What happened
On October 27, 2016, a Mooney M20K was conducting an IFR flight from Pattonville to Saarbrücken for a scheduled business meeting. After an initial approach was aborted due to insufficient visibility, the pilot entered a holding pattern near Zweibrücken. The aircraft remained in holding for approximately two hours.
During the approach to runway 27, the pilot was provided with updated Runway Visual Range (RVR) information by Air Traffic Control (ATC). At approximately 11:46 UTC, the tower instructed the pilot to follow the standard missed approach procedure. Following this instruction, the aircraft's radar track showed a slight left swing followed by a right swing, with the altitude increasing to approximately 1,400 ft AMSL. Shortly thereafter, the aircraft crashed on a grassy area near taxiway A, north of runway 27. The pilot, a highly experienced commercial pilot, sustained fatal injuries, and the aircraft was destroyed.
The investigation
The BFU examined radar data, ATC voice recordings, and engine monitoring data from an EDM-730 device. The investigation established that the pilot had not descended below the CAT I decision altitude (DA). Engine data showed a consistent increase in exhaust and cylinder head temperatures in the 30 seconds prior to impact, indicating a power increase. The investigation also noted that the left landing flap was in a mid-position, consistent with a go-around configuration, while the right flap had been torn off during the impact.
Findings
- The primary cause of the accident was likely a failure to execute the missed approach procedure consistently, leading to a loss of control during the maneuver.
- Contributing factors included high pilot workload and stress caused by operating alone under extremely poor weather conditions.
- While the pilot was aware of the deteriorating visibility, he had planned to divert to Mannheim if the approach failed, suggesting he was not flying under undue pressure to land.
- The absence of an Outer Marker (OM) on the ILS approach may have made it more difficult for the pilot to maintain situational awareness during the high-stress maneuver.