NYC97FA030

NTSB accident investigation · Cessna 425 · Bohemia, NY · December 16, 1996

Accident · FatalField investigationFinal report
Date
December 16, 1996, 18:40 local (23:40 UTC)
Place
Bohemia, NY
Injuries
3 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N425EWCessna 425
Weather
Instrument (IMC) · Night/dark
Status
Completed · report February 2, 1998
Report
Approved by Office Director
FAA report
19961216039439A
Case key
39265

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 early descent to decision height and his failure to perform the missed approach procedure. A factor was the failure of air traffic control to issue a safety advisory.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

In flight collision with terrain/waterApproach - faf/outer marker to threshold (ifr)
Weather condition - low ceilingFactor
Ifr procedure - improperPilot in commandCause
Safety advisory - not issuedAtc personnel(lcl/gnd/clnc)Factor

Analysis

The pilot had received clearance for the ILS Runway 6 approach and was advised that the previous landing traffic reported '...breaking out at minimums.' Radar data revealed that the airplane descended in instrument meteorological conditions to the decision height altitude of 294 feet, approximately 3 miles from the missed approach point. The pilot did not perform the missed approach procedure. The airplane leveled off and continued at or below decision height altitude for approximately 28 seconds, traveling a distance of approximately 1 mile. Four low altitude alerts appeared on the tower controller's display. The controller stated he withheld the alert because '...it was a critical phase of flight and the aircraft appeared to be climbing...' The airplane collided with trees and terrain approximately 1.5 miles from the approach end of the landing runway.

Factual narrative

History of flight

On December 16, 1996, at 1840 eastern standard time, a Cessna 425, N425EW, was destroyed when it collided with trees and impacted the ground in the Connetquot State Park, Bohemia, New York, while on an instrument approach to the Long Island-MacArthur Airport (ISP), Islip, New York. The certificated commercial pilot and two passengers were fatally injured. There was ground fire. Instrument meteorological conditions prevailed for the business flight that originated at Macon, Georgia (MCN), about 1600. An IFR flight plan had been filed for the flight conducted under 14 CFR Part 91.

According to air traffic control records, all handling of N425EW from MCN to ISP, was "normal." At 1823, N425EW was given an approach clearance for the ILS Runway 6 approach to ISP. According to the Federal Aviation Administration (FAA) Accident Report Form 8020-6-1 prepared by the ISP tower:

"The controller gave N425EW an approach clearance which included a right turn to 030. He also told N425EW he was 5 miles from LOKKS LOM (Locator Outer Marker) to maintain 2000 until established on the localizer. The pilot acknowledged the clearance. The controller advised N425EW that previous arrivals reported breaking out at minimums."

N425EW contacted Long Island Tower, at 1825, and was cleared to land. At 1825:22, Long Island Tower transmitted: "...conquest five echo whiskey previous arrivals reported breaking out at minimums." N425EW acknowledged the radio call.

Radar data revealed that approximately 2 miles prior to the LOKKS LOM, N425EW initiated a descent below the assigned altitude of 2,000 feet. N425EW crossed the LOKKS LOM at 900 feet msl., 872 feet below the published glide slope intercept altitude. N425EW continued descent underneath the glideslope, and did not intercept the glideslope during the approach.

At 1827:16, N425EW descended to 300 feet and continued flight at or below that altitude for approximately 28 seconds, and traveled a distance of approximately 1 mile. The published Decision Height altitude for the ILS Runway 6 approach was 294 feet. The last radar plot, at 1827:44, placed the airplane approximately 2 miles from the runway at an altitude of 300 feet MSL.

In a written statement, the Air Traffic Control Specialist from the Long Island Tower stated:

"At approximately 2328 UTC (1828), a Low Altitude Alert sounded. I observed N5EW on a two mile final indicating 200 feet. As I was going to issue the alert, I observed the altitude indicating 300. In my judgment, since it was a critical phase of flight and the aircraft appeared to be climbing, I withheld the alert."

In a statement provided to the New York State Park Police, a witness on the ground who resided in the park stated:

"...I heard an airplane on the usual flight path towards the airport. I heard the aircraft pass over and then heard what sounded like heavy lumber falling off a truck ... When I heard the airplane I did not hear any change in sound from the engines or any sounds that would suggest the plane was in trouble."

In a telephone interview, a second witness stated he was walking across an open field approximately 1 mile northwest of the accident site. He stated:

"I heard an aircraft with propeller driven engines running smoothly in level flight with the motor revved up a bit, quite loud and quite low. I thought he would be reported or something. Then it just stopped. There was no problem with the motor, it sounded quite smooth. I knew he wasn't climbing. It sounded like level - maybe descending ..."

The second witness estimated that the cloud ceiling was between 300-500 feet. He further stated that the clouds were "...right down to tree level over the park." The witness said there was a heavy mist in the air and the visibility was approximately one-quarter mile at ground level.

The airplane came to rest about 1.5 miles from the approach end of runway 06, in the vicinity of the ILS final approach course. The accident occurred during the hours of darkness approximately 40 degrees 46 minutes North latitude and 73 degrees 06 minutes West longitude. The reported weather for ISP at the time of the accident indicated cloud heights at 300 feet and the visibility as 3/4 of a mile.

Personnel information

The pilot held a commercial Pilot Certificate with ratings for airplane single and multi-engine land and instrument airplane.

The pilot's most recent FAA Second Class Medical Certificate was issued on January 9, 1987. According to Part 61, a second class medical certificate was valid for 12 months.

The pilot's logbook was not recovered. However, information provided by the pilot to his insurance company in 1995, indicated that he had a total of 10,846 hours of flight experience. He indicated 2,089 hours in the Cessna 425, and 276 hours in the Cessna 421.

The pilot provided a letter dated April 24, 1996 to his insurance company. The letter was signed by a Certified Flight Instructor and stated that the pilot had completed a Biennial Flight Review, an Instrument Competency Check, and was trained to proficiency in the Cessna 425, and the Cessna 421C. The pilot also represented to his insurance company that he held a Second Class Medical Certificate dated November 28, 1995.

Aircraft information

The maintenance records for the airplane were not recovered. No evidence of logbooks or logbook binders was discovered at the accident site. Two members of the investigation team, both FAA Aviation Safety Inspectors, traveled to the Long Island MacArthur Airport on December 21, 1996 to inspect the hangar where N425EW was stored prior to the accident. Both inspectors provided written statements indicating that they were denied access to the hanger by an attorney and an aircraft mechanic representing the owner of N425EW. According to one statement, the FAA Inspectors:

"...were denied access to the hanger where N425EW (CE-425) was stored prior to the accident. We were denied access by Mr. Bernard Burton and Mr. Daniel Slanovic. [The inspectors] were there to review the aircraft records for N425EW which was involved in an accident on 12/16/96..."

Meteorological information

The ISP weather observation, at 1845, was: measured ceiling 300 feet overcast with visibility 3/4 statute mile with mist. The wind was from 240 degrees at 5 knots. The temperature was 6 degrees Celsius and the dewpoint was 6 degrees Celsius. The altimeter setting was 29.95.

Aids to navigation

The FAA performed a flight check of the ILS Runway 6 Approach at the MacArthur-Islip Airport, on December 18, 1996. In the remarks section of the FAA Form 8240-17 it stated:

"ILS Facility found satisfactory. Approach Lights MALSR: The Approach Lighting System was operating normally. The Runway Alignment Indicator Flashers had one light operating out of the normal five. Airways Facility Maintenance issued NOTAM # 12/036-ISP RWY 06 Approach Lighting System out of service. This NOTAM was issued 12/17/96 at 12:20 AM E.S.T. through ISP FSS."

Wreckage and impact information

The airplane wreckage was examined at the accident site on December 17, 1996. The examination revealed that all major components of the airplane were accounted for at the scene. The airplane came to rest upright on an approximate magnetic heading of 240 degrees, at a ground elevation of about 100 feet above mean sea level (MSL). The fuselage, including the cockpit and cabin areas, was consumed by post crash fire.

The wreckage path was oriented approximately 060 degrees and covered a distance of approximately 300 feet. The path was identified in 1 foot increments called stations. The wreckage path was measured from the point of initial tree impact, station zero, to the site where the left engine was discovered, station 300.

Initial tree impact scars were approximately 40 feet above ground level. The tree trunk was broken at a poin

Aircraft

Registration
N425EW
Reported as
Cessna 425
Category
Airplane
Serial number
425-0150
Engine
P&W PT6A-112, 500 horsepower, turbo prop
Damage
Destroyed
Fire
On-Ground
Flight
Business · Part 91
Registered owner
U.S. Dynamics Corporation
Airworthiness certificate
Standard, Normal
Departed
MCN · Macon, GA
Destination
ISP · Islip, NY
Flight plan
IFR
Airport
ISP · Long Island-Mac Arthur, runway 6, 7,002 × 150 ft, asphalt

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
55
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Expired
Seat
Left
Toxicology
Performed
Flight hours
10,846 total · 2,089 in this make and model · 5 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Night/dark
Wind
60° at 6 knots
Visibility
0.75 statute miles
Lowest ceiling
300 ft overcast
Temperature
43 °F, dew point 43 °F
Altimeter
30.00 inHg
Observed at
ISP

FAA reports on this event · 1

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