Pilot Debrief

Mooney M20S near OLATHE, KS — 2019-12-31

Final reportCEN20FA049
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Date
2019-12-31
Location
OLATHE, KS, USA
Airport
OJC
Aircraft
Mooney M20S
Registration
N602TF
Category
Airplane
Highest injury
Fatal
Fatalities
2
Phase of flight
Takeoff roll

Probable cause

The pilot’s failure to set the elevator trim properly for takeoff, which resulted in an exceedance of the airplane’s critical angle of attack during climb out, an aerodynamic stall, and the subsequent impact with terrain.

NTSB narrative

The pilot and a passenger were departing from the airport to return to their home base airport. A witness reported that nothing was out of the ordinary on the airplane’s initial rollout. However, the airplane rotated at a much slower speed than would be expected and immediately started to climb at a very high pitch attitude. The witness reported that as the airplane gained altitude, it appeared to fly slower to the point that the left wing stalled, causing the airplane to nose over and continue its trajectory straight into the ground just east of the runway. The witness stated that the engine power was “on” throughout the entire flight. Videos recorded near the accident site and the accident airplane’s engine monitor data were consistent with the witness description of the accident flight. The airplane did not exhibit any in-flight fire or smoke in the videos, and a ground fire was observed after impact. The pilot had purchased the airplane about 1 month before the accident and, according to his flight instructor, had accumulated 6.8 hours of instructional flight time. A disassembly examination of the engine revealed no preimpact anomalies that would have precluded normal operation. Review of photographs of an exemplar trim jack screw and the accident airplane’s jack screw revealed that the airplane’s trim system components exhibited a setting consistent with a full nose-up trim. The before takeoff checklist for the airplane make and model includes the step, “Elevator Trim….TAKEOFF SETTING.” The autopsy did not detect any significant natural disease. Toxicology testing detected a muscle relaxant and an antinausea medication in the pilot’s liver and muscle tissue samples; it was unknown why the pilot was using these impairing medications. The witness who saw the pilot before he took off observed nothing out of the ordinary in the pilot’s behavior and “no red flags” with respect to the pilot‘s actions. Thus, it could not be determined if effects from the pilot’s use of a muscle relaxant and an antinausea medication were factors in this accident. A low level of carbon monoxide was detected in the pilot’s blood. The concentration would not be at a level to cause impairment and thus was determined not to be a factor in the accident. Given the available information, it is likely the pilot departed with the elevator trim set to a full nose-up setting as opposed to the takeoff setting, which resulted in the airplane pitching up steeply after liftoff and the subsequent aerodynamic stall.

Analysis

Primary failure mode
Loss of control
First missed decision gate
Properly setting elevator trim before takeoff could have prevented loss of control.

NTSB coding

Evidence available

  • Video
  • ADS-B / radar
  • Photos
  • 33 docket documents
View NTSB final reportView NTSB docket

Docket documents33

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