Friday, May 9, 2014

Navion G Rangemaster, N2473T, RTD Aviation, LLC: Fatal accident occurred May 09, 2014 in Hamilton Township, New Jersey

Aviation Accident Final Report - National Transportation Safety Board: http://app.ntsb.gov/pdf 

National Transportation Safety Board   - Docket And Docket Items:   http://dms.ntsb.gov/pubdms

National Transportation Safety Board  -  Aviation Accident Data Summary:   http://app.ntsb.gov/pdf


NTSB Identification: ERA14FA232 
14 CFR Part 91: General Aviation
Accident occurred Friday, May 09, 2014 in Hamilton Township, NJ
Probable Cause Approval Date: 04/14/2016
Aircraft: NAVION G, registration: N2473T
Injuries: 1 Fatal, 2 Serious, 1 Minor.

NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

The commercial pilot was traveling to attend an air show the following day. Upon arrival at the destination, he attempted a night instrument landing system approach but, due to low visibility, flew a missed approach. He subsequently requested and received vectors for a second attempt of the same approach. However, as the airplane neared the final approach course, the controller advised the pilot of worsening weather conditions, and the pilot then requested vectors to an alternate airport. After receiving a clearance, the pilot added power to the engine and initiated a climb, but the engine lost power, which the pilot attributed to either a fuel or an electrical problem. The airplane subsequently descended into trees and stuck the ground nose-low, on its left side, in a “violent deceleration.” The pilot stated that he had checked the fuel quantity in both of the airplane’s wing tip tanks and the connected main tanks before the flight using a calibrated stick and found about 10 gallons of fuel in each tip tank and 15 gallons of fuel in the main tanks. He also stated that he always took off and landed using the main fuel tanks and used the tip tanks in transit. The pilot further stated that, during the flight, he used the left tip tank for 22 minutes 40 seconds and was certain of the time because he used a stopwatch. He then used the main fuel tanks for the first approach and, after the missed approach, switched to the right tip tank. About 1 minute before the engine quit, he switched from the right tip tank to the main tanks again. Once the engine quit, the pilot moved the fuel selector through various positions and then checked the ignition, throttle, and mixture. The airplane was equipped with an engine monitor, which, among other parameters, tracked fuel flow. Data revealed that, at one point, fuel flow dropped to 0, with a concurrent reduction in all engine temperatures. Before the end of the recording, fuel flow spiked briefly up to 4 gallons per hour on four occasions before returning to 0, consistent with the pilot’s statement that he moved the fuel selector to different positions. Two of the spikes occurred for 2 seconds, and the other two occurred for 3 seconds. The pilot reported that, after intentionally running a tank out of fuel during en route operations, the engine would restart about 5 to 10 seconds after switching fuel tanks. At the accident site, fuel was found in all tanks except the left tip tank. Although compromised upon impact, there was no evidence of fuel leakage underneath or in the vicinity of that tank. Fuel supply system continuity, with no blockages noted, was later confirmed from all tanks to the engine, and after replacing some impact-damaged items, the engine was run from idle to full throttle multiple times with no anomalies noted. Although fuel was not found in the left tip tank at the accident site, a small amount was likely still present when the pilot initiated the climb after the missed approach, which then sloshed toward the aft end of the tank, unporting the fuel pickup. This introduced air into the engine fuel supply, which led to the loss of engine power. The lack of fuel found in the left tip tank, the absence of anomalies noted in either the fuel supply system or when the engine was test run, the cessation of fuel flow noted in the engine monitor data, and the fluctuation of fuel flow as the pilot subsequently moved the fuel selector through the tanks with fuel and tank-without-fuel positions cumulatively indicated the likelihood that the pilot inadvertently moved the fuel selector to the left tip tank when he began the climb to the alternate airport and was operating the engine from an almost depleted left wing tip tank when the engine lost power. The airplane was manufactured at a time when only seat belts were required; front-seat shoulder harnesses or other restraints with an equal level of protection were not mandatory. The airplane did not have shoulder harnesses at the time of the accident, and the Federal Aviation Administration does not mandate retrofit, instead relying on voluntary installation. The pilot-rated passenger in the right front seat was fatally injured when her head impacted the engine controls and instrument panel, an outcome that likely would have been mitigated with the presence and use of adequate shoulder restraints or other equal-level protection.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The pilot's mismanagement of the onboard fuel supply, which resulted in fuel starvation to the engine and a subsequent loss of engine power. Contributing to the death of the right front passenger was the inadequate occupant restraint.

HISTORY OF FLIGHT

On May 9, 2014, at 2031 eastern daylight time, a Navion G, N2473T, was substantially damaged when it impacted trees and terrain in Hamilton Township, New Jersey, after a loss of engine power. The commercial pilot and one of the passengers were seriously injured, while another passenger sustained minor injuries. A pilot-rated passenger in the right front seat was fatally injured. Night instrument meteorological conditions prevailed. No flight plan was filed for the flight, from St. Mary's Airport (2W6), Maryland, to Atlantic City International Airport (ACY), Atlantic City, New Jersey; however, approaching Atlantic City, the pilot requested and received an instrument flight rules clearance. The personal flight was conducted under the provisions of 14 Code of Federal Regulations (CFR) Part 91.

According to the pilot, the purpose of the flight was to attend a local area airshow the next day. Prior to the flight, he checked the weather via internet and called ACY Tower several times to check its progress. He was aware of potential low visibilities and his alternate plan if not be able to land at ACY was to either fly to an airport in Millville, New Jersey, or return home.

The pilot initially completed an ILS (Instrument Landing System) runway 13 approach to ACY; however, due to the low visibility, he could not complete the landing and flew a missed approach. The controller offered another approach, which he accepted. Commencing the second approach, the pilot was advised of the current weather [the controller reported a 200-foot overcast, ¼-mile visibility in fog], and knew then that he had no chance of completing the approach. He requested vectors to "Millville," and was told to climb to 2,000 feet. He added full power, and the engine "stopped" with the pilot perceiving either a fuel or an electrical problem.

Once the engine quit, the pilot moved the fuel selector through various positions, then checked the ignition, throttle and mixture.

In a written statement, the pilot further reported that after entering the climb, "the nose was in the climb attitude for a number of seconds and the engine simply stopped delivering power (propeller continued turning). I immediately checked the fuel [selector] (set to main), while entering a glide descent. I moved the fuel [selector] to right tip feed and moved and checked throttle, mixture and ignition settings. I am uncertain how long I held the fuel [selector] in the different positions but it was moved to main again after some delay. I remember my hand remaining on the fuel [selector] for some of the descent."

The pilot also made a "mayday" call to the tower and warned the passengers to brace themselves. The pilot maintained wings level and a nose attitude to maintain about 80 mph. The airplane subsequently struck the tops of trees, at which point the pilot released the controls and braced himself, followed by a "violent deceleration."

Radio Transmissions

According to FAA Air Traffic Control Accident Report excerpts,

At 1956, the approach controller advised the pilot that "the last couple of arrivals have been picking up the airport right at minimums."

At 1958, the airplane was cleared for the ILS (Instrument Landing System) runway 13 approach.

At 2004, the controller advised the pilot that the weather "goes all the way down to ground" and that runway visual range was 2,000 feet.

At 2010, the pilot advised the controller that the airplane was established on the approach. The pilot was then advised to contact the tower controller.

At 2011, the pilot contacted the local (tower) controller, who cleared the pilot to land, advised him of the current weather, and noted that he had the runway lights turned all the way up.

At 2016, the local controller asked the pilot if he had missed the approach, which the pilot advised that he had. The controller told the pilot to maintain runway heading and climb the airplane to 2,000 feet. He subsequently advised the pilot to contact departure control, which the pilot acknowledged.

At 2017, the pilot contacted departure control, and was asked if he wanted another approach. The pilot stated, "we'll try one more thanks."

The controller subsequently provided vectors, the first one left to 360 degrees, followed by 310 degrees.

At 2020, the pilot advised the controller that if they didn't "get in this time, we'd like to go to Millville."

At 2024, the controller advised the pilot to turn to heading 220 degrees.

At 2025, the controller advised the pilot that the airplane was 5 miles to MAYBN intersection, to turn left to heading 160 degrees, maintain 2,000 feet until established on the localizer, cleared for the ILS runway 13 approach.

At 2027, the controller advised the pilot to contact the local controller, which the pilot acknowledged.

At 2028, the pilot contacted the local controller, who asked if the airplane was left of course. The pilot responded that it was and that he was correcting to the right.

The controller then noted that the visibility was about ¼ mile with a 200-foot overcast, and the pilot asked him to confirm. After the controller did, the pilot stated, "we'll go around and if you could, give us vectors to Millville please." The controller then told the pilot to abandon the approach and climb to 2,000 feet. After consulting with the departure controller, the local controller, at 2029:39, advised the pilot to contact departure control, which the pilot acknowledged. (The latest radar contact, at 2029:32, indicated that the airplane was at 1,700 +/-50 feet.)

At 2030:04, the local controller noted to the departure controller that the airplane was still descending, which the departure controller also saw. The local controller then asked the pilot if he was "on the air." (Radar indicated that the airplane was about 1,300 feet.)

At 2030:13, the pilot answered, "affirm, we've got an engine problem; at the moment we're trying to restart." (Radar indicated that the airplane was about 1,200 feet.)

At 2030:17, the local controller stated, "I suggest you climb immediately," which the pilot responded, "that's a copy." (Radar indicated that the airplane was about 1,100 feet.)

At 2030:35, the local controller asked if everything was "okay," and the pilot responded, "that's a negative, we've got an engine out at the moment." (Radar indicated the airplane was about 700 feet.)

At 2031:02, the local controller asked the pilot if everything was okay again, and the pilot responded, "mayday, mayday, mayday, we've got an engine failure, we're about to crash." (The airplane was then below radar coverage; last contact was at 2030:50, at 500 feet.)

There were no further transmissions from the airplane.

PILOT INFORMATION

The pilot, age 45, held a commercial pilot certificate with airplane single engine land and instrument ratings. He also held a flight instructor certificate. The pilot reported 5,500 hours of time, with 100 hours in airplane make and model. His latest FAA second class medical certificate was dated January 23, 2014.

AIRPLANE INFORMATION

The airplane was powered by a Teledyne Continental Motors IO-520-series engine driving a three-bladed metal propeller. The latest annual inspection was completed on March 1, 2014, at 2,323 hours; at the time of the accident, airframe time was 2,339 hours and engine time was 92 hours since it was factory-rebuilt.

The operating manual found in the airplane stated that the fuel supply system provided 108 gallons of usable fuel. There were two center wing tanks, connected to a sump, filled via a filler neck incorporated in the right tank, and two wing tip tanks. Fuel tank selection was via a floor mounted selector. The selector face was circular with a handle on top that rotated through the following positions: "OFF" at the 6 o'clock position, "LEFT TIP" at the 9 o'clock position, "MAIN" at the 12 o'clock position, and "RIGHT TIP" at the 3 o'clock position. On top of the handle was a knob that had to be lifted upward to move the handle to the "OFF" position.

Tip tank fuel was supplied via a finger strainer assembly located at the bottom, center of each the tank, half way between the nose and tail of the tank.

According to the pilot, the airplane's fuel gauges were inaccurate and he checked the fuel quantity in both tip tanks and the main tanks prior to the accident flight using a calibrated stick. Both tip tanks had 10 gallons each while the main tanks had slightly over 15 gallons total. In addition, and as was normal procedure, he ran the engine for 3 minutes on the ground from each tip tank to ensure proper tip tank feed.

The pilot further noted that he always took off and landed on main fuel tanks and utilized the tip tanks in transit. On the accident flight he utilized the left tip tank for 22 minutes, 40 seconds and was certain of the time due to using a stopwatch. He utilized the main tanks for the first approach and after the missed, switched to the right tip tank. About 1 minute before the engine quit, he switched from right tip tank to the main tanks again.

The pilot also advised that the boost pump was utilized for start and could be used during approach and takeoff. In addition, when utilizing tip tanks in cruise flight, it was normal to run a tip tank out of fuel. At that point, the main tank would be selected, and the engine would return to operating 5-10 seconds later. He further noted that the airplane was recently flown several legs round trip to the Atlanta, Georgia, area, and during the last flight, when he ran a tip tank dry, it seemed that the engine took a little longer than normal to return to running.

The airplane was equipped with seat belts only (no shoulder harnesses) for all seats. When the airplane was manufactured, shoulder harnesses were not required by the FAA, nor are they required to be retrofitted. In December 2003, the certificate holder received an FAA Parts Manufacturer Approval (PMA) for pilot seat and copilot seat shoulder harnesses. The shoulder harness assembly included an anchor in the airplane's ceiling, above the inboard edge of the other occupant's seat, and a single belt that attached to the ceiling anchor, crossed the occupants' torsos, and attached to the seat belt near each occupant's outboard leg.

AIRPORT INFORMATION

ACY had crossing runways, designated 13/31 and 4/22. Runway 13 was 10,000 feet long and 150 feet wide with a touchdown elevation of 75 feet. The inbound course for the ILS RWY 13 approach was 128 degrees magnetic and the decision height was 275 feet above mean sea level.

METEOROLOGICAL INFORMATION

Weather, recorded at ACY at 2035, included calm winds, fog, ½ mile visibility, indefinite ceiling at 200 feet, and an altimeter setting of 30.03 inches Hg.

WRECKAGE AND IMPACT INFORMATION

The wreckage was located in a treed, flat wooded area the vicinity of 39 degrees, 28.26 minutes north latitude, 074 degrees, 39.03 minutes west longitude, at an elevation of about 70 feet. Tops of pine trees were cut in a descending path, with an estimated descent angle of 20 to 30 degrees, heading about 140 degrees magnetic for an estimated 200 feet. The tree cuts suddenly stopped about an estimated 60 feet above the ground in the vicinity of the wreckage location; there were no ground scars leading up to the wreckage.

The airplane came to rest on its left side, about 45-degrees nose down/tail up. The fuselage was mostly intact; however, both wings were separated from the airplane about 2 feet from their roots, and the empennage was separated from the fuselage.

All flight control surfaces were found at the scene, and flight control continuity was confirmed to the cockpit.

The propeller did not exhibit any chordwise scratching or leading edge damage that would have been consistent with the presence of engine power.

The left fuel tip tank was compromised. No fuel was found in it, nor was there an odor of fuel in the soil beneath it. Utilizing the calibrated stick, the right tip tank had about 5 gallons of fuel in it, and the connected main tanks had about 15 gallons of fuel in them. About 10 gallons of fuel were drained from the main tanks, with additional fuel remaining in the tanks. The fuel selector was found in the "main" position.

The wings were removed for transport, and they and the rest of the airplane were transferred to a storage facility for further documentation and an attempt to run the engine.

At the facility, fuel was run through the fuel supply system from the wing separation points through the engine firewall with no blockages noted. In the process, the fuel selector was moved through all positions successfully, with access to the "OFF" position requiring the knob on top of the selector handle to be lifted. About midway between the "LEFT TIP" and "MAIN" positions, as well as the "RIGHT TIP" and "MAIN" positions, there was a small area where the fuel flow would be turned off.

Air was also blown through the supply lines in the wings with no blockages noted. In addition, the finger strainers were removed from both tip tanks. The left tip tank finger strainer exhibited a small amount of debris on the strainer cage, while the right strainer cage exhibited no debris.

Closer examination of the engine revealed that it could not be run at that facility due to impact damage, and it was then shipped to the manufacturer to be run in a test chamber under NTSB oversight.

Engine Test

At the engine manufacturer's facility, due to impact damage, the engine's left front mount was replaced, along with the throttle body and Wye pipe. The oil quick drain was replaced with a plug. The cooling baffles, hydraulic pump, vacuum pump, and airframe breather system were removed, and the engine was fitted with a "test club" propeller.

The engine was subsequently started and allowed to warm up. It was advanced to 1,200 rpm and held at that rpm for 5 minutes to stabilize. It was subsequently advanced to 1,600 rpm, 2,450 rpm, and full throttle, and held at each power setting for 5 minutes to stabilize. The engine was later accelerated rapidly from idle to full throttle six times with no anomalies noted.

Engine Monitor

The airplane was equipped with an engine monitor, which among other parameters, tracked fuel flow. Data revealed that, at 20:30:06 (due to damage, the unit could not be powered up; the time noted was correlated to other in-flight events), fuel flow dropped to zero, with a concurrent reduction in all engine temperatures. Before the end of the recording, fuel flow spiked briefly up to 4 gallons per hour on four occasions before returning to zero, consistent with the pilot's statement that he subsequently moved the fuel selector to different positions. Two of the spikes were indicated for 2 seconds, while the other two were for 3 seconds.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was performed on the pilot-rated passenger by the Office of the State Medical Examiner, Woodbine, New Jersey. Cause of death was determined to be "massive head injuries."

Cockpit evidence, including damage to the instrument panel and engine controls, and direction of the damage, was consistent with the passenger's head having impacted them in a forward, left direction.

ADDITIONAL INFORMATION

Fuel Selector

During the final compilation of factual information, about 18 months after the accident, confirmation was requested as to how the pilot established what position the fuel selector was in, and whether he visually checked it with a flashlight, or used feel, or some combination. The pilot, who had returned to his home country, responded by email: "It's been a long time so I'm not sure I can be 100% certain but the changes to the fuel selection prior to the loss of power were checked visually. [The pilot-rated passenger] had a light which I used to reselect main but once we lost power I used feel only. I thought I secured the fuel after the crash but I honestly cannot be certain as that again was by feel."

Occupant Protection

According to the NTSB Safety Study, "Safety Airbag Performance in General Aviation Restraint Systems," adopted by the Board in January, 2011, NTSB has issued over 30 recommendations concerning general aviation (GA) occupant safety, "many of which have focused on the design, installation, testing, and use of shoulder harnesses."
A 1985 safety study conducted by the NTSB looked at 535 accidents in which at least one occupant was fatally or seriously injured. It found that shoulder harnesses were available for only 40 percent of occupants in those accidents and that only 40 percent of occupants used the shoulder harnesses that were available, resulting in a total usage rate of 16 percent. The study estimated that about 20 percent of the occupants who were fatally injured could have survived if they had worn shoulder harnesses and 88 percent of those who experienced serious injury would have had their injures mitigated by using shoulder harnesses.
In 1977, the FAA published an amendment to 14 CFR Part 23 that required shoulder harness installations in all newly manufactured GA aircraft starting in 1978, but only for front seats. Concurrently, 14 CFR Part 91 was revised to state that "required flight crewmembers" must use available shoulder harnesses during takeoff and landing. In response, the NTSB issued Safety Recommendations A-77-70 and -71, which respectively recommended that the FAA strengthen the rules to require installation of shoulder harnesses at all seat locations and require their installation on all GA aircraft, including those manufactured before 1978.

In 1985, the FAA modified 14 CFR 91.33 to require shoulder harnesses in all seats of GA airplanes manufactured after December 12, 1986, and amended 14 CFR Part 91 to require all occupants to wear shoulder harnesses, when available, during takeoff and landing. However, the FAA never modified its regulations to require retrofitting of aircraft manufactured before the 1978 and 1986 regulatory changes."

In June 1993, the FAA promulgated Advisory Circular (AC) 21-34, "Shoulder Harness – Safety Belt Installations," in which it provided benefits of shoulder harnesses and installation guidance. It noted that, "Shoulder harness-safety belt systems prevent serious head, neck, and upper torso injuries in what may be relatively minor accidents in terms of aircraft damage, and they can prevent irreversible or fatal injuries in more severe accidents. Therefore, the major benefits of shoulder harnesses occur in an accident environment, but they can be of no benefit if they are not available for use in an accident."

The 2011 NTSB Safety Study also found that, "Because of the longevity of aircraft, a large proportion of the active GA and air taxi fleet were manufactured before shoulder harnesses were required. For example, the 2008 FAA General Aviation and Air Taxi Survey found that 69 percent of active aircraft were manufactured prior to 1984, and 56 percent were manufactured prior to 1979. Although it is possible that many owners of older aircraft have retrofitted those aircraft to include shoulder harnesses without being required to do so, the NTSB continues to investigate numerous accidents in which shoulder harnesses are not present."
The 2011 NTSB Safety Study also included an evaluation of real-world performance of lap belt/shoulder harness combinations compared to lap belts only. An additional goal was to look at the relationships between shoulder harness effectiveness and other factors that might potentially influence survivability, such as whether there was a fire or a loss of control, whether the accident happened at or away from an airport, the phase of flight when the accident occurred, and pilot factors such as gender and age.
Data sampling included pilots involved in GA accidents between 1983 and 2008 for non-amateur-built airplanes with single reciprocating engines, with the primary outcome of interest being whether the pilot was fatally or seriously injured as a result of the accident. Other variables that were examined can be found in the Study.
Of the 37,344 pilots in the final sample, 15.2 percent were fatally injured and 8.7 percent sustained serious injuries. Over half (55.3 percent) of the pilots were reported to have used an shoulder harnesses, 23.9 percent used lap belts only, and 0.6 percent used no restraint. Restraint use was unknown in 18.9 percent of the cases.
Shoulder harness use was found to consistently reduce the risk of pilot fatalities and serious injuries when compared to lap belt only. The risk of fatality and serious injury with a lap belt alone was 50 percent higher than with shoulder harnesses. The benefits conveyed by shoulder harnesses were significant for multiple subgroups within the larger sample.
"Overall, the findings strongly suggest that lap belt/shoulder harness combinations provide significant protection beyond that offered by wearing only a lap belt and that there would be reductions in pilot fatalities and injuries if lap belt/shoulder harness combinations were installed and used in all GA airplanes."
As a result of the Safety Study, a number of recommendations were submitted to the FAA. One of those, A-11-004, referenced previous NTSB recommendations that the FAA require the installation of shoulder harnesses on aircraft manufactured before 1978, but also noted that the FAA never took steps to do so, using as its explanation that there was insufficient justification to impose additional costs on owners of older aircraft. A-11-004 then recommended again the required retrofit of shoulder harnesses on all GA airplanes in accordance with AC 21-34.

On February 15, 2012, the FAA responded that thousands of airplanes manufactured before December 12, 1986, do not have the structural provisions necessary for the installation of shoulder harnesses, and that the installation would "impose a severe economic burden, especially on airplanes requiring substantial structural modifications." The FAA suggested a two-point inflatable lap belt that would offer impact protection to the occupant's head and torso, and serve as a barrier between the occupant and cockpit structure. And, the FAA would permit the installation as a minor change.

On June 10, 2012, the FAA advised the NTSB that it intended to require that older airplanes be equipped with either a shoulder harness or inflatable lap belt.

On September 6, 2013, the FAA again advised the NTSB that many GA airplanes manufactured before December 12, 1986, did not have the necessary structure to install a shoulder harness, and that a two-point inflatable restraint would be the only possible solution. The FAA also noted that mandating the retrofit of aircraft manufactured before December 12, 1986, with a two-point inflatable restraint or a shoulder harness would require the determination that an unsafe condition existed and the issuance of an airworthiness directive. The cost of retrofitting the fleet would be substantial, and the economic burden levied on the GA fleet with such a mandate would outweigh any potential benefit. "Therefore the FAA does not intend to mandate the installation of a two-point inflatable restraint system or a shoulder harness on the existing fleet."

In addition, the FAA noted that "the intent has been, and continues to be, to develop a framework that permits an airplane owner to voluntarily replace a two-point conventional restraint with a two-point inflatable restraint. We will continue to promote the safety benefits of voluntary replacement of two-point conventional restraints with two-point inflatable restraints. I believe the FAA has effectively addressed this safety recommendation to the extent practicable and consider our actions complete."

On December 26, 2013, the NTSB acknowledged the FAA's response, including allowing owners to voluntarily replace a two-point conventional restraint with a two-point inflatable restraint as a noteworthy improvement, but "we do not consider it an acceptable substitute for the recommended requirement. Because the FAA believes that it has fully responded to this recommendation and no further action, Safety Recommendation A-11-004 is classified as CLOSED – UNACCEPTABLE ACTION."


Morgan Brittany Smith




HAMILTON TOWNSHIP — Pilot mismanagement of an onboard fuel supply system contributed to a May 2014 airplane crash, in the wooded area off Paddock Street, which killed a 28-year-old Maryland woman, according to a National Transportation Safety Board report.

A Navion-G single-engine plane, built in 1962, crashed into a wooded residential lot on Paddock Street near Cologne Avenue in Hamilton Township at about 8:30 p.m. on May 9, 2014, according to the report. Morgan Smith, of Lexington Park, Maryland; was killed in the crash. While fellow, passengers Cheyne Austin, 23, also of Lexington Park, and Alec Lewis, 23, of California, Maryland; and pilot Peter Kosogorin, 45, of Tall Timbers, Maryland; were injured.

“The pilot's mismanagement of the onboard fuel supply, which resulted in fuel starvation to the engine and a subsequent loss of engine power,” according to the report from the administration on April 14. “Contributing to the death of the right front passenger was the inadequate occupant restraint.”

Kosogorin was approaching Runway 13 at Atlantic City International Airport when the accident happened. Fuel was found in all the tanks except for the left tip tank and no anomalies and blockages where found in the fuel system, according to the report.


“The pilot inadvertently moved the fuel selector to the left tip tank when he began the climb to the alternate airport and was operating the engine from an almost depleted left wing tip tank when the engine lost power,” according the report.

FAA Philadelphia FSDO-17

http://registry.faa.gov/N2473T

NTSB Identification: ERA14FA232 
14 CFR Part 91: General Aviation
Accident occurred Friday, May 09, 2014 in Hamilton Township, NJ
Aircraft: NAVION G, registration: N2473T
Injuries: 1 Fatal,2 Serious,1 Minor.

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

On May 9, 2014, at 2031 eastern daylight time, a Navion G, N2473T, was substantially damaged when it impacted trees and terrain in Hamilton Township, New Jersey, after a loss of engine power. The commercial pilot and one of the passengers were seriously injured, while another passenger sustained minor injuries. A pilot-rated passenger was fatally injured. Night instrument meteorological conditions prevailed. No flight plan was filed for the flight, from St. Mary's Airport (2W6), Maryland, to Atlantic City International Airport (ACY), Atlantic City, New Jersey; however, approaching Atlantic City, the pilot requested and received an instrument flight rules clearance. The personal flight was conducted under the provisions of 14 Code of Federal Regulations Part 91.

According to the pilot, the purpose of the flight was to attend a local area airshow the next day. Prior to the flight, he checked the weather via internet and called ACY Tower several times to check its progress. He was aware of potential low visibilities and his alternate plan should he not be able to land at ACY was to either fly to an airport in Millville, New Jersey, or return home.

The pilot initially completed an ILS 13 approach to ACY; however, due to the low visibility, he could not complete the landing and flew a missed approach. The controller offered another approach, which he accepted. Commencing the second approach, the pilot was advised of the current weather [controller reported a 200-foot overcast, ¼-mile visibility in fog], and knew then that he had no chance of completing the approach. He requested vectors to Millville, and was told to climb to 2,000 feet. He added full power, and the engine "stopped" with the pilot perceiving either a fuel or an electrical problem.

Once the engine quit, the pilot moved the fuel selector through various positions, then checked the ignition, throttle and mixture.

The pilot also stated that the fuel gauges were inaccurate and that he checked the fuel quantity in both tip tanks and the main tanks prior to the flight using a calibrated stick. Both tip tanks had 10 gallons each while the main tanks had slightly over 15 gallons total. In addition, and as was normal procedure, he ran the engine for 3 minutes on the ground from each tip tank to ensure proper tip tank feed.

The pilot further noted that he always took off and landed on main fuel tanks and utilized the tip tanks in transit. On this flight he utilized the left tip tank for 22 minutes, 40 seconds and was certain of the time due to using a stopwatch. He utilized the main tanks for the first approach and after the missed, switched to the right tip tank. About 1 minute before the engine quit, he switched from right tip tank to the main tanks again.

The pilot also advised that the boost pump was utilized for start and could be used during approach and takeoff. In addition, when utilizing tip tanks in cruise flight, it was normal to run a tip tank out of fuel. At that point, the main tank would be selected, and the engine would return to operating 5-10 seconds later. He further noted that the airplane was recently flown several legs round trip to the Atlanta, Georgia, area, and during the last flight, when he ran a tip tank dry, it seemed that the engine took a little longer than normal to return to running.

The wreckage was located in a flat, wooded area the vicinity of 39 degrees, 28.26 minutes north latitude, 074 degrees, 39.03 minutes west longitude. Tops of pine trees were cut in a descending path, with an estimated descent angle of 20 to 30 degrees, heading about 140 degrees magnetic for an estimated 200 feet. The tree cuts suddenly stopped about an estimated 60 feet above the ground in the vicinity of the wreckage location; there were no ground scars leading up to the wreckage.

The airplane came to rest about on its left side, about 45-degrees nose down/tail up. The fuselage was mostly intact; however, both wings were separated from the airplane about 2 feet from their roots and the empennage was separated from the fuselage.

All flight control surfaces were found at the scene, and flight control continuity was confirmed to the cockpit.

The left fuel tip tank was compromised. No fuel was found in it, nor was there an odor of fuel in the soil beneath it. Utilizing the calibrated stick, the right tip tank had about 5 gallons of fuel in it, and the connected main tanks had about 15 gallons of fuel in them. About 10 gallons of fuel were drained from the main tanks, with additional fuel remaining in the tanks.

The propeller did not exhibit any chordwise scratching or leading edge damage that would have been consistent with the presence of engine power.

The engine and airframe were transferred to a storage facility for further documentation and a future attempt to run the engine.



Morgan Brittany Smith
Obituary

Lexington Park, MD - Morgan Brittany Smith, 28, of Great Mills, Md. and formerly of Norfolk, Va. perished Friday, May 9, 2014 doing what she truly loved, flying!

Born in Oakland, Calif., Morgan was a Flying Qualities Lead for the F-35C aircraft, Pilot, Mentor, Adventurer, Explorer and Entrepreneur. Above that she was an inspiration to all. Morgan had traveled the world and has seen more in her short time on earth than most others do in a full lifetime. She touched countless young people as a mentor through a number of different programs. The world is a lesser place with her passing.

She is survived by her boyfriend, Jeff Robbins of Great Mills; her parents, Frank and Joy Smith and brother, Luke Smith, all of Norfolk; maternal grandmother, Peggy Meyer; paternal grandparents, Mr. and Mrs. Charles Smith of Greenwich, N.Y.; aunts, Cindy, Jerrine and Jill; uncles, Rick, Mark and Chuck; and a close knit group of cousins, other relatives, friends the world over and fellow Aviation Enthusiast.The memorial service will be held at 1 p.m. Sat. May 17, at Hollomon-Brown Funeral Home, Tidewater Drive Chapel. 

In lieu of flowers, the family asks that donations be made to the Experimental Aircraft Association Inc. and specify the program to support is "Women Soar You Soar" at https://secure.eaa.org/development/index.html. 

Condolences may be offered to the family at: www.hollomon-brown.com

Township of Hamilton Police Department Press Release:  Plane Crash Victims Identified

Date of Incident:  5/9/2014

Location:  Wooded area off of Paddock Street

The Township of Hamilton Police Department has identified those on board the Navion G plane that crashed in a wooded area on Friday night.

The pilot is identified as:

Peter Kosogorin, age 45, of Tall Timbers, MD

The passengers are identified as:

Alec Lewis, age 23, of California, MD

Cheyne Austin, age 23, of Lexington Park, MD

Morgan Smith, age 28, of Lexington Park, MD

Kosogorin and Austin remain hospitalized at Atlantic City Medical Center Trauma Division.  Lewis has been treated and released.  Morgan Smith was pronounced dead at the scene of the crash.

The crash is being investigated by Investigator Paul Cox of the NTSB and assisted by Detective Michael Virga of the Township of Hamilton Police Department.

HAMILTON Twp., N.J. (CBS) – Hamilton Township Police have identified those on board the plane that crashed into a wooded area Friday night.

It happened around 8:30 p.m. Friday on the 4800 block of Paddock Street, northwest of the Atlantic City International Airport.

Police say Morgan Smith, 28, of Lexington Park, Maryland was pronounced dead at the scene of the crash.

The pilot, Peter Kosogorin, 45, and passenger Cheyne Austin, 23, both remain hospitalized at Atlantic City Medical Center Trauma Division.

Another passenger, Alec Lewis, 23, has been treated and released.

The crash is being investigated by the National Transportation Safety Board and assisted by the Hamilton Township Police Department.
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Police were still on the scene Saturday of a plane crash that left one dead and at least one injured Friday night in Hamilton Township.

The plane, a Navion G Rangemaster, crashed in a wooded area behind a residence near Cologne Avenue and Paddock Street at about 8:30 p.m., according to the Federal Aviation Administration (FAA).

Authorities said two of the four people onboard were able to walk away, while rescue crews removed the other two. The extent of injuries for the survivors was not available. Their identities had not yet been released Saturday.

FAA Spokeswoman Kathleen Bergen said Saturday that the pilot was on approach to Runway 13 of the Atlantic City International Airport when he reported engine problems.

On Saturday, 53-year-old Hamilton Township resident Greg Meyer, himself a local pilot, cycled past the scene after reading media reports.

"This area is right in the approach to the airport," he said. "Runway 13 is a large runway a lot of small and large planes use."

Peter Knudson, a spokesman for the National Transportation Safety Board, said the tail number N2473T.

According to the FAA registry database, the plane was a Navion G Rangemaster manufactured in 1962. It was registered to RTD Aviation, LLC, based out of Wilmington, Del. Messages left at two phone numbers associated with the company were not returned Saturday.

Knudson said an aircraft recovery company would arrive late Saturday with plans to remove the wreckage by Sunday evening. The crash did not result in a fire, he said.

Similarly, he said, an inspector will be on the scene with a preliminary report expected within five-to-10 business days.

The crash site was calm Saturday morning, with just a few police vehicles parked in the driveway of a private residence. It was a stark contrast of Friday evening when EMTs and firefighters worked late into the night. A number of observers also gathered near the site.

Jim Keefer, a nearby resident, said he heard three loud bangs and thought it was just a truck in the area.