# NTSB ERA17FA052: Ryan Navion, N4976K, New Gretna, NJ, November 20, 2016 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: November 19, 2016, 19:02 local (Nov 20, 2016, 00:02 UTC) - Place: New Gretna, NJ - Coordinates: 39.664722, -74.468055 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=39.6647&lon=-74.4681&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Windshear or thunderstorm](https://openairdocs.org/ntsb-events/390) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report May 16, 2017 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: Continental Motors, FAA/FSDO - NTSB case key (mKey): 94403 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA17FA052 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/94403/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=94403 - Page: https://openairdocs.org/ntsb/ERA17FA052 ## Probable cause The pilot's inadequate preflight weather planning and in-flight weather evaluation, which resulted in an encounter with a strong cold front and the pilot's subsequent loss of airplane control. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Planning/preparation: weather planning](https://openairdocs.org/ntsb-findings/02061020): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Ryan NAVION A, 1 case](https://openairdocs.org/ntsb-findings/02061020/cases.md?model=6150162), [All aircraft, 156 cases](https://openairdocs.org/ntsb-findings/02061020/cases.md) - [Info processing/decision: identification/recognition](https://openairdocs.org/ntsb-findings/02041510): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Ryan NAVION A, 1 case](https://openairdocs.org/ntsb-findings/02041510/cases.md?model=6150162), [All aircraft, 559 cases](https://openairdocs.org/ntsb-findings/02041510/cases.md) - [Performance/control parameters](https://openairdocs.org/ntsb-findings/01062000): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Ryan NAVION A, 2 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md?model=6150162), [All aircraft, 1,269 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md) - [Convective weather](https://openairdocs.org/ntsb-findings/03033000): Environmental issues › Conditions/weather/phenomena · Effect on operation (probable cause); cases with it: [Ryan NAVION A, 1 case](https://openairdocs.org/ntsb-findings/03033000/cases.md?model=6150162), [All aircraft, 17 cases](https://openairdocs.org/ntsb-findings/03033000/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Ryan NAVION A, 3 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=6150162), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: Windshear or thunderstorm](https://openairdocs.org/ntsb-events/390) (defining event); cases with it: [Ryan NAVION A, 1 case](https://openairdocs.org/ntsb-events/390/sequence.md?model=6150162), [All aircraft, 224 cases](https://openairdocs.org/ntsb-events/390/sequence.md) - [Enroute-cruise: Loss of control in flight](https://openairdocs.org/ntsb-events/240); cases with it: [Ryan NAVION A, 2 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=6150162), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Ryan NAVION A, 3 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=6150162), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The private pilot was conducting a personal cross-country flight. The pilot's friend reported that he provided weather information to the pilot about 1 hour before the flight; no record was found indicating that the pilot or the friend obtained a formal weather briefing before he departed for the night cross-country flight. A review of weather information revealed that, about 1 hour 20 minutes into the flight, as the airplane was nearing the destination airport, it encountered a strong cold front boundary with associated severe wind shear and turbulence. Review of radar data revealed that, during the following 13 minutes, the flight completed numerous course deviations, including three complete left circuits and two right circuits, before impacting wooded terrain. Review of the last 3 minutes of radar data revealed that the airplane's altitude oscillated between 2,100 and 200 ft mean sea level (msl) as it completed the two right circuits and one of the left circuits before it impacted terrain. The last target was recorded about 2,000 ft southeast of the accident site at an altitude of 525 ft msl. Examination of the wreckage did not reveal any preimpact mechanical malfunctions or failures that would have precluded normal operation. Based on the evidence, it is likely that the airplane encountered wind shear and turbulent conditions upon encountering the strong cold front boundary and that the pilot subsequently lost airplane control. ## Factual narrative The four-seat, low-wing, retractable tricycle-gear airplane was manufactured in 1949. It was powered by a 205-horsepower Continental E-185 engine and was equipped with a constant-speed Hartzell propeller. The pilot purchased the airplane in 1993. Review of maintenance records revealed that the airplane's most recent annual inspection was completed on July 12, 2016. At that time, the airframe had accumulated about 3,501 total flight hours, and the engine had accumulated about 548 hours since major overhaul. According to the tachometer, the airplane had flown about 23 hours from the time of the annual inspection until the accident. On November 19, 2016, about 1902 eastern standard time, a Ryan Navion A, N4976K, impacted wooded terrain while maneuvering near New Gretna, New Jersey. The private pilot was fatally injured, and the airplane was substantially damaged. The airplane was registered to and operated by the private pilot as a 14 Code of Federal Regulations Part 91 personal flight. Night visual meteorological conditions prevailed, and no flight plan was filed. The flight originated from Hummel Field (W75), Saluda, Virginia, about 1730, destined for Ocean County Airport (MJX), Toms River, New Jersey. The day before the accident, the pilot flew uneventfully from MJX to Accomack County Airport (MFV), Melfa, Virginia for an overnight visit with a friend who was also a pilot. On the day of the accident, both pilots flew their airplanes to W75 for dinner. After dinner, they both fueled their airplanes and about 1730, they departed for home (the pilot to MJX and the friend to MFV). While en route, they communicated with each other on their radios. During approach to MFV, about 1805, the friend experienced wind shear and performed a missed approach. He advised the pilot of the strong wind conditions, which he acknowledged. The friend radioed the pilot again about 1830 to check on him, and he replied that he was okay and had reached the Delaware Bay. No further communications were received from the pilot. Review of weather information and radar data provided by the Federal Aviation Administration (FAA) revealed that, after departure, the accident flight proceeded on a relatively direct course until about 1849, when it encountered the leading edge of a cold front boundary. During the following 13 minutes, the flight completed numerous course deviations, including three complete left circuits and two right circuits, before impacting wooded terrain. Review of the last 3 minutes of radar data revealed that the airplane's altitude oscillated between 2,100 and 200 ft mean sea level (msl) as it completed the two right circuits and one of the left circuits before impacting terrain. The last target was recorded at 1902:36, when the airplane was about 2,000 ft southeast of the accident site at an altitude of 525 ft msl. The Burlington County Medical Examiner, Mount Holly, New Jersey, conducted an autopsy on the pilot. The autopsy report noted the cause of deathas "multiple injuries." The FAA's Bioaeronautical Science Research Laboratory, Oklahoma City, Oklahoma, conducted toxicological testing on specimens from the pilot. The results were negative for alcohol and drugs. The pilot's friend reported that he had obtained a weather briefing about 1630 via flight service for both his and the pilot's flights. The friend added that he told the pilot that the weather was forecast to deteriorate near his destination airport between 1900 and 1930; however, a search of flight service records did not reveal any contact from either pilot's airplane registration numbers on the day of the accident. Additionally, the friend reported that he plotted a route on the pilot's iPad using a Garmin Pilot app, which overlaid weather information; however, a search of ForeFlight and Garmin did not reveal any current subscriptions for the pilot. MJX was located about 16 miles northeast of the accident site. At 1856, the recorded weather at MJX was wind from 150° at 5 knots, visibility 3 statute miles in mist, sky clear, temperature 12°C, dew point 12°C, and altimeter setting 29.64 inches of mercury. Atlantic City International Airport (ACY), Atlantic City, New Jersey, located about 14 miles southwest of the accident site. At 1730, the recorded wind at ACY was from 290° at 24 knots, gusting to 31 knots. Further review of weather data revealed multiple area forecasts for a strong cold front moving through the area with associated severe wind shear and turbulence (for more information, see the Weather Study in the public docket for this accident). The pilot held a private pilot certificate with an airplane single-engine land rating. He did not have an instrument rating. His most recent FAA third-class medical certificate was issued on May 7, 2015. At that time, he reported a total flight experience of 800 hours. The pilot's logbook was not recovered. A debris path, beginning with freshly cut tree branches and a section of right stabilizer tip and right elevator, extended about 420 ft on a magnetic heading north of the main wreckage. The right and left flaps, left wing tip, left aileron, and cabin roof were located about 340 ft along the debris path. The right aileron and left stabilizer tip were located about 390 ft along the debris path. The main wreckage was inverted at the end of the debris path with both wings separated. The right main landing gear and nose landing gear remained attached to the airframe and were observed in the extended positon. The left main landing gear had separated, and the landing gear tire was located next to the main wreckage. The empennage and rudder remained attached to the airframe. The wreckage was transported to a recovery facility for further examination. Aileron control continuity was confirmed from the cockpit area to the wing roots, where the left and right aileron cable ends exhibited broomstraw separation, consistent with overload. Continuity was also confirmed from the cockpit area to theempennage area, where the elevator and elevator trim cables exhibited broomstraw separation, consistent with overload. The rudder cables exhibited cuts consistent with recovery of the wreckage. The propeller remained attached to the engine. Both propeller blades exhibited S-bending, chordwise scratching, leading edge gouging, and tip curling. Due to an impact fracture at the front of the engine crankcase, the propeller could only be rotated about 90°. Using a lighted borescope during rotation, crankshaft continuity was confirmed to the pistons, and camshaft continuity was confirmed to the cylinder valves. Both magnetos sparked at all leads when rotated by hand. Throttle control continuity was confirmed to the throttle lever at the carburetor. Mixture control continuity was confirmed to the mixture lever at the carburetor, where the mixture lever was impact separated. ## Aircraft - Registration: [N4976K](https://openairdocs.org/deregistered/N4976K-2018-06-08), registration cancelled 2018-06-08, S/N NAV-4-1976, built 1949 (OpenAirDocs) - Reported make and model: RYAN NAVION (A) - Registry model: [Ryan NAVION A](https://openairdocs.org/model/ryan-navion-a) (registry code 6150162) (OpenAirDocs) - Registry engine: [Continental E185 series](https://openairdocs.org/engine/continental-e185-series) (registry code 17014, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: NAV-4-1976 - Year built: 1949 - Airframe hours: 3501.1 - Engines: Continental E-185 205 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, July 12, 2016, 23 hours before - Departed: W75, SALUDA, VA - Destination: MJX, TOMS RIVER, NJ - Equipment: Electronic flight bag or handheld device ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 75; injuries: fatal; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; seat: left; restraint: lap only; toxicology performed; flight hours: 800 total, 999,999 in this make and model ## Weather - Conditions: Visual (VMC), Night - Wind: 150° at 5 knots - Visibility: 3 statute miles - Lowest ceiling: none - Temperature: 54 °F, dew point 54 °F - Altimeter: 29.63 inHg - Observed at: MJX, 16 nm away ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20161119020639A](https://openairdocs.org/incident/20161119020639A), Nov 19, 2016: Ryan NAVION A, New Gretna, NJ, Substantial damage, 1 fatal. On November 20, 2016 aircraft N4976K, a navion had crashed in a heavily wooded area, in southern new jersey. Pilot sustained fatal injuries. He was the sole… ## Docket (13 files) The files NTSB released with the investigation on May 11, 2017, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=94403. 8.2 MB in all. - Interview Summaries (item 1, .PDF, 68 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40452067&FileExtension=.PDF&FileName=Interview%20Summaries-Master.PDF - Fueling Record (item 2, .PDF, 54 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40452068&FileExtension=.PDF&FileName=Fueling%20Record-Master.PDF - Excerpts from Maintenance Records (item 3, .PDF, 370 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40452069&FileExtension=.PDF&FileName=Excerpts%20from%20Maintenance%20Records-Master.PDF - Weather Study Report (item 4, .PDF, 3.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40452070&FileExtension=.PDF&FileName=Weather%20Study%20Report-Master.PDF - Weather Attachment 1 (item 5, .GIF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40452071&FileExtension=.gif&FileName=Weather%20Attachment%201-Master.gif - Radar Plot (item 6, .PDF, 288 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40452072&FileExtension=.PDF&FileName=Radar%20Plot-Master.PDF - Radar Data (Excel File) (item 7, .CSV, 32 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40452073&FileExtension=.csv&FileName=Radar%20Data%20(Excel%20File)-Master.csv - Wreckage Map (item 8, .PDF, 1 photo, 311 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40452074&FileExtension=.PDF&FileName=Wreckage%20Map-Master.PDF - Memorandum for Record - Wreckage Examination (item 9, .PDF, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40452075&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20-%20Wreckage%20Examination-Master.PDF - Photo Array (item 10, .PDF, 4 photos, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40452076&FileExtension=.PDF&FileName=Photo%20Array-Master.PDF - Toxicological Report (item 11, .PDF, 151 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40452077&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 12, .PDF, 237 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40452078&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 13, .PDF, 235 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40452079&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Master.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.