NTSB Factual Report

HISTORY OF FLIGHT

On May 9, 2014, at 2031 eastern daylight time, a Navion G, N2473T, was substantially damaged when it impacted trees and terrain in Hamilton Township, New Jersey, after a loss of engine power. The commercial pilot and one of the passengers were seriously injured, while another passenger sustained minor injuries. A pilot-rated passenger in the right front seat was fatally injured. Night instrument meteorological conditions prevailed. No flight plan was filed for the flight, from St. Mary's Airport (2W6), Maryland, to Atlantic City International Airport (ACY), Atlantic City, New Jersey; however, approaching Atlantic City, the pilot requested and received an instrument flight rules clearance. The personal flight was conducted under the provisions of 14 Code of Federal Regulations (CFR) Part 91.

According to the pilot, the purpose of the flight was to attend a local area airshow the next day. Prior to the flight, he checked the weather via internet and called ACY Tower several times to check its progress. He was aware of potential low visibilities and his alternate plan if not be able to land at ACY was to either fly to an airport in Millville, New Jersey, or return home.

The pilot initially completed an ILS (Instrument Landing System) runway 13 approach to ACY; however, due to the low visibility, he could not complete the landing and flew a missed approach. The controller offered another approach, which he accepted. Commencing the second approach, the pilot was advised of the current weather [the controller reported a 200-foot overcast, ¼-mile visibility in fog], and knew then that he had no chance of completing the approach. He requested vectors to "Millville," and was told to climb to 2,000 feet. He added full power, and the engine "stopped" with the pilot perceiving either a fuel or an electrical problem.

Once the engine quit, the pilot moved the fuel selector through various positions, then checked the ignition, throttle and mixture.

In a written statement, the pilot further reported that after entering the climb, "the nose was in the climb attitude for a number of seconds and the engine simply stopped delivering power (propeller continued turning). I immediately checked the fuel [selector] (set to main), while entering a glide descent. I moved the fuel [selector] to right tip feed and moved and checked throttle, mixture and ignition settings. I am uncertain how long I held the fuel [selector] in the different positions but it was moved to main again after some delay. I remember my hand remaining on the fuel [selector] for some of the descent."

The pilot also made a "mayday" call to the tower and warned the passengers to brace themselves. The pilot maintained wings level and a nose attitude to maintain about 80 mph. The airplane subsequently struck the tops of trees, at which point the pilot released the controls and braced himself, followed by a "violent deceleration."

Radio Transmissions

According to FAA Air Traffic Control Accident Report excerpts,

At 1956, the approach controller advised the pilot that "the last couple of arrivals have been picking up the airport right at minimums."

At 1958, the airplane was cleared for the ILS (Instrument Landing System) runway 13 approach.

At 2004, the controller advised the pilot that the weather "goes all the way down to ground" and that runway visual range was 2,000 feet.

At 2010, the pilot advised the controller that the airplane was established on the approach. The pilot was then advised to contact the tower controller.

At 2011, the pilot contacted the local (tower) controller, who cleared the pilot to land, advised him of the current weather, and noted that he had the runway lights turned all the way up.

At 2016, the local controller asked the pilot if he had missed the approach, which the pilot advised that he had. The controller told the pilot to maintain runway heading and climb the airplane to 2,000 feet. He subsequently advised the pilot to contact departure control, which the pilot acknowledged.

At 2017, the pilot contacted departure control, and was asked if he wanted another approach. The pilot stated, "we'll try one more thanks."

The controller subsequently provided vectors, the first one left to 360 degrees, followed by 310 degrees.

At 2020, the pilot advised the controller that if they didn't "get in this time, we'd like to go to Millville."

At 2024, the controller advised the pilot to turn to heading 220 degrees.

At 2025, the controller advised the pilot that the airplane was 5 miles to MAYBN intersection, to turn left to heading 160 degrees, maintain 2,000 feet until established on the localizer, cleared for the ILS runway 13 approach.

At 2027, the controller advised the pilot to contact the local controller, which the pilot acknowledged.

At 2028, the pilot contacted the local controller, who asked if the airplane was left of course. The pilot responded that it was and that he was correcting to the right.

The controller then noted that the visibility was about ¼ mile with a 200-foot overcast, and the pilot asked him to confirm. After the controller did, the pilot stated, "we'll go around and if you could, give us vectors to Millville please." The controller then told the pilot to abandon the approach and climb to 2,000 feet. After consulting with the departure controller, the local controller, at 2029:39, advised the pilot to contact departure control, which the pilot acknowledged. (The latest radar contact, at 2029:32, indicated that the airplane was at 1,700 +/-50 feet.)

At 2030:04, the local controller noted to the departure controller that the airplane was still descending, which the departure controller also saw. The local controller then asked the pilot if he was "on the air." (Radar indicated that the airplane was about 1,300 feet.)

At 2030:13, the pilot answered, "affirm, we've got an engine problem; at the moment we're trying to restart." (Radar indicated that the airplane was about 1,200 feet.)

At 2030:17, the local controller stated, "I suggest you climb immediately," which the pilot responded, "that's a copy." (Radar indicated that the airplane was about 1,100 feet.)

At 2030:35, the local controller asked if everything was "okay," and the pilot responded, "that's a negative, we've got an engine out at the moment." (Radar indicated the airplane was about 700 feet.)

At 2031:02, the local controller asked the pilot if everything was okay again, and the pilot responded, "mayday, mayday, mayday, we've got an engine failure, we're about to crash." (The airplane was then below radar coverage; last contact was at 2030:50, at 500 feet.)

There were no further transmissions from the airplane.

PILOT INFORMATION

The pilot, age 45, held a commercial pilot certificate with airplane single engine land and instrument ratings. He also held a flight instructor certificate. The pilot reported 5,500 hours of time, with 100 hours in airplane make and model. His latest FAA second class medical certificate was dated January 23, 2014.

AIRPLANE INFORMATION

The airplane was powered by a Teledyne Continental Motors IO-520-series engine driving a three-bladed metal propeller. The latest annual inspection was completed on March 1, 2014, at 2,323 hours; at the time of the accident, airframe time was 2,339 hours and engine time was 92 hours since it was factory-rebuilt.

The operating manual found in the airplane stated that the fuel supply system provided 108 gallons of usable fuel. There were two center wing tanks, connected to a sump, filled via a filler neck incorporated in the right tank, and two wing tip tanks. Fuel tank selection was via a floor mounted selector. The selector face was circular with a handle on top that rotated through the following positions: "OFF" at the 6 o'clock position, "LEFT TIP" at the 9 o'clock position, "MAIN" at the 12 o'clock position, and "RIGHT TIP" at the 3 o'clock position. On top of the handle was a knob that had to be lifted upward to move the handle to the "OFF" position.

Tip tank fuel was supplied via a finger strainer assembly located at the bottom, center of each the tank, half way between the nose and tail of the tank.

According to the pilot, the airplane's fuel gauges were inaccurate and he checked the fuel quantity in both tip tanks and the main tanks prior to the accident flight using a calibrated stick. Both tip tanks had 10 gallons each while the main tanks had slightly over 15 gallons total. In addition, and as was normal procedure, he ran the engine for 3 minutes on the ground from each tip tank to ensure proper tip tank feed.

The pilot further noted that he always took off and landed on main fuel tanks and utilized the tip tanks in transit. On the accident flight he utilized the left tip tank for 22 minutes, 40 seconds and was certain of the time due to using a stopwatch. He utilized the main tanks for the first approach and after the missed, switched to the right tip tank. About 1 minute before the engine quit, he switched from right tip tank to the main tanks again.

The pilot also advised that the boost pump was utilized for start and could be used during approach and takeoff. In addition, when utilizing tip tanks in cruise flight, it was normal to run a tip tank out of fuel. At that point, the main tank would be selected, and the engine would return to operating 5-10 seconds later. He further noted that the airplane was recently flown several legs round trip to the Atlanta, Georgia, area, and during the last flight, when he ran a tip tank dry, it seemed that the engine took a little longer than normal to return to running.

The airplane was equipped with seat belts only (no shoulder harnesses) for all seats. When the airplane was manufactured, shoulder harnesses were not required by the FAA, nor are they required to be retrofitted. In December 2003, the certificate holder received an FAA Parts Manufacturer Approval (PMA) for pilot seat and copilot seat shoulder harnesses. The shoulder harness assembly included an anchor in the airplane's ceiling, above the inboard edge of the other occupant's seat, and a single belt that attached to the ceiling anchor, crossed the occupants' torsos, and attached to the seat belt near each occupant's outboard leg.

AIRPORT INFORMATION

ACY had crossing runways, designated 13/31 and 4/22. Runway 13 was 10,000 feet long and 150 feet wide with a touchdown elevation of 75 feet. The inbound course for the ILS RWY 13 approach was 128 degrees magnetic and the decision height was 275 feet above mean sea level.

METEOROLOGICAL INFORMATION

Weather, recorded at ACY at 2035, included calm winds, fog, ½ mile visibility, indefinite ceiling at 200 feet, and an altimeter setting of 30.03 inches Hg.

WRECKAGE AND IMPACT INFORMATION

The wreckage was located in a treed, flat wooded area the vicinity of 39 degrees, 28.26 minutes north latitude, 074 degrees, 39.03 minutes west longitude, at an elevation of about 70 feet. Tops of pine trees were cut in a descending path, with an estimated descent angle of 20 to 30 degrees, heading about 140 degrees magnetic for an estimated 200 feet. The tree cuts suddenly stopped about an estimated 60 feet above the ground in the vicinity of the wreckage location; there were no ground scars leading up to the wreckage.

The airplane came to rest on its left side, about 45-degrees nose down/tail up. The fuselage was mostly intact; however, both wings were separated from the airplane about 2 feet from their roots, and the empennage was separated from the fuselage.

All flight control surfaces were found at the scene, and flight control continuity was confirmed to the cockpit.

The propeller did not exhibit any chordwise scratching or leading edge damage that would have been consistent with the presence of engine power.

The left fuel tip tank was compromised. No fuel was found in it, nor was there an odor of fuel in the soil beneath it. Utilizing the calibrated stick, the right tip tank had about 5 gallons of fuel in it, and the connected main tanks had about 15 gallons of fuel in them. About 10 gallons of fuel were drained from the main tanks, with additional fuel remaining in the tanks. The fuel selector was found in the "main" position.

The wings were removed for transport, and they and the rest of the airplane were transferred to a storage facility for further documentation and an attempt to run the engine.

At the facility, fuel was run through the fuel supply system from the wing separation points through the engine firewall with no blockages noted. In the process, the fuel selector was moved through all positions successfully, with access to the "OFF" position requiring the knob on top of the selector handle to be lifted. About midway between the "LEFT TIP" and "MAIN" positions, as well as the "RIGHT TIP" and "MAIN" positions, there was a small area where the fuel flow would be turned off.

Air was also blown through the supply lines in the wings with no blockages noted. In addition, the finger strainers were removed from both tip tanks. The left tip tank finger strainer exhibited a small amount of debris on the strainer cage, while the right strainer cage exhibited no debris.

Closer examination of the engine revealed that it could not be run at that facility due to impact damage, and it was then shipped to the manufacturer to be run in a test chamber under NTSB oversight.

Engine Test

At the engine manufacturer's facility, due to impact damage, the engine's left front mount was replaced, along with the throttle body and Wye pipe. The oil quick drain was replaced with a plug. The cooling baffles, hydraulic pump, vacuum pump, and airframe breather system were removed, and the engine was fitted with a "test club" propeller.

The engine was subsequently started and allowed to warm up. It was advanced to 1,200 rpm and held at that rpm for 5 minutes to stabilize. It was subsequently advanced to 1,600 rpm, 2,450 rpm, and full throttle, and held at each power setting for 5 minutes to stabilize. The engine was later accelerated rapidly from idle to full throttle six times with no anomalies noted.

Engine Monitor

The airplane was equipped with an engine monitor, which among other parameters, tracked fuel flow. Data revealed that, at 20:30:06 (due to damage, the unit could not be powered up; the time noted was correlated to other in-flight events), fuel flow dropped to zero, with a concurrent reduction in all engine temperatures. Before the end of the recording, fuel flow spiked briefly up to 4 gallons per hour on four occasions before returning to zero, consistent with the pilot's statement that he subsequently moved the fuel selector to different positions. Two of the spikes were indicated for 2 seconds, while the other two were for 3 seconds.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was performed on the pilot-rated passenger by the Office of the State Medical Examiner, Woodbine, New Jersey. Cause of death was determined to be "massive head injuries."

Cockpit evidence, including damage to the instrument panel and engine controls, and direction of the damage, was consistent with the passenger's head having impacted them in a forward, left direction.

ADDITIONAL INFORMATION

Fuel Selector

During the final compilation of factual information, about 18 months after the accident, confirmation was requested as to how the pilot established what position the fuel selector was in, and whether he visually checked it with a flashlight, or used feel, or some combination. The pilot, who had returned to his home country, responded by email: "It's been a long time so I'm not sure I can be 100% certain but the changes to the fuel selection prior to the loss of power were checked visually. [The pilot-rated passenger] had a light which I used to reselect main but once we lost power I used feel only. I thought I secured the fuel after the crash but I honestly cannot be certain as that again was by feel."

Occupant Protection

According to the NTSB Safety Study, "Safety Airbag Performance in General Aviation Restraint Systems," adopted by the Board in January, 2011, NTSB has issued over 30 recommendations concerning general aviation (GA) occupant safet

NTSB Probable Cause

The pilot's mismanagement of the onboard fuel supply, which resulted in fuel starvation to the engine and a subsequent loss of engine power. Contributing to the death of the right front passenger was the inadequate occupant restraint.