Pilot Debrief

BEECH C35 near Hicksville, NY — 2015-08-16

Final reportERA15FA313
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Date
2015-08-16
Location
Hicksville, NY, USA
Aircraft
BEECH C35
Registration
N5946C
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Cruise

Probable cause

The pilot's improper decision to delay turning toward a suitable runway once he realized that an engine failure had occurred, which resulted in his having inadequate altitude to glide to a suitable runway, and the New York terminal radar approach control LaGuardia Airport area controller's provision of erroneous emergency divert airport information to the pilot. Contributing to the accident were (1) the Federal Aviation Administration's lack of a requirement to periodically review and validate radar video maps, (2) the failure of the engine crankshaft due to a bearing shift, and (3) the pilot's impairment due to his abuse of amphetamine and underlying medical condition(s).

Contributing factors

Contributing to the accident were (1) the Federal Aviation Administration's lack of a requirement to periodically review and validate radar video maps, (2) the failure of the engine crankshaft due to a bearing shift, and (3) the pilot's impairment due to his abuse of amphetamine and underlying medical condition(s).

NTSB narrative

The commercial pilot was conducting an on-demand air taxi flight. The passenger reported that, while they were in cruise flight (about 6,500 ft mean sea level, according to radar data), he heard a loud "pop" sound and saw a flicker of light from the engine area, followed by an "oil smell." The engine then began to "sputter" and lost power. The pilot attempted to restart the engine without success. The pilot reported the problem to air traffic control (ATC); however, he did not declare an emergency. The New York terminal radar approach control (N90) LaGuardia Airport (LGA) departure controller subsequently provided the pilot with the relative locations of several nearby airports, and the pilot determined that he was closest to Republic Airport (FRG), Farmingdale, New York, but that he did not have sufficient altitude to reach it. The LGA controller then provided vectors to Bethpage Airport, an alternate airport depicted on his radar video map (RVM), and noted that, although the airport was closed, there was a runway there. The controller provided vectors to Bethpage for a forced landing, but the pilot reported that he did not see the runway. The next several transmissions between the controller and the pilot revealed that the pilot was unable to acquire the Bethpage runway (because it no longer existed) while the controller continued to provide heading and distance to it. The controller subsequently lost radar contact with the pilot, and the airplane eventually crashed into a railroad grade crossing cantilever arm before coming to rest on railroad tracks. The investigation revealed that the runway the controller was directing the pilot to no longer existed; industrial buildings occupied the location of the former airport and had been there for several years. However, the runway was depicted on the controller's RVM because it had not been removed following the closure of the airport. If the RVM had not shown Bethpage as an airport, the controller might have provided alternative diversion options, including nearby parkways, to the pilot, which would have prevented him from focusing on a runway that did not exist. Further investigation revealed that the Federal Aviation Administration (FAA) did not require periodic review and validation of RVMs and had no procedures to ensure that nonoperational airports were removed from RVMs systemwide. Since this accident, the FAA has revised and corrected its internal procedures to ensure all nonoperational airports are removed from RVMs in the United States. An examination of the engine revealed that the crankshaft failed at the No. 2 main journal. The No. 2 main bearings were heat damaged and extruded into the crank cheek. The No. 2 main bearing supports had bearing shift and fretting signatures. The No. 2 main bearing had rotated in the bearing support. Contact with the crankshaft by the main bearing initiated the fracture of the crankshaft. The engine maintenance records did not reveal evidence of a recent engine repair in this area. Torque values obtained during the engine disassembly did not reveal evidence of an undertorqued condition. The engine had operated about 1,427 hours since its last major overhaul. Toxicological testing detected amphetamine, oxycodone, oxymorphone, losartan, 7-amino-clonazepam, and acetaminophen in the pilot's blood and/or urine. It is unlikely that the losartan and acetaminophen impaired the pilot's judgment. The direct effects of clonazepam, which is used to treat panic disorder or seizures, did not contribute to the accident; however, it could not be determined whether the pilot's underlying medical conditions contributed to the accident. The exact effects of oxycodone on the pilot at or around the time of the accident could not be determined. The level of amphetamine was significantly higher than the therapeutic range, indicating that the pilot was likely abusing the drug and that he was impaired by it at the time of the accident. The combination of the pilot's use of drugs and his medical conditions likely significantly impaired his psychomotor functioning and decision-making and led to his delay in responding appropriately to the in-flight loss of engine power and, therefore, contributed to the accident. Review of radar data revealed that 2 minutes 18 seconds had elapsed and that the airplane had lost about 2,000 ft of altitude while continuing on a westerly heading before the pilot turned the airplane toward FRG. If the pilot had turned immediately after he realized the engine had lost power, he would have had adequate altitude to glide to a suitable runway.

Analysis

Primary failure mode
Engine power loss
First missed decision gate
Pilot could have declared an emergency earlier when experiencing engine issues.

NTSB coding

Evidence available

  • ADS-B / radar
  • Photos
  • 22 docket documents
View NTSB final reportView NTSB docket

Docket documents22

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