CEN12FA170

The pilot's inadvertent overboost of the turbocharged engine during initial climb, which resulted in detonation and a partial loss of engine power followed by the pilot's failure to maintain airspeed and the instructor's delayed remedial action, which resulted in an aerodynamic stall. Contributing to the accident was the instructor's improper judgment in acting as a pilot with disqualifying medical conditions and while taking impairing medications.

After takeoff, when the airplane was about 200 feet above ground level, the tower controller noticed the airplane in a right turn and instructed the pilot to make a left turn to the northeast. An incomplete radio call from the pilot indicated he was turning back. The controller saw the airplane flying southwest at a low altitude and shortly thereafter saw a cloud of black smoke about 1/2 mile south of the airport. Two other witnesses saw the airplane suddenly roll to the right and enter a nose-down dive, indicative of a stall. Evidence at the scene showed that the airplane impacted terrain in a nose-down attitude and came to rest inverted. There was a postimpact explosion and fire. Based on the pilot's lack of previous experience in flying an airplane with a turbocharged engine, and the evidence of detonation found in the postaccident examination of the engine, it is likely that the pilot inadvertently overboosted the engine during takeoff and initial climb, which resulted in a partial loss of engine power. Based on the sudden change of flight direction, it is likely that the pilot became preoccupied with the partial loss of engine power and lost control of the airplane. The instructor should have been able to successfully complete an emergency off-field landing, but it does not appear that he attempted one. This instructor had been using a series of psychotropic medications, culminating in his use of paroxetine, which would have been disqualifying for him to act as a required flight crewmember. Major depression itself is associated with significant cognitive degradation, particularly in executive functioning. While the exact degree of impairment from the instructor's incompletely controlled depression and his use of impairing medications at the time of the accident is impossible to determine, it is likely that there was some impairment in cognitive functioning as a result of his uncontrolled depression. Further, the instructor had sleep apnea, and that, combined with his recent use of sedating medications, chronic pain, and depression may well have contributed to his failure to take control of the airplane and conduct an emergency of-field landing after the partial loss of engine power.

HISTORY OF FLIGHT On February 26, 2012, about 1709 central standard time, a Mooney M20E airplane, N9224M, impacted terrain during initial climb after departure from Stinson Municipal Airport (SSF), San Antonio, Texas. The certified flight instructor (CFI) and the pilot were fatally injured. The airplane was substantially damaged. The airplane was registered to and operated by Niclan Corporation, under the provisions of 14 Code of Federal Regulations Part 91 as a positioning flight. Day visual meteorological conditions prevailed and no flight plan was filed. The flight departed SSF at 1707, and was destined for Gillespie County Airport (T82), Fredericksburg, Texas. The pilot was cleared for takeoff to the southeast from runway 14 with instructions to turn left to the northeast because of traffic approaching the airport from the south. After takeoff, when the airplane was about 200 feet above ground level (agl), the SSF tower controller noticed the airplane in a right turn and again instructed the pilot to make a left turn to the northeast. An incomplete radio comment from the pilot indicated he was turning back. The controller saw the airplane flying southwest bound at a low altitude and shortly thereafter saw a cloud of black smoke about 1/2 mile south of SSF. One witness was watching the airplane while it was turning to the right. He saw the wing of the airplane then suddenly roll sharply to the right and the airplane pointed about 45 degrees nose-down and the airplane went into a dive. A second witness heard sputtering, looked up and saw the airplane as it banked to one side and dove toward the ground. A third witness also heard sputtering and then heard the sounds of a crash and an explosion. Evidence at the scene showed the airplane impacted terrain in a nose-down attitude and came to rest inverted. There was a postimpact explosion and fire. PERSONNEL INFORMATION Certified Flight Instructor The CFI, age 63, held an airline transport pilot certificate with airplane single and multiengine land, airplane single engine sea, glider, and instrument airplane ratings. He held a type rating for CE-500. In addition, he held a flight instructor certificate with airplane single and multiengine, glider, and instrument airplane privileges. He was issued a second class airman medical certificate, with limitations, on February 3, 2012. The CFI's pilot logbook was not available for examination; however on his most recent medical certificate application he reported that he had logged 20,825 hours of total flight experience; with about 120 of those hours in the previous six months. No other records of the CFI's flight experience were available. For most of the time following his retirement from military service the CFI had been working full-time as a flight instructor, with most of that activity at SSF. The CFI was known to usually fly from the right cockpit seat any time there was another pilot in the cockpit, who would be flying from the left cockpit seat. Pilot The pilot, age 54, held a private pilot certificate with a rating for airplane single land. He was issued a third class airman medical certificate, with limitations, on September 17, 2010. The damaged parts of the pilot's logbook that were found in the wreckage showed that he had 209.1 hours of total flight experience in airplane single engine land. 127.5 of those hours were in complex airplanes, and about 110 hours were logged as flight instruction received. There was no evidence that the pilot had ever before flown an airplane with a turbocharged engine. The pilot, who was a law enforcement officer, had recently been receiving that flight instruction from the CFI in order to earn his instrument airplane rating and a commercial pilot certificate. Of the most recent 45 flights in the logbook, 29 of the flights were logged as flight instruction received from the CFI. Most of those flights were in a similar Mooney M20C and included the pilot's most recent flight review which was completed on June 6, 2011. AIRCRAFT INFORMATION The four-seat, low-wing, retractable landing gear, single engine airplane, serial number (s/n) 1183, was manufactured in 1966. It was equipped with a 200-horsepower Lycoming model IO-360-A1A engine, serial number L-2509-51A, which drove an MT-Propeller, model MTV-12-B/180-59B, 3-blade wood composite propeller. The engine had been modified with a turbo-normalizer system manufactured by M-20 Turbos, Inc., which was installed on July 21, 2009, under FAA Supplemental Type Certificate Number SE01643AT and SA01642AT. The airplane had been modified by the installation of a redesigned pilot's and co-pilot's instrument panel equipped with a Garmin G500 dual screen Primary Flight Display (PFD) and Multifunction Display (MFD); Aspen EFD 1000 Pro Flight Display; Avidyne WSI AV300 Datalink Receiver; J.P. Instruments EDM-930, Engine Data Monitoring System; a back-up electric attitude indicator; and other modifications. The airplane was also equipped with an S-TEC 30 autopilot. A review of the airframe logbooks and engine logbooks showed that the most recent entry was made on September 1, 2011, with entries certifying that an annual inspection had been completed at 6,343.2 total aircraft hours and 6,343.2 total engine hours since new. The total time since major overhaul for the engine was listed as 980.1 hours. Federal Aviation Administration (FAA) records show the airplane had been registered to the current owner since March 6, 1998. METEOROLOGICAL INFORMATION The automated weather observation station at SSF, issued at 1653, reported wind from 170 degrees at 8 knots, visibility of 10 miles, overcast clouds at 3,400 feet above ground level, temperature 17 degrees C, dew point temperature 10 degrees C, with an altimeter setting of 30.04 inches of mercury. COMMUNICATIONS AND RADAR At 1653:30, N9224M (voice identified as the pilot) contacted the SSF Federal Contract Tower (FCT) controller and advised he was ready to taxi with information Romeo At 1653:47, the controller responded At 1653:51, N9224M (voice identified as the pilot) advised he was VFR and going to T82 At 1653:59, the controller issued taxi instructions to runway 14 At 1654:06, N9224M (voice identified as the pilot) responded he was taxiing to runway 14 At 1654:16, N9224M (voice identified as the CFI) requested flight following, and during the next minute there were several exchanges between the controller and N9224M (voice identified as the CFI) At 1706:51, N9224M (voice identified as the pilot) advised ready for takeoff runway 14 At 1706:58, the controller instructed N9224M to "turn left northeast bound" and gave clearance for takeoff At 1707:06, N9224M (voice identified as the pilot) responded he was departing runway 14 and was turning northeast bound At 1708:46, the controller instructed N9224M " … ah left turn to ah northeast" At 1708:59, N9224M (voice identified as the pilot) said "mooney nine two two four turning back for ⦠" (there was a change in the sense of urgency noted in the voice of the pilot and the end of the transmission was cut off) No further communications from N9224M were received. At 1709:04, the controller said "mooney two four mike traffic a mile southwest of the airport cessna entering right downwind" FAA Air Traffic Control radar showed at total of four returns from N9224M. The first two radar returns at 1708:32 and 1708:41 had altitude data at 800 feet. The last two returns at 1708:46 and 1708:55 had no altitude data. WRECKAGE AND IMPACT INFORMATION The airplane impacted in a flat unimproved field. The debris trail from the main crater led on a direction of 330 degrees for 57 feet to the main wreckage. The wreckage came to rest in an inverted position with the nose of the airplane oriented to about 360 degrees. All major components of the airplane were observed at the accident scene. Th