Aviation Accident Factual Report

noise coming from behind him that kept getting louder. He slowed his vehicle, looked out his left window, and saw the accident airplane in a 45° left bank about 80 ft above the ground, flying west. He did not observe the landing gear extended. He subsequently witnessed the airplane strike a tree and then a house. He reported that the engines were “extremely loud.” A second witness, located about 1/2 mile south of the accident site, reported that while outside of his home, he saw the airplane descend through an overcast cloud layer. He added that the engines were “running fine, no stuttering.” He noted that the landing gear were down and that the airplane was “lumbering along with the nose up” in level flight several hundred feet above the trees. The airplane subsequently exited his view, and he heard a loud impact about 10 seconds later. Pilot Information Certificate: Commercial Age: 74,Male Airplane Rating(s): Single-engine land; Single-engine sea; Multi-engine land Seat Occupied: Left Other Aircraft Rating(s): Glider Restraint Used: Unknown Instrument Rating(s): Airplane Second Pilot Present: No Instructor Rating(s): None Toxicology Performed: Yes Medical Certification: Class 2 With waivers/limitations Last FAA Medical Exam: April 3, 2019 Occupational Pilot: No Last Flight Review or Equivalent: January 17, 2019 Flight Time: (Estimated) 7173 hours (Total, all aircraft), 1384 hours (Total, this make and model) Fragments of the pilot's logbook were recovered in the wreckage; however, the majority of its contents were illegible. On the application for the pilot’s most recent medical certificate, dated April 3, 2019, he reported 7,173 total hours of flight experience, including 66 hours in the previous 6 months. On an aircraft insurance application from January 2019, the pilot reported a total of 2,284 multiengine airplane flight hours, including 1,384 flight hours in the accident airplane. Page 5 of 13 ERA20FA020 According to the pilot’s spouse, he had flown into the destination airport “hundreds of times,” as he was accustomed to commuting to the New York City area on a regular basis. Aircraft and Owner/Operator Information Aircraft Make: Cessna Registration: N959MJ Model/Series: 414 A Aircraft Category: Airplane Year of Manufacture: 1980 Amateur Built: Airworthiness Certificate: Normal Serial Number: 414A0471 Landing Gear Type: Retractable - Tricycle Seats: 6 Date/Type of Last Inspection: October 18, 2019 Annual Certified Max Gross Wt.: 7087 lbs Time Since Last Inspection: Engines: 2 Reciprocating Airframe Total Time: 7712 Hrs as of last inspection Engine Manufacturer: Continental ELT: Installed, not activated Engine Model/Series: TSIO-520-NB Registered Owner: Rated Power: 335 Horsepower Operator: On file Operating Certificate(s) Held: None According to FAA airworthiness records, the six-seat, multiengine, low-wing airplane was manufactured in 1980. It was powered by two Continental TSIO-520-NB, 335-horsepower engines, which had been modified with the RAM Aircraft conversion. The airplane was also equipped with RAM Aircraft winglets and vortex generators. According to the RAM winglets, vortex generator airplane flight manual supplement, the aerodynamic stall speeds varied with weight, bank angle, and the configuration of the landing gear and wing flaps. Figure 3 shows the range of stall speeds that could be expected. For example, at weight between 6,750 lbs - 5,200 lbs, 20° bank, flaps 15°, and landing gear down, the stall speed would vary from 76 to 67 knots indicated airspeed. The supplement stated that the maximum altitude loss during a conventional stall was approximately 550 ft. Page 6 of 13 ERA20FA020 Figure 3: Aerodynamic stall speed chart provided in the applicable airplane flight manual supplement Page 7 of 13 ERA20FA020 Meteorological Information and Flight Plan Conditions at Accident Site: Instrument (IMC) Condition of Light: Day Observation Facility, Elevation: LDJ,22 ft msl Distance from Accident Site: 3 Nautical Miles Observation Time: 11:15 Local Direction from Accident Site: 240° Lowest Cloud Condition: 700 ft AGL Visibility 2 miles Lowest Ceiling: Overcast / 700 ft AGL Visibility (RVR): Wind Speed/Gusts: / Turbulence Type Forecast/Actual: None / None Wind Direction: Turbulence Severity Forecast/Actual: N/A / N/A Altimeter Setting: 30.32 inches Hg Temperature/Dew Point: 14°C / 13°C Precipitation and Obscuration: Moderate - None - Mist Departure Point: Leesburg, VA (JYO ) Type of Flight Plan Filed: IFR Destination: Linden, NJ (LDJ ) Type of Clearance: IFR Departure Time: 09:50 Local Type of Airspace: Class E A search of archived ForeFlight information indicated that the pilot requested weather information via ForeFlight Mobile at 1206 on October 28 with a planned departure of 0830 on October 29. The weather briefing information contained all the standard weather information valid at that time; however, most of the weather forecast information was only valid through 0500 on October 29. The pilot obtained an additional weather briefing at 0920 the day of the accident via telephone from Leidos Flight Service. The pilot specifically requested the current conditions and outlook for LDJ and Teterboro Airport (TEB), which was the pilot’s alternate airport. The briefer asked whether the pilot was aware of the AIRMETs for IFR conditions, and the pilot confirmed that he was aware. The briefer provided the pilot with current and forecast weather conditions at LDJ and TEB, which included visibilities between 5 and 10 statute miles with drizzle and mist and ceilings between 700 ft above ground level (agl) to 2,500 ft agl. The pilot subsequently inquired when the weather was expected to improve in the Linden- Newark area. The briefer stated, “there may be a slight improvement, still remaining marginal.” The pilot asked when the improved conditions were expected, and the briefer reported that, “it could be 1,400 broken through 1500 zulu [1100 local].” The 1055 recorded weather observation at LDJ included an overcast ceiling at 700 ft agl, 10 statute miles visibility, and calm wind. At 1115, LDJ reported 2 miles visibility, mist, and an overcast ceiling at 700 ft agl. The 1051 recorded weather observation at EWR, located about 8 miles northeast of the accident site, included a broken ceiling at 800 ft and 4 statute miles visibility with light drizzle Page 8 of 13 ERA20FA020 and mist. At 1135, EWR reported 2 statute miles visibility, light drizzle and mist, and broken ceiling varying between 500 ft to 900 ft agl. A PIREP filed at 1048 from an Airbus A320 on final approach into runway 4R at EWR reported an overcast ceiling base of 500 ft mean sea level. Airport Information Airport: Linden LDJ Runway Surface Type: Airport Elevation: 22 ft msl Runway Surface Condition: Dry Runway Used: IFR Approach: Circling;Global positioning system Runway Length/Width: VFR Approach/Landing: None The pilot was performing the GPS-A nonprecision circling instrument approach procedure (IAP) to LDJ. Review of the IAP chart valid at the time of the accident found that the IAP utilized a series of step-down altitudes concluding with a minimum descent altitude of 620 ft msl (597 ft agl). The final approach course was not aligned with the runway. The missed approach point (MAP), BAUTZ, was about 2 nautical miles from runway 09. The accident site was located about 1.4 nautical miles southwest of BAUTZ. According to the LDJ FAA Chart Supplement, the airport was nontower-controlled and runway 09 was equipped with runway end identifier lights (REIL) in addition to a visual approach slope indicator (VASI) on the right side of the runway. According to a Linden Airport Operations lineman, for the entire time surrounding the accident, he had been continuously monitoring the airport’s common traffic advisory frequency (CTAF). He reported that there were no radio calls from the accident airplane nor did he hear any “clicks” that would have indicated that a pilot was attempting to activate the airport lighting. He reported that every morning, he checked the REILs, taxiway lights and runway lights via the pilot-controlled lighting frequency, and on the day of the accident, the lights functioned as expected. Review of the LDJ NOTAMs found that there were two active airport NOTAMs, both for the runway 09 VASI. The NOTAMs stated that the low and medium intensity light settings were “unusable.” Page 9 of 13 ERA20FA020 Wreckage and Impact Information Crew Injuries: 1 Fatal Aircraft Damage: Destroyed Passenger Injuries: N/A Aircraft Fire: On-ground Ground Injuries: N/A Aircraft Explosion: On-ground Total Injuries: 1 Fatal Latitude, Longitude: 40.590158,-74.310767 The main wreckage was located in the basement of a residence. The airplane sustained significant impact and thermal damage as a result of postcrash fire and the wreckage was intermingled with house debris and rubble. The initial impact point was identified by large broken tree branches about 40 ft east of the main wreckage; the wreckage path was oriented on a true heading of 278°. Multiple tree branches were cut at 45° angles and exhibited gray paint transfer consistent with propeller blade contact. The largest piece of the airframe was the forward cabin area, which included the left side cockpit instrument panel. The majority of the right cockpit fuselage skin and the right cockpit instrument panel was consumed by fire. Complete flight control cable continuity could not be established to the flight control surfaces, as a majority of the left and right wings and empennage were consumed by the postimpact fire and were not located in the house debris. Partial aileron and elevator flight control cable continuity was established by observing the cables moving in the lower forward floor assembly area when the left yoke was moved by hand. The left and right wing flap tubes and bellcranks were observed. The right flap chain, when measured, was consistent with a flap setting of 15°. The left flap chain was not observed. Rudder cable continuity was not established. The left, right, and nose landing gear had separated from the fuselage; the landing gear position could not be determined based on observation of the landing gear actuators. The landing gear handle arm was twisted, and its position could not be determined. The throttle, mixture, and propeller control levers were found full forward. The left and right fuel selector handles were found pointing straight forward in an intermediate position between main and crossfeed. The airspeed indicator was found indicating about 55 knots, the primary attitude indicator was found displaying a 120° left roll, and the pitch indicated a 5° nose up pitch attitude. When disassembled, the gyro moved freely within its housing and displayed small rotational scoring marks. The altimeter was set to 30.31 inches of mercury and indicated 200 ft. The barometric setting was consistent with the LDJ weather observation. The primary heading indicator was found indicating a heading of 260°, the course was set to 010°, and the heading bug was found set to 050°. The altitude alerter was found set to 30,000 ft. The course deviation indicator was found Page 10 of 13 ERA20FA020 indicating that the airplane was left of course. The left and right engine ignition switches were found in the ON position. The right engine had separated from the wing and was located in the basement of the house forward of the main wreckage. It sustained impact and thermal damage. The three-bladed propeller remained attached to the propeller hub and displayed chordwise scratching, torsional twisting, and s-bending. The crankshaft was rotated by hand through 360°; crankshaft continuity was established from the forward section of the engine to the accessory section. All cylinders displayed normal operating and combustion signatures and thumb compression. The right engine magnetos turned freely by hand and spark was observed on all ignition terminals. No debris was noted in fuel nozzles or fuel manifold. The top spark plugs for each cylinder displayed normal operating combustion signatures. The right turbocharger exhibited thermal damage and the compressor housing and compressor wheel were not located. The vacuum pump attached to the right engine was removed and disassembled; the drive coupling remained intact. The left engine had separated from the wing and was located under the fuselage. It sustained impact and thermal damage. The three-bladed propeller displayed chord-wise scratching and torsional twisting. The crankshaft was rotated by hand through 360° of motion; crankshaft continuity was established from the forward section of the engine to the accessory section. All cylinders displayed normal operating and combustion signatures. Each cylinder, with the exception of the Nos. 4 and 6 cylinders, displayed thumb compression. The Nos. 4 and 6 cylinders contained fire debris on the valve seats, which prevented full closure of the valves. The left engine magnetos sustained significant external and internal thermal damage; the ignition leads could not be tested. The top spark plugs for each cylinder displayed normal operating combustion signatures. The left turbocharger was intact, and the turbine wheel turned freely. The vacuum pump attached to the left engine was removed and disassembled; the drive coupling remained intact. Communications Air Traffic Control Low Altitude Alerts ATC services were provided by New York Terminal Radar Approach Control (TRACON) (N90) for the pilot’s approach into LDJ. The N90 TRACON was equipped to issue a “Minimum Safe Altitude Warning (MSAW)”. FAA Order 7110.65Y, Air Traffic Control, Pilot/Controller Glossary, provided the following definition for an MSAW: Page 11 of 13 ERA20FA020 A function of the ARTS [Automated Radar Terminal System] III computer that aids the controller by alerting him/her when a tracked Mode C equipped aircraft is below or is predicted by the computer to go below a predetermined minimum safe altitude. At 1056:01, an MSAW low altitude (LA) alert visually and aurally activated at the approach controllers’ position for the accident airplane. According to FAA radar data from the EWR ASR-9 antenna, the airplane’s altitude indicated 1,000 ft msl. About 55 seconds later, the approach controller instructed the pilot to say flight conditions. At 1058:06, a second LA alert activated for the airplane. According to radar data, the altitude indicated 200 ft. The approach controller instructed the pilot to “say flight conditions.” The pilot did not respond. Five seconds later, the approach controller instructed the pilot to “check altitude immediately.” There were no responses from the pilot. Safety Alert FAA Order 7110.65Y, Air Traffic Control, paragraph 2-1-6, “Safety Alert,” described the circumstances for a controller to issue a “safety alert.” The paragraph stated in part: Issue a safety alert to an aircraft if you are aware the aircraft is in a position/altitude that, in your judgment, places it in unsafe proximity to terrain, obstructions, or other aircraft. Once the pilot informs you action is being taken to resolve the situation, you may discontinue the issuance of further alerts. Do not assume that because someone else has responsibility for the aircraft that the unsafe situation has been observed and the safety alert issued; inform the appropriate controller. NOTE- 1. The issuance of a safety alert is a first priority…once the controller observes and recognizes a situation of unsafe aircraft proximity to terrain, obstacles, or other aircraft. Conditions, such as workload, traffic volume, the quality/limitations of the radar system, and the available lead time to react are factors in determining whether it is reasonable for the controller to observe and recognize such situations. While a controller cannot see immediately the development of every situation where a safety alert must be issued, the controller must remain vigilant for such situations and issue a safety alert when the situation is recognized. 2. Recognition of situations of unsafe proximity may result from MSAW14/E-MSAW, automatic altitude readouts, Conflict/Mode C Intruder Alert, observations on a PAR scope, or pilot reports. 3. Once the alert is issued, it is solely the pilot’s prerogative to determine what course of action, if any, will be taken. a. Terrain/Obstruction Alert. Immediately issue/ initiate an alert to an aircraft if you are aware the aircraft is at an altitude that, in your judgment, places it in unsafe proximity to terrain and/or obstructions. Issue the alert as follows: Page 12 of 13 ERA20FA020 PHRASEOLOGY- LOW ALTITUDE ALERT (call sign) CHECK YOUR ALTITUDE IMMEDIATELY. Medical and Pathological Information According to the autopsy report from the County of Middlesex, North Brunswick, New Jersey, Medical Examiner, the pilot’s cause of death was blunt impact trauma of the head, and the manner of death was accident. The medical examiner listed the contributing causes of death as smoke inhalation and blunt impact trauma of torso; he reported soot in the pilot’s upper and lower airways. The medical examiner discovered a cardiac monitoring device in the pilot’s chest; according to the medical examiner, the readout by the manufacturer showed that the pilot had an abnormal rhythm several minutes after impact with the house; prior to the impact, there was a normal heart rhythm. With the exception of atherosclerosis in the aorta and a tumor on the left kidney, there was no other significant natural disease identified. The FAA Forensic Sciences Laboratory toxicology testing detected the non-impairing medications irbesartan, famotidine, and tamsulosin, used to treat high blood pressure, acid reflux, and an enlarged prostate, respectively, in the pilot’s cardiac blood and urine. They detected carboxyhemoglobin at 34% in cardiac blood. Toxicology testing performed for the County of Middlesex, Office of the Chief Medical Examiner, detected carboxyhemoglobin at 43% in cardiac blood. Carbon monoxide (CO) is an odorless, colorless gas that is a byproduct of combustion, such as from an exhaust system or fire. Carboxyhemoglobin is formed when CO binds to hemoglobin, the protein in red blood cells that carries oxygen. The degree of carboxyhemoglobin formation is related to the concentration of CO and the duration of exposure. The binding of CO impairs oxygen transport and use, and results in symptoms of exposure that can be mild and vague to impairing and incapacitating. Carboxyhemoglobin levels above 5% in nonsmokers and above 10% in smokers would suggest exposure to carbon monoxide. Page 13 of 13 ERA20FA020 Administrative Information Investigator In Charge (IIC): Gerhardt, Adam Additional Participating Persons: Richard Rohrig; FAA/ FSDO; Teterboro, NJ Peter Basile; Textron Aviation; Wichita, KS Phillip Grice; Continental Motors; Mobile, AL Report Date: December 1, 2021 Note: The NTSB traveled to the scene of this accident. Investigation Docket: https://data.ntsb.gov/Docket?ProjectID=100503