Philip J. Clements
The National Transportation Safety Board traveled to the scene of this accident.
Investigator In Charge (IIC): Rayner, Brian
Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Eric Sanford; Allentown, Pennsylvania
Lycoming Engines; Williamsport, Pennsylvania
Investigation Docket - National Transportation Safety Board: https://data.ntsb.gov/Docket
Location: Somerset, New Jersey
Accident Number: ERA15FA348
Date and Time: September 8, 2015, 20:48 Local
Registration: N1401P
Aircraft: AEROFAB INC. Lake LA-4-250
Aircraft Damage: Destroyed
Defining Event: Abrupt maneuver
Injuries: 1 Fatal
Flight Conducted Under: Part 91: General aviation - Personal
Analysis
The pilot departed in dark night conditions without performing a preflight inspection and with an unknown quantity of fuel on board. Surveillance video captured the takeoff, and, about 30 seconds later, a bright light travelled the opposite direction, and descended approximately parallel to the runway into the wooded area of the accident site. There was no fuel, no odor of fuel, and no evidence of fuel spillage at the scene. Examination of the wreckage revealed no mechanical anomalies that would have prevented normal operation, and propeller signatures and angularly-cut wood at the accident site suggested the engine was producing power when it entered the trees. The engine was later placed in a test cell, where it started immediately, accelerated smoothly, and ran continuously without interruption at all power settings.
The pilot's most recent logbook entry was for a round trip, 7.45-hour flight 3 weeks before the accident flight. Fuel receipts, performance data, and a partial radar track suggested a 3-hour flight away from his home base where he purchased 45 gallons of fuel to replace the fuel consumed. The return flight was about 4.4 hours in duration, but the pilot's route of flight and the number of takeoffs and landings performed en route could not be determined. Further, the fuel totals found programmed in the digital fuel flow indicator did not correlate to the actual usage of the airplane but rather to a partial fuel-load setting at an interim point of the flight, which could not be explained.
The video evidence indicates that the pilot did not complete a preflight inspection before the accident flight. Thus, it is likely that he discovered the airplane's low fuel state at takeoff and performed a turn back to the airport immediately. It is likely that the airplane lost power on takeoff or in the turn, then engine power was restored when the wings were leveled; however, this scenario could not be definitively determined. Further, the pilot was not instrument-rated, and a rapid, steep turn at low altitude in dark night conditions with little or no visual reference greatly reduced the likelihood of a safe return to the runway.
Probable Cause and Findings
The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's attempted 180-degree return to the runway immediately after takeoff in dark night conditions, which resulted in collision with trees and terrain. Also causal was the pilot's inadequate preflight inspection, which resulted in a takeoff with little-to-no fuel on board the airplane.
Findings
Aircraft Descent rate - Attain/maintain not possible
Personnel issues Aircraft control - Pilot
Environmental issues Dark - Effect on personnel
Personnel issues Decision making/judgment - Pilot
Personnel issues Fuel planning - Pilot
Aircraft Fuel - Fluid level
Environmental issues Tree(s) - Contributed to outcome
Factual Information
History of Flight
Prior to flight Miscellaneous/other
Initial climb Abrupt maneuver (Defining event)
On September 8, 2015, about 2048 eastern daylight time (EDT), an Aerofab Inc. Lake LA-4-250 amphibious airplane, N1401P, was destroyed when it impacted trees and terrain during a forced landing after takeoff from Somerset Airport (SMQ), Bedminster, New Jersey. 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 14 Code of Federal Regulations Part 91.
The pilot was reported missing September 10, 2015, by coworkers, and a search by air and ground discovered the wreckage on the SMQ property about 1300.
According to the pilot's wife and his coworkers, he departed his office at 1700 on the day of the accident to recover his boat from a repair shop and return it to SMQ, where it shared hangar space with the accident airplane. A coworker estimated that, based on the time he departed the office, he would not reach SMQ until after 2000.
Multiple surveillance cameras around the terminal building and mounted on the pilot's hangar captured video on the night of the accident. Review of the video revealed that the pilot arrived at SMQ at 2022 (after sunset). He towed his airplane from its hangar, parked the boat inside, disconnected his vehicle from the boat trailer, and parked the vehicle outside the hangar at 2032.
The pilot then boarded his airplane, taxied away from the hangar at 2039, and departed runway 30 at 2048. Video from a camera located on the airport terminal captured a bright light travelling the opposite direction about 30 seconds after the takeoff. The light was seen descending approximately parallel to the runway in the wooded area that surrounded the accident site. The video faced toward the departure end of the runway and the wood line where the airplane came to rest. There were bright lights in the foreground, and the view beyond displayed very dark night conditions with little to no ambient lighting.
The NTSB Recorders Laboratory completed a day/night video overlay of the airport and the accident flight. The composite video product allowed for a comparison of the path of the airplane's light and the runway orientation.
Pilot Information
Certificate: Private
Age: 62,Male
Airplane Rating(s): Single-engine land; Single-engine sea
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: Lap only
Instrument Rating(s): None
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 3 Waiver time limited special
Last FAA Medical Exam: September 8, 2015
Occupational Pilot: No
Last Flight Review or Equivalent: November 7, 2014
Flight Time: (Estimated) 900 hours (Total, all aircraft), 625 hours (Total, this make and model)
According to Federal Aviation Administration (FAA) records, the pilot held a private pilot certificate with ratings for airplane single engine land and sea. He did not possess an instrument rating.
The pilot's most recent FAA third-class medical certificate was issued on September 8, 2015, and he reported 900 total hours of flight experience on that date. A pilot logbook was recovered, and entries began with 625 total hours of flight experience carried forward from a previous logbook. The pilot's total flight experience could not be reconciled due to incomplete entries; however, all entries appeared to reflect flight experience in the accident airplane.
Aircraft and Owner/Operator Information
Aircraft Make: AEROFAB INC.
Registration: N1401P
Model/Series: Lake LA-4-250
Aircraft Category: Airplane
Year of Manufacture: 1984
Amateur Built:
Airworthiness Certificate: Normal
Serial Number: 12
Landing Gear Type: Tricycle; Amphibian
Seats: 4
Date/Type of Last Inspection: April 27, 2015 Annual
Certified Max Gross Wt.: 3140 lbs
Time Since Last Inspection: 21 Hrs
Engines: 1 Reciprocating
Airframe Total Time: 1633 Hrs at time of accident
Engine Manufacturer: LYCOMING
ELT: Not installed
Engine Model/Series: IO-540-C4B5
Registered Owner:
Rated Power: 300 Horsepower
Operator: On file
Operating Certificate(s) Held: None
The four-seat, single-engine, high-wing, retractable-gear, amphibious airplane was manufactured in 1984 and was equipped with a pylon-mounted Lycoming 250-horsepower reciprocating engine.
According to the airplane's maintenance records, the most recent annual inspection was completed on April 27, 2015, at 1,612 total aircraft hours. The tachometer indicated 1,633 total aircraft hours at the accident site.
The airplane was configured with one main fuselage tank (40 gallons useable), two wing tanks (17 gallons each useable), and two wing-mounted auxiliary tanks (7 gallons each useable). Fuel was supplied to the engine from the main tank only. Fuel from the auxiliary tanks was supplied to the main tank by auxiliary fuel pumps. Fuel from the wing tanks to the main tank was gravity-fed through oneway valves.
The normal procedures checklist for the Supplemental Type Certificate (Installation of Wing Fuel Tanks) directs the pilot to check each tank for quantity and contamination:
2a. CHECK VISUALLY (DIPSTICK) FOR FUEL LEVEL. ANGLE DIPSTICK THROUGH AFT LIGHTNING HOLES INSIDE TANK.
2c. Fuel tank sump drain – DRAIN AND CHECK FOR CONTAMINATION
A fuel boost pump was actuated for takeoff and landing only. The engine-driven fuel pump provided fuel pressure to the engine in all other modes of flight.
According to airport and maintenance personnel, the pilot did not service the auxiliary tanks with fuel whenever he serviced the airplane.
Meteorological Information and Flight Plan
Conditions at Accident Site: Visual (VMC)
Condition of Light: Night
Observation Facility, Elevation: SMQ, 106 ft msl
Distance from Accident Site: 0 Nautical Miles
Observation Time: 20:53 Local
Direction from Accident Site: 0°
Lowest Cloud Condition: Clear
Visibility: 10 miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: /
Turbulence Type Forecast/Actual: / None
Wind Direction:
Turbulence Severity Forecast/Actual: / N/A
Altimeter Setting: 29.95 inches Hg
Temperature/Dew Point: 23°C / 18°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Somerset, NJ (SMQ)
Type of Flight Plan Filed: None
Destination: Somerset, NJ (SMQ)
Type of Clearance: None
Departure Time:
Type of Airspace: Class G
The 2053 weather observation at SMQ included clear skies, calm winds, and 10 statute miles visibility. The temperature was 23° C, the dew point was 18° C, and the altimeter setting was 29.96 inches of mercury.
At the time of the accident, the moon was below the horizon with 19 percent of the visible disk illuminated.
Airport Information
Airport: Somerset Airport SMQ
Runway Surface Type: Asphalt
Airport Elevation: 106 ft msl
Runway Surface Condition: Dry
Runway Used: 30
IFR Approach: None
Runway Length/Width: 2739 ft / 65 ft
VFR Approach/Landing: Unknown
The field elevation at SMQ was 106 ft mean sea level (msl) and the pattern altitude was 1,101 ft msl.
The airport was equipped with one asphalt runway oriented 12/30, which was 2,739 ft long and 65 ft wide, and an intersecting turf runway oriented 08/26, which was 1,923 ft long and 100 ft wide.
The area off the departure end of runway 30 and surrounding the airport was rural farmland, with very little man-made ambient light.
Wreckage and Impact Information
Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries:
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Fatal
Latitude, Longitude: 40.622222,-74.673332(est)
The wreckage was examined at the accident site on September 11, 2015, and all major components were accounted for at the scene. There was no odor of fuel and no evidence of fuel spillage. The wreckage came to rest upright on flat wooded terrain. The wreckage path was 93 ft long, and oriented about 090 degrees magnetic. The initial impact was in trees about 50 ft above the ground, and the left wing and right wing auxiliary tanks were found between the first tree strike and the main wreckage. Several pieces of angularly-cut wood were found along the wreckage path.
The nose of the airplane faced approximately opposite the direction of travel. The cabin roof was separated to the aft cabin. The aft cabin, wing box structure, empennage, and tail section were collapsed and wrapped in a "U" shape such that the tail section rested immediately adjacent to the nose section.
The empennage lay atop the right wing, while the engine pylon was fractured at its base, and lay adjacent to the left wing. The left and right wing tanks were both breached on impact, contained no residual fuel, and there was no evidence of fuel blighting of the vegetation surrounding the wreckage.
Both auxiliary tanks were intact and contained no fuel.
The engine remained inside the nacelle, and the nacelle appeared intact and undamaged. The 3-bladed propeller displayed similar twisting, bending, leading-edge gouging, and chordwise scratching. Two blades displayed similar curling at the tips, and one blade tip was separated. The fracture surface displayed features consistent with overload.
During recovery of the airplane, flight control continuity was confirmed from the flight controls in the cockpit to all flight control surfaces. The aft fuselage, which contained the main fuel tank, was inverted for transport, and trace amounts of fuel drained from the vent lines. The main fuel tank was intact and contained no fuel.
Engine Examination
The engine was examined and placed in a test cell at the manufacturer's facility in Williamsport, Pennsylvania.
The top spark plugs were removed to visually inspect the cylinder condition and provide a thumb compression check. All cylinders were unremarkable, and all produced thumb compression. Mechanical continuity of the valve train was confirmed with hand rotation of the crankshaft via the crankshaft propeller flange. Magneto-to-engine timing was confirmed to be 25 degrees before top dead center in
accordance with the data plate specification. All accessories not needed in the production test cell were removed, including the starter, alternator, vacuum pump, and oil cooler. The original fuel servo was installed and used for the test run.
The engine started immediately, accelerated smoothly, and ran continuously without interruption at all power settings.
Additional Information
Previous Flight Activity
A portable Garmin GPS unit was recovered from the wreckage and was forwarded to the NTSB Recorders Laboratory for examination and download. The batteries removed from the device were corroded, and no useful flight history data was recovered.
Based on a pilot logbook entry, fuel receipts, and data stored on a commercial flight-following website, the airplane completed a flight from SMQ to Yeager Airport (CRW), Charleston, West Virginia on August 16, 2015.
Before departing SMQ, the pilot purchased 51 gallons of fuel. It could not be determined if that fuel service filled all of the fuel tanks. The pilot purchased 45.5 gallons of fuel at CRW before the return flight. No fuel purchase was purchased at SMQ after the return flight, and the usage of the airplane between August 16, 2015 and the day of the accident could not be determined.
The commercial flight-following website captured only a portion of the flight between SMQ and CRW and did not capture the return flight. Interpolation of the radar data, performance data, and the fuel purchase at CRW revealed an approximate fuel consumption rate of 15 gallons per hour (gph), which was consistent with available performance data for the airplane.
A Shadin fuel flow indicator was removed from the airplane and sent to the NTSB Recorders Laboratory for examination. The panel-mounted gauge acted as a digital fuel management system, and had capabilities to interface with other devices via a RS-232 serial connection. It provided endurance (time), fuel flow (gph), fuel used (gallons), and fuel remaining (gallons) when the operator set the initial fuel level correctly before starting the engine. The system included a non-volatile memory that retained fuel remaining and fuel used information when power to the unit was removed.
Power was applied, the self-test report was "good," and the gallons-used display showed 44.7 gallons, and the gallons-remaining display showed 21.0 gallons, for an approximate total of 66 gallons. The fuel values displayed could not be directly attributed to a specific flight before the accident flight.
A review of the pilot's logbook revealed that the pilot recorded the flight to CRW, and the return flight to SMQ, as a single entry of 7.45 hours.
Medical and Pathological Information
The Office of the State Medical Examiner, Newark, New Jersey, performed the autopsy on the pilot and noted the cause of death as blunt traumatic injuries.
Toxicological testing was performed on the pilot by the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. The results were negative for any tested-for substances.
An excerpt of the police report filed by medical examiner staff against Joseph Fantasia.
'THE NEXT DEAD BODY'
Joseph Fantasia has had more than one angry encounter, records show.
In September 2015, a death investigator with the state's northern regional office was headed to the scene of a single-engine plane crash in which the pilot had died. He asked a dispatcher to call Fantasia to make sure he was sending a team, according to the documents.
Fantasia had been feuding with the investigator, whom he accused of "taking food out of my mouth" by sending jobs to other contractors, the records show.
When the dispatcher got him on the phone, Fantasia allegedly blew up.
With at least three state employees listening in on the call, Fantasia "threatened to assault the investigator stating that his body would be the next dead body at the crash site that would have to be picked up," according to an incident report filed with the Newark Police Department.
No criminal charges were filed, although the state Treasury later issued a formal complaint claiming the threat violated the state contract.
"They are very sneaky in the medical examiner office, by putting me on speakerphone when I was irate at the fact that they continually take business from me on a daily basis," Fantasia wrote in response to the complaint. "Maybe I should file police reports, with the way my men and me are threatened and verbally abused daily by these investigators."
He never disputed making the threat.
Joseph Fantasia photographed outside Hackettstown, New Jersey, home on February 7, 2018.
It should have taken about 30 minutes, depending on traffic that day.
The body in Passaic was fresh and an investigator with New Jersey's busiest medical examiner's office wanted it taken straight to the lab in Newark to figure out how the person died.
The task fell to a company run by a funeral director with a troubled past, Joseph Fantasia.
But it would be a full eight hours until state officials saw the body again. It was stacked with other corpses in an unrefrigerated vehicle, briefly stashed in a county morgue and carted between several death scenes across four counties before it was delivered, according to state records.
One state official described the road trip as "the most egregious treatment of human remains" he'd ever seen by the small group of contractors paid by taxpayers to transport the dead.
The account was one of more than 70 contract violations tallied against Fantasia's company, which was repeatedly accused of mishandling bodies before it and state officials agreed to end their contract last June, newly uncovered records show.
An NJ Advance Media investigation published in December revealed that New Jersey's patchwork medical examiner system has been plagued by four decades of neglect and dysfunction, resulting in everything from bungled criminal cases to long delays returning bodies to loved ones.
The latest trove of records, obtained using the state Open Public Records Act, shines light on a little-regulated corner of that broken system: the business of transporting bodies from death scenes to laboratories, a crucial link in the chain of custody that can make or break a case.
For years, red tape and a lack of oversight allowed Fantasia's company to earn hundreds of thousands of dollars in taxpayer money as medical examiner staff complained the company carted away bodies in dented and rusty vehicles, used contract employees who failed background checks and violated state rules, according to the records.
In addition, Fantasia, the owner and manager of Community Funeral Home in Passaic, has been accused of misusing money from funeral customers, failing to pay bills and threatening to "knock out" a state official, according to the records, as well as interviews with funeral directors and medical examiner staff.
"Joe Fantasia has been a black mark on the industry for a long time," said state Sen. Richard Codey, D-Essex, who also works as a funeral director, adding he's a "bad actor and an embarrassment."
In emails and state records, Fantasia has defended himself as an honest businessman taking on a job few would want.
Last year, Fantasia surrendered his funeral director's license under a consent order with the state Board of Mortuary Sciences over accusations of "acts of dishonesty" and professional misconduct. As part of the agreement, Fantasia admitted no wrongdoing and was allowed to stay in the business of hauling the dead.
Peter Aseltine, a spokesman for the New Jersey Attorney General's Office, which oversees the state medical examiner's office, said officials were "not aware of any instance where evidence in a criminal investigation was compromised" as a result of the behavior alleged in the medical examiner staff records.
Aseltine said the office began "a robust dialogue" with the Treasury Department to end the contract in 2015, but it was unable to do so on its own.
More than 200 pages of records show employees at the state medical examiner's office spent two years building a case to revoke the company's contract before Treasury officials took action, eventually allowing Fantasia to withdraw from the agreement last June.
Asked why it took so long, Treasury spokeswoman Jennifer Sciortino, who was recently hired to serve in Gov. Phil Murphy's administration, said she "cannot speak to decisions made by the previous administration."
Though Fantasia's company no longer works for the state, it still performs transports through a separate contract with the Morris County Medical Examiner's Office, which also serves Sussex and Warren counties. Morris County officials say they've had no complaints.
Reached by phone and then by email in December, Fantasia said he had asked to end the state contract early because of late payments and other problems with the state medical examiner office.
"You have no idea what (it) is like to work there," Fantasia said. "I quit on my own accord."
Contacted again in January and given a summary of the complaints and violations compiled by the state, Fantasia referred questions to his attorney, who did not return multiple messages seeking comment.
Then, on Feb. 7, NJ Advance Media sent a reporter and photographer to Fantasia's Hackettstown home to photograph him in public and confront him with the news organization's findings.
Upon seeing the journalists in a car, Fantasia got into a black Cadillac Escalade, drove toward them and began screaming at them. The pair tried to leave the area, but Fantasia and another man in a separate SUV chased them out of the neighborhood and down Route 46.
Fantasia and the second man eventually boxed in the journalists' car on the highway, stopped traffic, got out and began approaching them on foot. Two off-duty Mount Olive police officers who happened to be on the highway witnessed the chase and intervened.
No charges were filed, though a police report described the ordeal as a "road rage" incident. Authorities in Mount Olive said an investigation is ongoing.
In New Jersey, the grim task of transporting bodies often falls to contractors because the state does not have the manpower or resources to do it on its own. Fantasia's company was one of three employed by the state medical examiner's office to do the work. A spokesman for the office said neither of the other two companies had been the subject of a formal complaint.
Fantasia's company has held state contracts going back to at least 2004, though it's unclear how much the company was paid in total. Since 2013, taxpayers have shelled out $1.8 million for body removal, nearly $642,000 of which went to Community Funeral Home, records show.
DROPPED BODIES
The spreadsheet compiled by the state medical examiner staff is a catalog of gruesome stories.
In a six-month span in 2015 alone, they documented more than 70 violations alleging Fantasia's company struggled to meet basic requirements of its contract. The issues were detailed in three formal complaints filed through the Treasury's contract compliance unit.
There are few regulations for transporting bodies for medical examiner's offices, but there are a few minimum requirements to try and keep contractors in order.
For example, the contract required drivers arrive within the hour, but those working for Fantasia's company "continually" showed up after 90 minutes or more, blaming traffic or car trouble, according to one complaint. The vehicles were dirty and on a number of occasions broke down, the complaints said.
At least two employees were supposed to respond to scenes under the contract, but that requirement was repeatedly violated, one complaint said. In one case, a driver arrived with a man he identified as "his father" to help him move a body, according to the records. The man had no ID.
The state's contract also required all employees who transported bodies to pass a background investigation by the state Division of Criminal Justice, but Fantasia struggled to find workers who passed muster, records show.
"It's hard first of all to find someone to do this job, and when I do they get denied," Fantasia wrote in response to one complaint, dated Feb. 23, 2016. "I ask for explanation and so do they and again (it) falls on deaf ears."
Then there were the dropped bodies.
In February 2016, medical examiner staff reported that a driver who arrived alone dropped a body on the ground while removing it from his vehicle outside the Newark lab, records show.
Security guards watching a surveillance camera saw the fall and alerted investigators, who ran out and found the driver with the body already back on the stretcher, according to one complaint. A staff member later wrote in an e-mail that if the accident hadn't been caught on camera, it would have "translated to unexplained post mortem injuries" that could undermine their investigation.
In August 2016, another official wrote, a driver failed to heed advice not to carry the body of a 300-pound man "down three flights of stairs head first" on a broken stretcher. It fell three times before he made it to the vehicle a and again at the lab, the official wrote.
In response to the formal complaints, Fantasia did not dispute many of the allegations. He said his employees had been "reprimanded" for the delay in delivering the body in the Passaic case. He said he had given employees vehicles to take home so they could respond quicker to scenes.
While there were more than 70 violations tallied against his company, he noted, he moved "over 1,800 bodies" during that same period.
Fantasia denied complaints from medical examiner staff that he was "confrontational" and "threatening," saying he coached youth sports and was "not a threatening presence."
"I have awards from politicians for my work in the community with children," he wrote. "They assume that I am nasty, I just speak what is right and they do not like that."
Poorly scanned images of one of Community Funeral Home's vehicles.
He also offered counter-accusations.
Fantasia said an investigator called him "fat" and a staff member called one of his employees "white trash." He accused medical examiner staff of "taking selfies and putting them on twitter" and other inappropriate behavior.
In his last email to NJ Advance Media, Fantasia again said the issues stemmed from problems at the state office, which is chronically underfunded and short-staffed.
"We currently had our contract extended in Morris County," he said, "so it's not us."
Larry Ragonese, a spokesman for Morris County, said they entered into the two-year contract with Community Funeral Home in May 2016. The contract allowed for a one-year probationary period, which was approved, he said.
He said county officials were unaware of ongoing disputes between Fantasia and the state, but were notified when Fantasia surrendered his funeral license and "took appropriate action to ensure" his company "was in full compliance with the law."
During the current contract period, Fantasia's company has billed $25,230 and the county has "not had any substantive issues" with Community Funeral Home, though they had found the condition of the company's vehicles "to be less-than-acceptable," Ragonese said.
Fantasia has promised to replace them, he said. The contract will go back up for bid in May.
Original article can be found here ➤ http://www.nj.com
Is that a 2018 Cadillac Escalade he's sitting in? Note to self, don't crash plane in New Jersey.
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