ERA21LA035

NTSB accident investigation · Grumman GA7 · Ellicott, NY · November 1, 2020

Accident · FatalClass 3 · LimitedFinal report
Date
November 1, 2020, 17:48 local (22:48 UTC)
Place
Ellicott, NY
Injuries
3 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N791GAGrumman GA7
Defining event
Approach-IFR final approach: Controlled flight into terr/obj (CFIT)
Weather
Instrument (IMC) · Night
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Eastern Region Aviation
Parties
Lycoming Engines, FAA/FSDO
FAA report
20201101017979A
Case key
102223

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The pilot’s continued descent below the minimum descent altitude while conducting an instrument approach in instrument meteorological conditions, which resulted in controlled flight into terrain.

Findings · 2

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Performance/control parameters: descent/approach/glide pathAircraft › Aircraft oper/perf/capability · Not attained/maintainedGrumman American Avn. GA-7: 1 caseAll aircraft: 809 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The pilot rented the airplane and completed a long cross-country flight 4 days before the accident. Before the return (accident) flight, the pilot discussed weather decisions and avoiding icing conditions with his flight instructor via telephone. The instructor subsequently checked a commercial website and realized that the pilot had departed on the return flight. He hoped that the pilot would divert due to the poor weather conditions and sent him a text message to that effect. Review of air traffic control data revealed that, while approaching the destination airport, the pilot provided a pilot report indicating that the airplane was in and out of clouds, updrafts, downdrafts, snow, and light-to-moderate turbulence. The pilot then flew an instrument approach to the destination airport, but radar contact was lost while the airplane was on a 1-mile final approach to the runway. Review of the last 1 minute of data revealed an approximate 500 ft-per-minute descent, consistent with the pilot’s descent on the instrument approach. A witness who lived near the airport reported that he could not see well due to wind and snow and did not initially hear the airplane. He then heard loud engine noise for 10 to 15 seconds followed by silence. The wreckage was located the following day about 1/2 mile from the runway threshold. The wreckage path was consistent with a gradual descent into trees. Examination of the airframe, engines, and recorded data did not reveal any preimpact mechanical malfunctions. The last automatic dependent surveillance-broadcast target indicated an altitude of 2,250 ft mean sea level (msl), which was 527 ft above airport elevation. The recorded weather at the airport 2 minutes after the accident included scattered clouds at 500 ft above ground level and 3/4-mile visibility in light snow and mist. Review of the instrument approach chart revealed a minimum descent altitude of 2,100 ft msl at a distance of 1.1 miles (with minimum visibility 1/2 mile) from the airport with a local altimeter setting and no vertical guidance. If vertical guidance was used on the GPS, the minimum descent altitude was 1,921 ft msl (with minimum visibility 1/2 mile) with local altimeter setting. Although the last target was recorded about 1 mile from the runway threshold and the wreckage was located about 1/2 mile from the runway threshold, there were no data available from the last target to the wreckage. The pilot’s logbook was not recovered, and neither his total time nor his recent instrument flight rules experience could be determined. The circumstances of the accident are consistent with the pilot’s continued descent below the minimum descent altitude while conducting an instrument approach in instrument meteorological conditions, which resulted in controlled flight into terrain.

Factual narrative

The last automatic dependent surveillance-broadcast (ADS-B) target was recorded at 1747:44, about 1 mile from the runway threshold, indicating an altitude of 2,250 ft msl, 527 ft above airport elevation. Review of the instrument approach procedure for the JHW RNAV (GPS) RWY 25 revealed a minimum descent altitude of 2,100 ft msl at a distance of 1.1 miles (with minimum visibility 1/2 mile) from the airport with a local altimeter setting and no vertical guidance. If vertical guidance was used on the GPS, the minimum descent altitude was 1,921 ft msl (with minimum visibility 1/2 mile) with local altimeter setting. Although the last ADS-B target was recorded about 1 mile from the runway threshold and the wreckage was located about 1/2 mile from the runway threshold, there was no data available from the last ADS-B target to the wreckage. On November 1, 2020, about 1748 eastern daylight time, a Grumman American GA-7, N791GA, was destroyed when it was involved in an accident near Ellicott, New York. The pilot and two passengers were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The airplane was based at Chautauqua County/Jamestown Airport (JHW), Jamestown, New York. The pilot rented the airplane and flew uneventfully from JHW to Burlington-Alamance Regional Airport (BUY), Burlington, North Carolina, on October 28, 2020. According to the pilot’s flight instructor, they spoke via telephone before the accident flight and discussed weather decisions and avoiding icing conditions. The instructor then checked a commercial website and realized that the pilot had departed on the return flight to JHW. He hoped that the pilot would divert and sent him a text message to that effect. The instructor subsequently drove to the airport and listened to air traffic control communications as well as common traffic advisory frequency communication (CTAF). The instructor did not hear any communications on the CTAF and added that the weather conditions were conducive to in-flight icing. According to air traffic control data provided by the Federal Aviation Administration (FAA), a controller asked for a pilot report while the airplane was in-bound to JHW. The pilot did not report ice accumulation, but reported being in and out of clouds, updrafts, downdrafts, snow, and light-to-moderate turbulence. The pilot requested and was cleared for the RNAV RWY 25 approach to JHW. Radar contact was lost about 1 mile northeast of the runway 25 threshold (consistent with a 1-mile final approach to runway 25) and no further communications were received from the accident airplane. Review of the last 1 minute of data revealed a descent from 2,750 ft mean sea level (msl) to 2,250 msl, consistent with a descent on the approach. (see figure 1.) Figure 1. Flightpath while on final approach to runway 25 at JHW. A witness who lived near the airport reported that he was in a tree stand for hunting purposes. The witness could not seewell due to wind and snow and did not initially hear the airplane. He then heard loud engine noise for 10 to 15 seconds, followed by silence. The tree stand was located about 3/4 mile northeast of the accident site. Later that evening, the witness was notified that there had been an airplane accident and he assisted first responders in their search for the airplane. The witness subsequently observed tops of trees severed near where he heard the engine noise increase. The severed trees were located about 1/4 mile east of where the wreckage was located. An autopsy was performed on the pilot by the Erie County Medical Examiner’s Office, Buffalo, New York. The cause of death was multiple blunt force injuries. Toxicology testing was performed by the FAA’s Forensic Sciences Laboratory. The results were negative for drugs and alcohol. The pilot obtained weather briefings via a commercial weather service. For more information, see Weather Factual Report in the public docket for this investigation. The weather conditions reported at JHW at 1750 (about 2 minutes after the accident) included wind from 280° at 20 knots with gusts to 30 knots, visibility 3/4 statute miles in light snow and mist, scattered clouds at 500 ft above ground level (agl), a broken ceiling at 1,000 ft agl, an overcast ceiling at 1,700 ft agl, a temperature of -1°C, a dew point of -2°C, and an altimeter setting of 29.85 inches of mercury. The remarks of the weather observation noted a peak wind from 270° at 30 knots at 1747, ceiling varying between 800 and 1,300 ft agl, 0.01 inches of precipitation since 1656, the freezing rain sensor was not operating, and the runway visual range sensor was not operating. The pilot’s logbook was not recovered. According to an insurance application dated October 2018, the pilot had accrued 1,082 total hours of flight experience; of which 37 hours were in actual instrument meteorological conditions (IMC). The pilot’s total and recent IMC experience at the time of the accident could not be determined. The wreckage was located the following day in a wooded area about 1/2 mile from the approach end of runway 25. The wreckage came to rest upright, and the left engine had separated. The wreckage was fragmented, but all major components of the airplane were accounted for at the scene. The wreckage was examined following recovery. Both outer wing sections had separated, the empennage separated, and the cockpit was destroyed. The landing gear was extended and the preimpact flap position could not be determined. The elevator trim tab was in a position consistent with cruise flight. Flight control continuity could not be verified due to fragmentation, but all cable breaks were consistent with overload during the impact. The fuel selectors could not be located. Examination of the airframe did not reveal any preimpact mechanical anomalies. A Garmin GDU 700L was recovered and data successfully downloaded. The unit did not record flight parameters, but recordedengine parameters. Examination of both engines and review of the recorded engine data did not reveal any preimpact mechanical anomalies. Both propeller blades remained attached to the left engine propeller hub. One blade exhibited leading edge gouges, chordwise scratching and tip curling. The other blade exhibited s-bending, leading edge gouges and tip curling. Both propeller blades also remained attached to the right engine propeller hub. Both propeller blades exhibited leading edge gouging and chordwise scratching.

Aircraft

Registration
N791GA
Reported as
Grumman GA7
Category
Airplane
Serial number
GA7-0080
Built
1979
Airframe hours
4,381
Engines
Lycoming O-320, 160 horsepower, reciprocatingLycoming O-320, 160 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Operator
Majestic Aviation
Registered owner
Cougar Air JV LLC
Airworthiness certificate
Standard, Normal
Last inspection
Annual · June 18, 2020
Departed
BUY · Burlington, NC
Destination
JHW · Jamestown, NY
Flight plan
IFR
Airport
JHW · Chautauqua County/Jamestown Airport, runway 25, 5,299 × 100 ft, asphalt
Equipment
Stall warning system, Electronic multifunction display, ADS-B

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
65
Injuries
Fatal
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
July 4, 2019
Seat
Left
Restraint
3-point
Toxicology
Performed
Flight hours
1,082 total · 1,082 as pilot in command

Weather

Conditions
Instrument (IMC) · Night
Wind
280° at 20 knots, gusting 30
Visibility
0.75 statute miles
Lowest ceiling
1,000 ft broken
Temperature
30 °F, dew point 28 °F
Altimeter
29.85 inHg
Icing
Unknown
Turbulence
Moderate
Observed at
JHW, 1 nm away

Docket · 29

The files NTSB released with the investigation on September 28, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 439 MB in all.

Interview summary - FAA inspectorItem 1 · PDF · 1 page · 122 KBWitness statementsItem 2 · PDF · 3 pages · 109 KBFuel receiptItem 3 · PDF · 1 page · 72 KBExcerpt from pilot insurance file (flight experience)Item 4 · PDF · 1 page · 484 KBExcerpts from maintenance recordsItem 5 · PDF · 10 pages · 795 KBWeather factual reportItem 6 · PDF · 35 pages · 5.4 MBWeather attachment 1Item 7 · GIF · 17.3 MBWeather attachment 2Item 8 · GIF · 6.9 MBWeather attachment 3Item 9 · PDF · 5 pages · 2.5 MBWeather attachment 4Item 10 · PDF · 3 pages · 106 KBWeather attachment 5Item 11 · ZIP · 70.6 MBAir traffic control specialist reportItem 12 · PDF · 8 pages · 1.2 MBAir traffic control - attachment 1 - aircraft accident packageItem 13 · PDF · 84 pages · 2.5 MBAir traffic control - attachment 2 - ADS-B dataItem 14 · ZIP · 8.6 MBAir traffic control - attachment 3 - FAA radar dataItem 15 · GZ · 44.4 MBAir traffic control - attachment 4 - east radar position audio recordingItem 16 · WAV · 61.4 MBAir traffic control - attachment 5 - erie radar position audio recordingItem 17 · WAV · 71.1 MBAir traffic control - attachment 6 - ground control position audio recordingItem 18 · WAV · 67.3 MBRecorded audio of ATC communications from buffalo approach (37 minutes, wav format, 68 mb)Item 19 · WAV · 71.1 MBJhw RNAV (GPS) rwy 25 chartItem 20 · PDF · 1 page · 778 KBMap of witness location, wreckage location, and location of tree scarsItem 21 · PDF · 1 page · 97 KBPhoto arrayItem 22 · PDF · 6 pages · 1.7 MBCorrespondence - IA examItem 23 · PDF · 1 page · 108 KBToxicological reportItem 24 · PDF · 1 page · 168 KBCockpit display - specialist's factual reportItem 25 · PDF · 5 pages · 1.1 MBAttachment 1 to cockpit display - specialist's factual reportItem 26 · CSV · 2.1 MBStatement of party representatives to NTSB investigationItem 27 · PDF · 9 pages · 365 KBRelease of aircraft wreckage, NTSB form 6120.15Item 28 · PDF · 1 page · 176 KBEvidence control formItem 29 · PDF · 1 page · 42 KB

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.