ERA20FA020

The pilot’s failure to maintain airspeed during a circling instrument approach procedure, which resulted in an exceedance of the airplane’s critical angle of attack and an aerodynamic stall and spin.

The pilot was conducting a GPS circling instrument approach in instrument meteorological conditions to an airport with which he was familiar. During the final minute of the flight, the airplane descended to and leveled off near the minimum descent altitude (MDA) of about 600 ft mean sea level (msl). During this time, the airplane’s groundspeed slowed from about 90 knots to a low of 65 knots. In the few seconds after reaching 65 knots groundspeed, the flight track abruptly turned left off course and the airplane rapidly descended. The final radar point was recorded at 200 ft msl less than 1/10 mile from the accident site. Two home surveillance cameras captured the final few seconds of the flight. The first showed the airplane in a shallow left bank that rapidly increased until the airplane descended in a steep left bank out of camera view below a line of trees. The second video captured the final 4 seconds of the flight; the airplane entered the camera view already in a steep left bank near treetop level, and continued to roll to the left, descending out of view. Both videos showed the airplane flying below an overcast cloud ceiling, and engine noise was audible until the sound of impact. Postaccident examination of the airplane revealed no evidence of preimpact mechanical malfunctions that would have precluded normal operation. The propeller signatures, witness impact marks, audio recordings, and witness statements were all consistent with the engines producing power at the time of impact. The pilot likely encountered restricted visibility of about 2 statute miles with mist and ceilings about 700 ft msl. When the airplane deviated from the final approach course and descended below the MDA, the destination airport remained 3.5 statute miles to the northeast. Although the airplane was observed to be flying below the overcast cloud layer, given the restricted visibility, it is likely that the pilot was unable to visually identify the airport or runway environment at any point during the approach. According to airplane flight manual supplements, the stall speed likely varied from 76 to 67 knots indicated airspeed. The exact weight and balance and configuration of the airplane could not be determined. Based upon surveillance video, witness accounts, and automatic dependent surveillance-broadcast data, it is likely that, as the pilot leveled off the airplane near the MDA, the airspeed decayed below the aerodynamic stall speed, and the airplane entered an aerodynamic stall and spin from which the pilot was unable to recover. Based on a readout of the pilot’s cardiac monitoring device and autopsy findings, while the pilot had a remote history of arrhythmia, sudden incapacitation was not a factor in this accident. Autopsy findings suggested that the pilot’s traumatic injuries were not immediately fatal; soot material in both the upper and lower airways provided evidence that the pilot inhaled smoke. This autopsy evidence supports that the pilot’s elevated carboxyhemoglobin level was from smoke inhalation during the postcrash fire. In addition, there were no distress calls received from the pilot and there was no evidence found that would indicate there was an in-flight fire. Thus, carbon monoxide exposure, as determined by the carboxyhemoglobin level, was not a contributing factor to the accident.

Fragments of the pilot's logbook were recovered in the wreckage; however, the majority of its contents were illegible. On the application for the pilot’s most recent medical certificate, dated April 3, 2019, he reported 7,173 total hours of flight experience, including 66 hours in the previous 6 months. On an aircraft insurance application from January 2019, the pilot reported a total of 2,284 multiengine airplane flight hours, including 1,384 flight hours in the accident airplane. According to the pilot’s spouse, he had flown into the destination airport “hundreds of times,” as he was accustomed to commuting to the New York City area on a regular basis. According to FAA airworthiness records, the six-seat, multiengine, low-wing airplane was manufactured in 1980. It was powered by two Continental TSIO-520-NB, 335-horsepower engines, which had been modified with the RAM Aircraft conversion. The airplane was also equipped with RAM Aircraft winglets and vortex generators. According to the RAM winglets, vortex generator airplane flight manual supplement, the aerodynamic stall speeds varied with weight, bank angle, and the configuration of the landing gear and wing flaps. Figure 3 shows the range of stall speeds that could be expected. For example, at weight between 6,750 lbs - 5,200 lbs, 20° bank, flaps 15°, and landing gear down, the stall speed would vary from 76 to 67 knots indicated airspeed. The supplement stated that the maximum altitude loss during a conventional stall was approximately 550 ft. Figure 3: Aerodynamic stall speed chart provided in the applicable airplane flight manual supplement The main wreckage was located in the basement of a residence. The airplane sustained significant impact and thermal damage as a result of postcrash fire and the wreckage was intermingled with house debris and rubble. The initial impact point was identified by large broken tree branches about 40 ft east of the main wreckage; the wreckage path was oriented on a true heading of 278°. Multiple tree branches were cut at 45° angles and exhibited gray paint transfer consistent with propeller blade contact. The largest piece of the airframe was the forward cabin area, which included the left side cockpit instrument panel. The majority of the right cockpit fuselage skin and the right cockpit instrument panel was consumed by fire. Complete flight control cable continuity could not be established to the flight control surfaces, as a majority of the left and right wings and empennage were consumed by the postimpact fire and were not located in the house debris. Partial aileron and elevator flight control cable continuity was established by observing the cables moving in the lower forward floor assembly area when the left yoke was moved by hand. The left and right wing flap tubes and bellcranks were observed. The right flap chain, when measured, was consistent with a flap setting of 15°. The left flap chain was not observed. Rudder cable continuity was not established. The left, right, and nose landing gear had separated from the fuselage; the landing gear position could not be determined based on observation of the landing gear actuators. The landing gear handle arm was twisted, and its position could not be determined. The throttle, mixture, and propeller control levers were found full forward. The left and right fuel selector handles were found pointing straight forward in an intermediate position between main and crossfeed. The airspeed indicator was found indicating about 55 knots, the primary attitude indicator was found displaying a 120° left roll, and the pitch indicated a 5° nose up pitch attitude. When disassembled, the gyro moved freely within its housing and displayed small rotational scoring marks. The altimeter was set to 30.31 inches of mercury and indicated 200 ft. The barometric setting was consistent with the LDJ weather observation. The primary heading indicator was found indicating a heading of 260°, the course was set to 010°, and the heading bug was found set to 050°. The altitude alerter was found set to 30,000 ft. The course deviation indicator was found indicating that the airplane was left of course. The left and right engine ignition switches were found in the ON position. The right engine had separated from the wing and was located in the basement of the house forward of the main wreckage. It sustained impact and thermal damage. The three-bladed propeller remained attached to the propeller hub and displayed chordwise scratching, torsional twisting, and s-bending. The crankshaft was rotated by hand through 360°; crankshaft continuity was established from the forward section of the engine to the accessory section. All cylinders displayed normal operating and combustion signatures and thumb compression. The right engine magnetos turned freely by hand and spark was observed on all ignition terminals. No debris was noted in fuel nozzles or fuel manifold. The top spark plugs for each cylinder displayed normal operating combustion signatures. The right turbocharger exhibited thermal damage and the compressor housing and compressor wheel were not located. The vacuum pump attached to the right engine was removed and disassembled; the drive coupling remained intact. The left engine had separated from the wing and was located under the fuselage. It sustained impact and thermal damage. The three-bladed propeller displayed chord-wise scratching and torsional twisting. The crankshaft was rotated by hand through 360° of motion; crankshaft continuity was established from the forward section of the engine to the accessory section. All cylinders displayed normal operating and combustion signatures. Each cylinder, with the exception of the Nos. 4 and 6 cylinders, displayed thumb compression. The Nos. 4 and 6 cylinders contained fire debris on the valve seats, which prevented full closure of the valves. The left engine magnetos sustained significant external and internal thermal damage; the ignition leads could not be tested. The top spark plugs for each cylinder displayed normal operating combustion signatures. The left turbocharger was intact, and the turbine wheel turned freely. The vacuum pump attached to the left engine was removed and disassembled; the drive coupling remained intact. On October 29, 2019, at 1058 eastern daylight time, a Cessna 414A airplane, N959MJ, was destroyed when it was involved in an accident in Colonia, New Jersey. The commercial pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight. The pilot’s spouse reported that he planned to depart Leesburg Executive Airport (JYO), Leesburg, Virginia, about 0900 local; however, he delayed his departure due to the weather at his destination, Linden Airport (LDJ), Linden, New Jersey. She reported that the pilot was scheduled to give a lecture in Queens, New York, in the afternoon. Review of radar and flight plan data provided by the Federal Aviation Administration (FAA) revealed that the airplane departed JYO at 0950 on an instrument flight rules (IFR) flight plan and proceeded on course to LDJ. At 1053:20, the airplane’s radar altitude was 2,000 ft mean sea level (msl) and its position was over the DAPVY GPS waypoint, which was the first waypoint associated with the GPS-A circling instrument approach procedure to LDJ. The airplane then turned to a northeast heading, which was consistent with the final approach course for the GPS-A approach. For the next 2 1/2 minutes, the airplane descended along the final approach course and crossed the final approach fix (GEZSY) about 1,200 ft msl (radar altitude). During the descent from DAPVY to GEZSY, the airplane’s groundspeed varied from about 110 knots, to 140 knots, and then to 100 knots. The airplane continued to descend after GEZSY and crossed the subsequent waypoint of 3 nautical miles (nm)