Thursday, May 12, 2016

Beech V35B Bonanza, N440H: Fatal accident occurred May 03, 2016 in Syosset, Nassau County, New York

 
Benjamin Bridges

Dana Parenteau and  David Berube


Captain Doron: Vacuum System Failure and Bonanza 440 Hotel 
https://youtu.be/3uNhwxpysEw 


The National Transportation Safety Board traveled to the scene of this accident.  

Additional Participating Entries:
Federal Aviation Administration / Flight Standards District Office; Farmingdale, New York
Continental Motors; Mobile, Alabama
Textron Aviation; Wichita, Kansas

Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms

Aviation Accident Factual Report - National Transportation Safety Board:  https://app.ntsb.gov/pdf

David C. Berube: http://registry.faa.gov/N440H
 

Robert Gretz, Investigator In Charge
 National Transportation Safety Board 


NTSB Identification: ERA16FA176
 14 CFR Part 91: General Aviation
Accident occurred Tuesday, May 03, 2016 in Syosset, NY
Aircraft: BEECH V35, registration: N440H
Injuries: 3 Fatal.

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.

HISTORY OF FLIGHT

On May 3, 2016, at 1542 eastern daylight time, a Beech V35B airplane, N440H, experienced an in-flight breakup near Syosset, New York. The airline transport pilot and two passengers were fatally injured, and the airplane was destroyed. The pilot was operating the airplane as a 14 Code of Federal Regulations (CFR) Part 91 personal flight. Instrument meteorological conditions (IMC) existed near the accident site about the time of the accident, and an instrument flight rules (IFR) flight plan was filed for the planned flight to Robertson Field (4B8), Plainville, Connecticut. The flight originated from Grand Strand Airport, North Myrtle Beach, South Carolina, about 1240.

According to air traffic control (ATC) transcripts provided by the Federal Aviation Administration (FAA), about 1522, the pilot checked in with ATC and stated that he was level at 7,000 ft. About 1 minute later, he reported to a controller that the vacuum system had failed and that he had lost the associated gyroscopic instruments and part of the instrument panel, and he asked for the easiest approach to descend to the destination airport. The pilot then stated that the flight was currently operating in visual flight rules (VFR) on top of clouds and that he wanted to continue VFR at 7,000 ft to his destination airport because he did not want to descend into the clouds. The controller asked the pilot if he wanted to declare an emergency, and the pilot stated, "yes," and confirmed that he wanted to proceed to his destination airport because the "weather's…better there." The controller then briefed the next controller along the airplane's flight route.

The next controller subsequently confirmed that the pilot was declaring an emergency. At 1529, the pilot requested the weather for the "Hartford-Bradley area"(near his destination) and the controller advised the pilot that the reported weather at Hartford included an overcast ceiling of 1,600 ft and that it looked like Hartford had the best weather conditions compared to alternate nearby airports. The pilot then requested radar vectors for the GPS approach to 4B8, which the controller acknowledged. He then instructed the pilot to proceed direct to Bridgeport, Connecticut, which the pilot acknowledged. The pilot then reported that the flight had entered IMC. At 1538, the pilot reported that he had just lost a "little bit" of control. The controller told him to turn left to 060°, which the pilot acknowledged. At 1539, the pilot reported that more of the instruments had failed and that he was turning to 060° and trying to get back to 7,000 ft. At 1541, the controller provided the pilot with the weather conditions at Republic Airport (FRG), Farmingdale, New York, and asked him if he would like to try to land there; however, no further communications were received from the pilot.

Review of radar data revealed that the airplane made several course and altitude deviations as it proceeded northeast over Long Island until the end of the data.




 


PILOT INFORMATION

The pilot held an airline transport pilot certificate with an airplane multiengine land rating. He also held a commercial pilot certificate with an airplane single-engine land rating. His most recent FAA third-class medical certificate was issued on September 3, 2014. At that time, he reported a total flight experience of 4,000 hours. The pilot's logbook was not recovered.

AIRCRAFT INFORMATION

The six-seat, low-wing, retractable tricycle-gear airplane was manufactured in 1973. It was powered by a 285-horsepower Continental IO-520 engine and was equipped with a three-bladed, constant-speed McCauley propeller.

Review of maintenance records revealed that the airplane's most recent annual inspection was completed on February 3, 2016. At that time, the airframe had accumulated 6,166 total hours of operation, and the engine had accumulated 520 hours of operation. The airplane had flown about 20 hours from the time of the last inspection until the accident. The vacuum pump was installed on February 10, 2000, at a tachometer time of 5,813 hours, which was 373 hours of operation before the accident.

Review of the vacuum pump manufacturer's Service Letter (SL) 58A revealed that the mandatory replacement time for the make and model vacuum pump was 500 aircraft hours or 6 years from the data of manufacture, whichever came first. Compliance with the SL was mandatory for Part 135 operations, but it was not mandatory for Part 91 operations. The accident vacuum pump was manufactured in May 1999, which was 17 years before the accident. The airplane was not equipped with a backup/standby vacuum pump.

METEOROLOGICAL INFORMATION

FRG was located about 8 miles southeast of the accident site. At 1553, the recorded weather at FRG was wind from 040° at 5 knots, visibility 4 miles in mist, broken ceiling at 800 ft, overcast ceiling at 1,200 ft, temperature 11°C, dew point 9°C, and altimeter setting of 29.81 inches of mercury.

The pilot had telephoned flight service on the morning of the accident, filed an IFR flight plan, and received a standard weather briefing. The standard briefing included current conditions and a forecast for overcast ceilings with bases between 1,000 and 2,000 ft and multiple cloud layers with tops above 18,000 ft.



 

WRECKAGE INFORMATION

The wreckage impacted a populated area consisting of residences, fields, and wooded terrain. A debris path extended about 0.4 mile on a magnetic heading of about 010°. The outboard section of the right ruddervator, remaining right ruddervator, and sections of the interior overhead panel were located at the beginning of the debris path. The fuselage, outboard section of the left wing, left ruddervator, and right wing were located about 400 ft farther along the debris path. The inboard left wing was located about another 400 ft farther along the debris path, and the engine and instrument panel were located at the end of the debris path.

The outboard left wing had separated near the aileron/flap junction and exhibited paint transfer marks, consistent with right ruddervator contact. The left aileron had separated and fractured into two sections. The left inboard wing remained attached to the carry-through spar, and the spar caps displayed deformation damage in an upward direction. The left flap remained attached to the inboard left wing section. The right wing had separated near the root, and about 8 gallons of fuel remained in the right wing. The right flap and an approximate 15-inch-long section of inboard right aileron remained attached to the right wing. The right ruddervator had separated, and the left ruddervator remained attached to the tailcone. Measurement of the elevator trim jackscrew corresponded to an approximate 10°-tab-up (nose-down) trim setting. Due to multiple separations and cabin fragmentation, flight control continuity could not be verified; however, all recovered flight control cables exhibited broomstraw separation, consistent with overstress.

The propeller had separated from the engine at the crankcase, and the engine came to rest inverted and was buried in a 3-ft-deep crater. One propeller blade had separated from the hub, but the other two propeller blades remained attached. All three propeller blades exhibited scoring and bending. The crankshaft could not be rotated due to front engine case damage, but borescope inspection of all six cylinders revealed no evidence of any preimpact mechanical malfunctions. Both magnetos sustained impact damage and could not be tested. The top and bottom spark plugs were removed from the six cylinders, and their electrodes were intact and light gray. The engine-driven fuel pump remained attached, and its drive coupling was intact. When the drive coupling was rotated by hand, the engine-driven fuel pump shaft rotated. The fuel metering unit and manifold valve exhibited impact damage.

The vacuum pump remained attached to the engine and was removed for metallurgical examination. The examination revealed that the pump housing was jammed and would not rotate. The opposite end of the coupling rotated freely. Disassembly of the pump housing revealed that that the rotor had separated radially in numerous locations. Three vanes remained intact, and three vanes had separated into numerous pieces. Rotational scoring/rubbing marks were observed on the rotor and pump housing. Additionally, debris was noted in the inlet screen; the engine had impacted a dirt field.

A panel-mounted GPS was removed from the instrument panel, and examination of the unit revealed that it did not store track data.

MEDICAL AND PATHOLOGICAL INFORMATION

The Nassau County Medical Examiner's Office, East Meadow, New York conducted an autopsy on the pilot. The autopsy report noted the cause of death as "multiple blunt impact injuries." The autopsy identified significant coronary artery disease.

The FAA's Bioaeronautical Science Research Laboratory, Oklahoma City, Oklahoma performed toxicological testing on the pilot's specimens. The toxicology testing detected diphenhydramine in his urine, 0.03 (ug/ml. ug/g) diphenhydramine in his blood, ibuprofen in his urine, 0.007 (ug/ml, ug/g) zolpidem in his urine, and 0.007 (ug/ml, ug/g) zolpidem in his blood. Diphenhydramine is a sedating antihistamine used to treat allergy symptoms and as a sleep aid and carries the following Federal Drug Administration warning: "may impair mental and/or physical ability required for the performance of potentially hazardous tasks (e.g., driving, operating heavy machinery)." Zolpidem is a prescription sleep aid and carries a warning about sedation and changes in judgment or behavior.











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NTSB Identification: ERA16FA176
14 CFR Part 91: General Aviation
Accident occurred Tuesday, May 03, 2016 in Syosset, NY
Aircraft: BEECH V35B, registration: N440H
Injuries: 3 Fatal.

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 3, 2016, at 1542 eastern daylight time, a Beech V35B, N440H, operated by a private individual, was destroyed during an in-flight breakup and collision with terrain near Syosset, New York. The certificated airline transport pilot and two passengers were fatally injured. The personal flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. Instrument meteorological conditions (IMC) prevailed and an instrument flight rules flight plan was filed for the planned flight to Robertson Field (4B8), Plainville, Connecticut. The flight originated from Grand Strand Airport (CRE), North Myrtle Beach, South Carolina, about 1240.

According to preliminary air traffic control (ATC) information provided by the Federal Aviation Administration (FAA), the pilot was in radio contact with ATC about 1530 and the airplane was level at 7,000 feet. At that time, the pilot reported to the controller that the airplane had experienced a failure of the vacuum system and associated gyroscopic instruments. The pilot added that the flight was currently operating in visual flight rules (VFR) on top of clouds and he planned to continue VFR to his destination airport. Subsequently, the airplane re-entered IMC and the pilot reported losing control of the airplane in addition to losing more instrument functionality. Radio and radar contact was lost with the airplane at 1542.

The wreckage impacted a populated area consisting of residences, fields and wooded terrain. A debris path extended approximately .4 miles on a magnetic course about 010 degrees. The outboard section of the right ruddervator, remaining right ruddervator, and sections of the interior overhead panel were located at the beginning of the debris path. The fuselage, outboard section of the left wing, left ruddervator and right wing were located about 400 feet further along the debris path. The inboard left wing was located about another 400 feet further and the engine and instrument panel were located at the end of the debris path.

The outboard left wing separated near the aileron/flap junction and exhibited paint transfer consistent with right ruddervator contact. The left aileron separated and fractured into two sections. The left inboard wing remained attached to the carry-through spar and the spar caps displayed deformation damage in an upward direction. The left flap remained attached to the inboard left wing section. The right wing separated near the root and approximately 8 gallons of fuel remained in the right wing. The right flap remained attached to the right wing along with an approximate 15-inch section of inboard right aileron. The right ruddervator separated and the left ruddervator remained attached to the tailcone. Measurement of the elevator trim jackscrew corresponded to an approximate 10-degree tab up (nose down) trim setting. Due to multiple separations and cabin fragmentation, flight control continuity could not be verified; however, all recovered flight control cables exhibited broomstraw separation, consistent with overstress.

The propeller separated from the engine at crankcase and the engine came to rest inverted, buried in a 3-foot crater. One propeller blade had separated from the hub while the other two propeller blades remained attached. All three propeller blades exhibited scoring and bending. The crankshaft could not be rotated due to front engine case damage; however, borescope inspection of all six cylinders did not reveal any preimpact mechanical malfunctions. Both magnetos sustained impact damage and could not be tested. The top spark plugs were removed from the Nos. 1, 3, and 5 cylinders for examination, and the bottom spark plugs were removed from the Nos. 2, 4, and 6 cylinders for examination. Their electrodes were intact and light gray in color. The engine driven fuel pump remained attached and its drive coupling was intact. When the drive coupling was rotated by hand, the engine driven fuel pump shaft rotated. The fuel metering unit and manifold valve also sustained impact damage.

The vacuum pump remained attached to the engine and was retained for examination at the NTSB Materials Laboratory. A panel-mounted GPS was removed from the instrument panel and also retained for data download at the NTSB Recorders Laboratory.

The pilot held an airline transport pilot certificate with a rating for airplane multiengine land. He also held a commercial pilot certificate with a rating for airplane single-engine land. His most recent FAA third-class medical certificate was issued on September 3, 2014. At that time, he reported a total flight experience of 4,000 hours.

The six-seat, low-wing, retractable tricycle-gear airplane, serial number D-9464, was manufactured in 1973. It was powered by a Continental IO-520, 285-horsepower engine, equipped with a three-blade constant-speed McCauley propeller.

Republic Airport (FRG), Farmingdale, New York, was located about 8 miles southeast of the accident site. The recorded weather at FRG, at 1553, was: wind from 040 degrees at 5 knots; visibility 4 miles in mist; broken ceiling at 800 feet; overcast ceiling at 1,200 feet; temperature 11 degrees C; dew point 9 degrees C; altimeter 29.81 inches of mercury.

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