The NTSB recently released an accident report that contains ammunition for those folks who have axes to grind about the way things are being done in aviation today. For example, those who believe that pilots can’t be trusted to self-certify that they’re medically safe to fly are certain to take comfort in what the NTSB found about drug use by the pilot. Those who believe that the FAA has been an inept bureaucracy that has had trouble getting even the simple things right will find what this investigation says about FAA handling of controller displays to be interesting. Those who want to see air traffic control privatized will enjoy the anecdotes about controller scheduling and overtime.
The accident took place on August 16, 2015, at Hicksville, New York. A Beech C35 Bonanza was being used for a Part 135 on-demand air taxi flight from Francis S. Gabreski Airport (KFOK) at Westhampton Beach, N.Y., to Morristown Municipal Airport (KMMU) in New Jersey. It was about 7:45 a.m., when the airplane crashed onto Long Island Rail Road tracks and burst into flames. The commercial pilot was killed. The passenger was rescued from the wreckage by witnesses and survived with serious injuries. The airplane initially hit a railroad-grade crossing cantilever arm. The main wreckage came to rest inverted on the tracks in a debris field that was about 100 feet long and about 20 feet wide.
The surviving passenger said he hired the pilot’s company, which operated only the 1952 Bonanza, for the air taxi flight. They departed VFR at about 7:20. The wind was calm, visibility was greater than 10 miles, and there was no ceiling. The pilot checked in with a New York Approach controller at Islip while climbing through 1,300 feet about 2 miles east of KFOK. The pilot wanted to obtain clearance through the New York Class B airspace for a fairly direct route to KMMU. He asked for a climb to 6,500 feet MSL. The pilot was given a squawk of 4356 and identified on radar. At 7:30, the pilot was handed off to a Kennedy International Airport departure controller. The pilot again requested clearance into the New York Class B airspace at 6,500 feet and was granted the clearance. At 7:38, the flight was handed off to a departure controller for LaGuardia Airport.
At 7:38:18, the pilot checked in with LaGuardia and reported at 6,500 feet. The controller responded about 50 seconds later with the altimeter setting, which was acknowledged by the pilot. The airplane had entered a turn to the east, it climbed about 100 feet, its ground speed was slowing, and it was beginning a descent. The LaGuardia controller observed the descent and realized he had to do something to prevent the Bonanza from descending into the LaGuardia departure corridor. The controller didn’t ask the pilot about the reason for the descent but, at 7:39:57, radioed for the flight to “...turn right heading three six zero.” The pilot responded, “Okay, four six charlie, I’m having a little bit of a problem here, uh, sir. I think I’m going to have to return to Farmingdale, well, give me a second if I may.” The flight didn’t originate from Farmingdale, but it had flown beyond Republic Airport at Farmingdale (KFRG).
The passenger later told investigators he heard a loud “pop” sound and saw a flicker of light coming from the engine, followed by an oil smell. He said the engine sputtered and lost power, and the pilot was “checking the aircraft controls and switches” to try to get the engine restarted.
At 7:40:09, the controller radioed, “...sure, just, uh, let me know what ya, uh, what ya need.” The pilot responded, “Affirmative” and the controller said, “...if ya can keep me in the loop, uh, let me know what’s going on and any assistance you need.” At 7:40:30, the pilot radioed, “...I’m gonna have to take it down and, uh, the closest spot (unintelligible).”
The controller pointed out that “...LaGuardia Airport is at your twelve o’clock and about twelve miles, Kennedy ten o’clock and about twelve miles, uh, Westchester is to the north and Farmingdale is to the southeast. You can go anywhere you like, just let me know what you need and what you need to do.”
The controller advised his supervisor that he thought the Bonanza had a problem. At that time, both the LaGuardia controller and the controller-in-charge at the facility considered it to be an emergency, even though the pilot had not declared an emergency. The controller did not request information regarding the nature of the problem or solicit information normally associated with emergency handling. The controller had the option to annotate the radar data block for the Bonanza with the letter “E” to indicate an emergency. This would have alerted all the controllers handling traffic in other sectors who could see the aircraft’s data block that an emergency was in progress, but the controller told investigators it did not occur to him to do so.
The controller who handled the accident airplane told investigators his normal work schedule varied, but he had been working six day weeks and an occasional 10-hour shift twice a month. His normal days off were Wednesday and Thursday; however, he typically worked Wednesdays as overtime.
The controller-in-charge told investigators he had been working six-day weeks for as long as he could recall, specifically during the summer, spring and fall. Winter traffic allowed for some relief from the six-day weeks. In addition to the six-day work weeks, he worked an occasional 10-hour day every other week and had the opportunity to work a 10-hour day every day.
At 7:40:54, the pilot radioed, “...okay, Farmingdale is the closest airport, uh, nine miles, okay, I’m not going to make Farmingdale, well, let’s just (unintelligible).” The controller asked, “...you going back to Farmingdale, you said?” and the pilot replied, “Yeah, I don’t know if I can make Farmingdale, give me the closest one, Farmingdale is the closest, is that correct?”
Investigators found that when properly configured, the Bonanza would have been able to glide about 1.7 nautical miles (2 statute miles) for every 1,000 feet of altitude above the ground. They calculated that had the pilot gone to best glidespeed as soon as the engine quit at 6,500 feet, the airplane would have been able to glide about 10.8 nm. The approach end of Runway 14 at KFRG was about 7 nm away at that time.
The pilot continued on a westerly heading for 2 minutes, 18 seconds, after the sudden decrease in airspeed, and the airplane lost about 2,000 feet of altitude before the pilot turned the airplane left toward the Bethpage area. Several golf courses were located at the pilot’s 10- to 12-o’clock positions if he had continued to descend on a westerly heading.
The controller’s radar video map (RVM) showed that the airplane also was near the Bethpage Airport, and when the controller responded to the pilot’s question about Farmingdale, he said, “Yes, sir, there is, uh, uh, a strip about your ten o’clock and five miles, uh, Bethpage Airport there, if you want to try that one we could do that, too.” A few seconds later, the controller added, “...the, uh, Bethpage strip again, ten o’clock, four miles, you’re just about lined up on the extended centerline.”
To find out more about the Bethpage Airport, the controller used an automation function of his display system called a “splat 1” keyboard entry. If an airplane needs to get down quickly, a “splat” entry will display bearing, range and airport information for the airport closest to the aircraft in distress. The controller types an asterisk followed by a number 1 through 4. The numerals reflect the category of airplane: the Bonanza is a category 1 aircraft; category 2 is larger; a Boeing 737 would be a category 3 airplane; category 4 is a helicopter. When the controller queried the radar target associated with the Bonanza using the “splat 1” keystroke sequence, the aircraft was near the Bethpage Airport symbol shown on the RVM. However, no text information for Bethpage came up. Instead, the query returned information for KFRG.
At 7:42:35, the pilot asked, “...give me that strip again, please.” The controller responded, “...about twelve o’clock and, uh, four miles now, it looks like you are set up right on the extended centerline for the runway there.” The controller added, “Farmingdale airport’s about three miles southeast of there if you want to go into Farmingdale.” The pilot said, “I’m losing altitude, this is the best I can do altitude-wise.”
At 7:43:47, the pilot radioed that he was not seeing the Bethpage Airport, and the controller told him, “...uh, there’s a strip right about your twelve o’clock and three miles, it’s the Bethpage strip right there, and again Farmingdale is about ten o’clock and six.”
The pilot radioed that he could not glide six miles and, at 7:44:00, the controller explained that “...the strip is, uh, a closed airport, I just know there is a runway there about eleven o’clock and about a mile and half now.” But, all he knew was what the display in front of him was showing; a runway labeled Bethpage. The pilot asked, “...you’ve got to give me a little bit of a heading on that if you would.” The controller suggested, “...about, um, ten more degrees to the right but, uh, if you need to there’s a [unintelligible] parkway right there, uh, to the parkway.” The pilot asked, “...and, Farmingdale I got three miles right?” The controller said, “Farmingdale’s about eleven o’clock and five miles,” to which the pilot responded, “...okay, no way I’m going to make that, um, show me this strip again if you would I’m sorry.”
The controller said, “...the strip is, ah, the strip is about one o’clock, less than a mile, it’s a closed airport, I have no information about it unfortunately.”
At 7:45:38, the controller radioed “....radar contact lost, uh, three miles northwest of Farmingdale airport.” There were no additional transmissions from the pilot.
In fact, there once had been a Bethpage Airport, with one of its runways sporting the name “Grumman” in huge white letters. From the mid-1930s through the mid-1990s, it was a beehive of activity for Grumman Aircraft. But, the airport closed and buildings replaced one runway and soon straddled another. By the time of this accident, the land was built up and there was nothing left resembling a runway.
Bethpage Airport was removed from FAA sectional charts in October 2012. Data for the airport were removed from the LaGuardia automation database used to display information for controllers, but investigators could not determine the exact date. However, at the time of this accident, the RVM continued to carry code used to create a display of the single runway that had remained before Bethpage Airport completely disappeared.
The FAA vice president of air traffic services issued a memo on September 1, 2015, requiring all terminal air traffic facilities to immediately review all displays for controllers and ensure only operational airports were depicted, and to check all RVM files for airport information accuracy. A team of FAA personnel was directed to review all video maps in the national airspace system. The plan included the development of automation to assist with the review of an estimated 10,500 RVM files. Corrected RVM files that removed the Bethpage Airport symbol were installed at the LaGuardia approach control position, which handled the accident aircraft on the evening of September 3, 2015.
The 59-year-old pilot held a commercial pilot certificate with airplane single-engine, multi-engine and instrument airplane ratings. His second-class medical certificate was current and required him to wear glasses for near vision. At the time of his medical, he reported 3,300 total flight hours. No recent logbooks were located. FAA records revealed that he completed a Part 135 line check on June 18, 2015. He was listed as a single-pilot operator under the name Milo Air, Inc., conducting on-demand air taxi flights.
The four-seat, low-wing, retractable-gear airplane was powered by a 260 hp Continental IO-470-N engine. At the time of the accident, the engine had about 2,913 hours, with 1,427 since major overhaul. It had been removed and disassembled twice following propeller strikes in 2006 and 2007.
The engine was sent to the manufacturer’s facility for examination. There was a large hole in the bottom of the oil sump. Metal particles were observed in the oil filter element. All six cylinders had rust in the barrels. There was evidence that bearings had suffered heat distress, including the No. 2 bearing, which was dry with no oil, was partially melted and extruded into the crank cheek, and had rotated in the bearing support. The crankshaft was broken at the No. 2 main journal and the crank cheek.
Toxicology testing performed by the FAA’s Bioaeronautical Research Sciences Laboratory indicated that the pilot had used the drugs amphetamine, oxycodone and losartan.
Amphetamine is a central nervous system stimulant prescribed for the treatment of narcolepsy and attention deficit hyperactivity disorder. Oxycodone is an opioid commonly available in combination with acetaminophen with the names Percocet and Roxicet. Losartan is a blood pressure-lowering medication. Investigators were not provided with full information on the pilot’s medical history.
The NTSB determined that the probable cause of this accident was the pilot’s improper decision to delay turning toward a suitable runway once he realized that an engine failure had occurred, which resulted in his having inadequate altitude to glide to a suitable runway, and the New York terminal radar approach control LaGuardia Airport area controller’s provision of erroneous emergency divert airport information to the pilot.
Contributing to the accident were: 1) the FAA’s lack of a requirement to periodically review and validate radar video maps; 2) the failure of the engine crankshaft due to a bearing shift; and 3) the pilot’s impairment due to his abuse of amphetamine and underlying medical conditions(s).
While this probable cause blames the pilot for delaying a turn to a suitable runway, the pilot seemed to be rationally analyzing the situation and ultimately believed he was going toward a suitable runway and that he could have made it. It blames the controller for giving erroneous information, but the controller believed he was giving accurate information to the pilot from seeing a runway depicted in a circle representing the Bethpage Airport right there on the display in front of him. The pilot is declared to have been impaired by drugs based on toxicology testing, although the radio transcript doesn’t seem to show impairment, nor did the passenger mention any signs of confusion, panic or inaction by the pilot. It might have been useful for those of us who worry about engine health and maintenance to learn about what caused the bearing shift in this engine being run under Part 135, but there wasn’t much detail.
I’m afraid those of us looking for safety lessons may find less here than those looking to argue for dramatic changes in U.S. aviation.
Peter Katz is editor and publisher of NTSB Reporter, an independent monthly update on aircraft accident investigations and other news concerning the National Transportation Safety Board. To subscribe, visit www.ntsbreporter.us or write to: NTSB Reporter, Subscription Dept., P.O. Box 831, White Plains, NY 10602-0831.