Sunday, May 28, 2017

Flight Design CLTS, N622BT: Fatal accident occurred November 04, 2015 in Queens, New York

Phillip McGee (left) with his deceased pilot brother James Bradley (Brad) McGee in September 2015.



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

Additional Participating Entity:
Federal Aviation Administration / Flight Standards District Office; Garden City, New York

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

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

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

http://registry.faa.gov/N622BT


James "Brad" McGee 


NTSB Identification: ERA16FA031
14 CFR Part 91: General Aviation
Accident occurred Wednesday, November 04, 2015 in Queens, NY
Probable Cause Approval Date: 05/23/2017
Aircraft: FLIGHT DESIGN GMBH CTLS, registration: N622BT
Injuries: 1 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.

The noninstrument-rated private pilot departed on a cross-country flight in night visual meteorological conditions in the light sport airplane. After takeoff, the pilot leveled the airplane at an altitude about 1,400 ft mean sea level (msl) and continued toward the destination airport for about 30 minutes until he requested and was cleared by air traffic control to fly along a coastal shoreline at 400 ft msl, under the 500-ft shelf of Class Bravo airspace. About 1 minute after the pilot was cleared to descend, at an altitude of 700 ft and 0.2 nautical mile from the lateral limits of the Class Bravo shelf, the airplane began a 90° right turn. The airplane deviated from the course to the destination and did not level off at 400 ft, as requested. The airplane continued on a southeasterly heading and descended to 200 ft before radar contact was lost. There were no radio communications or other indications of distress from the airplane before the loss of radar contact.

A witness reported seeing the airplane descending at a 45° angle into the water. A pilot involved with the search and recovery of the airplane classified the conditions as "pitch black." Examination of the airframe and engine revealed no evidence of mechanical malfunctions or abnormalities that would have precluded normal operation.

The pilot was neither qualified nor proficient to conduct the flight by reference to instruments, and had likely used lights on the shoreline as a ground reference in the dark light conditions. However, when he turned away from the shoreline to continue his descent, likely to avoid entering the Class Bravo airspace, the pilot did not have adequate external visual cues by which to maintain attitude and altitude; he likely became spatially disoriented, and lost control of the airplane. Although toxicological testing was positive for hydroxyzine, an antihistamine, the drug was detected in muscle tissue and not in blood indicating that it likely had no impairing effect.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The noninstrument-rated pilot's spatial disorientation and subsequent loss of airplane control while maneuvering at low altitude, over water with no visible horizon, in dark night conditions, which resulted in a collision with the water.




HISTORY OF FLIGHT

On November 4, 2015, at 1933 eastern standard time, a Flight Design GMBH CTLS light sport airplane, N622BT, was substantially damaged after it impacted the Atlantic Ocean near Queens, New York. The private pilot was fatally injured. The airplane was owned and operated by the private pilot under the provisions of 14 Code of Federal Regulations Part 91 personal cross-country flight. Night visual meteorological conditions prevailed, and no flight plan was filed. The flight originated from Northeast Philadelphia Airport (PNE), Philadelphia, Pennsylvania, about 1900, with an intended destination of Portsmouth International Airport, Pease (PSM), Portsmouth, New Hampshire.

According to personnel at the departure airport, the airplane was "topped off" with fuel before departure. A fuel receipt indicated 17 gallons of 100 low-lead (LL) aviation fuel was added to the airplane about 1840 on the evening of the accident.

Federal Aviation Administration (FAA) Air Traffic Control radar and voice communication information revealed that the airplane departed PNE and leveled off at 1,400 ft mean sea level (msl). At 1916, the pilot requested to remain at 1,500 ft then descend to 400 ft under the John F. Kennedy Airport (JFK) Class Bravo airspace along the south shore of Long Island. The controller acknowledged the request, and the pilot continued toward his destination. At 1931, the pilot contacted JFK tower, and the tower controller cleared the pilot to fly along the shoreline at or below 500 ft. The pilot acknowledged the clearance at 1932:30. About 1 minute later, while at 700 ft msl and 0.2 nautical mile (nm) from the lateral limits of the Class Bravo airspace 500-ft shelf that he was cleared to fly underneath, the airplane began a 90° right turn, off his previously-established course, and descended through 500 ft msl. The airplane continued on a southeasterly heading and descended to 200 ft msl before radar contact was lost at 1933:32 about 0.6 nm to the southeast of the coast of Breezy Point, Queens, New York. There were no radio transmissions or other indications of distress from the airplane.

Several witnesses saw the airplane descend into the ocean. One witness described the descent angle as about 45°. The witness stated that he heard an "explosion" a short time later. A helicopter pilot who assisted in the search for the wreckage noted that it was "pitch black" over the water.

PERSONNEL INFORMATION

The pilot held a private pilot certificate with a rating for airplane single-engine land. His most recent third-class FAA medical certificate was issued on August 5, 2014. According to the pilot's logbook, he had accumulated about 280 total hours of flight time, of which about 270 hours were in the accident airplane make and model. The logbook showed 4 hours of night experience, which was all accumulated in September 2014 while the pilot was receiving primary flight instruction. The logbook showed 3.5 hours of simulated instrument time under the hood, with the most recent occurring on October 8, 2014, for 0.3 hour; in the remarks section of the logbook it listed that flight as "private pilot practical exam."

AIRPLANE INFORMATION

According to FAA records, the light sport airplane was manufactured in 2011 and was powered by a 100-horsepower Rotax 912ULS reciprocating engine. The airplane's most recent condition inspection was completed on November 2, 2015, at a total time in service of 321.4 hours.

METEOROLOGICAL INFORMATION

A recorded weather observation about the time of the accident at JFK, about 9 nm from the accident site, included wind from 100° at 3 knots, visibility 10 statute miles, clear skies below 12,000 ft above ground level, temperature 14°C, dew point 11°C, and an altimeter setting of 30.35 inches of mercury.

According to the Astronomical Applications Department at the United States Naval Observatory, sunset was at 1648, the end of civil twilight was at 1717, and moonrise was at 0040 of November 5, 2015. The phase of the moon on the day of the accident was waning crescent, with 39% of the moon's visible disk illuminated.

According to a representative from Lockheed Martin Flight Services (LMFS), the pilot had no contact with LMFS or DUATS on the date of the accident.



WRECKAGE AND IMPACT INFORMATION

The wreckage was recovered from the water and examined. Flight control continuity was confirmed from all flight control surfaces to the cockpit flight controls. The engine controls remained attached to the cockpit. The throttle was in the full-forward position and the mixture was in the mid-range position. The flap indicator, ignition switch, ELT position switch, circuit breaker panel, and radio volume control remained attached to the instrument panel and no other instruments were recovered. The two seats were separated from the seat tracks.

The wing spar was separated from the fuselage. The forward section of the left wing was separated from the remainder of the wing and fragmented. The wingtip was impact-separated. The left aileron remained attached to the wing at its inboard attach point. The flap remained attached to the left wing.

The empennage was separated from the fuselage. The left stabilator remained attached to the empennage, and the right stabilator was partially separated. The rudder remained attached to the vertical stabilizer via the control cables.

The right wing remained attached to the carry-through spar. The outboard forward section of the right wing was impact-separated and fragmented, and the right wingtip was impact-separated. The right aileron remained attached to the wing at the inboard attach point, and the right flap remained attached at all attach points.

The left main landing gear remained attached to the fuselage; however, that section of the fuselage was separated from the cabin area. The left tire was impact-separated from the left main landing gear. The right main landing gear was impact-separated and the right tire remained attached. The nose landing gear remained attached to the engine mounts.

The propeller remained attached to the engine. All three blades were fractured about midspan from the propeller hub. The propeller was rotated by hand, and thumb compression was confirmed on all cylinders. The Nos. 1 and 3 top spark plugs and the Nos. 2 and 4 bottom spark plugs were removed; they were wet, light grey in color, and exhibited normal wear. The rocker box covers were removed, and crankshaft and valve train continuity was confirmed throughout the engine.

The right carburetor was impact-separated and not recovered. The left carburetor was disassembled and no anomalies were noted. The butterfly valve operated without anomaly. An odor similar to 100LL aviation fuel was noted in the carburetor. The carburetor gasket displayed no anomalies.

The engine ignition harness remained attached to the engine. All of the engine harness leads were present; however, some of the harness leads were impact-separated from their associated spark plugs.

The ballistic recovery system parachute was recovered. The parachute was separated from the airplane and was partially deployed, and the rocket motor was discharged. The ballistic recovery system handle was not recovered from the water.

MEDICAL AND PATHOLOGICAL INFORMATION

The Office the Chief Medical Examiner for the City of New York, Queens, New York, performed the autopsy on the pilot. The autopsy report indicated that the pilot died as a result of multiple blunt injuries.

The FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological testing of the pilot. Fluid and tissue specimens from the pilot tested negative for carbon monoxide and carbon dioxide. Hydroxyzine, an antihistamine, was detected in liver; however, it was not detected in blood.

ADDITIONAL INFORMATION

Spatial Disorientation

The FAA's Pilot's Handbook of Aeronautical Knowledge contained guidance that stated that, "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 airplane. When visual contact with the horizon is lost, the vestibular system becomes unreliable. Without visual references outside the airplane, there are many situations where combinations of normal motions and forces can create convincing illusions that are difficult to overcome."

The Handbook also advised, "unless a pilot has many hours of training in instrument flight, flight in reduced visibility or at night when the horizon is not visible should be avoided."

FAA Publication "Spatial Disorientation Visual Illusions" (OK-11-1550) , stated, in part, that "false visual reference illusions may cause you to orient your aircraft in relation to a false horizon; these illusions are caused by flying over a banked cloud, night flying over featureless terrain with ground lights that are indistinguishable from a dark sky with stars, or night flying over a featureless terrain with a clearly defined pattern of ground lights and a dark starless sky." The publication provided guidance on the prevention of spatial disorientation. One of the preventive measures was "When flying at night or in reduced visibility, use and rely on your flight instruments."




NTSB Identification: ERA16FA031
14 CFR Part 91: General Aviation
Accident occurred Wednesday, November 04, 2015 in Queens, NY
Aircraft: FLIGHT DESIGN GMBH CTLS, registration: N622BT
Injuries: 1 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 November 4, 2015, at 1933 eastern standard time, a Flight Design GMBH CTLS, light-sport airplane, N622BT, was destroyed after it impacted the Atlantic Ocean near Queens, New York. The private pilot was fatally injured. Night visual meteorological conditions prevailed and no flight plan was filed for the personal flight, which was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. The flight originated from Northeast Philadelphia Airport (PNE), Philadelphia, Pennsylvania, about 1900, with the intended destination of Portsmouth International Airport at Pease (PSM), Portsmouth, New Hampshire.

According to airport personnel at the departure airport, the airplane was "topped off" with fuel prior to departure. A fuel receipt, time stamped on the day of the accident around 1840, indicated 17 gallons of 100LL aviation fuel was added to the airplane.

According to witnesses, they watched as the airplane descended into the ocean. One eyewitness described the descent angle as an approximate 45-degree nose down attitude into the water. Also, the witness stated that he heard an "explosion" a short time later. In addition, a pilot, who responded to the search for the wreckage, noted that it was "pitch black" out over the water.

A postaccident examination of the airplane revealed that all major components were recovered from the water. In addition, flight control continuity was confirmed from the cockpit controls to all flight control surfaces through tensile overload breaks and cuts facilitated for recovery.

The propeller remained attached to the engine. All three blades were fractured about midspan from the propeller hub. The top spark plugs associated with cylinder nos. 1 and 3 and the bottom spark plugs, associated with cylinder nos. 2 and 4 were removed. The spark plugs were light grey in color, and exhibited normal wear. The propeller was rotated by hand and thumb compression was confirmed on all cylinders. The rocker box covers were removed in order to visually confirm valve train and crankshaft continuity throughout the engine.

The ballistic recovery system parachute was recovered. The parachute was found separated from the airplane and was partially deployed. The rocket motor was discharged. The ballistic recovery system handle was not recovered from the water.

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