Friday, November 12, 2021

Medical Event: Cessna 150M, N714LK; fatal accident occurred November 04, 2019 near New Bedford Regional Airport (KEWB), Bristol County, Massachusetts

Paul Vidal
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Lynn Spencer, Investigator In Charge.
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Aviation Accident Factual Report - National Transportation Safety Board 

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

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; Boston, Massachusetts
Textron Aviation; Wichita, Kansas
Continental Aerospace Technologies; Mobile, Alabama

Investigation Docket - National Transportation Safety Board:


Location: New Bedford, Massachusetts
Accident Number: ERA20FA031
Date and Time: November 4, 2019, 15:32 Local
Registration: N714LK
Aircraft: Cessna 150
Aircraft Damage: Destroyed
Defining Event: Medical event
Injuries: 1 Fatal
Flight Conducted Under: Part 91: General aviation - Personal

On November 4, 2019, at 1532 eastern standard time, a Cessna 150M, N714LK, was destroyed when it was involved in an accident near New Bedford, Massachusetts. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.

According to an employee of the fixed based operator at the New Bedford Regional Airport (EWB), New Bedford, Massachusetts, where the owner/pilot based his airplane, the pilot was “cheerful and happy to be flying” the morning of the accident. He reported that the pilot spent about 10 to 15 minutes performing a preflight inspection of his airplane before departing.

Automatic dependent surveillance-broadcast (ADS-B) data obtained from the Federal Aviation Administration (FAA) indicated that the airplane departed EWB around 1450 and climbed to about 2,500 ft mean sea level (msl) while tracking in a southwesterly direction for about 20 minutes. The airplane then began a gradual descent, turned to the northeast, and flew along the shoreline. It then proceeded to fly north toward EWB, descending to around 250 ft above ground level over a golf course fairway less than 3 nm from EWB. The airplane then commenced a climbing right turn at increasing pitch attitudes to an altitude of about 4,000 ft msl, when the airplane then descended rapidly in a left circular pattern.

According to a witness who had exited his car in a parking lot near the accident site, he heard a sound "like a motor revving up high." He looked up and saw an airplane "swoop down like it was going to land,” climb very high, and then “pivot on its left wing” before “coming straight down.” He thought the airplane was “doing tricks.”

Examination of the accident site and wreckage revealed that the airplane impacted a tree in a cemetery in a near vertical nose-down attitude.

Pilot Information

Certificate: Private 
Age: 74, Male
Airplane Rating(s): Single-engine land
Seat Occupied: Left
Other Aircraft Rating(s): None 
Restraint Used: 3-point
Instrument Rating(s): None 
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 3 With waivers/limitations 
Last FAA Medical Exam: November 1, 2018
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time: 1323 hours (Total, all aircraft), 1209 hours (Total, this make and model), 1281.5 hours (Pilot In Command, all aircraft), 9 hours (Last 90 days, all aircraft), 0 hours (Last 30 days, all aircraft).

Interviews with friends and acquaintances of the pilot revealed that it was highly unusual and uncharacteristic behavior for the pilot to perform aerobatics. They considered him to be a very conservative pilot.

According to a friend of the pilot who flew with him regularly, the pilot often flew toward Newport, Rhode Island, and then along the shoreline back toward West Island, Massachusetts, where the pilot would typically contact the EWB air traffic control tower when inbound for landing.

According to the president of the EWB fixed based operator, the business staff monitored the tower frequency for incoming airplanes and did not hear the pilot make any radio transmissions, adding that the pilot “would never enter the airspace without calling.”

Aircraft and Owner/Operator Information

Aircraft Make: Cessna 
Registration: N714LK
Model/Series: 150M 
Aircraft Category: Airplane
Year of Manufacture: 1977
Amateur Built:
Airworthiness Certificate: Utility 
Serial Number: 15079256
Landing Gear Type: Tricycle 
Seats: 2
Date/Type of Last Inspection: June 7, 2019 Annual
Certified Max Gross Wt.: 1601 lbs
Time Since Last Inspection: 14 Hrs 
Engines: 1 Reciprocating
Airframe Total Time: 5064.6 Hrs at time of accident
Engine Manufacturer: Continental
ELT: C91 installed
Engine Model/Series: O-200-A (48)
Registered Owner: 
Rated Power: 100 Horsepower
Operator: On file 
Operating Certificate(s) Held: None

Cabin Heat System

According to the Cessna 150 Pilot Operating Handbook, “the temperature and volume of airflow into the cabin can be regulated to any degree by manipulation of the push-pull CABIN HT and CABIN AIR control knobs.” The left engine muffler was constructed with a shroud around the outside, which forms a heating chamber for the cabin heater air. The heated air from the muffler shroud is then routed to the cabin when the CABIN HT knob is pulled out.

Maintenance and Muffler History

A logbook entry indicated that the muffler was last replaced June 1, 2004, at tachometer time 4,321.5 hours, or 742.9 hours before the accident flight; however, the maintenance entry did not specify which muffler was replaced.

The mechanic who performed the most recent annual inspection stated that he opened each muffler shroud to inspect the muffler, looking for stains, soot or cracks, which would indicate the need to change the muffler. He stated that he found no anomalies during the muffler inspections.

The airplane was not equipped with any type of carbon monoxide (CO) detector.

The inspection chart contained in the Model 150 Series (1977) Service Manual indicates that a general inspection of the exhaust system should be conducted every 50 hours and references a more detailed procedure later in the manual for an inspection every 100 hours. The 100-hour inspection information starts by stating, “Inspection of the exhaust system shall be thorough because the cabin heating system uses air heated by the heat exchangers of the exhaust system. Since exhaust systems of this type are subject to burning, cracking, and general deterioration from alternate thermal stresses and vibration, inspection is very important and should be accomplished every 100 hours of operation. The airplane was generally inspected on an annual basis, and not a 100-flight hour basis. A review of the maintenance records indicated that the annual inspections occurred at flight hour intervals ranging from 39 hours to 55 hours in the 10 years preceding the accident flight.

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual (VMC)
Condition of Light: Day
Observation Facility, Elevation: EWB,792 ft msl 
Distance from Accident Site: 35 Nautical Miles
Observation Time: 14:53 Local
Direction from Accident Site: 16°
Lowest Cloud Condition: Clear
Visibility: 10 miles
Lowest Ceiling: None 
Visibility (RVR):
Wind Speed/Gusts: 9 knots / 17 knots 
Turbulence Type Forecast/Actual: Unknown / Unknown
Wind Direction: 180° 
Turbulence Severity Forecast/Actual: Unknown / Unknown
Altimeter Setting: 30.34 inches Hg 
Temperature/Dew Point: 11°C / -2°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: New Bedford, MA (EWB)
Type of Flight Plan Filed: None
Destination: New Bedford, MA (EWB)
Type of Clearance: None
Departure Time: 14:50 Local
Type of Airspace: Class D

Airport Information

Airport: New Bedford Regional Airport EWB 
Runway Surface Type: Asphalt
Airport Elevation: 792 ft msl
Runway Surface Condition: Dry
Runway Used: 23 
IFR Approach: None
Runway Length/Width: 5400 ft / 150 ft 
VFR Approach/Landing: None

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: N/A 
Aircraft Fire: None
Ground Injuries: N/A 
Aircraft Explosion: None
Total Injuries: 1 Fatal 
Latitude, Longitude: 41.621112,-70.938331

Examination of the accident site and wreckage revealed that the airplane impacted a tree in a near vertical nose down attitude about 3.5 nautical miles and about 164° magnetic from EWB. The debris field extended about 240 ft from the tree on a heading of about 220°. The left wing with the strut attached was located about 10 ft from the tree, followed by the empennage, cabin and engine at 30 ft, the right wing at 40 ft, the carburetor at 87 ft, a ruptured fuel tank at 122 ft, and the main wheels and directional gyro at 240 ft. All major components of the airplane were present at the accident site.

The fuselage was significantly fragmented. Both wings were impact fractured, bent on all surfaces, and exhibited leading edge damage consistent with tree impact. The empennage was impact fractured and bent. The instrument panel was largely fragmented. The engine controls were in the full forward position. The cabin heat control was in the full aft (ON) position.

The engine was examined, and no pre-impact anomalies were noted that would have prevented normal production of power. The propeller remained attached to the engine crankshaft propeller flange. Examination of the propeller blades revealed aft bending and twisting along the length of both blades with leading-edge gouging and chordwise rotational scoring on the camber sides. Control continuity was established from the flight controls through overload fractures to the control surfaces.

The left muffler outer casing was impact crushed exposing the end plate which exhibited an erosion hole and several other smaller pin holes. The cabin heat shroud was removed from the muffler, and additional evidence of internal deterioration was present. The muffler metal was corroded and thin, and pin holes were observed on the sides of the muffler. The right muffler was crushed and compacted, and the shroud, which provides heated air to the carburetor heat control, remained intact around the muffler.

Additional Information

FAA Carbon Monoxide and Exhaust System Guidance

On November 24, 1972, the FAA issued advisory circular (AC) 20-32B "Carbon Monoxide (CO) Contamination in Aircraft—Detection and Prevention." The AC provided information on the potential dangers of carbon monoxide contamination from faulty engine exhaust systems or cabin heat exchangers. It also discussed means of detection and procedures to follow when contamination is suspected.

In October 2009, the FAA issued report DOT/FAA/AR-09/49, "Detection and Prevention of Carbon Monoxide Exposure in General Aviation Aircraft." The report documented research on detection and prevention of CO exposure in general aviation aircraft, with the objective of identifying exhaust system design issues related to CO exposure, evaluating inspection methods and maintenance practices with respect to CO generation, and the identification of protocols to quickly alert users to the presence of excessive CO in the cockpit and cabin.

On March 17, 2010, the FAA published Special Airworthiness Information Bulletin (SAIB) CE-10-19 R1. It recommended that owners and operators of general aviation aircraft consider the information in the DOT/FAA/AR-09/49 report and use CO detectors while operating their aircraft. The SAIB also recommended a cabin CO level check during every 100-hour or annual inspection, along with continued inspection of the complete engine exhaust system during 100-hr or annual inspections and at inspection intervals recommended by the aircraft and engine manufacturers in accordance with the applicable maintenance manual instructions.

On August 16, 2010, the FAA also published Special Airworthiness Information Bulletin SAIB CE-10-33R1, which reiterated the recommendation to use CO detectors as documented by SAIB CE-10-19R1. It recommended the replacement of mufflers on reciprocating engine-powered airplanes that use an exhaust system heat exchanger for cabin heat with more than 1,000 hours time in service (TIS) and at intervals of 1,000 hours TIS. It further recommended following guidance for exhaust system inspections and maintenance provided in SAIB CE-04-22, dated December 17, 2003, and Advisory Circular (AC) 43-16A, Aviation Maintenance Alert, issued October 2006. The FAA also recommended continuing to inspect the complete exhaust system during annual inspections and at intervals recommended by the aircraft and engine manufacturers.

SAIBs are for information only, their recommendations are not mandatory. Likewise, compliance with manufacturer-issued service letters (SLs) is not mandatory.

NTSB CO and Exhaust System Guidance

On June 24, 2004, the NTSB issued Safety Recommendation A-04-028 to the FAA to require installation of CO detectors in all single-engine airplanes with forward-mounted reciprocating engines and enclosed cockpits that are already equipped with systems needed to operate the CO detector. In response, the FAA undertook the creation of the DOT/FAAIAR-09/49 report and recommended the use of CO detectors in SAIB CE-10-33R1. However, in 2011, the FAA concluded that the primary method to prevent CO contamination in the cabin is through proper inspection and maintenance of mufflers and exhaust system components, and CO detectors are a secondary method to prevent CO exposure. The FAA referenced the subsequent publication of SAIB CE-10-19 R1, and further stated that, since a lack of a CO detector alone is not unsafe, installing a CO detector does not correct an unsafe condition as defined by 14 CFR Part 39.

Because the FAA did not require installation of CO detectors, Safety Recommendation A-04-028 was classified by the NTSB as "Closed – Unacceptable Action".

Medical and Pathological Information

The pilot had his last aviation medical examination on November 1, 2018. At that time, he reported having prostate cancer and using no medications. He was issued a third-class medical certificate limited by a requirement he wear corrective lenses.

The Commonwealth of Massachusetts Office of the Chief Medical Examiner performed the pilot’s autopsy. According to the autopsy report, the pilot’s cause of death was multiple blunt force injuries. The autopsy identified coronary artery disease, including up to 80% stenosis of the left anterior descending coronary artery. Due to the severity of the pilot’s injuries, there was no available autopsy
information about his brain. The autopsy did not identify any other significant natural disease.

Toxicological testing by two laboratories identified only the non-impairing prescription prostate medication tamsulosin, in the pilot’s liver and muscle. One laboratory used a qualitative test by diffusion to screen pooled/cavity blood for carboxyhemoglobin, reporting a result of “none detected at 12%.” The other laboratory was unable to test carboxyhemoglobin as the available blood specimen had become unsuitable.

Carboxyhemoglobin is formed when carbon monoxide (CO) binds to hemoglobin in blood, impairing the blood’s ability to deliver oxygen to body tissues (hypemic hypoxia). CO is an odorless, tasteless, colorless, nonirritating gas that can be produced during hydrocarbon combustion. Exposure to CO usually occurs by inhalation of smoke or exhaust fumes. Nonsmokers normally have carboxyhemoglobin levels of less than 1-3%. Heavy smokers may normally have levels as high as 10-15%. Symptoms of low-level CO exposure are nonspecific and variable, and may include headache, nausea, and tiredness. Increasing levels of exposure may become impairing or incapacitating, causing more serious neurocognitive, cardiac, and/or vision problems, progressing to fatality as blood carboxyhemoglobin surpasses about 40-50% (possibly lower in elderly people or those with serious coexisting medical conditions). As with other causes of tissue hypoxia, CO poisoning may be insidious and difficult for an exposed person to recognize; there is no reliable physical sign of exposure.




Loss of Engine Power (Partial): Cessna T303 Crusader, N303TL; fatal accident occurred August 17, 2019 near Sky Acres Airport (44N), Lagrangeville, Dutchess County, New York

Gerald Bocker
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Molly
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Francisco “Frank” Knipping-Diaz
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Aviation Accident Factual Report - National Transportation Safety Board 

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

Additional Participating Entities: 
Federal Aviation Administration / Flight Standards District Office; Teterboro, New Jersey
Continental Aerospace Technologies; Mobile, Alabama
Textron Aviation; Wichita, Kanas

Investigation Docket - National Transportation Safety Board:


Location: Lagrangeville, New York
Accident Number: ERA19FA249
Date and Time: August 17, 2019, 16:13 Local 
Registration: N303TL
Aircraft: Cessna T303 
Aircraft Damage: Destroyed
Defining Event: Loss of engine power (partial)
Injuries: 2 Fatal, 3 Serious, 1 Minor
Flight Conducted Under: Part 91: General aviation - Personal

Factual Information

HISTORY OF FLIGHT

On August 17, 2019, about 1613 eastern daylight time, a Cessna T303, N303TL, was destroyed when it was involved in an accident in Lagrangeville, New York. The private pilot and one person on the ground were fatally injured. Two passengers and one person on the ground sustained serious injuries, and one person on the ground sustained minor injuries. The airplane was operated as a 14 Code of Federal Regulations Part 91 personal flight.

According to the passenger seated in the copilot’s seat, on the morning of the accident the pilot and two passengers departed Republic Airport (FRG) and flew to Orange County Airport (MGJ), Montgomery, New York, where the pilot had a business meeting. After the meeting, they departed MGJ for the return flight to FRG, which included a stop at Sky Acres Airport (44N) in Lagrangeville, New York, to purchase fuel. The passenger reported that the flight from FRG to MGJ and the flight from MGJ to 44N were uneventful. He recalled that the pilot performed an engine runup prior to departing FRG; he did not recall if one was performed prior to the departure from MGJ or prior to the accident flight. The pilot fueled the airplane at 44N, where fuel records indicated he purchased 100 gallons of 100LL aviation fuel.

A review of surveillance video revealed that the airplane engines were shut down for about 10 minutes while the pilot and one of the passengers added fuel to both wing tanks. After the fueling, they did not take any fuel samples from the airplane’s sump drains. After the pilot and both passengers boarded the airplane, the pilot made several unsuccessful attempts to start the left engine for about 30 seconds. Next, the pilot attempted to start the right engine several times over a period of about 30 seconds. During the last attempt, the engine started. The left engine was then started after about 10 seconds of engine cranking. No smoke was visible at any time during the engine start attempts. The airplane remained in position with the engines idling for about 2 minutes before it taxied around to the opposite side of the fuel pump and stopped for about 45 seconds with the engines at or near idle. The pilot then taxied from the fuel pump to runway 17 and did not appear to stop for an engine run-up (although the airplane was out of the camera view for about 14 seconds near the end of the taxiway). The pilot performed a rolling takeoff, and the airplane lifted off the runway in the vicinity of the windsock, which was located on the left side of the runway about 2,100 ft from the runway 17 threshold.

According to the passenger in the copilot’s seat, shortly after liftoff at an altitude of less than 50 to 100 ft, both engines lost partial power. They did not stop completely but sounded as though they were “not getting full RPM.” The engines began “stuttering,” which continued until impact with the house. As the airplane proceeded down the runway, it began to drift toward the left until they were over the grass next to the runway. The pilot corrected the drift and the airplane then tracked straight and remained over the grass. As the airplane continued beyond the end of the runway, it was not climbing, and the passenger noticed obstacles that he described as trees and a structure or building. The pilot pitched the airplane up to clear those obstacles. The airplane then began a left turn and as it reached the house the left wing struck the ground, and the right wing struck a tree and the house. The airplane had “very little forward motion” after the initial impact. The passenger estimated that the airplane remained below 100 ft of altitude for the entire flight. He reported that the pilot continued to fly the airplane until impact and did not make any radio calls or say anything to the passengers. He did not hear any warning bells or alarms during the flight. The pilot and both passengers wore their seatbelts and shoulder harnesses.

The airport manager who was mowing the grass at the airport described the airplane’s rotation as “very abrupt” compared to other light twin airplanes he has observed taking off at the airport. Immediately after rotation, he noticed the airplane maintained very shallow bank angles; however, the nose was “high”, and the airplane appeared to yaw slightly to the left. The airplane appeared to correct toward the right before he lost sight of it behind the airport fuel tank. When the airplane emerged from the other side of the tank, the nose was initially lower, but then it pitched up again near the end of the runway before it disappeared behind some trees. The airport manager was wearing ear protection and listening to music and did not hear any engine noise.

Another witness reported that the airplane was “went in a straight line for a short distance and then quickly turned left about 40-45°” which she described as appearing “deliberate and controlled.” She added that she was “surprised the left wing didn’t dip down as the airplane turned. The wings looked like they were steady and pretty parallel to the ground during and after the turn.”

A review of Federal Aviation Administration (FAA) recorded automatic dependent surveillance – broadcast data revealed that after the airplane reached the end of the runway, it climbed from about 675 ft to 775 ft pressure altitude (about 20 to 120 ft above ground level [agl]) in a gradual left turn. During this time the calculated groundspeed decreased from about 80 knots to about 69 knots. The pressure altitude then decreased to 725 ft (about 50 ft agl), the calculated groundspeed decreased to about 66 knots, and the left turn decreased in radius until the recorded data ended about 100 ft west of the accident site.

AIRCRAFT INFORMATION

According to the airplane’s pilot operating handbook (POH), engine mis-starts (without puffs of black smoke) can result from an excessively lean mixture in cold or warm temperatures or by vapor lock in extremely high temperatures. If vapor lock is suspected, the primer switch (which operates the auxiliary fuel pumps) should be turned on for 5 to 10 seconds prior to starting the engine, to flush the vapor through the fuel lines. Additionally, the auxiliary fuel pumps are to be turned on for takeoff, landing, or any time vapor is suspected in the fuel system, such as in hot day/high altitude conditions or conditions during a climb that are conducive to fuel vapor formation.

The POH also prescribes a “Hot Day Takeoff” procedure which includes a static runup of the engines and evaluation of the maximum engine RPM achieved before takeoff. The procedure includes an adjustment to lean the mixture, if necessary, to ensure sufficient engine RPM and establish a required minimum fuel flow, prior to takeoff. The normal maximum RPM achieved during the procedure should be 2,400 and must be at least 2,300. The procedure does not specify an ambient temperature range for which the procedure is required but does specify that it should be performed “on warm humid or hot days with heated engine(s) and oil and cylinder temperatures near mid-scale or higher.” It prescribes adjustments and performance calculation penalties if the maximum RPM achieved is between 2,300 and 2,400.

METEOROLOGICAL INFORMATION

At 1653, the weather conditions at Hudson Valley Regional Airport (POU), Poughkeepsie, New York, located about 8 miles southwest of the accident site included temperature 30° C, dewpoint 20° C, wind from 170° at 7 knots, and an altimeter setting 29.93 inches of mercury. The density altitude calculated for the takeoff at 44N (field elevation 697 ft) was 2,633 ft.

WRECKAGE AND IMPACT INFORMATION

Examination of the wreckage revealed that most of the fuselage forward of the aft bulkhead was destroyed by fire. Except for the empennage, most of the wreckage that remained was found within the right (north) half of the house foundation perimeter. The north half of the house structure and roof was consumed by fire. The empennage remained largely intact and was found with the right horizontal stabilizer leaning against what remained of the rear wall of the house, oriented on a heading of about 030° magnetic. The damaged left wingtip, left engine, right engine, and the right (green) navigation light lens were found oriented along a line from the rear of the house to a bush by the front wall of the house, roughly the length of the wingspan and oriented perpendicular to the empennage. The cabin heater, which was mounted in the nose of the airplane, was found about 15 ft away from and in line with the orientation of the empennage.

Flight control continuity was confirmed from what remained of the flight control tubes near the cockpit, to the rudder, the elevator and to the outboard aileron bell cranks in each wing. Neither of the aileron pushrods were found. All cable ends were found at their respective attachment points. The right aileron cable was fractured in one location near the bell crank. The rudder and elevator trim actuators were near the neutral position. The aileron trim condition could not be determined. The remnants of the landing gear were found in the retracted position. The flap jackscrew actuator was consistent with the retracted position. All of the cockpit instruments were consumed by fire, and none were located except for one 2-inch diameter dial face that was illegible but consistent with a vacuum gauge. A metal avionics rack was located with ash inside. Several loose metal unidentified toggle switches were found near the cockpit area. Neither of the two electric fuel boost pumps were located. Remnants of both fuel selector valves were found; however, both were too thermally damaged to determine their position.

The cockpit engine and propeller controls were located; however, the preimpact position of the levers and the cable continuity to each engine could not be determined due to thermal damage.

Several spark plugs, rocker arm assemblies, and pushrods were found loose in the wreckage and could not be associated with a specific engine or cylinder. 

The left engine was found in an upright position with damage consistent with thermal and impact forces. The crankshaft could not be rotated by hand. All six cylinders remained attached but exhibited impact and thermal damage. Cylinder Nos. 1, 3, and 5 exhibited impact and thermal damage with cooling fins being crushed. Cylinder Nos. 2, 4, and 6 were impact and thermally damaged with the top half of each cylinder melted away. The intake and exhaust rocker arms and shafts were separated from cylinder Nos. 2 and 4. The No. 6 cylinder head separated exposing a thermally destroyed piston dome. Only the piston skirt remained in the cylinder with the piston pin in place.

The left three-blade constant speed propeller assembly remained attached to the crankshaft propeller flange. A single propeller blade was visible in the debris with the other two blades thermally destroyed. All three propeller shanks remained attached to the thermally damaged propeller hub.

The right engine was found inverted with damage consistent with thermal and impact forces. The crankshaft could not be rotated by hand. All cylinder bases remained attached at their respective mounting pads. Cylinder Nos. 1 and 3 rocker covers were partially separated with thermal and impact damage. Rocker arms and shafts were intact on cylinder Nos. 1 and 3. The cylinder No. 5 cylinder head (forward portion) was separated exposing an intact piston. The Nos. 2, 4, and 6 cylinder heads were separated or melted away exposing intact pistons.

The right three-blade constant speed propeller was separated from the crankshaft propeller flange. Three propeller blade inboard shanks were located near the inverted right engine; however, the blade portions were thermally destroyed. A partial propeller hub was also located nearby with the dome cover and spring intact.

The Nos. 1 and 3 pistons on the right engine did not exhibit any damage or signatures consistent with pre-ignition or detonation. All other pistons identified for both engines had varying degrees of thermal and melting damage that precluded the identification of any signatures uniquely consistent with detonation or pre-ignition.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy of the pilot was performed by the Office of the Medical Examiner, Dutchess County, New York. The autopsy report listed the cause of death as “thermal injuries and smoke inhalation.” A contributing cause of death was “atherosclerotic cardiovascular disease.”

Toxicology testing performed at the FAA Forensic Sciences Laboratory identified cocaine at 51 nanograms per milliliter (ng/mL) in the pilot’s urine; cocaine was not detected in his iliac blood. The FAA laboratory also reported benzoylecgonine, an inactive cocaine metabolite, in his iliac blood and urine at 72 ng/mL and 3,084 ng/mL, respectively. Ecgonine methyl ester, a minor inactive metabolite of cocaine, was detected in the pilot’s blood and urine.

Anhydroecgonine methyl ester, a pyrolysis product of smoked crack cocaine, was detected in the pilot’s urine. No carboxyhemoglobin level was reported in the pilot’s iliac blood.

ADDITIONAL INFORMATION

An FAA inspector obtained a 100 LL fuel sample from the fueling station at 44N. He reported that it was blue in color and no water was present.

Pilot Information

Certificate: Private 
Age: 65,Male
Airplane Rating(s): Single-engine land; Multi-engine land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: 3-point
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): None 
Toxicology Performed: Yes
Medical Certification: Class 3 With waivers/limitations 
Last FAA Medical Exam: November 1, 2017
Occupational Pilot: No
Last Flight Review or Equivalent: November 5, 2017
Flight Time: (Estimated) 1586 hours (Total, all aircraft), 358 hours (Total, this make and model), 1325 hours (Pilot In Command, all aircraft)

Aircraft and Owner/Operator Information

Aircraft Make: Cessna 
Registration: N303TL
Model/Series: T303 No Series
Aircraft Category: Airplane
Year of Manufacture: 1984
Amateur Built:
Airworthiness Certificate: Normal 
Serial Number: T30300286
Landing Gear Type: Retractable - Tricycle 
Seats: 6
Date/Type of Last Inspection: July 17, 2019 Annual
Certified Max Gross Wt.: 5150 lbs
Time Since Last Inspection:
Engines: 2 Reciprocating
Airframe Total Time: 2932 Hrs as of last inspection
Engine Manufacturer: Continental
ELT: C91 installed 
Engine Model/Series: TSIO-520-AE3B
Registered Owner:
Rated Power: 250 Horsepower
Operator:
Operating Certificate(s) Held: None

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual (VMC)
Condition of Light: Day
Observation Facility, Elevation: POU, 166 ft msl
Distance from Accident Site: 8 Nautical Miles
Observation Time: 16:53 Local 
Direction from Accident Site: 237°
Lowest Cloud Condition: 
Visibility: 10 miles
Lowest Ceiling: Broken / 4700 ft AGL
Visibility (RVR):
Wind Speed/Gusts: 7 knots / Turbulence Type
Forecast/Actual:  /
Wind Direction: 170° 
Turbulence Severity Forecast/Actual: /
Altimeter Setting: 29.93 inches Hg 
Temperature/Dew Point: 30°C / 20°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Lagrangeville, NY (44N)
Type of Flight Plan Filed: None
Destination: Farmingdale, NY (FRG)
Type of Clearance: None
Departure Time: 16:12 Local 
Type of Airspace: Class G

Airport Information

Airport: Sky Acres 44N 
Runway Surface Type: Asphalt
Airport Elevation: 697 ft msl
Runway Surface Condition:  Dry
Runway Used: 17 
IFR Approach: None
Runway Length/Width:  3830 ft / 60 ft
VFR Approach/Landing: None

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: 2 Serious
Aircraft Fire: On-ground
Ground Injuries: 1 Fatal, 1 Serious, 1 Minor 
Aircraft Explosion: On-ground
Total Injuries: 2 Fatal, 3 Serious, 1 Minor 
Latitude, Longitude: 41.7,-73.729164

Piper PA-18-150 Super Cub, N4221Z: Incident occurred November 11, 2021 in Palmer, Alaska

Federal Aviation Administration / Flight Standards District Office; Anchorage, Alaska

Aircraft on landing incurred a propeller strike. 

Blue River Aviation LLC


Date: 11-NOV-21
Time: 01:50:00Z
Regis#: N4221Z
Aircraft Make: PIPER
Aircraft Model: PA18
Event Type: INCIDENT
Highest Injury: MINOR
Aircraft Missing: No
Damage: MINOR
Activity: PERSONAL
Flight Phase: LANDING (LDG)
Operation: 91
City: PALMER
State: ALASKA

Bell 407, N619DE: Incident occurred November 10, 2021 in Eloy, Pinal County, Arizona

Federal Aviation Administration / Flight Standards District Office; Scottsdale, Arizona

Rotorcraft made a forced landing on a road due to a skid getting caught in a paraglider tether. 

United States Department of Energy


Date: 10-NOV-21
Time: 18:50:00Z
Regis#: N619DE
Aircraft Make: BELL
Aircraft Model: 407
Event Type: INCIDENT
Highest Injury: NONE
Aircraft Missing: No
Damage: MINOR
Activity: PUBLIC USE
Flight Phase: EN ROUTE (ENR)
City: ELOY
State: ARIZONA

Cessna 177RG Cardinal, N177VS: Incident occurred November 11, 2021 at Yuba County Airport (KMYV), Marysville, California

Federal Aviation Administration / Flight Standards District Office; Sacramento, California

Aircraft landed gear up.  


Date: 12-NOV-21
Time: 01:40:00Z
Regis#: N177VS
Aircraft Make: CESSNA
Aircraft Model: 177RG
Event Type: INCIDENT
Highest Injury: NONE
Aircraft Missing: No
Damage: MINOR
Activity: PERSONAL
Flight Phase: LANDING (LDG)
Operation: 91
City: MARYSVILLE
State: CALIFORNIA

Let L-23 Super Blanik, N259BA: Incident occurred November 06, 2021 in Elbert, Colorado

Federal Aviation Administration / Flight Standards District Office; Denver, Colorado

Glider landed hard short of the runway. 

Black Forest Soaring Society Inc


Date: 06-NOV-21
Time: 17:30:00Z
Regis#: N259BA
Aircraft Make: LET
Aircraft Model: L-23 SUPER BLANIK
Event Type: INCIDENT
Highest Injury: NONE
Aircraft Missing: No
Damage: UNKNOWN
Activity: PERSONAL
Flight Phase: LANDING (LDG)
Operation: 91
City: ELBERT
State: COLORADO

Swearingen SA-226T, N749L: Incident occurred November 10, 2021 at Fort Lauderdale Executive Airport (KFXE), Broward County, Florida

Federal Aviation Administration / Flight Standards District Office; South Florida

Aircraft landed and experienced steering issues and struck a sign. 

GECO Inc


Date: 10-NOV-21
Time: 23:45:00Z
Regis#: N749L
Aircraft Make: SWEARINGEN
Aircraft Model: SA-226T
Event Type: INCIDENT
Highest Injury: NONE
Aircraft Missing: No
Damage: UNKNOWN
Activity: PERSONAL
Flight Phase: LANDING (LDG)
Operation: 91
City: FORT LAUDERDALE
State: FLORIDA

Cirrus SR22, N230WJ: Incident occurred November 07, 2021 at Clark Regional Airport (KJVY), Jeffersonville, Indiana

Federal Aviation Administration / Flight Standards District Office; Indianapolis, Indiana

Aircraft struck a deer on takeoff. 

Center Ice Scouting LLC


Date: 07-NOV-21
Time: 22:48:00Z
Regis#: N230WJ
Aircraft Make: CIRRUS
Aircraft Model: SR22
Event Type: INCIDENT
Highest Injury: NONE
Aircraft Missing: No
Damage: UNKNOWN
Activity: PERSONAL
Flight Phase: TAKEOFF (TOF)
Operation: 91
City: JEFFERSONVILLE
State: INDIANA

Mooney M20C Ranger, N7856V: Incident occurred November 10, 2021 at Maryland Airport (2W5), Indian Head, Charles County, Maryland

Federal Aviation Administration / Flight Standards District Office; Washington, District of Columbia

Aircraft landed gear up.  


Date: 10-NOV-21
Time: 21:43:00Z
Regis#: N7856V
Aircraft Make: MOONEY
Aircraft Model: M20C
Event Type: INCIDENT
Highest Injury: NONE
Aircraft Missing: No
Damage: UNKNOWN
Activity: PERSONAL
Flight Phase: LANDING (LDG)
Operation: 91
City: INDIAN HEAD
State: MARYLAND

Cessna 172M Skyhawk, N4423Q: Incidents occurred November 10, 2021 and October 10, 2021

Federal Aviation Administration / Flight Standards District Office; Jackson, Mississippi 

November 10, 2021:  Aircraft made a forced landing in a field for unknown reasons in Holly Springs, Marshall County, Mississippi.

OBAP


Date: 10-NOV-21
Time: 17:40:00Z
Regis#: N4423Q
Aircraft Make: CESSNA
Aircraft Model: 172
Event Type: INCIDENT
Highest Injury: NONE
Aircraft Missing: No
Damage: UNKNOWN
Activity: INSTRUCTION
Flight Phase: EN ROUTE (ENR)
Operation: 91
City: HOLLY SPRINGS
State: MISSISSIPPI

Federal Aviation Administration / Flight Standards District Office; Jackson, Mississippi

October 10, 2021:  Aircraft made a forced landing in a field due to an engine failure in Olive Branch, DeSoto County, Mississippi.  

OBAP


Date: 10-OCT-21
Time: 12:52:00Z
Regis#: N4423Q
Aircraft Make: CESSNA
Aircraft Model: 172M
Event Type: INCIDENT
Highest Injury: NONE
Aircraft Missing: No
Damage: UNKNOWN
Activity: PERSONAL
Flight Phase: EMERGENCY DESCENT (EMG)
Operation: 91
City: OLIVE BRANCH
State: MISSISSPPI

Bombardier Challenger 300, N726QS: Incident occurred November 10, 2021 at Albany International Airport (KALB), New York

Federal Aviation Administration / Flight Standards District Office; Albany, New York

Aircraft taxiing to runway and left wing struck Bombardier Challenger 350, N333WC.

NetJets Sales Inc


Date: 10-NOV-21
Time: 14:10:00Z
Regis#: N726QS
Aircraft Make: BOMBARDIER
Aircraft Model: BD-100-1A10
Event Type: INCIDENT
Highest Injury: UNKNOWN
Aircraft Missing: No
Damage: UNKNOWN
Activity: ON DEMAND
Flight Phase: TAXI (TXI)
Operation: 135
Aircraft Operator: NET JETS
Flight Number: EJA726
City: ALBANY
State: NEW YORK

Texas Sport Aircraft TX-11C-100, N8924L: Incident occurred November 11, 2021 in Wallace, North Carolina

Federal Aviation Administration / Flight Standards District Office; Greensboro, North Carolina

Aircraft on landing experienced a gust of wind, veered off runway and ended up in a ditch. 

Legend Aero Holdings Inc


Date: 11-NOV-21
Time: 21:45:00Z
Regis#: N8924L
Aircraft Make: TEXAS SPORT
Aircraft Model: TX-11C
Event Type: INCIDENT
Highest Injury: NONE
Aircraft Missing: No
Damage: UNKNOWN
Activity: PERSONAL
Flight Phase: LANDING (LDG)
Operation: 91
City: WALLACE
State: NORTH CAROLINA

Piper PA-24-250 Comanche, N5151P: Incident occurred November 11, 2021 in Helix, Umatilla County, Oregon

Federal Aviation Administration / Flight Standards District Office; Portland, Oregon

Aircraft made a precautionary landing in a field. 


Date: 12-NOV-21
Time: 00:51:00Z
Regis#: N5151P
Aircraft Make: PIPER
Aircraft Model: PA24
Event Type: INCIDENT
Highest Injury: NONE
Aircraft Missing: No
Damage: UNKNOWN
Activity: PERSONAL
Flight Phase: EN ROUTE (ENR)
Operation: 91
City: HELIX
State: OREGON

Robinson R44 II, N3027W: Accident occurred November 10, 2021 in Fort Davis, Jeff Davis County, Texas

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. 

The National Transportation Safety Board did not travel to the scene of this accident. 

Additional Participating Entity:
Federal Aviation Administration / Flight Standards District Office; Lubbock, Texas

S2 Helicopter Services LLC


Location: Fort Davis, Texas
Accident Number: CEN22LA034
Date and Time: November 10, 2021, 13:50 Local
Registration: N3027W
Aircraft: ROBINSON HELICOPTER COMPANY R44 II
Injuries: 3 None
Flight Conducted Under: Part 91: General aviation - Business

Aircraft and Owner/Operator Information

Aircraft Make: ROBINSON HELICOPTER COMPANY
Registration: N3027W
Model/Series: R44 II 
Aircraft Category: Helicopter
Amateur Built:
Operator: 
Operating Certificate(s) Held: None
Operator Designator Code:

Meteorological Information and Flight Plan

Conditions at Accident Site:
Condition of Light:
Observation Facility, Elevation: 
Observation Time:
Distance from Accident Site: 
Temperature/Dew Point:
Lowest Cloud Condition: 
Wind Speed/Gusts, Direction: / ,
Lowest Ceiling: 
Visibility:
Altimeter Setting: 
Type of Flight Plan Filed:
Departure Point:
Destination:

Wreckage and Impact Information

Crew Injuries: 1 None
Aircraft Damage: Substantial
Passenger Injuries: 2 None
Aircraft Fire: None
Ground Injuries: 
Aircraft Explosion: None
Total Injuries: 3 None
Latitude, Longitude: 30.735729,-104.00638 

Robinson R22 Beta, N7198A: Accident occurred November 10, 2021 in Freer, Duval County, Texas

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. 

The National Transportation Safety Board did not travel to the scene of this accident. 

Additional Participating Entity:
Federal Aviation Administration / Flight Standards District Office; Baton Rouge, Louisiana

Flying J Services LLC


Location: Freer, Texas
Accident Number: CEN22LA033
Date and Time: November 10, 2021, 14:30 Local
Registration: N7198A
Aircraft: ROBINSON HELICOPTER R22 BETA 
Injuries: 2 None
Flight Conducted Under: Part 91: General aviation - Other work use

Aircraft and Owner/Operator Information

Aircraft Make: ROBINSON HELICOPTER 
Registration: N7198A
Model/Series: R22 BETA 
Aircraft Category: Helicopter
Amateur Built:
Operator: 
Operating Certificate(s) Held: None
Operator Designator Code:

Meteorological Information and Flight Plan

Conditions at Accident Site: 
Condition of Light:
Observation Facility, Elevation: 
Observation Time:
Distance from Accident Site: 
Temperature/Dew Point:
Lowest Cloud Condition: 
Wind Speed/Gusts, Direction: / ,
Lowest Ceiling: 
Visibility:
Altimeter Setting: 
Type of Flight Plan Filed:
Departure Point: 
Destination:

Wreckage and Impact Information

Crew Injuries: 2 None 
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries:
Aircraft Explosion: None
Total Injuries: 2 None 
Latitude, Longitude: 27.8828,98.6178 (est)


Piper PA-28-161, N47615: Incident occurred November 11, 2021 at Fort Worth Meacham International Airport (KFTW),

Federal Aviation Administration / Flight Standards District Office; North Texas

Aircraft landed and veered off runway into the grass and gear collapsed.  


Date: 11-NOV-21
Time: 15:55:00Z
Regis#: N47615
Aircraft Make: PIPER
Aircraft Model: PA28
Event Type: INCIDENT
Highest Injury: NONE
Aircraft Missing: No
Damage: MINOR
Activity: INSTRUCTION
Flight Phase: LANDING (LDG)
Operation: 91
City: FORT WORTH
State: TEXAS

Piper PA-42-1000 Cheyenne 400LS, N450MW: Incident occurred November 11, 2021 at Houston-David Wayne Hooks Airport (KDWH), Harris County, Texas

Federal Aviation Administration / Flight Standards District Office; Houston, Texas

Aircraft taxiing and veered off taxiway into the grass, rear wheel sunk into the ground and incurred a propeller strike. 

Aircraft Guaranty Corp Trustee


Date: 11-NOV-21
Time: 17:32:00Z
Regis#: N450MW
Aircraft Make: PIPER
Aircraft Model: PA42
Event Type: INCIDENT
Highest Injury: NONE
Aircraft Missing: No
Damage: UNKNOWN
Activity: PERSONAL
Flight Phase: TAXI (TXI)
Operation: 91
City: HOUSTON
State: TEXAS

Cessna 182T Skylane, N3YU: Incident occurred November 09, 2021 at Richard I. Bong Memorial Airport (KSUW), Superior, Douglas County, Wisconsin

Federal Aviation Administration / Flight Standards District Office; Minneapolis, Minnesota

Aircraft made a hard landing.  

Van Bortel Aircraft Inc


Date: 09-NOV-21
Time: 20:00:00Z
Regis#: N3YU
Aircraft Make: CESSNA
Aircraft Model: 182
Event Type: INCIDENT
Highest Injury: NONE
Aircraft Missing: No
Damage: UNKNOWN
Activity: PERSONAL
Flight Phase: LANDING (LDG)
Operation: 91
City: SUPERIOR
State: WISCONSIN