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ASN Wikibase Occurrence # 44912
Last updated: 14 June 2020
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Date:16-MAR-2004
Time:17:03
Type:Silhouette image of generic M20T model; specific model in this crash may look slightly different
Mooney M20K
Owner/operator:Private
Registration: N1148V
C/n / msn: 25-0725
Fatalities:Fatalities: 2 / Occupants: 2
Other fatalities:0
Aircraft damage: Written off (damaged beyond repair)
Category:Accident
Location:Los Angeles, CA -   United States of America
Phase: Approach
Nature:Private
Departure airport:MammothYosemite, CA (MMH)
Destination airport:Santa Monica, CA (SMO)
Investigating agency: NTSB
Narrative:
During an attempted missed approach in instrument meteorological conditions (IMC), the airplane descended into a residence. The pilot had successfully completed a flight review 10 days before the accident flight. During the review the pilot flew his airplane about 2 minutes under simulated instrument flight conditions. No other evidence of instrument flying was found during the preceding 6 months. The accident occurred while the pilot was returning home following a vacation. As the pilot approached the airport, a fog bank moved in and the local weather conditions deteriorated. The VOR/GPS circling instrument approach procedure for the airport lists a minimum descent altitude of 680 feet mean sea level (msl), with a 1-mile minimum visibility requirement. The overcast ceiling was 400 feet above ground level (597 feet msl), and the visibility was 1 mile as the flight entered the terminal area. Near the time that the pilot received his instrument approach clearance, the visibility decreased to 1/2-mile and the ceiling lowered to 200 feet above ground level (agl) (397 feet msl); however, that information was not disseminated to the pilot by either the tower or approach controller, contrary to Federal Aviation Administration (FAA) internal directives. The pilot's approach was monitored by both the radar approach controller, and by the local tower controller on the tower's digital bright radar indicator (DBrite). Radar data showed that the airplane was consistently left of course and the local tower controller advised the pilot of that fact and asked him if he was correcting back. About 0.4 miles from the runway's end, the pilot advised the controller that he was going around. The pilot failed to adhere to the published missed approach procedure. During the next 1 to 2 minutes, the radar data showed the airplane making 360 degree turns about 0.5 miles from the runway until descending with what ground witnesses described as increasingly steep angles of bank into a house. The airplane was certificated and equipped for flight into IMC. Examination of the wreckage found no evidence of any mechanical malfunction.
Probable Cause: The pilot's loss of airplane control while maneuvering due to spatial disorientation. Contributing factors were the low ceiling, reduced visibility (fog), and the pilot's lack of instrument flying currency. An additional factor was the failure of air traffic control personnel to follow established Federal Aviation Administration directives to disseminate updated weather information.

Sources:

NTSB: https://www.ntsb.gov/_layouts/ntsb.aviation/brief.aspx?ev_id=20040330X00399&key=1


Revision history:

Date/timeContributorUpdates
28-Oct-2008 00:45 ASN archive Added
21-Dec-2016 19:24 ASN Update Bot Updated [Time, Damage, Category, Investigating agency]
07-Dec-2017 17:49 ASN Update Bot Updated [Source, Narrative]

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