ASN Wikibase Occurrence # 215090
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| Date: | Tuesday 4 September 2018 |
| Time: | 11:00 |
| Type: |  Mooney M20J 201 |
| Owner/operator: | Angel Flight West |
| Registration: | N701JM |
| MSN: | 24-3281 |
| Year of manufacture: | 1992 |
| Total airframe hrs: | 1063 hours |
| Engine model: | Lycoming IO-360-B1E |
| Fatalities: | Fatalities: 1 / Occupants: 3 |
| Aircraft damage: | Destroyed |
| Category: | Accident |
| Location: | Palo Alto Airport (KPAO), Palo Alto, CA -
 United States of America
|
| Phase: | Initial climb |
| Nature: | Passenger |
| Departure airport: | Redding Airport, CA (RDD/KRDD) |
| Palo Alto Airport, CA (PAO/KPAO) | |
| Investigating agency: | NTSB |
| Confidence Rating: |  Accident investigation report completed and information captured |
The pilot was flying two passengers on an Angel Flight. When the airplane was about 10 miles north of the destination, the pilot contacted the air traffic control tower (ATCT). He was given instructions to fly to a charted VFR checkpoint, but then reported that he was not familiar with it and asked for directions from the controller. The pilot navigated to that checkpoint after several communications, and was then instructed to overfly a second checkpoint, about 2.5 miles north of the runway, as his left base leg for the arrival. The pilot was unable to locate the airport and requested ATCT assistance to advise him when to turn final, which the controller did. The pilot saw the airport and continued the approach.
Witnesses observed the airplane touch down about mid-field and began to porpoise, alternately bouncing between the main and nose landing gear. After 3 to 4 oscillations, the pilot initiated a go-around and reported to the controller of the go-around. In response, the controller instructed the pilot to make a left closed traffic and asked if he needed assistance, to which the pilot replied “negative, I just came in too fast." The airplane climbed a few hundred feet and was then observed to enter a very steep left bank. The nose pitched sharply down, and the airplane descended rapidly to the ground.
Examinations of the airplane and engine did not reveal any evidence of any pre-impact mechanical deficiencies or failures. Physical examination of the engine and propeller, combined with review of recorded engine operating
parameter data, indicated that the engine operated normally, and was producing power at impact.
The pilot’s logbook indicated that he had flown into that airport at least 32 times before, and therefore he should have been familiar with both the physical location of the airport and the names and locations of the local navigation fixes. Even if he had never been into that airport before, proper preflight planning dictates that he should have become familiar with those aspects.
Data downloaded from the onboard GPS device revealed the airplane was about 10 to 15 knots above the manufacturer's approach speed (75 knots for the calculated landing weight) during final approach. The data also indicated that for most of the final approach, the airplane remained below the runway's 4° PAPI approach slope path.
The pitch trim was found slightly airplane nose down from the normal takeoff setting, but the flaps were
found fully retracted. The manufacturer's go-around procedures called for full power, liftoff, and retraction of the flaps from the landing position (full down) to the takeoff position (approximately half) once the climb was established. Then, in sequence, this was to be followed by re-trimming in pitch, acceleration to 76 knots, landing gear retraction, flap retraction to the full-up position, and acceleration to 86 knots. Witnesses reported that the landing gear was retracted very soon after liftoff, making it likely that the pilot did not comply with the manufacturer's retraction sequence.
The flaps-retracted 0° bank stall speed for the calculated airplane weight was about 58 knots, and the stall speed for 30° bank was about 63 knots. Takeoff flaps reduce these speeds by about 2 knots. Both the short amount of time between liftoff and the stall, and the stall itself, indicate that the pilot had fully retracted the flaps prior to achieving the prescribed speed of 86 knots. Based on the available information, speed mismanagement by the pilot, and a reduced stall margin due to the pilot prematurely retracting the flaps, caused the airplane to stall during the early portion of its go-around climb out at an altitude too low for recovery.
Probable Cause: The pilot’s failure to maintain aircraft control during a go-around due to his premature flap retraction, which resulted in an aerodynamic stall and subsequent loss of control.
Accident investigation:
 |
|
Sources:
Palo Alto Fire Department
https://sfbay.ca/2018/09/04/one-killed-in-palo-alto-plane-crash/
https://www.mercurynews.com/2018/09/04/palo-alto-small-plane-down-near-airport/
https://www.aviationpros.com/news/12431946/ntsb-report-says-pilot-in-fatal-palo-alto-crash-appeared-confused-about-airport-location
Data_______________
https://flightaware.com/live/flight/N701JM
https://registry.faa.gov/aircraftinquiry/NNum_Results.aspx?NNumbertxt=N701JM%20
NTSB_______________
https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/98235/pdf
Location
Images:
Photo: Palo Alto Fire Department
Media:
— Planes Of Legend (@PlanesOfLegend) 2 octobre 2018
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 04-Sep-2018 20:12 | harro | Added |
| 04-Sep-2018 20:14 | harro | Updated [Time, Phase, Nature] |
| 04-Sep-2018 20:46 | Iceman 29 | Updated [Departure airport, Source, Narrative] |
| 04-Sep-2018 22:32 | Geno | Updated [Time, Aircraft type, Operator, Location, Phase, Nature, Departure airport, Destination airport, Source, Damage, Narrative] |
| 02-Oct-2018 15:46 | Iceman 29 | Updated [Time, Departure airport, Source, Embed code, Narrative] |
| 24-Aug-2021 17:33 | Anon. | Updated [Location, Departure airport, Destination airport, Embed code] |
| 18-Apr-2022 13:28 | aaronwk | Updated [Time, Phase, Source, Damage, Narrative] |
| 18-Apr-2022 19:53 | Captain Adam | Updated [Narrative] |
Corrections or additions? ... Edit this accident description
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