New York

The commercial pilot of the multiengine airplane was the first of a flight of two airplanes to depart on the cross-country flight, most of which was over the Atlantic Ocean. The pilot of the second airplane stated that he and the accident pilot reviewed the weather for the route and the destination before departing; however, there was no record of the accident pilot receiving an official weather briefing and the information the pilots accessed before the flight could not be determined. The second pilot departed and contacted air traffic control, which advised him of thunderstorms near the destination; he subsequently altered his route of flight and landed uneventfully at the destination. The second pilot stated that he did not hear the accident pilot on the en route air traffic control frequency. Two inflight weather advisories were issued for the route and the area of the destination about 42 and 15 minutes before the accident flight departed, respectively, and warned of heavy to extreme precipitation associated with thunderstorms. It could not be determined whether the accident pilot received these advisories. Review of air traffic control communications and radar data revealed that, about 5 miles from the destination airport, the pilot of the accident airplane reported to the tower controller that he was flying at 700 ft and "coming in below" the thunderstorm. There were no further communications from the pilot. The airplane's last radar target indicated 532 ft about 2 miles south of the shoreline. The airplane was found in about 50 ft of water and was fragmented in several pieces. Postaccident examination revealed no preimpact anomalies with the airplane or engines that would have precluded normal operation. A local resident about 1/2 mile from the accident site took several photos of the approaching thunderstorm, which documented a shelf cloud and cumulus mammatus clouds along the leading edge of the storm, indicative of potential severe turbulence. Review of weather imagery and the airplane's flight path showed that the airplane entered the leading edge of "extreme" intensity echoes with tops near 48,000 ft. Imagery also depicted heavy to extreme intensity radar echoes over the accident site extending to the destination airport. It is likely that the pilot encountered gusting winds, turbulence, restricted visibility in heavy rain, and low cloud ceilings in the vicinity of the accident site and experienced an in-flight loss of control at low altitude. Such conditions are conducive to the development of spatial disorientation; however, the reason for the pilot's loss of control could not be determined based on the available information.

The commercial pilot departed on a planned 1-hour cargo cross-country flight in the autopilot-equipped airplane. About 3 minutes after departure, the controller instructed the pilot to fly direct to the destination airport at 2,000 ft mean sea level (msl). The pilot acknowledged the clearance, and there were no further radio transmissions from the airplane. The airplane continued flying past the destination airport in straight-and-level flight at 2,100 ft msl, consistent with the airplane operating under autopilot control, until it was about 100 miles beyond the destination airport. A witness near the accident site watched the airplane fly over at a low altitude, heard three "pops" come from the airplane, and then saw it bank to the left and begin to descend. The airplane continued in the descending left turn until he lost sight of it as it dropped below the horizon. The airplane impacted trees in about a 45° left bank and a level pitch attitude and came to rest in a heavily wooded area. The airplane sustained extensive thermal damage from a postcrash fire; however, examination of the remaining portions of the airframe, flight controls, engines, and engine accessories revealed no evidence of preimpact failure or malfunction. The fuel selector valves were found on the outboard tanks, which was in accordance with the normal cruise procedures in the pilot's operating handbook. Calculations based on the airplane's flight records and the fuel consumption information in the engine manual indicated that, at departure, the outboard tanks of the airplane contained sufficient fuel for about 1 hour 10 minutes of flight. The airplane had been flying for about 1 hour 15 minutes when the accident occurred. Therefore, it is likely that the fuel in the outboard tanks was exhausted; without pilot action to switch fuel tanks, the engines lost power as a result of fuel starvation, and the airplane descended and impacted trees and terrain. The overflight of the intended destination and the subsequent loss of engine power due to fuel starvation are indicative of pilot incapacitation. The pilot's autopsy identified no significant natural disease:however, the examination was limited by the severity of damage to the body. Further, there are a number of conditions, including cardiac arrhythmias, seizures, or other causes of loss of consciousness, that could incapacitate a pilot and leave no evidence at autopsy. The pilot's toxicology results indicated that the pilot had used marijuana/tetrahydrocannabinol (THC) at some point before the accident. THC can impair judgment, but it does not cause incapacitation; therefore, the circumstances of this accident are not consistent with impairment from THC, and, the pilot's THC use likely did not contribute to this accident. The reason for the pilot's incapacitation could not be determined.

According to the pilot in command (PIC), he was conducting an instructional flight for his "new SIC (second in command)," who was seated in the left seat. He reported that they had flown two previous legs in the retractable landing gear-equipped airplane. He recalled that, during the approach, they discussed the events of their previous flights and had complied with the airport control tower's request to "keep our speed up." During the approach, he called for full flaps and retarded the throttle to flight idle. The PIC asserted that there was no indication that the landing gear was not extended because he did not hear a landing gear warning horn; however, he was wearing a noise-cancelling headset. He added that the landing gear position lights were not visible because the SIC's knee obstructed his view of the lights. He recalled that, following the flare, he heard the propellers hit the runway and that he made the decision not to go around because of unknown damage sustained to the propellers. The airplane touched down and slid to a stop on the runway. The airplane sustained substantial damage to the fuselage bulkheads, longerons, and stringers. The SIC reported that the flight was a training flight in visual flight rules conditions. He noted that the airspace was busy and that, during the approach, he applied full flaps, but they failed to extend the landing gear. He added that he did not hear the landing gear warning horn; however, he was wearing a noise-cancelling headset. The Federal Aviation Administration Aviation Safety Inspector that examined the wreckage reported that, during recovery, the pilot extended the nose landing gear via the normal extension process. However, due to significant damage to the main landing gear (MLG) doors, the MLG was unable to be extended hydraulically or manually. He added that an operational check of the landing gear warning horn was not accomplished because the wreckage was unsafe to enter after it was removed from the runway. The landing gear warning horn was presented by an aural tone in the cockpit and was not configured to be heard through the pilots' noise-cancelling headsets. When asked, the PIC and the SIC both stated that they could not remember who read the airplane flight manual Before Landing checklist.

The private pilot, who was experienced flying the accident airplane, was conducting a personal flight with three passengers on board the single-engine turboprop airplane. Earlier that day, the pilot flew uneventfully from his home airport to an airport about 1 hour away. During takeoff for the return flight, the airplane impacted wooded terrain about 0.5 mile northwest of the departure end of the runway. There were no witnesses to the accident, but the pilot's radio communications with flight service and on the common traffic advisory frequency were routine, and no distress calls were received. A postcrash fire consumed a majority of the wreckage, but no preimpact mechanical malfunctions were observed in the remaining wreckage. Examination of the propeller revealed that the propeller reversing lever guide pin had been installed backward. Without the guide pin installed correctly, the reversing lever and carbon block could dislodge from the beta ring and result in the propeller blades traveling to an uncommanded feathered position. However, examination of the propeller components indicated that the carbon block was in place and that the propeller was in the normal operating range at the time of impact. Additionally, the airplane had been operated for about 9 months and 100 flight hours since the most recent annual inspection had been completed, which was the last time the propeller was removed from and reinstalled on the engine. Therefore, the improper installation of the propeller reversing lever guide pin likely did not cause the accident. Review of the pilot's autopsy report revealed that he had severe coronary artery disease with 70 to 80 percent stenosis of the right coronary artery, 80 percent stenosis of the left anterior descending artery, and mitral annular calcification. The severe coronary artery disease combined with the mitral annular calcification placed the pilot at high risk for an acute cardiac event such as angina, a heart attack, or an arrhythmia. Such an event would have caused sudden symptoms such as chest pain, shortness of breath, palpitations, or fainting/loss of consciousness and would not have left any specific evidence to be found during the autopsy. It is likely that the pilot was acutely impaired or incapacitated at the time of the accident due to an acute cardiac event, which resulted in his loss of airplane control.

The aircraft was landing on runway 13 at LaGuardia Airport (LGA), New York, New York, when it departed the left side of the runway, contacted the airport perimeter fence, and came to rest with the airplane’s nose on an embankment next to Flushing Bay. The 2 pilots, 3 flight attendants, and 98 of the 127 passengers were not injured; the other 29 passengers received minor injuries. The airplane was substantially damaged. Flight 1086 was a regularly scheduled passenger flight from Hartsfield-Jackson Atlanta International Airport, Atlanta, Georgia, operating under the provisions of 14 Code of Federal Regulations Part 121. An instrument flight rules flight plan had been filed. Instrument meteorological conditions prevailed at the time of the accident. The captain and the first officer were highly experienced MD-88 pilots. The captain had accumulated about 11,000 hours, and the first officer had accumulated about 3,000 hours, on the MD-88/-90. In addition, the captain was previously based at LGA and had made many landings there in winter weather conditions. The flight crew was concerned about the available landing distance on runway 13 and, while en route to LGA, spent considerable time analyzing the airplane’s stopping performance. The flight crew also requested braking action reports about 45 and 35 minutes before landing, but none were available at those times because of runway snow clearing operations. The unavailability of braking actions reports and the uncertainty about the runway’s condition created some situational stress for the captain, who was the pilot flying. After runway 13 became available for arriving airplanes, the flight crews of two preceding airplanes (which landed on the runway about 16 and 8 minutes before the accident landing) reported good braking action on the runway, so the flight crew expected to see at least some of the runway’s surface after the airplane broke out of the clouds. However, the flight crew saw that the runway was covered with snow, which was inconsistent with their expectations based on the braking action reports and the snow clearing operations that had concluded less than 30 minutes before the airplane landed. The snowier-than-expected runway, along with its relatively short length and the presence of Flushing Bay directly off the departure end of the runway, most likely increased the captain’s concerns about his ability to stop the airplane within the available runway distance, which exacerbated his situational stress. The captain made a relatively aggressive reverse thrust input almost immediately after touchdown. Reverse thrust is one of the methods that pilots use to decelerate the airplane during the landing roll. Reverse thrust settings are expressed as engine pressure ratio (EPR) values, which are measurements of engine power (the ratio of the pressure of the gases at the exhaust compared with the pressure of the air entering the inlet). Both pilots were aware that 1.3 EPR was the target setting for contaminated runways.As reverse thrust EPR was rapidly increasing, the captain’s attention was focused on other aspects of the landing, which included steering the airplane to counteract a slide to the left and ensuring that the spoilers had deployed (a necessary action for the autobrakes to engage). The maximum EPR values reached during the landing were 2.07 on the left engine and 1.91 on the right engine, which were much higher than the target setting of 1.3 EPR. These high EPR values likely resulted from a combination of the captain’s stress; his relatively aggressive reverse thrust input; and operational distractions, including the airplane’s continued slide to the left despite the captain’s efforts to steer it away from the snowbanks alongside the runway. All of these factors reduced the captain’s monitoring of EPR indications. The high EPR values caused rudder blanking (which occurs on MD-80 series airplanes when smooth airflow over the rudder is disrupted by high reverse thrust) and a subsequent loss of aerodynamic directional control. Although the captain stowed the thrust reversers and applied substantial right rudder, right nosewheel steering, and right manual braking, the airplane’s departure from the left side of the runway could not be avoided because directional control was regained too late to be effective.

The pilot arrived at the fixed-base operator on the morning of the accident and requested that his airplane be brought outside and prepared for an immediate departure; this occurred 1 hour 15 minutes before his scheduled departure time. Radar data showed that the airplane departed 23 minutes later. According to air traffic control data, shortly thereafter, the ground and departure controllers contacted the tower controller and asked if the airplane had departed yet; the tower controller responded, "I have no idea. We have zero visibility." Weather conditions about the time of the accident included a 200-ft overcast ceiling with about 1/4-mile visibility. Only five radar targets identified as the accident airplane were captured, and all of the targets were located over airport property. The first three radar targets began about midpoint of the 6,500-ft-long runway, and each of these targets was at an altitude of about 60 ft above ground level (agl). The final two targets showed the airplane in a shallow right turn, consistent with the published departure procedure track, at altitudes of 161 and 261 ft agl, respectively. The final radar target was about 1/2 mile from the accident site. Witnesses reported observing the airplane impact trees in a wings-level, slightly right-wing-down attitude at high speed. Examination of the wreckage revealed no preimpact mechanical malfunctions or anomalies of the airplane. The pilot's personal assistant reported that the pilot had an important meeting that required his attendance on the day of the accident flight. His early arrival to the airport and his request to have the airplane prepared for an immediate departure were actions consistent with self-induced pressure to complete the flight. Due to the poor weather conditions, which were expected to continue or worsen, he likely felt pressure to expedite his departure to ensure he was able to make it to his destination and to attend the meeting. This pressure may have further affected his ability to discern the risk associated with departing in low-visibility and low-ceiling conditions. As noted, the weather conditions were so poor that the local air traffic controller stated that he could not tell whether the airplane had departed. Such weather conditions are highly conducive to the development of spatial disorientation. Further, the altitude profile depicted by the radar data and the airplane's near wings-level attitude and high speed at impact were consistent with the pilot experiencing a form of spatial disorientation known as "somatogravic illusion," in which the pilot errantly perceives the airplane's acceleration as increasing pitch attitude, and efforts to hold the nose down or arrest the perception of increasing pitch attitude can exacerbate the situation. Such an illusion can be especially difficult to overcome because it typically occurs at low altitudes after takeoff, which provides little time for recognition and subsequent corrective inputs, particularly in very low-visibility conditions.

As the airplane was on final approach, the captain, who was the pilot monitoring (PM), realized that the flaps were not configured as had been briefed, with a setting of 40 degrees for the landing. Data from the flight data recorder (FDR) indicate that the captain set the flaps to 40 degrees as the airplane was descending through about 500 ft altitude, which was about 51 seconds from touchdown. When the airplane was between 100 to 200 ft altitude, it was above the glideslope. Concerned that the airplane was too high, the captain exclaimed repeatedly "get down" to the first officer about 9 seconds from touchdown. About 3 seconds from touchdown when the airplane was about 27 ft altitude, the captain announced "I got it," indicating that she was taking control of the airplane, and the first officer replied, "ok, you got it." According to FDR data, after the captain took control, the control column was relaxed to a neutral position and the throttles were not advanced until about 1 second before touchdown. The airplane touched down at a descent rate of 960 ft per minute and a nose-down pitch attitude of -3.1 degrees, resulting in the nose gear contacting the runway first and a hard landing. The airplane came to a stop on the right side of the runway centerline about 2,500 ft from its initial touchdown. The operator's stabilized approach criteria require an immediate go-around if the airplane flaps or landing gear were not in the final landing configuration by 1,000 ft above the touchdown zone; in this case, the flaps were not correctly configured until the airplane was passing through 500 ft. Further, the airplane's deviation about the glideslope at 100 to 200 ft would have been another opportunity for the captain, as the PM at this point during the flight, to call for a go-around, as indicated in the Southwest Airlines Flight Operations Manual (FOM). Accident data suggest that pilots often fail to perform a go-around or missed approach when stabilized approach criteria are not met. A review of NTSB investigated accidents by human factors researchers found that about 75% of accidents were the result of plan continuation errors in which the crew continued an approach despite cues that suggested it should not be continued. Additionally, line operations safety audit data presented at the International Air Safety Summit in 2011 suggested that 97% of unstabilized approaches were continued to landing even though doing so was in violation of companies' standard operating procedures (SOPs). The Southwest FOM also states that the captain can take control of the airplane for safety reasons; however, the captain's decision to take control of the airplane at 27 ft above the ground did not allow her adequate time to correct the airplane's deteriorating energy state and prevent the nose landing gear from striking the runway. The late transfer of control resulted in neither pilot being able to effectively monitor the airplane's altitude and attitude. The first officer reported that, after the captain took control of the airplane, he scanned the altimeter and airspeed to gain situational awareness but that he became distracted by the runway "rushing" up to them and "there was no time to say anything." The captain should have called for a go-around when it was apparent that the approach was unstabilized well before the point that she attempted to salvage the landing by taking control of the airplane at a very low altitude. In addition, the captain did not follow SOPs at several points during the flight. As PM, she should have made the standard callout per the Southwest FOM when the airplane was above glideslope, stating "glideslope" and adding a descriptive word or words to the callout (for example, "one dot high"). Rather than make this callout, however, the captain repeatedly said "get down" to the first officer before stating "I got it." The way she handled the transfer of airplane control was also contrary to the FOM, which indicates that the PM should say "I have the aircraft." The flight crew's performance was indicative of poor crew resource management.

Michael B. Braunstein, aged 72, was the owner of this vintage aircraft built in 1943 and was performing a local flight within the State of New York. Aircraft was destroyed when it impacted the waters of the Hudson River, near Catskill, New York. The certificated airline transport pilot was fatally injured. Visual meteorological conditions prevailed, and no flight plan had been filed for the local personal flight conducted under Title 14 Code of Federal Regulations Part 91, which departed from B Flat Farm Airport (3NK8), Copake, New York about 1600. Approximately 25 witnesses were interviewed. Witnesses reported observing the twin-engine amphibious airplane flying southbound low above a river and hearing the engine running. The airplane then made a 180-degree left turn, which was consistent with the pilot flying a tight traffic pattern before attempting a water landing. The airplane then descended, leveled off above the water, and suddenly banked left. The airplane’s nose and left pontoon then struck the water, and the airplane nosed over, caught fire, and sank. Postrecovery examination of the wreckage revealed that the landing gear was in the “up” position and that the flaps were extended, which indicates that the airplane had been configured for a water landing. No evidence of any preimpact failures or malfunctions of the airplane or engines was found that would have precluded normal operation. At the time of the accident, a light breeze was blowing, the river was at slack tide, and the water conditions were calm, all of which were conducive to glassy water conditions. It is likely that the glassy water conditions adversely affected the pilot’s depth perception and led to his inability to correctly judge the airplane’s height above the water. He subsequently flared the airplane too high, which resulted in the airplane exceeding its critical angle-of-attack, entering an aerodynamic stall, and impacting the water in a nose-low attitude.

On February 12, 2009, about 2217 eastern standard time, a Colgan Air, Inc., Bombardier DHC-8-400, N200WQ, operating as Continental Connection flight 3407, was on an instrument approach to Buffalo-Niagara International Airport, Buffalo, New York, when it crashed into a residence in Clarence Center, New York, about 5 nautical miles northeast of the airport. The 2 pilots, 2 flight attendants, and 45 passengers aboard the airplane were killed, one person on the ground was killed, and the airplane was destroyed by impact forces and a post crash fire. The flight was operating under the provisions of 14 Code of Federal Regulations Part 121. Night visual meteorological conditions prevailed at the time of the accident.

Aircraft experienced an almost complete loss of thrust in both engines after encountering a flock of birds and was subsequently ditched on the Hudson River about 8.5 miles from La Guardia Airport (LGA), New York City, New York. The flight was en route to Charlotte Douglas International Airport, Charlotte, North Carolina, and had departed LGA about 2 minutes before the in-flight event occurred. The 150 passengers, including a lap held child, and 5 crew members evacuated the airplane via the forward and overwing exits. One flight attendant and four passengers were seriously injured, and the airplane was substantially damaged.