Pilot Debrief

MOONEY M20M near Albany, IN — 2009-09-30

Final reportCEN09FA610
Sign in to save
Date
2009-09-30
Location
Albany, IN, USA
Aircraft
MOONEY M20M
Registration
N400DE
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Climb

Probable cause

The incapacitation of the pilot during high-altitude cruise flight for undetermined reasons.

NTSB narrative

The pilot became unresponsive to the air traffic controller after his last radio transmission, made as the airplane was climbing through 24,000 feet. The airplane leveled off at its assigned cruise altitude of 25,000 feet and continued northbound to a navigational fix, where it made a planned course reversal to the south and proceeded back toward the departure airport. A plot of the radar track data was consistent with the airplane being flown by its autopilot. A military F-16 fighter jet pilot, who had intercepted and escorted the flight, noted that the accident pilot was lying against the pilot-side cockpit window, unresponsive and possibly hypoxic. The airplane continued on a southerly course for over an hour, after which it entered a series of right turns that were followed by a gradual descent on a north-northeasterly course. After reaching 22,000 feet, the airplane descended rapidly to the ground, colliding with trees and terrain before a ground fire ensued. The postaccident investigation revealed no preimpact mechanical malfunctions or failures that would have prevented the normal operation of the airplane. The extensive impact and fire damage to the airplane's oxygen system prevented a determination of whether the pilot was actively using supplemental oxygen during the accident flight. A review of the flights since the most recent oxygen cylinder service, completed about 6 months before the accident, indicated that under normal usage there should have been sufficient oxygen available for the accident flight. A review of available medical information did not reveal any findings that would have resulted in pilot incapacitation, including a cardiovascular event, carbon monoxide poisoning, or the use of unapproved medication, illegal drugs, or alcohol.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot did not use supplemental oxygen at high altitude, leading to hypoxia.

NTSB coding

Evidence available

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

Docket documents34

Related mishaps