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N54PM accident description

Wisconsin map... Wisconsin list
Crash location 43.978889°N, 91.213611°W
Nearest city Holmen, WI
43.963296°N, 91.256254°W
2.4 miles away
Tail number N54PM
Accident date 28 Jul 2016
Aircraft type Mooney M20J
Additional details: None

NTSB Factual Report

HISTORY OF THE FLIGHT

On July 28, 2016, about 1138 central daylight time, a Mooney M20J, N54PM, impacted terrain near Holmen, Wisconsin, while being vectored for an instrument approach to runway 18 at La Crosse Regional Airport (LSE), La Crosse, Wisconsin. The commercial pilot sustained fatal injuries, and the airplane was destroyed by impact forces. The airplane was registered to and operated by the pilot under Title 14 Code of Federal Regulations (CFR) Part 91 as a personal flight that was operating on an instrument flight rules flight plan. Day instrument meteorological conditions prevailed at the time of the accident. The flight originated from Willmar Municipal Airport-John L Rice Field (BDH), Willmar, Minnesota, at 1024 and was destined for LSE.

A friend of the pilot stated that the pilot planned the flight a "few weeks" earlier. The friend reported that the pilot was going to pick him up at LSE and that they were going to fly to Appleton, Wisconsin, to buy tickets for the Oshkosh air show and then fly to Oshkosh, Wisconsin. The friend said that he received a text message from the pilot at 1013 stating that he was ready for takeoff from BDH and would be in the air in about 10 minutes. According to the friend, the flight departed at 1024. He stated that, according to Flightaware, the flight was to land at 1137.

Minneapolis Center provided radar vectors to the pilot for the final approach course for the instrument landing system (ILS) runway 18 approach and then was instructed to contact LSE Air Traffic Control Tower (ATCT). The pilot contacted LSE ATCT and reported that the airplane was over Mindi (Mindi was the locator outer marker for the ILS runway 18 approach and was located 6.6 miles north of runway 18.) The pilot then asked for radar vectors for the localizer. LSE ATCT instructed the pilot to maintain 4,000 feet and to contact Minneapolis Center for radar vectors. The pilot acknowledged the instruction. There were no further radio transmissions from the pilot.

A witness near the accident site stated that he heard the airplane going very fast about 1145 or 1150. He added that the weather was "bad," it was "misting." and the clouds were lower than 700 ft above ground level. He stated that he heard the engine running but could not tell where the engine sound was coming from. The engine then "quit." After the airplane's engine quit, 3 to 4 minutes elapsed and then he heard a "boom."

PERSONNEL INFORMATION

The pilot's logbook showed that his last instrument proficiency check, as specified in 14 CFR Part 61 section 57(d), which included a 1.0 hour biennial flight review, was dated September 7, 2013, and was conducted in the accident airplane. The last filled-in page of the pilot's logbook had flight entries dated from August 1 to May 31 with no year(s) entered; the previous logbook page had its last entry dated July 31, 2014. There was an endorsement at the back of the pilot's logbook for a biennial flight review that was dated November 29, 2015.

Title 14 CFR 61.57(c)(1) states that a person may act as pilot in command under IFR or weather conditions less than the minimums prescribed for VFR only if:

"Within the 6 calendar months preceding the month of the flight, that person performed and logged at least the following tasks and iterations in an airplane, powered-lift, helicopter, or airship, as appropriate, for the instrument rating privileges to be maintained in actual weather conditions, or under simulated conditions using a view-limiting device that involves having performed the following—

(i) Six instrument approaches.

(ii) Holding procedures and tasks.

(iii) Intercepting and tracking courses through the use of navigational electronic systems."

Title 14 CFR 61.57(d) states that "a person who has failed to meet the instrument experience requirements of paragraph (c) for more than six calendar months may reestablish instrument currency only by completing an instrument proficiency check. The instrument proficiency check must consist of the areas of operation and instrument tasks required in the instrument rating practical test standards."

According to the Federal Aviation Administration publication, "Instrument Proficiency Check (IPC) Guidance," regulations for the biennial flight review require a minimum of 1 hour of ground training and 1 hour of flight training. The publication states that, while Part 61.57(d) does not stipulate a minimum time requirement for the IPC, a good rule of thumb is to plan at least 90 minutes of ground time and at least 2 hours of flight time for a solid evaluation of the pilot's instrument flying knowledge and skills. The publication further states that, depending on the pilot's level of instrument experience and currency, the instructor administering the IPC may want to plan on two or more separate sessions to complete an IPC. For pilots with little or no recent instrument flying experience, it is a good idea to schedule an initial session in an appropriate aircraft training device.

AIRCRAFT INFORMATION

METEOROLOGICAL INFORMATION

WRECKAGE AND IMPACT INFORMATION

The accident site was located about 5.6 miles north/northeast of runway 18 at LSE at an elevation of 805 ft msl. The wreckage path was about 800 ft in length and oriented on a north/south heading in a grass/corn field. The fuselage, wings, empennage, control surfaces, engine, and propeller were present along the wreckage path. At the northern edge of the wreckage path about a 35-ft-long by 6- to 10-ft-wide area of corn stalks were cut at an angle of about 45°, sloping down toward the east. The southern edge of the wreckage path contained the engine, which was separated from the airframe. The fuselage was located about 80 ft south of the cut corn stalks and was upright. The left and right wings were located about 6 ft north and 45 ft east of the fuselage, respectively. There was no evidence of soot or fire on the airframe, engine, or terrain.

Examination of the flight controls confirmed flight control continuity from the wing and empennage control surfaces to the cockpit controls through separations of the control system that were consistent with overload. The wing flaps were in the 0° position.

The base of the propeller hub was attached to the engine crankshaft with all the attachment bolts in place. The upper portion of the propeller hub was broken off, and its pieces were located along the wreckage path. The hub fracture surfaces exhibited 45° granular fracture faces consistent with overstress. Both propeller blades were separated from the hub. One propeller blade was buried near corn stalks near the northern edge of the wreckage path, and the other propeller blade was located about 35 ft from the corn stalks. Both propeller blades exhibited leading edge damage and chordwise scratching consistent with propeller rotation/engine power at impact.

The instrument panel was located about 37 ft south from the fuselage. The flight instruments were separated from the panel and were located along the wreckage path. The attitude indicator, which was vacuum driven, was broken apart exposing the gyro casing and gimbals. The gyro was separated from the casing and was not found during recovery of the airplane wreckage. The gyro casing showed circumferential smearing/scoring and was attached to the pitch and roll gimbals.

The engine-driven vacuum pump was attached to the engine accessory section. Removal of the vacuum pump showed that the vacuum pump's drive teeth were intact, but the drive was separated from its opaque plastic coupling, with separation features consistent with torsional overstress. The coupling exhibited counterclockwise witness marks (the drive rotates counterclockwise during engine operation as viewed from the rear of the engine).

The engine did not exhibit any mechanical anomalies that would have precluded engine operation.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was not performed, and no toxicology samples were available for testing. During the pilot's most recent aviation medical exam, no concerns were reported by the pilot and no significant issues were identified by the aviation medical examiner.

NTSB 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.

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