N1025CMooney M20R · 2003

On June 14, 2023, about 0903 central daylight time, a Mooney M20R airplane, N1025C, was destroyed during an accident near Watertown, Wisconsin. The pilot and passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight.

The pilot filed an instrument flight rules (IFR) flight plan from Watertown Municipal Airport (RYV), Watertown, Wisconsin, direct to Manitowish Waters Airport (D25), Manitowish Waters, Wisconsin, with an enroute cruise altitude of 8,000 ft msl. The RYV airport had a remote communications outlet monitored by an individual who relayed the instrument clearance from Madison Approach Control to the pilot before the flight departed RYV. At 0853, the pilot was cleared direct D25, then told to climb and maintain 3,000 ft msl after takeoff and to expect 6,000 ft msl about 10 minutes after departure.

According to ADS-B flight data, at 0900:46, the airplane was on initial climb from runway 5 at RYV, as depicted in figure 1. An airport surveillance video camera at RYV captured the airplane climbing wings level into an overcast ceiling. The RYV weather station reported an overcast ceiling at 300 ft above ground level (agl). Based on several pilot reports, the reported cloud tops were about 3,000 ft msl.

At 0901:07, the airplane entered a climbing left turn toward west-northwest, as depicted in figures 2 and 3. At 0901:50, the airplane entered a descent from 1,734 ft msl while still in the left turn. At 0902:00, the airplane descended at 1,941 fpm with a 30° left-wing-down roll angle. About 5 seconds later, the airplane entered a climb from 1,481 ft msl while in a left turn toward west-northwest at 163 knots calibrated airspeed (KCAS).

At 0902:22, the airplane was flying west at 133 KCAS and climbing 3,394 fpm. About 8 seconds later, the airplane was in a left turn toward southwest at 111 KCAS and climbing at 1,986 fpm.

At 0902:44, the airplane entered a climbing right turn toward north. At 0902:53, the airplane entered a descending right turn from a maximum altitude of 2,793 ft msl. About 15 seconds later, the airplane’s roll angle was about 80° right-wing-down as the airplane descended at 11,411 fpm in a right turn toward northeast.

At 0903:10, the final ADS-B data point, the airplane was flying at 211 KCAS as it descended 13,504 fpm with a 56° right-wing-down roll angle. According to the Mooney M20R Pilot Operating Handbook, the VNE for the airplane was 196 KCAS. The final track point was at 1,166 ft msl and about 255 ft east-northeast of the initial impact with the ground.

A witness reported seeing the airplane descend “nose first” into a grass field and wooded area near the soccer fields in Brandt-Quirk Park. The witness also reported there was a large explosion after the airplane impacted the ground.

Figure 1. Plot of airplane flight track data.

Figure 2. Plots of airplane altitude, ground speed, true airspeed, calibrated airspeed, and vertical speed.

Figure 3. Plots of airplane ground track, roll angle, and flight path angle.

The pilot’s flight logbook was recovered at the accident site. The final logbook entry was dated May 15, 2023; based on postaccident calculations, the pilot had a total flight experience of 1,714.9 hours. Although the pilot routinely logged actual and simulated instrument flight time, the recovered logbook pages did not include a previously accumulated total instrument flight time parameter that could be used to calculate his total instrument flight experience.

According to the pilot’s son, the pilot was the only individual who flew the airplane. A postaccident review of ADS-B flight data associated with the airplane concluded that the pilot flew the airplane at least 26.1 hours during the year before the accident, 8.3 hours during the previous 6 months, 8.3 hours in the previous 3 months, and 5.7 hours during the month before the accident. The pilot flew at least 4.5 hours after his final logbook entry; when combined with his flight logbook information the pilot had a total flight experience of about 1,719.4 hours.

On October 4, 2022, the pilot completed his last flight review and instrument proficiency check (IPC) in the airplane. According to the pilot’s flight logbook, during the 6 months following his last IPC he routinely logged the entirety of the flight as simulated instrument time and having completed one instrument approach every flight. However, the logbook entries did not provide the location and type of each instrument approach, nor the name of the individual who acted as the safety pilot while the pilot flew the airplane under simulated instrument conditions as required by 14 CFR 61.51. As such, the pilot’s recent instrument flight experience could not be adequately assessed with the available logbook evidence.

The accident site was located in between two low-level troughs with the low-level wind flow moving across the area from the Great Lakes region increasing the low-level moisture. In addition, the surface winds were light, creating an environment favorable for the formation of low clouds and fog. The weather station at the departure airport reported a calm wind, visibility of 5 miles, and a 300 ft agl overcast ceiling at the time of the accident.

The weather forecast information applicable for the accident time indicated that Airmen's Meteorological Information (AIRMET) Sierra for IFR conditions due to precipitation and mist was valid for the site at the accident time. The Graphical Forecasts for Aviation (GFA) applicable to the accident site and that were valid when the flight departed indicated low instrument flight rules (LIFR) to IFR conditions and a north wind of 5 knots. The GFA cloud forecast indicated broken-to-overcast clouds with bases about 1,000 ft msl and cloud tops about 3,000 ft msl.

A review of weather satellite imagery and High-Resolution Rapid Refresh models noted cloud tops around 6,500 ft msl. However, several pilot reports located around the site and within 90 minutes of the accident reported cloud tops between 3,000 ft msl and 3,800 ft msl.

A search of archived information established that the pilot filed a flight plan with Leidos Flight Service before the flight departed, but he did not request any weather information from Leidos. Although the pilot had a registered account with ForeFlight, an online service that can provide weather information, there was no recorded activity for his account on June 13-14, 2023. Based on the available information, it is unknown what weather information, if any, the pilot checked or received before or during the flight.

A GoPro Hero 8 device was recovered from the wreckage and its contents were reviewed by the NTSB Vehicle Recorder Laboratory. The last file written to the device’s memory card was a photo, shown as figure 4, that captured the airplane’s right wing as seen through the right passenger window. Additionally, the photo showed that there were significant clouds that obstructed the view of the ground and were consistent with IMC. Based on the file metadata, the photo was captured at 0903:01, about 0.35 nm southwest of the accident site, at a GPS altitude of 2,297 ft.

Figure 4. GoPro Hero 8 photo captured at 0903:01

The initial impact point was a concrete curb and asphalt road in Brandt-Quirk Park. The wreckage debris path projected to the east. The initial impact included multiple propeller strike gouges and linear scratches in the asphalt road. The main wreckage was in a wooded area situated along a creek about 260 ft from the initial impact point.

There were multiple areas of turf and tree foliage that exhibited evidence of fuel blight and/or fire. The local fire department reported several small fires after the accident. Most of the airplane wreckage was in a wooded area on the east side of the creek. The left wing separated from the fuselage near the wing root and was found relatively intact. The highly fragmented components of the cabin, cockpit, seats, aft fuselage, empennage, and right wing were found scattered throughout the wooded area on the east side of the creek.

The engine separated from the fuselage and was in a grass field about 333 ft east of the initial impact point. Both main landing gear wheels/tires/brake assemblies were also located in the grass field. The farthest component along the wreckage debris path was part of the engine starter motor assembly, which was about 739 ft east of the initial impact point.

A wreckage layout confirmed that all major structural components were accounted for at the accident site. The ailerons, flaps, rudder, elevator, and speed brakes were identified. Flight control continuity could not be confirmed due to extensive impact-related damage. The recovered flight control push-pull tubes were highly fragmented and exhibited overstress features that were consistent with impact-related damage. The landing gear linear actuator jackscrew was fully exposed, consistent with a retracted landing gear position at impact.

The engine exhibited extensive impact-related damage that prevented the crankshaft from being rotated. The upper crankcase exhibited a large crack between cylinder Nos. 2 and 3. Three of the six cylinder heads separated during impact. The remaining three cylinder heads exhibited extensive impact-related damage. There were numerous cylinder head fragments recovered from the debris path. There were multiple intake and exhaust valves found separated from their respective cylinder heads. All six pistons remained in their respective cylinders. The propeller flange and crankshaft exhibited features consistent with an overload separation. All engine accessories separated from the engine crankcase during impact. Portions of the left and right magnetos exhibited extensive impact-related damage and could not be tested. The engine-driven fuel pump and propeller governor exhibited impact-related damage and were not tested. The fuel manifold and injector lines separated from the top of the engine crankcase. The oil filter separated from the engine. The engine oil sump separated from the crankcase. The rear of the engine crankcase was missing, exposing the aft accessory gears. The intake, exhaust, and muffler separated from the engine and was fragmented and/or crushed.

The propeller hub with two blades separated from the engine crankshaft. The remaining propeller blade separated from the hub and was found in two pieces. All three propeller blades exhibited extensive impact-related damage, including spanwise bending, blade fractures, blade twisting, chordwise scratching, and leading-edge damage.

The vacuum pump separated from the engine and exhibited impact-related damage. The vacuum pump rotor/vanes were not recovered. A separated gyro housing was recovered and exhibited impact-related damage. The interior surface of the gyro housing exhibited rotational scoring. The gyro rotor was not recovered.

Sound Spectrum Analysis

A sound spectrum analysis of recorded audio from a digital doorbell camera revealed that the engine was operating at or near 2,500 rpm as the airplane passed abeam the camera’s location about 28 seconds before impact. The recorded audio was consistent with the engine operating until the airplane impacted terrain.

Spatial Disorientation

The FAA Civil Aerospace Medical Institute's publication "Introduction to Aviation Physiology” defines spatial disorientation as a loss of proper bearings or a state of mental confusion as to position, location, or movement relative to the position of the earth. Factors contributing to spatial disorientation include changes in acceleration, flight in IMC, frequent transfer between visual meteorological conditions (VMC) and IMC, and unperceived changes in aircraft attitude.

The FAA's Airplane Flying Handbook (FAA-H-8083-3C) describes some hazards associated with flying when the ground or horizon are obscured. The handbook states in part, "The vestibular sense (motion sensing by the inner ear) can and will confuse the pilot. Because of inertia, the sensory areas of the inner ear cannot detect slight changes in airplane attitude, nor can they accurately sense attitude changes that occur at a uniform rate over a period of time. On the other hand, false sensations are often generated, leading the pilot to believe the attitude of the airplane has changed when, in fact, it has not. These false sensations result in the pilot experiencing spatial disorientation.”

Federal Regulations Concerning Maintaining and Logging Instrument Experience

According to 14 CFR 61.57, an instrument-rated pilot may not act as pilot-in-command under IFR or weather conditions less than the minimums prescribed for visual flight rules (VFR) unless they have within the 6 calendar months preceding the month of the flight performed and logged, in either actual or simulated instrument conditions, at least 6 instrument approaches, holding procedures and associated tasks, and intercepting/tracking courses through the use of navigational electronic systems.

According to 14 CFR 61.51, a pilot may only log instrument flight time if operating the aircraft by reference to instruments under actual or simulated flight conditions. Additionally, for the purposes of logging instrument time to meet recent instrument experience requirements the pilot must record the location and type of each instrument approach flown and, if required, the name of the safety pilot.

Federal Regulation Concerning Prohibition on Operations During Medical Deficiency

According to 14 CFR 68.3, if authorized to fly under BasicMed, pilots shall certify in a statement that they understand the existing prohibition on operations during medical deficiency, to include acting as pilot-in-command, or any other required flight crew member, if they have reason to know of any medical condition that would make them unable to operate the aircraft in a safe manner.

According to a review of FAA medical records, the 73-year-old pilot’s last aviation medical examination was completed on September 18, 2016. At that time, he reported having high blood pressure and sleep apnea treated with a continuous positive airway pressure (CPAP) device. He reported taking the medications lansoprazole, valsartan/hydrochlorothiazide, tamsulosin, aspirin, fluticasone, and topical testosterone. The Aviation Medical Examiner (AME) noted glucose in the pilot’s urine. After discussion with the FAA Regional Flight Surgeon, the AME re-tested the pilot’s urine the next day and did not detect glucose. The AME then issued the pilot a third-class medical certificate via AME-Assisted Special Issuance (AASI) for sleep apnea and high blood pressure, with the limitations that the pilot must wear corrective lenses for distance and have glasses available for near vision. The medical certificate was not valid after September 30, 2017. The pilot subsequently completed the BasicMed course and the Comprehensive Medical Examination Checklist on September 17, 2021.

A review of the pilot’s recent medical records indicated that he was being treated for high blood pressure, arthritis, back pain, insomnia, obstructive sleep apnea (OSA) and low testosterone. He also had extensive systemic steroid use for back pain and was prescribed muscle relaxants and narcotics and his OSA was being treated with a CPAP device. There was no information regarding the pilot’s CPAP usage and the machine was not recovered. No formal report was available for the results of the cardiac catheterization.

At the request of the Dodge County Medical Examiner, the Fond du Lac County Chief Medical Examiner performed the pilot’s autopsy. According to the pilot’s autopsy report, his cause of death was multiple injuries. Due to the extent of the pilot’s injuries, structural evaluation of brain, heart and lungs was not possible. Within these limitations, the autopsy did not identify significant natural disease.

At the request of the Medical Examiner, NMS Labs performed toxicological testing of muscle tissue from the pilot. Caffeine and acetaminophen were presumptively positive. Codeine was detected at 220 ng/g. Ethanol was not detected in muscle tissue at a reporting threshold of 0.08 g/hg.

The FAA Forensic Sciences Laboratory performed toxicological testing of postmortem specimens from the pilot. Ethanol was detected in lung tissue at 0.022 g/hg and in muscle tissue at 0.059 g/hg. Gabapentin was detected in lung tissue at 5237 ng/g and in muscle tissue at 5028 ng/g. Codeine was detected in lung tissue at 403 ng/g and in muscle tissue at 139 ng/g. Hydrocodone was detected in lung tissue at 1 ng/g and was not detected in muscle tissue. Morphine was detected in lung tissue at 18 ng/g and in muscle tissue at 8 ng/g. Delta-8-tetrahydrocannabinol (delta-8-THC) was detected in lung tissue at 10.9 ng /g and in muscle tissue at 24 ng/g. Carboxy-delta-8 THC was detected in lung tissue at 34.4 ng/g and detected in muscle tissue at 9.8 ng/g. 11-hydroxy-tetrahydrocannabinol (11-hydroxy THC) was detected in lung tissue and was not detected in muscle tissue. Acetaminophen, valsartan, hydrochlorothiazide, and diclofenac were detected in lung and muscle tissue.

Ethanol is a type of alcohol. It is the intoxicating alcohol in beer, wine, and liquor and, if consumed, can impair judgment, psychomotor performance, cognition, and vigilance. FAA regulation imposes strict limits on flying after consuming ethanol, including prohibiting pilots from flying with a blood ethanol level of 0.04 g/dL or greater. Alcohol consumption is not the only possible source of ethanol in postmortem specimens. Ethanol can sometimes be produced by microbes in a person’s body after death. Postmortem ethanol production is made more likely by extensive traumatic injury.

Gabapentin is a prescription medication that can be used to treat nerve pain, certain types of seizures, restless legs syndrome, and other conditions. Gabapentin generally carries a warning that use may cause drowsiness, dizziness, blurred vision, and general central nervous system (CNS) depression. Precautions are advised when driving a vehicle or operating heavy machinery until the user can assess the impact of dosing on alertness and motor activities. Gabapentin use in adults over the age of 65 may increase the risk of decline of executive function, information processing, and motor skills. The use of opioids with gabapentin is not advised due to increased risk of CNS side effects, especially in the elderly. The FAA considers gabapentin a “do not issue/do not fly” medication.

Codeine, morphine, and hydrocodone are opioid drugs. These drugs can be individual prescription medications, or metabolites of other opioid drugs. Because morphine and hydrocodone are metabolites of codeine, use of codeine alone can cause a person to test positive for codeine, morphine, and hydrocodone. Codeine commonly is used to treat moderate to severe pain. Codeine also commonly is used in prescription cough medications to relieve shortness of breath and cough. Codeine carries a warning that use may impair the mental or physical ability needed to perform potentially hazardous activities such as driving a car or operating dangerous machinery. Use of opioids with other CNS depressants increases the risk of sedation. Codeine also can be used illicitly. An open prescription for codeine generally is disqualifying for FAA medical certification, although certification may be granted by the FAA in certain cases of infrequent use for acceptable medical conditions. Regardless, the FAA states that a pilot should not fly after using an opioid like codeine until adequate time has elapsed for the drug to be eliminated from circulation.

Delta-8 THC is a psychoactive cannabinoid chemical. Although delta-8 THC is similar to the primary psychoactive chemical in cannabis (delta-9 THC), very little delta-8 THC is present in the cannabis plant. Delta-8 THC used in consumer products typically is chemically manufactured from cannabidiol (CBD), another chemical in the cannabis plant. Delta-8 THC products are often marketed as “hemp” products, which consumers may not associate with psychoactive effects. Delta-8 THC is available in a variety of over-the-counter products for oral consumption, smoking, and inhalation. Delta-8 THC has psychoactive and intoxicating effects that can impair motor coordination, reaction time, decision making, problem solving, and vigilance. The potency of delta-8 THC varies widely in consumer products. Delta-8 THC products may also contain impurities including delta-9 THC. Delta-8 THC products have not been evaluated or approved by the Food and Drug Administration (FDA) for safe use in any context. Carboxy-delta-8 THC is a non-psychoactive metabolite of delta-8 THC. 11-hydroxy THC is a psychoactive metabolite of both delta-8 THC and delta-9 THC (the FAA Forensic Sciences Laboratory does not distinguish between 11-hydroxy-delta-8 THC and 11-hydroxy-delta-9 THC).

Valsartan and hydrochlorothiazide are prescription medications commonly used to control high blood pressure. Diclofenac is a non-steroidal anti-inflammatory drug commonly used to relieve pain from arthritis. Acetaminophen is an over-the-counter medication used for pain relief and fever reduction. It can also be used in a prescription combination with opioids such as codeine to relieve mild to moderately severe pain. Valsartan, hydrochlorothiazide, diclofenac, and acetaminophen are not generally considered impairing.