N19MT

HISTORY OF FLIGHTOn January 19, 2023, about 1729 EST, a Beech A36, N19MT, was substantially damaged when it was involved in an accident near North Castle, New York. The private pilot and one passenger were fatally injured. The airplane was operated as a Title 14?Code of Federal Regulations Part 91 personal flight.

According to ADS-B and air traffic control audio information, the flight departed from runway 4L at John F Kennedy International Airport (JFK), New York, New York, at 1658, and continued on a north-northeast heading.

After takeoff, data from the on-board Graphic Engine Monitor (GEM) indicated the cylinder head temperature (CHT) value for the No. 4 cylinder was generally higher than the values for the other cylinders but all were well within normal limits until 1659:23. At that time, when the flight was about 1 nautical mile north-northeast from the departure end of the runway, the No. 4 CHT value was indicating 463° F, which was above the maximum red line value of 460°F. The CHT values for the No. 4 cylinder continued increasing, reaching a maximum of 711°F at 1700:39 and then falling below the CHT values for the remaining cylinders, which were normal.

The flight continued as instructed by air traffic control with normal communications until 1710:15, at which time the pilot advised the controller he was “…doing my best here…” in response to the controller’s instruction to maintain best rate of climb to 8,000 ft. Normal communications continued again until 1715:54, when the airplane was at 5,100 ft barometric altitude climbing to the assigned altitude of 8,000 ft above mean sea level (msl),;the pilot then asked the controller if he could stop the climb at 6,000 ft msl. The airplane at that time was about 6 nautical miles south-southeast of the Westchester County Airport (HPN), White Plains, New York. The controller approved the request and the pilot informed the controller at 1716:14 and again at 1716:33 about poor aircraft performance and only climbing about 200 feet per minute. Twenty-one seconds after his last transmission about performance, at 1716:54, while south of HPN, the pilot advised the controller that nothing was depicted on the instrumentation to explain the poor climb performance. The controller advised the pilot that HPN was nearby, and he could proceed there to have it checked out. The pilot did not acknowledge that suggestion; at 1718:30, when about 4.8 nautical miles due south of HPN, the pilot informed the controller that the problem was a “…dead cylinder” and requested to proceed to HPN. The controller instructed the pilot to maintain a 340° heading consistent with vectoring the airplane onto the downwind leg on the west side of HPN, but the flight did not proceed on that heading. At 1719:52, the controller asked the pilot if he was declaring an emergency, to which he replied he was not. The airplane remained on a west-northwest (WNW) heading and at 1720:11 the GEM data indicated that the oil pressure decreased below the minimum specified value of 30 psi and continued decreasing to 0 psi.

While on the WNW heading the pilot was informed that the instrument landing system (ILS) runway 16 approach was in-use, then about 1720:58, the pilot turned to the vectored heading issued by the controller 2 minutes 17 seconds earlier. At 1721:18, when the flight was about 6 nautical miles southwest of HPN, the pilot declared an emergency and advised the controller that the oil pressure was dropping. Shortly after that transmission the airplane began a right turn that was not directed by the controller or announced by the pilot. The controller informed the pilot to level the wings and maintain 5,000 ft msl. The flight proceeded on an east-northeast heading. At 1722:58, while about 3 nautical miles southwest of HPN, the pilot again declared an emergency and informed the controller again that they were losing oil pressure.

The controller responded to the pilot’s second emergency call and instructed him to fly heading 070° for vectors to the downwind leg of the airport traffic pattern for runway 16 at HPN. The pilot repeated that he indeed had an emergency, and the flight continued the east-northeasterly heading flying south of HPN while gradually descending. During that time the controller informed the pilot that he intended to vector the flight onto the downwind leg for runway 16 and then cleared the pilot to descend to 3,000 ft msl, which he acknowledged. The flight remained on the east-northeasterly heading until about 1724:22, when about 1.5 nautical miles east-southeast of HPN, the flight turned to a northerly heading. The flight remained on the northerly heading while gradually descending. At 1725:13, while flying at 4,600 ft barometric altitude about 2.5 nautical miles northeast from HPN, the pilot broadcast, “mayday mayday mayday mayday.” At that time the engine rpm was 2,454, the fuel flow was 3.1 gallons-per-hour (GPH), and the No. 3 exhaust gas temperature (EGT) and CHT values had decreased to 892°F from the steady state value of about 1,350°F and to 306°F from the steady state value of about 317° F, respectively.

The controller informed the pilot that HPN was behind him and to turn left or right as necessary. The flight continued briefly on the northerly heading when, at 1725:46, the engine rpm and fuel flow were reading zero. The pilot turned left, flying in a southwest direction while descending, with the controller continually advising the pilot about direction and distance from HPN. The pilot was cleared to land at 1727:48; during that transmission from the controller, the low altitude alert sounded. About 16 seconds later, the controller informed the pilot that he should be clear of the ceiling at 300 ft. The controller continued to point out direction and distance from HPN to the pilot which he acknowledged in his last transmission at 1728:23. The airplane at that time was about 1 nautical mile northwest of the approach end of runway 16 flying at 900 ft barometric altitude. The controller continued to advise the pilot of heading information until, at 1728:56, the controller broadcast on the frequency for the accident pilot that radar contact was lost.

Multiple agencies involved in the air, water, and land searches located the wreckage at 2255. PERSONNEL INFORMATIONA review of the pilot’s logbook that began with his 1st logged flight in May 2013 and his last logged flight on December 2, 2022., revealed that including the date of a flight associated with his instrument rating received on May 29, 2017, he logged a total of 3.0 hours actual instrument flight time and 50.5 hours simulated instrument flight time. Since obtaining his instrument rating, he logged about 9 hours of actual instrument flight time and 29 hours of simulated instrument time. His last logged instrument proficiency check flight occurred on October 3, 2021. In August 2022, he flew 5 flights with a flight instructor, logging “holds” and performing a total of 17 instrument approaches and accruing 1.5 hours of actual instrument flight time and 4.4 hours of simulated instrument flight time. His last logged actual instrument flight of 0.2 hour occurred on November 3rd/4th 2022, while his last logged simulated instrument flight time of 2.0 hours occurred on December 2, 2022. AIRCRAFT INFORMATIONThe airplane underwent modifications in accordance with (IAW) Supplemental Type Certificates (STC) covering installation of a different model engine and propeller, overhaul and calibration of the manifold pressure/fuel flow gauge, installation of new cooling air baffles, aileron and wing flap gap seals, and lower cowling access panels.

Section II, Limitations, of the POH/AFM specified that the maximum CHT was 460°F, and the minimum oil pressure was 30 psi. Section III, Emergency Procedures, of the POH/AFM revealed there were no checklists for loss of oil pressure or CHT exceedance.

The engine manufacturer Standard Practice Maintenance Manual specified that the fuel flow at full power be between 24.9 to 26.6 gallons-per-hour (GPH).

Two mobile phones, a tablet computer, two Garmin G5’s, and a Stratus Attitude Heading and Reference System (AHRS) were recovered from the wreckage. No data were recovered from either mobile phone, the tablet computer, or either Garmin G5.

An Insight GEM which was installed in the instrument panel, just above and to the right of the center control yoke, in accordance with installation instructions that specified it was to be installed where it was easily visible by the pilot. Data were successfully recovered from the device following the accident.

Further review of the GEM data associated with the accident flight, correlated with ADS-B data, revealed that the recorded fuel flow values from about takeoff power application to when it decreased and remained at 0 were nearly always above the maximum limit of 26.6 GPH, averaging about 44 GPH with the highest value slightly over 99 GPH. The EGT values, which were not an engine operating limitation, appeared “noisy” and erratic for the No. 4 cylinder and had not trended with the remaining cylinders since December 13, 2022. The oil temperature values from takeoff power application to where the fuel flow decreased to and remained at 0 were above normal, averaging about 693°F.

Data from the GEM for the flight before the accident flight revealed that the CHT values for the No. 4 cylinder were generally equal to or slightly higher than the highest values for the remaining cylinders; however, all CHT readings were below the maximum specified value. The data also indicated that the fuel flow was generally steady and within limits except for a short period about 5 minutes after takeoff power was applied, periodically during the flight, and then again for about 19 minutes before power was reduced. During the times when the fuel flow was erratic and exceeded the maximum specified value, the CHT values for all cylinders were below the maximum value and all trended genera...