhibited torsional overstress consistent with operation at the time of impact. The wreckage did not display any mechanical anomalies that would have precluded normal airplane operation. An autopsy of the pilot was not performed, and no toxicology samples were available for testing. The pilot's logbook showed that his most recent instrument proficiency check took place about 3 years before the accident and that he did not meet recent instrument flight experience requirements for flight in instrument meteorological conditions.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot did not maintain instrument currency required for IFR flight.

NTSB coding

Evidence available

  • ATC audio
  • ADS-B / radar
  • Photos
  • 12 docket documents
View NTSB final reportView NTSB docket

Docket documents12

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