COLUMBIA AIRCRAFT MFG LC41 550FG

Full Narrative

HISTORY OF FLIGHTOn June 17, 2014, at 0903 eastern daylight time, a Columbia LC-41-550FG, N610MH, was destroyed when it impacted terrain in a residential area, and was subsequently consumed by postcrash fire, while maneuvering near East Patchogue, New York. The private pilot was fatally injured. Instrument meteorological conditions were reported near the accident site, and no flight plan was filed for the flight, which departed Farmingdale Republic Airport (FRG), Farmingdale, New York, at 0850, and was destined for Long Island MacArthur Airport (ISP), Islip, New York. The personal flight was operated under the provisions of Title 14 Code of Federal Regulations Part 91. PERSONNEL INFORMATIONThe pilot held a private pilot certificate with a rating for airplane single engine land. The pilot did not hold an instrument rating. His most recent third-class FAA medical certificate was issued April 22, 2013. The pilot's logbooks were not recovered and no determination could be made of his flight experience in the accident airplane make and model; however, he reported a total flight experience of 1,200 hours on his most recent medical certificate application. The pilot's most recent flight review was conducted on August 26, 2013. According to the flight instructor who conducted the review, the pilot had never received any formal training on the airplane's Garmin G1000 avionics system. AIRCRAFT INFORMATIONThe low-wing, single engine, carbon fiber construction airplane was manufactured in 2006, and registered to the pilot in October 2008. It was equipped with a Continental Motors TSIO-550C, 310 hp turbocharged, reciprocating engine and a Hartzell 3-bladed, constant-speed propeller. The airplane's most recent annual inspection was completed on July 5, 2013, at a total aircraft time of 321.8 hours. The airplane's maintenance logbooks were not recovered, and complete maintenance history for the airplane could not be determined.

According to manufacturer and FAA airworthiness records, the airplane was equipped with a Garmin G1000 system, which was comprised of dual LCD primary and multifunction flight displays that provided information about the airplane's altitude, airspeed, attitude, engine parameters, and navigation and communication systems status, as well as a moving map display. The airplane was equipped with a backup altimeter, attitude indicator, and airspeed indicator instruments. The G1000 also included an integrated automatic flight control, or autopilot, system that had the capability to control the airplane in the roll, pitch, and yaw axes. METEOROLOGICAL INFORMATIONThe 0753 weather observation at FRG included wind from 200 degrees at 4 knots, 10 statute miles visibility, and clear skies.

The 0853 weather observation at FRG included wind from 210 degrees at 3 knots, 10 statute miles visibility, and broken clouds at 10,000 feet.

The 0807 weather observation at ISP, located about 6 nautical miles (nm) west of the accident site, included wind from 190 degrees at 8 knots, 7 statute miles visibility, broken cloud layers at 700 feet and 11,000 feet, and an overcast ceiling at 13,000 feet.

The 0856 weather observation at ISP included wind from 220 at 8 knots, 7 statute miles visibility, and overcast clouds at 700 feet.

The 0756 weather observation at Brookhaven Airport (HWV), Brookhaven, New York, located about 5 nm east of the accident site, included wind from 190 degrees at 8 knots, 6 statute miles visibility, mist, and an overcast cloud layer at 700 feet.

The 0856 weather observation at HWV included 6 statute miles visibility, mist, and overcast clouds at 500 feet.

A terminal aerodrome forecast (TAF) for ISP, issued at 0741, forecast conditions at 0800 with visibility better than 6 statute miles, scattered clouds at 700 feet and 13,000 feet, and a broken cloud layer at 25,000 feet. An amended TAF for ISP, issued at 0854, forecast visibility greater than 6 statute miles, with broken cloud layers at 700 feet, 13,000 feet, and 25,000 feet.

A rawinsonde (weather balloon) launched from the National Weather Service Forecast Office in Upton, New York (KOKX), located about 6.5 miles northeast of the accident site, about 0800 EDT, indicated that the relative humidity decreased from 95% to 75% between about 1,050 feet and about 1,330 feet above ground level (agl). This suggested a visible cloud boundary between these altitudes at the rawinsonde's location at that time.

The pilot of a multi-engine airplane departed FRG for New Jersey about 20 minutes prior to the accident airplane's departure. He stated that after departure, he climbed to an altitude about 1,000 feet and flew south towards the Long Island shoreline. As he neared the shoreline, the weather began to deteriorate "rapidly" and he began to lose visibility. He elected to return to FRG and land due to the weather conditions.

The pilot of a single-engine airplane reported that he and a student conducted a flight from Bridgeport, Connecticut (BDR), to ISP on the morning of the accident, and conducted an instrument approach at ISP about 0920. He stated that the weather conditions between BDR and ISP were consistent, with ceilings about 700 feet above ground level and cloud tops around 1,500 feet. He further stated that they experienced visual meteorological conditions at their cruise altitude of 2,000 feet after climbing through the cloud layer. He remarked that the weather conditions predicted in that morning's TAF were better than the actual conditions experienced in the area on the day of the accident. AIRPORT INFORMATIONThe low-wing, single engine, carbon fiber construction airplane was manufactured in 2006, and registered to the pilot in October 2008. It was equipped with a Continental Motors TSIO-550C, 310 hp turbocharged, reciprocating engine and a Hartzell 3-bladed, constant-speed propeller. The airplane's most recent annual inspection was completed on July 5, 2013, at a total aircraft time of 321.8 hours. The airplane's maintenance logbooks were not recovered, and complete maintenance history for the airplane could not be determined.

According to manufacturer and FAA airworthiness records, the airplane was equipped with a Garmin G1000 system, which was comprised of dual LCD primary and multifunction flight displays that provided information about the airplane's altitude, airspeed, attitude, engine parameters, and navigation and communication systems status, as well as a moving map display. The airplane was equipped with a backup altimeter, attitude indicator, and airspeed indicator instruments. The G1000 also included an integrated automatic flight control, or autopilot, system that had the capability to control the airplane in the roll, pitch, and yaw axes. WRECKAGE AND IMPACT INFORMATIONThe airplane's initial impact point was identified as a tree about 25 feet in height that displayed numerous broken and angularly-cut branches. The wreckage path extended about 185 feet from the tree on a magnetic heading of approximately 223 degrees. The propeller, various engine components, and pieces associated with both left and right wings were located along the wreckage path. The main wreckage, comprised of the engine, cabin area, and empennage, came to rest in the backyard of a residence, and was completely consumed by post-impact fire. The extensive thermal damage precluded examination of the cockpit instruments, flight control surfaces, and control tubes.

The three-bladed propeller, along with the crankshaft propeller flange, was separated from the engine and located along the wreckage path. One blade was fractured near the propeller hub; the other two blades exhibited s-bending, leading edge gouging, and chordwise scratching.

The engine exhibited significant thermal damage, and several of its accessories were separated during the impact sequence. Removal and inspection of one spark plug from each cylinder revealed thermal damage and light-colored combustion deposits. The crankshaft was seized, consistent with the observed thermal damage, and could not be rotated by hand. Borescope examination of the cylinders revealed no anomalies. Only one magneto was recovered, and exhibited significant thermal and impact damage. COMMUNICATIONSInformation provided by Lockheed Martin Flight Service revealed that the pilot placed a phone call to the flight service station at 0630 the morning of the accident and received an abbreviated briefing. The pilot indicated that he would be departing FRG for ISP at 0730, and inquired whether the conditions were "good VFR [visual flight rules]." The briefer advised the pilot of a presidential temporary flight restriction for the area that would be effective later that day, and asked when the pilot would be returning to FRG. The pilot replied that he would return to FRG by 0900. The briefer then provided local notice to airmen (NOTAM) information and advised the pilot of the current cloud ceilings and visibilities at FRG and ISP, which included 9 miles visibility and few clouds at 7,000 feet, and 10 miles visibility, few clouds at 6,500 feet, scattered clouds at 9,000 feet, and an overcast ceiling at 26,000 feet, respectively. The briefer did not provide, nor did the pilot request, forecast conditions for either airport.

Official recordings of air traffic control communications provided by the Federal Aviation Administration (FAA) revealed that the pilot contacted FRG ground control at 0840, and was cleared for takeoff from runway 14 at 0850. At 0854, the pilot requested a frequency change and subsequently contacted the New York Terminal Radar Approach Control (TRACON) facility, who provided him with another frequency for the appropriate TRACON controller based on his position and route of flight. The pilot contacted the second controller at 0859. When the controller asked the pilot to state his position, the pilot replied that he had departed FRG and stated, "I need your help sir." About 0901, the controller queried the pilot as to his location, heading, and destination, and the pilot replied he was, "heading to Islip I just don't have visibility."

The controller asked the pilot, "Are you declaring an emergency because Islip's IFR [instrument flight rules]," to which the pilot did not respond. When the controller called the accident airplane again about 1 minute later, the pilot stated, "I will go back to FRG." The controller instructed the pilot to "squawk VFR" and approved a frequency change, which the pilot subsequently acknowledged about 0902.

Review of FAA radar information showed a VFR target correlated to be the accident airplane depart from FRG at 0851. The target tracked eastbound at altitudes averaging between 1,000-1,300 feet mean sea level (msl) before beginning a left turn toward the north around 0858, about 5 miles south of ISP. About this time, as the airplane tracked north, it penetrated and continued through the Class C airspace surrounding ISP prior to establishing contact with air traffic control. The pilot contacted the second controller about 0859, and during the ensuing conversation with ATC, the airplane tracked north before turning northeast at an altitude about 1,200-1,300 feet, passing within 3 miles of ISP. At 0901:45, about the time the pilot indicated to ATC that he would be returning to FRG, the airplane climbed about 100 feet and began a slight turn to the left before initiating a descending, 540-degree right turn that continued to ground contact. The last four radar targets, at 0902:31, 0902:36, 0902:40, and 0902:45, identified the airplane at altitudes of 900, 700, 700, and 500 feet msl, respectively (See figure 1).

A witness located near the accident site observed the accident airplane approach from the east and circle his home twice at a "very low" altitude. The witness described the airplane "flying on its side" in a right-wing-low attitude as it passed over his home the second time, and shortly thereafter, he heard a "loud boom" and observed black smoke.





Figure 1 - Final Turn MEDICAL AND PATHOLOGICAL INFORMATIONAn autopsy was performed by the Suffolk County Medical Examiner, Hauppauge, New York. The cause of death was listed as multiple blunt force injuries. Toxicological testing was performed on the pilot by the FAA Bioaeronautical Sciences Research Laboratory in Oklahoma City, Oklahoma. Rosuvastatin, used to treat high cholesterol and related conditions, was detected in liver and blood. Ethanol was detected in blood in a concentration of 59 mg/dL. The ethanol detected was most likely from sources other than ingestion. AIR TRAFFIC CONTROLThe FAA Aeronautical Information Manual, Chapter 5, "Air Traffic Procedures," Section 5; Pilot/Controller Roles and Responsibilities, stated in part:

b. The pilot-in-command of an aircraft is directly responsible for, and is the final authority as to the safe operation of that aircraft. In an emergency requiring immediate action, the pilot-in-command may deviate from any rule in the General Subpart A and Flight Rules Subpart B in accordance with 14 CFR Section 91.3.

c. The air traffic controller is responsible to give first priority to the separation of aircraft and to the issuance of radar safety alerts, second priority to services that are required, but do not involve separation of aircraft and third priority to additional services to the extent possible.

d. In order to maintain a safe and efficient air traffic system, it is necessary that each party fulfill their responsibilities to the fullest.

Chapter 6, "Emergency Procedures," Section 2, Emergency Services Available to Pilots, stated in part:

If continued flight in VFR conditions is not possible, the noninstrument rated pilot should so advise the controller indicating the lack of an instrument rating, declare a distress condition…

Section 3, Distress and Urgency Procedures, stated in part:

a. A pilot who encounters a distress or urgency condition can obtain assistance simply by contacting the air traffic facility or other agency in whose area of responsibility the aircraft is operating, stating the nature of the difficulty, pilot's intentions and assistance desired.

d. Distress communications have absolute priority over all other communications, and the word MAYDAY commands radio silence on the frequency in use.

FAA Order 7110.65 (Air Traffic Control) provided guidance and instruction to controllers for determining emergencies and obtaining information for handling an emergency. Paragraph 10-2-8 stated in part:

10-2-8. RADAR ASSISTANCE TO VFR AIRCRAFT IN WEATHER DIFFICULTY

a. If a VFR aircraft requests radar assistance when it encounters or is about to encounter IFR weather conditions, ask the pilot if he/she is qualified for and capable of conducting IFR flight.

b. If the pilot states he/she is qualified for and capable of IFR flight, request him/her to file an IFR flight plan and then issue clearance to destination airport, as appropriate.

c. If the pilot states he/she is not qualified for or not capable of conducting IFR flight, or if he/she refuses to file an IFR flight plan, take whichever of the following actions is appropriate:

1. Inform the pilot of airports where VFR conditions are reported, provide other available pertinent weather information, and ask if he/she will elect to conduct VFR flight to such an airport.

2. If the action in subpara 1 above is not feasible or the pilot declines to conduct VFR flight to another airport, provide radar assistance if the pilot:

(a) Declares an emergency.

(b) Refuses to declare an emergency and you have determined the exact nature of the radar services the pilot desires.

3. If the aircraft has already encountered IFR conditions, inform the pilot of the appropriate terrain/obstacle clearance minimum altitude. If the aircraft is below appropriate terrain/obstacle clearance minimum altitude and sufficiently accurate position information has been received or radar identification is established, furnish a heading or radial on which to climb to reach appropriate terrain/obstacle clearance minimum altitude.

Spatial Disorientation

The Airplane Flying Handbook (FAA-H-8083-3A) stated, "…the VFR pilot is, in effect, in IMC anytime he or she is inadvertently, or intentionally for an indeterminate period of time, unable to navigate or establish geographical position by visual reference to landmarks on the surface. These situations must be accepted by the pilot involved as a genuine emergency, requiring appropriate action…If the natural horizon were to suddenly disappear, the untrained instrument pilot would be subject to vertigo, spatial disorientation, and inevitable control loss."

The FAA Pilot's Handbook of Aeronautical Knowledge, chapter 16, "Aeromedical Factors," stated, "Under normal flight conditions, when there is a visual reference to the horizon and ground, the sensory system in the inner ear helps to identify the pitch, roll, and yaw movements of the aircraft. When visual contact with the horizon is lost, the vestibular system becomes unreliable. Without visual references outside the aircraft, there are many situations in which normal motions and forces create convincing illusions that are difficult to overcome…Unless a pilot has many hours of training in instrument flight, flight should be avoided in reduced visibility or at night when the horizon is not visible. A pilot can reduce susceptibility to disorienting illusions through training and awareness, and learning to rely totally on flight instruments."

The FAA publication Medical Facts for Pilots (AM-400-03/1), described several vestibular illusions associated with the operation of aircraft in low visibility conditions. Somatogyral illusions, those involving the semicircular canals of the vestibular system, were generally placed into one of four categories, one of which was the "graveyard spiral." According to the text, the graveyard spiral, "…is associated with a return to level flight following an intentional or unintentional prolonged bank turn. For example, a pilot who enters a banking turn to the left will initially have a sensation of a turn in the same direction. If the left turn continues (~20 seconds or more), the pilot will experience the sensation that the airplane is no longer turning to the left. At this point, if the pilot attempts to level the wings this action will produce a sensation that the airplane is turning and banking in the opposite direction (to the right). If the pilot believes the illusion of a right turn (which can be very compelling), he/she will reenter the original left turn in an attempt to counteract the sensation of a right turn. Unfortunately, while this is happening, the airplane is still turning to the left and losing altitude. Pulling the control yoke/stick and applying power while turning would not be a good idea–because it would only make the left turn tighter. If the pilot fails to recognize the illusion and does not level the wings, the airplane will continue turning left and losing altitude until it impacts the ground."

All figures in this report are available in the public docket for this accident, which can be found at: http://dms.ntsb.gov/pubdms/search/dockList.cfm?mKey=89451