What Happened
On October 20, 2008, around 1315 Pacific daylight time, a Mooney M20J registered N201EN lifted off runway 22 at Catalina Airport in Avalon, California, crossed the departure end bluff, and descended into the valley below. The private pilot and both rear-seat passengers were killed. The front-right passenger survived with serious injuries. The airplane was destroyed by post-impact fire.
The trip had started three days earlier. The pilot, a 74-year-old physician holding a private certificate with single-engine land and instrument ratings, had flown the group out from John Wayne-Orange County Airport in Santa Ana on October 17. That departure went normally. The surviving passenger described nothing unusual about that takeoff roll, and the flight to Catalina was uneventful. He noted the runway at John Wayne was considerably longer than what they would face on the island. The group spent three days in the Catalina area. During that time, by the passenger’s account, the pilot seemed relaxed and showed no signs of illness or distress.
Catalina Airport sits on top of a ridge at 1,602 feet mean sea level. Runway 22 is 3,000 feet long and 60 feet wide, asphalt surface, with an uphill grade of 1.8 percent across the first 2,000 feet. The final third is level. The airport has no fueling facilities, which meant the fuel load for the return flight was whatever remained from the last fill-up at Corona Municipal four days earlier, when 27 gallons of 100LL had been added. On all three sides of the runway’s departure end, the terrain drops away sharply. The AFD description is blunt: “1,600-foot-plus dropoffs to sea.” The runway also has a documented history of potholes, soft spots, and loose fragments. A pilot standing at the threshold of runway 22 cannot see the far end because the uphill grade conceals it, making the runway appear shorter than its 3,000 feet.
The surviving passenger described the accident takeoff roll as slower and more “labored” than the inbound flight had been. He said the airplane seemed to keep going and going down the runway surface without getting airborne. Eventually it did lift off, but almost immediately began to wobble. Around the midpoint of the runway he sensed the airplane decelerate, then accelerate again. Wreckage evidence would later confirm what he felt: two sets of main gear tire marks and a 20-foot paint transfer mark from the right wingtip appeared on the runway surface at approximately the 2,100-foot mark, meaning the airplane had briefly touched back down after the initial liftoff attempt. From there the tire marks veered left off the runway edge and into the adjacent infield gravel area, continuing for about 800 feet before swinging back toward the runway. A nose wheel impression was found in the gravel at roughly the 2,540-foot mark, and main gear impressions were found in the soft soil right at the runway’s departure end, where the terrain drops away steeply.
As they approached the end of the pavement, the passenger watched the pilot pulling back on the control yoke. The pilot said, “I’m sorry.” The airplane cleared the bluff and descended. A witness standing on a road in the valley below had been watching. He had seen a previous airplane depart normally, then looked up and observed N201EN depart further left of the runway centerline. As it went over the bluff it began to bank right and dive. He watched dust and fire erupt in the valley floor. He reported the engine sounded like it was running at a high power setting, and he saw no smoke trailing from the airplane during the sequence. The airplane came to rest in a ravine approximately 180 feet below the departure end of runway 22, headed 330 degrees magnetic. The cabin area and inboard wing sections were consumed by fire.
Investigation Findings
Investigators established control continuity through all control surfaces back to the center cabin area. Fire damage prevented full confirmation forward to the cockpit controls, but no preimpact mechanical anomalies were found in the airframe or flight control system. The elevator jackscrew trim setting corresponded to a normal takeoff trim position. One propeller blade showed an S-shaped bend with twist from root to tip; the other was bent aft at the root. These signatures are consistent with the engine producing power at impact, which aligned with the ground witness’s observation of high engine RPM.
The engine told a more complicated story. The spark plugs showed normal wear, dark gray in color and oil-soaked, with no anomalies. Fuel injector passages were clear. Thumb compression was obtained on all four cylinders and drive train continuity was confirmed. But when cylinders two and four were removed for internal inspection, the shared intake valve cam lobes showed significant wear. The Lycoming representative told investigators the lobe lifting peaks had worn down to approximately 75 percent of their original size. He stated this could result in an undetermined reduction in engine power, though such wear would have developed progressively over time, not suddenly. The engine had accumulated 743 hours since its last major overhaul in March 1997, and the maintenance records showed extended periods of low utilization: 23 hours accumulated between November 2004 and January 2006, and 20 hours in the period following that. Low-cycle, low-hour operation is associated with accelerated cam lobe wear in Lycoming engines.
The weight and balance picture was difficult to pin down precisely. The airplane’s basic empty weight was 1,795 pounds against a useful load of 944 pounds. The two front-seat occupants weighed 387 pounds combined, and the two rear-seat occupants weighed 255 pounds. The passenger estimated the baggage at 160 to 200 pounds, noting they had to cram three duffel bags and three hanging clothes bags into the aft compartment. The POH limits the baggage area to 120 pounds. Investigators weighed the partially burned remnants of the baggage at the accident site and recorded approximately 80 pounds, but fire and emergency response activity had clearly altered the scene. Fuel state at the time of departure could not be confirmed. The autopsy on the pilot found severe coronary atherosclerosis and near-complete occlusion of the left anterior descending coronary artery by a thrombus. On his most recent third-class medical application, filed February 27, 2007, the pilot had reported no medications, no medical history items, and no visits to health professionals in the past three years. Toxicological testing found no carbon monoxide, cyanide, drugs, or alcohol. The pilot’s logbook showed his last recorded flight entry was September 15, 2007, giving him 1,348 total hours and 27 hours in the accident airplane at that time. His last documented flight at Catalina Airport had been in December 1983, 25 years before the accident. A witness at Corona Airport said he had observed the pilot flying the accident airplane between 30 and 40 times in the 18 months before the accident, suggesting the logbook entries had simply not been kept current.
NTSB Probable Cause
The pilot’s failure to maintain aircraft control during takeoff for undetermined reasons. Contributing to the accident was the pilot’s failure to abort the takeoff while sufficient runway remained to stop.
Safety Lessons
Three separate threads converge in this accident, and any one of them, handled differently, might have changed the outcome.
- Know your abort criteria before you line up. The surviving passenger felt the airplane decelerate around the midpoint of the runway. The wreckage confirmed a touchdown at approximately 2,100 feet, with roughly 900 feet of pavement remaining. That 900 feet, on a downhill-gradient portion of the runway, may not have been enough to stop the airplane at that point, but earlier in the roll, before liftoff, the option existed. Catalina’s uphill grade masks how much runway is behind you. Experienced Catalina pilots brief a go/no-go point before every departure, typically somewhere in the first third of the visible runway. That decision gets made on the ground, not in the moment.
- Cam lobe wear in low-utilization Lycomings is a known and inspectable hazard. The IO-360 in this airplane had spent years accumulating very few hours between oil changes. Lycoming engines stored or flown infrequently are susceptible to cam lobe and lifter corrosion and wear, and the signatures found during the post-accident teardown were consistent with that pattern. The engine’s annual inspection four months before the accident did not detect the wear. A borescope inspection of the cam lobes and a review of oil analysis trend data are not required by the annual standard but are tools that exist and that catch exactly this kind of progressive degradation before it affects power output on a mountain runway departure.
- Catalina is not John Wayne. The pilot’s most recent documented departure from AVX was 1983. The airport demands specific familiarity: an uphill grade that makes the runway appear shorter than it is, no go-around option once you’re over the bluff, and a departure environment where a performance shortfall becomes terrain contact within seconds. The POH takeoff ground roll distance of approximately 1,050 feet for maximum gross weight assumes a level runway. The 1.8-percent uphill grade on the first two-thirds of runway 22 adds meaningfully to that number. Any uncertainty about the airplane’s performance state, including cam lobe wear, over-gross baggage loading, or residual fuel quantity, compounds in an environment where there is no second chance at the end of the pavement.
Frequently Asked Questions
Q: What makes Catalina Airport so dangerous for departures?
A: Runway 22 at Catalina climbs 1.8 percent uphill for the first 2,000 feet, which hides the far end of the runway from pilots at the threshold and makes the runway look shorter than its 3,000 feet. The departure end drops away in a 1,600-foot cliff to sea on three sides, meaning there is no go-around once you are over the bluff. The runway surface is documented to have potholes, soft spots, and loose fragments. The airport also has no fuel, so pilots must plan fuel loads carefully for the return flight.
Q: Can cam lobe wear cause engine power loss in a Lycoming IO-360?
A: Yes. Lycoming engines that accumulate low flight hours between oil changes are susceptible to cam lobe and lifter wear, particularly when moisture causes surface corrosion during extended ground storage. In this accident, the shared intake valve cam lobe lifting peaks had worn to approximately 75 percent of their original dimensions, which the Lycoming representative stated could cause an undetermined reduction in engine power. This type of wear develops progressively and may not be detectable during a standard annual inspection without a borescope examination of the cam.
Q: Did the pilot have a heart attack during the Catalina takeoff?
A: The autopsy found severe coronary atherosclerosis and near-complete occlusion of the left anterior descending coronary artery by a thrombus, findings consistent with a cardiac event around the time of the accident. However, the surviving passenger stated the pilot did not appear incapacitated at any point, spoke during the accident sequence, and was actively manipulating the controls. The NTSB analysis noted the findings were consistent with a cardiac event but could not determine whether it caused or contributed to the loss of control. The pilot had reported no cardiac history on his most recent medical application.
Q: When should a pilot abort a takeoff at Catalina Airport?
A: Experienced pilots operating into and out of Catalina brief a specific abort point before lining up for departure on runway 22, typically somewhere in the first 1,000 feet of the roll, while the uphill grade still allows braking to a stop. Once the airplane reaches the crest and the terrain drops away, options disappear quickly. If the airplane has not reached a safe liftoff speed with sufficient energy margin well before the departure end, the only survivable decision is already behind you.
Q: What is the maximum baggage weight for a Mooney M20J?
A: The POH for the Mooney M20J limits the aft baggage compartment to 120 pounds. In this accident the passenger estimated the total baggage at 160 to 200 pounds, and investigators recovered approximately 80 pounds of partially burned remnants at the accident site. Overloading the aft baggage area shifts the center of gravity rearward and increases gross weight, both of which affect takeoff performance and pitch stability.
