N5946CBeech C35 · 1952

On August 16, 2015, at 0745 eastern daylight time, a Beech C35, N5946C, collided with a railroad grade crossing cantilever arm and terrain during a forced landing in Hicksville, New York. The commercial pilot was fatally injured, and one passenger sustained serious injuries. The airplane was destroyed by impact forces and a postimpact fire. The airplane was registered to and operated by the pilot as a 14 Code of Federal Regulations (CFR) Part 135 on-demand air taxi flight. Day, visual meteorological conditions were reported near the accident site about the time of the accident, and no flight plan was filed. The flight originated from Francis S. Gabreski Airport (FOK), Westhampton Beach, New York, and was destined for Morristown Municipal Airport (MMU), Morristown, New Jersey.

The pilot departed FOK about 0720 under visual flight rules, and according to Federal Aviation Administration (FAA) air traffic control (ATC) transcript information, checked in with the New York terminal radar approach control (N90) Islip departure controller while passing through 1,300 ft mean sea level (msl) 2 miles east of FOK. (For the purposes of this report, all altitudes are in msl, unless otherwise noted.) The pilot requested to climb to 6,500 ft to transition to the New York class B airspace en route to MMU. The Islip controller identified the flight at 1,500 ft and directed the pilot to squawk a mode 3 transponder code of 4356. The Islip controller transferred the flight to the John F. Kennedy International Airport (JFK), Jamaica, New York, departure controller at 0730, at which time radar data depicted the airplane was traveling westbound at 140 knots ground speed at 6,500 ft.

The pilot checked in with the JFK departure controller and reiterated his request for a clearance through New York class B airspace. The JFK controller cleared the flight through the class B airspace and directed the pilot to maintain 6,500 ft. At 0738, the JFK controller transferred the flight to the LaGuardia Airport (LGA), Flushing, New York, departure controller.

The pilot checked in with the LGA controller at 6,500 ft and was issued the LGA altimeter setting. About 10 seconds later, at 0738:43, as the airplane was on an easterly heading, it began a slight ascent to 6,600 ft while its groundspeed started to suddenly decrease. The pilot did not report any difficulty to the LGA controller, and the controller did not ask the pilot about the change in the flight profile. About 0740, the LGA controller directed the pilot to turn right heading 360°. The airplane was traveling at 60 knots ground speed at 5,700 ft at the time. One second later, the pilot responded that he was "having a little bit of a problem" and was considering diverting to Republic Airport (FRG), Farmingdale, New York. The LGA controller acknowledged and asked the pilot to keep him informed of the situation and to let him know if he any needed assistance.

At 0740:31, the pilot advised that he was going to "have to take it down at…the closest spot." The LGA controller provided the pilot with the relative locations of LGA, JFK, FRG, and Westchester County Airport, White Plains, New York, and told the pilot that he could go anywhere he wanted to go. At 0740:55, the pilot responded that FRG was the closest airport but that he was not going to make it there. At 0741:16, the LGA controller asked the pilot to verify that he was going to FRG. The pilot responded, "yeah," and then asked the controller to verify that FRG was the closest airport. At this time, the pilot had started a left turn to the southeast, and the airplane was descending out of 4,400 ft at 70 knots groundspeed. At 0741:26, the LGA controller advised that there was also a landing strip at Bethpage, New York, at the pilot's 10-o'clock position at 5 miles and that the pilot might want to try that airport. The controller advised the pilot that he was about lined up for the runway's extended centerline. The pilot acknowledged, but part of the acknowledgement was unintelligible. At 0742:36, the pilot asked the controller to provide information on the location of the landing strip. The controller advised that the landing strip was at the pilot's 12-o'clock position at 4 miles and that the pilot was set up on the runway's extended centerline. At 0742:50, the LGA controller advised the pilot that FRG was 3 miles southeast of Bethpage in the event that the pilot wanted to go to FRG. The pilot responded that the airplane was losing altitude and that he was doing the best he could to maintain it.

At 0743:36, the pilot again asked for the location of the Bethpage airport and said he was not seeing it. The controller responded that there was a landing strip at Bethpage at the pilot's 12-o'clock position at 3 miles and that FRG was at the pilot's 10-o'clock position at 6 miles. The pilot responded that he was not going to make the 6 miles to FRG. At 0744:01, the LGA controller advised the pilot that Bethpage was a closed airport but that there was a runway there at the pilot's 11-o'clock position at 1.5 miles. At 0744:35, the pilot told the controller "you gotta give me a little better heading on that if you would." The controller advised that the runway was about 10° to the right and added that there was also a parkway nearby. The pilot then asked the controller, "and FRG I got 3 miles right?" The controller responded that FRG was at the pilot's 11-o'clock position at 5 miles. The pilot stated that there was no way he was going to make it to FRG and asked the controller to "show me this strip again if you would I'm sorry." The controller responded that the Bethpage runway was at the pilot's 1-o'clock position at less than 1 mile, that it was a closed airport, and that he had no additional information about the airport. There were no further communications with the pilot.

The passenger reported that they were in cruise flight when 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, age 59, held a commercial pilot certificate with airplane single engine, multiengine, and instrument airplane ratings. The pilot was issued a second-class FAA airman medical certificate on December 22, 2014, with the limitation that he must wear glasses for near vision. At that time, he reported 3,300 total flight hours.

Records provided by the FAA revealed that the pilot completed a 14 CFR Part 135.299 line check on June 18, 2015. He was listed as a single-pilot operator under the name Milo Air, Inc., conducting on-demand air taxi flights. The accident airplane was the only airplane used by Milo Air.

The pilot's family provided copies of two pilot logbooks; however, the latest logbook entries were dated May 13, 2008. No recent pilot logbooks were located.

The four-seat, low wing, retractable-gear airplane, was manufactured in 1952. It was powered by a 260-horsepower Continental Motors IO-470-N engine, driving a three-bladed Hartzell model constant-speed propeller. The airplane was modified with two Beryl D'Shannon fiberglass 15-gallon auxiliary wing tip tanks in accordance with a supplemental type certificate.

According to copies of maintenance logbook pages provided by the pilot's family, the most recent annual inspection of the airframe and engine was completed on June 7, 2015. At that time, the airframe total time was 6,979 hours. The airplane's original engine, a Continental E-185-11, was removed and replaced with the Continental IO-470-N engine on December 15, 1998. The total time on the engine at the last inspection was about 2,913 hours, including 1,427 hours since the last major overhaul.

The engine was removed and disassembled on two occasions, on February 23, 2006, and on October 24, 2007, to facilitate inspections following propeller strikes. Engine maintenance records revealed no evidence of a recent disassembly of the engine or removal or replacement of cylinders.

FRG, located about 4 nm east-southeast of the accident site, was the closest official weather station. The FRG weather at 0753 included calm wind, visibility 10 statute miles, few clouds at 9,000 ft, temperature 25° C, dew point 19° C, and altimeter setting 30.12 inches of Mercury.

Velocity azimuth display wind profile data for JFK showed that at 4,000 and 3,000 ft above ground level (agl), the wind was from the northwest at 20 knots. At 2,000 ft agl, the wind was from the northwest at 15 knots, and at 1,000 ft agl, the wind was from the northwest at 10 knots. Data at 5,000 and 6,000 ft agl were not available.

After the pilot determined that he wanted to land at FRG, the LGA departure controller advised that there was also a landing strip at Bethpage Airport, an alternate airport depicted on his radar video map (RVM) 3 miles northwest of FRG and closer to the airplane, and he subsequently provided distance and heading information to the airport. Although Bethpage was still shown on the RVM, the airport no longer existed; it had been closed for several years, and the former airport area was occupied by buildings. The accident site was about 0.25 nm northwest of the former location of the runway 15 approach end. (See the section in this report titled, "RVMs," for more information about the RVMs used by the controllers in the LGA, JFK, and Islip areas.)

Bethpage Airport was removed from FAA sectional charts in October 2012. Bethpage Airport data were removed from the N90 airport display automation database before 2001, but the exact date was unknown. There were no known or reported equipment discrepancies related to N90 RVMs. The Air Traffic Control Group Chairman's Factual Report, located in the public docket for this investigation, includes photographs of Bethpage Airport as early as the 1940s.

The airplane initially impacted a railroad grade crossing cantilever arm. The main wreckage came to rest inverted on the tracks of the Long Island Rail Road. The wreckage debris field was about 100 ft long and about 20 ft wide, oriented on a heading of 150°. All of the airplane's major structural components were found within the confines of the debris field. The outboard section of the right wing was found under the grade crossing cantilever arm, which separated from its mount structure during the initial impact.

The cockpit instrument panel was destroyed by impact forces and a postimpact fire. Some of the flight and performance instruments were separated. No useful information was obtained from the instruments. The forward, center, and aft sections of the fuselage exhibited postimpact fire signatures. The nose landing gear was found in the retracted position. The fuel selector handle and valve were damaged from postaccident fire, and a preaccident position could not be determined.

The left wing remained attached to the fuselage. A 6-ft-long section of the leading edge was separated outboard of the fuel tank. The left aileron and the left wing flap remained attached to the wing. The left aileron exhibited impact damage at its midspan area. The left flap was found in the retracted position and was crushed in the forward direction. The inboard section of the left wing was damaged by postimpact fire. The left main landing gear was found in the retracted position. The left wing fuel tank was breached and damaged by postimpact fire, and its fuel cap was installed and secure. During recovery, fuel was noted in the tank; however, the quantity was not determined. Control cable continuity was established to the aileron. The 15-gallon, tip-mounted fuel tank was breached from impact forces, and its fuel cap was installed and secure.

The right wing separated during the initial collision with the grade crossing cantilever arm at a point about 3.5 ft outboard of the wing root. The inboard half of the right wing was damaged by postimpact fire. The right aileron and the outboard half of the right wing flap remained attached to the wing. The separated section of the right wing exhibited no fire damage. The right main landing gear was found in the retracted position. The right wing fuel tank was breached and damaged by postimpact fire, and its fuel cap was installed and secure. No fuel was noted in the area of the right wing tank. Control cable continuity was established to the aileron. The 15-gallon, tip-mounted fuel tank was in place, and its fuel cap was installed and secure.

The left ruddervator remained attached to the aft fuselage. The balance weight and trim tab were in place. The elevator trim actuator measured 1.1 inches, which corresponded to a 5° tab-up trim position. The right ruddervator exhibited impact damage. About 1 ft of the outboard section was separated. Control cable continuity was established from the ruddervator to the cables in the aft fuselage that were cut by recovery personnel.

The propeller assembly separated from the engine during the accident sequence and was located adjacent to the main wreckage. The propeller blades remained attached to the hub and exhibited no rotational damage signatures.

The engine was sent to the manufacturer's facility for examination. A large hole was observed in the bottom of the oil sump. The oil pickup tube was impact damaged. The oil pump gears were intact and coated with oil. The oil filter was opened, and metal particulates were observed in the filter element. All six cylinders were intact with rust in the barrel, and the valves and guides were in place and undamaged. The rocker arms and shafts were undamaged. The pistons were intact and undamaged and had normal combustion deposits, and all of the rings were in place and moved freely.

The crankcase halves were intact with some internal impact damage noted. The right case half had cracks in the forward bearing saddle. The No. 1 bearing was in place, and exhibited heat distress, but it was coated with oil. The No. 2 bearing was dry, exhibited heat distress, and was partially melted and extruded into the crank cheek. The No. 2 main bearing supports exhibited bearing shift and fretting signatures. The No. 2 main bearing had rotated in the bearing support. The No. 3 bearing was in place and exhibited some heat distress, but it was coated with oil. The No. 4 bearing was in place and exhibited heat distress and was impact damaged. The crankshaft was separated at the No. 2 main journal and the crank cheek. The forward area of the crankshaft was impact damaged near the thrust flange. The transfer collar was impact damaged and partly separated from the crankshaft. The connecting rods were not damaged. The rod cap bearings were dry and heat distressed. The camshaft was intact and had impact damage. Torque values obtained during the engine disassembly did not reveal evidence of an undertorqued condition.

The Office of the Medical Examiner, Nassau County, New York, conducted an autopsy on the pilot, and the cause of death was determined to be "blunt and thermal injuries," and the manner of death was "accident." No significant natural disease was identified.

Toxicology testing on specimens from the pilot was performed by the FAA's Bioaeronautical Research Sciences Laboratory. Testing identified amphetamine (1.26 ug/ml), oxycodone (0.236 ug/ml), and losartan in the heart blood. In addition, 7-amino-clonazepam, acetaminophen, amphetamine, oxycodone, oxymorphone, and losartan were identified in the urine.

Amphetamine is a central nervous system stimulant prescribed as a Schedule II controlled substance for the treatment of narcolepsy and attention deficit hyperactivity disorder. Common trade names for amphetamine include Adderall and Dexedrine. Prescribers and users are cautioned about the high potential for abuse of this drug. The therapeutic range of blood levels is considered between 0.002 and 0.10 ug/ml; levels significantly higher than this suggest abuse. Oxycodone is an opioid analgesic prescribed as a Schedule II controlled substance. It is commonly available in combination with acetaminophen with the names Percocet and Roxicet. Losartan is a blood pressure lowering medication. 7-amino-clonazepam is a metabolite of clonazepam, a sedating benzodiazepine prescription medication used to treat panic disorder and petit mal seizures. It is commonly marketed with the name Klonopin. Acetaminophen is an analgesic and fever reducer available over the counter and is commonly marketed with the names Tylenol and Panadol. Oxymorphone is an active metabolite of oxycodone and is also available as an opioid analgesic with the name Opana.

Oxycodone, oxymorphone, and clonazepam all carry Federal Drug Administration warnings about their psychoactive effects and cautions against operating machinery.

Information on the pilot's medical history was requested from the pilot's widow through an attorney; no information was provided to investigators.

Air Traffic Controller Actions

The N90 LGA area controller, who was working the Harp, Nobbie, Nyack, and LGA departure positions combined, was being supervised by the LGA area controller-in-charge (CIC) at the time of the accident. The CIC had relieved the LGA area front line manager, who was on a break during the accident sequence and out of the facility. The operations manager (OM) was providing overall supervision for the N90 operating floor.

The accident flight had been uneventful when the pilot checked in with the LGA departure controller at 0738 at 6,500 ft. Shortly thereafter, the radar track indicated a decrease of groundspeed from 140 to 100 knots and a slight ascent to 6,600 ft, followed by a slow descent. The LGA controller observed the descent and directed the pilot to turn right to a heading of 360° to prevent the airplane from descending into the LGA departure corridor. The controller did not solicit information from the pilot about the reason for the descent. Immediately following the instruction to turn right to a heading of 360°, the pilot stated that he was having a problem and needed to return to FRG, even though the flight did not originate at FRG. The LGA controller advised the CIC that he thought the pilot had a problem. At that time, the LGA controller and CIC considered the flight to be an emergency.

As the situation was developing, the airplane was in the N90 JFK sector airspace but was being worked by the LGA controller because control of the flight had already been transferred to the LGA area by the JFK departure controller. When providing ATC services to an aircraft in another controller's area of jurisdiction, any deviation from the expected flightpath must be coordinated with the controller responsible for the airspace in which the aircraft is operating. Accordingly, the CIC walked over to coordinate with the JFK controller to advise of a potential deviation from the anticipated flightpath of the airplane and then to the Islip departure controller to redirect other traffic away from the LGA controller.

The pilot did not declare an emergency, and the LGA controller did not request information regarding the nature of his problem or solicit information normally associated with emergency handling. Although the controller had the option to annotate the radar data block of the flight with the letter "E" to indicate an emergency, which would have alerted all of the controllers in the sectors that could see the airplane's data block that an emergency was in progress, he reported in postaccident interviews that it did not occur to him to do so.

The LGA controller was assisted by the CIC and the OM, who both stood behind the LGA controller as the situation progressed. The OM advised the LGA controller that Bethpage Airport was closed and suggested alternate landing areas such as the nearby parkways.

The LGA controller requested information on Bethpage Airport by slewing his cursor to the emergency airplane's radar target and entering the airplane's pertinent information. Bethpage did not show up in the query for the closest emergency airport; however, FRG did.

After the LGA controller lost radar contact with the flight, he was relieved from the position, and he assumed that the airplane had landed at Bethpage Airport. It was not immediately known that the airplane had crashed. A controller from the JFK area called FRG tower personnel and asked them to be on the lookout for the airplane. They reported seeing a smoke plume near Bethpage and called 911. The OM then called the Nassau County Police Department Aviation Unit, which happened to be based at Bethpage. They were able to respond immediately to the accident site but could not confirm the burning airplane's tail number. Once identification of the accident airplane was confirmed, the OM called the flight service station (FSS) to get information from the flight plan about how many people were on board the airplane and the departure airport. According to the FSS, no flight plan had been filed. The OM initially assumed the airplane had departed FRG but was able to determine the departure airport was FOK by talking to the controllers from the Islip and JFK areas.

RVMs

Although there was geographic overlap between the RVMs used by the controllers in the LGA, JFK, and Islip areas, the information on each area's RVMs was inconsistent. Bethpage Airport was depicted on the LGA RVM but not on the Islip RVM. FRG was depicted on the Islip, JFK, and LGA RVMs, but the symbology used was different. The N90 ATC standard operating procedures (SOP) manual depicted the RVMs for the Islip, JFK, and LGA areas individually. The LGA section of the SOP showed Bethpage as an airport, but the Islip and JFK sections did not. The data provided in the SOP did not correlate with the actual radar presentation the controllers were using. At the time of the accident, the LGA controller was using RVM number N90-3100C, which was included in an N90 system adaptation on December 20, 2013.

Research revealed that the FAA did not require periodic review and validation of RVMs such as the RVM that depicted Bethpage Airport on the N90 area controller's RVM. The only periodic review requirement for RVMs, as defined in FAA Order 7210.3, "Facility Operation and Administration," was a biennial review of emergency obstruction video maps. The FAA also did not have procedures to ensure that closed 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.

Beech C35 Glide Performance

The Beech C35 Pilot's Operating Handbook (POH), Chapter 3, "Emergency Procedures," includes the following maximum glide configuration procedures in the event of an engine failure:

1. Landing Gear – UP

2. Flaps – UP

3. Cowl Flaps – CLOSED

4. Propeller – LO RPM

5. Airspeed – 105 KTS/121 MPH

Glide distance is about 1.7 nm (2 statute miles) per 1,000 ft of altitude above the terrain.

Recorded radar data revealed that the airplane experienced a sudden decrease in airspeed and a deviation in altitude at 0738:43 as it was on an easterly heading at 6,500 ft. At this point, the airplane was about 7 nm northwest of the approach end of runway 14 at FRG. At 6,500 ft, the lateral glide distance at the maximum glide configuration would have been about 10.8 nm, assuming calm wind conditions. The msl altitude at the accident site was about 125 ft.

The pilot continued on a westerly heading for 2 minutes 18 seconds after the sudden decrease in airspeed, and the airplane lost about 2,000 ft of altitude before he turned the airplane left toward the Bethpage area. At the farthest point from FRG, the airplane was about 8.8 nm at 4,000 ft. At this point, the maximum glide distance was about 6.6 nm, assuming calm wind conditions. Wind conditions at the time were from the northwest about 15 to 20 knots. Once the airplane was on a heading toward FRG, or a southeasterly direction, the prevailing tailwind would have improved glide performance. Several golf courses were located at the pilot's 10- to 12-o'clock positions if he had continued to descend on a westerly heading.