Mooney M20J accident near Palo Alto, California, September 4, 2018

The NTSB's narrative final · quoted from the NTSB record

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.

The complete narrative as the NTSB published it. The NTSB's docket holds the report as a PDF and any photographs, statements and other documents from the investigation.