Why the NTSB investigation into the landing accident at Lake Placid, New York on September 9, 2008 was inadequate. 

Introduction

This accident deserves a much more thorough discussion than NTSB provided.  I find this to be a much more interesting accident than the landing in the Hudson.  In that accident it seems fairly certain that after an appropriately long and detailed investigation involving all concerned parties the probable cause will probably be related to bird ingestion. It is an important accident with much to teach us, but it there is no mystery to it.  There is mystery to the accident at Lake Placid.

This accident however was so minor that it merely rated a brief mention in the local press and it was quickly forgotten by all but the pilot and his passenger.  In many, if not most, GA accidents a brief investigation is usually sufficient to determine the cause and the contributing factors and the accident rates no more investigation than is normally done.  However, this accident involves a pilot apparently doing everything a pilot is taught to do and yet he still landed on a closed runway. I should also note that the task of keeping the airplane's cabin in one piece may have been quite difficult.

 NTSB Reports

The NTSB Summary:

 NTSB Identification: MIA08CA190
14 CFR Part 91: General Aviation
Accident occurred Tuesday, September 09, 2008 in Lake Placid, NY
Probable Cause Approval Date: 1/22/2009
Aircraft: CESSNA 310R, registration: N115CA
Injuries: 2 Uninjured.

The pilot was on a night visual flight rules cross-country flight with air traffic control (ATC) flight following, from Iowa to Lake Placid, New York. Throughout the flight the pilot was in contact with several ATC centers. When the flight was about 2 hours from arrival, he obtained a briefing from a flight service station. During the briefing, the pilot was not provided with the notice to airmen regarding the closed runway at his destination airport. During his approach, the pilot was able to activate the closed runway’s lights at the destination airport. The pilot did not notice any abnormality during the approach and landing. During the landing roll, the airplane encountered several gaps on the runway. The airplane incurred damage from the runway surface conditions. The runway was closed and under construction. The runway had unlit "X" markings, eight flashing markers in the middle, and cones located at both approach ends.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The pilot's failure to observe the ongoing construction to the closed runway while landing. Contributing to the accident was flight service's failure to brief the pilot of the closed

The Full NTSB investigative findings are here.

Discussion

The NTSB is not charged with enforcing the aviation laws.  It only investigates and reports on transportation accidents.  The Board issues probable cause findings, but these are often of only marginal usefulness.  The NTSB found the probable cause of the accident was the pilot landing the aircraft on a closed runway and the FSS contributed because they did not tell him the runway was closed.  Not very helpful.  The report makes no recommendations. But most importantly the report fails to answer the question - Why?  This is especially critical in an accident where the pilot appears to have done what pilot's are supposed to do.

Three Questions

1. Was the Notam properly distributed and sufficient to warn the pilot that the only runway at the airport was closed for construction, arguably closing the airport to fixed wing operations.
2. Were the runway closure markings consistent with good aviation safety practices?
3. Were the runway closure markings sufficient to warn the pilot that the runway was closed?

The Notam

Was the Notam sufficient to warn the pilot that only runway at the airport was closed for construction, arguably closing the airport to fixed wing operations?

To answer this question we need to know three things.  First, was the Notam properly distributed?  Second, was the Notam readily available  to the FSS specialist? Third, assuming the Notam was available, why did the FSS specialist not confirm with the pilot that he was aware of it, and if the specialist was not required to do so, why not?

The NTSB answers none of these questions.

Closure Marking Propriety

Were the runway closure markings consistent with good aviation safety practices? 

The report states that there was an unlit "X" at the approach end of the runway and flashing markers at the midpoint. Why was the closure "X" unlit? Were the flashing runway markers consistent with FAA guidance to airport operators and  pilots? If they were not, then should there be an expectation that they were reasonable to warn the pilot? If they were consistent with FAA guidance to airport operators and pilots, were they working properly? 

The NTSB answers none of these questions.

Closure Marking Adequacy

Were the runway closure markings sufficient to warn the pilot that the runway was closed? 

Finally, notwithstanding the propriety of the closure markings, were the closure markings adequate to alert a reasonably prudent pilot to the runway closure?  Would a pilot flying a normal VFR glide path at night with the lighting equipment installed on the C-310 have been able to see the unlit "X" and if so at what altitude and for how long?  If the midpoint flashing lights were working, and not withstanding their propriety, would a reasonably prudent pilot have been able to see them and recognize them for what they were?

The NTSB answers none of these questions.

Conclusion

Because this accident was completely avoidable, with no apparent error by the pilot, it is an accident that should be documented in much greater detail.  The contributing causes to this accident are complex and sufficiently important that other pilots understand and learn from it.  The NTSB has left many important questions unanswered and for this they should be taken to task.