# NTSB NYC00FA064: Aerostar 601P, N905DK, Coatesville, PA, January 10, 2000 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: January 10, 2000, 05:19 local (10:19 UTC) - Place: Coatesville, PA - Coordinates: 39.980175, -75.809516 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=39.9802&lon=-75.8095&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report April 19, 2001 - Report: Approved by Office Director - NTSB case key (mKey): 48485 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC00FA064 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/48485/pdf - Page: https://openairdocs.org/ntsb/NYC00FA064 ## Probable cause The pilot's failure to follow the published instrument approach procedure, and his failure to establish a climb after passing the missed approach point. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight collision with object, approach - object - tree(s) - ifr procedure - not followed, pilot in command (cause) - climb - not obtained, pilot in command (cause) ## Analysis While operating in IMC, the pilot was vectored to the final approach course for an ILS approach. Weather at the airport was ceiling 200 feet and visibility 3/4 mile in mist. The pilot was cleared for the approach, which he acknowledged. No other transmissions were received from the accident airplane. Radar data showed the airplane intercept the final approach course, then track inbound. The airplane crossed the outer marker 420 feet below the glide slope. The last radar return showed the airplane at 440 feet agl, 3.9 miles from the runway. The airplane impacted the ground at a shallow angle about 1 mile north of the airport on the opposite side of the missed approach procedure. The elevation of the accident site was approximately 40 feet lower than the airport. The pilot had about 350 hours of total flight experience. No pre-impact failures were identified with the airframe, engines, flight controls, or flight instruments. ## Factual narrative HISTORY OF FLIGHT On January 10, 2000, at 0519 Eastern Standard Time, an Aerostar 601P, N905DK, was destroyed when it impacted terrain near the Chester County G.O. Carlson Airport, Coatesville, Pennsylvania. The certificated commercial pilot and pilot rated passenger were fatally injured. Instrument meteorological condition prevailed, and an instrument flight rules (IFR) flight plan was filed and activated. The positioning flight departed Millville, New Jersey, and was conducted under 14 CFR Part 91. According to Federal Aviation Administration (FAA) records, on the day before the accident, at 1610, the pilot obtained a preflight weather briefing in person from the Millville Automated Flight Service Station (AFSS) for the accident flight. On the day of the accident, at 0435, the pilot contacted Millville AFSS by radio and filed an IFR flight plan to Chester County, and declared himself the pilot-in-command. At 0437, the pilot requested current weather conditions for Millville from the AFSS. He was told, wind 120 degrees at 5 knots, altimeter 29.93 inches of mercury, visibility 3/4 mile in mist, ceiling 200 feet overcast, temperature 6 degrees Fahrenheit, and dewpoint 6 degrees Fahrenheit. At 0445, the pilot received his IFR clearance to Chester County, and reported airborne at 0452. At 0458, he checked in with Philadelphia Approach Control, and was instructed to proceed direct to the Modena VOR for a visual approach to Chester County. At 0509, the approach controller instructed the pilot to turn right 10 degrees, and join the localizer for the ILS Runway 29. The controller gave no reason for the change in approaches. The pilot acknowledged the transmission, and the controller added maintain 3,000 feet, which was also acknowledged. At 0512, the pilot was cleared for the ILS Runway 29 approach, and at 0513, radar services were terminated. The pilot acknowledged both transmissions. No other communications were received from the accident airplane. According to radar data, the accident airplane intercepted the final approach course for the ILS Runway 29, about 3 miles outside the outer maker, on a ground track of approximately 314 degrees magnetic and 2,600 feet. After intercepting the course, the ground track for the airplane changed from 314 degrees to approximately 296 degrees; afterward, the ground track remained relatively constant, and coincided with the localizer course. The airplane crossed the outer marker, which was located 5.8 miles from the runway, about 1,900 feet. The next return was at 1,400 feet, 4.8 miles from the runway, and the last return was at 1,100 feet, 3.9 miles from the runway. A witness, approximately 750 feet from the accident site, who was driving parallel to the debris path, stated he did not see the airplane before impact, nor did he notice anything unusual until the airplane contacted the ground. He added that when the airplane hit, a fire erupted and he felt an over pressurization. The fire lasted for approximately 12 seconds, and the flames reached about 250 feet in height. The accident happened during the hours of darkness. The wreckage was located 39 degrees, 59.40 minutes north latitude, 75 degrees, 52.70 minutes west longitude, and about 630 feet elevation. PERSONNEL INFORMATION According to FAA records, the pilot held a commercial pilot certificate with ratings for airplane single engine land, multi-engine land, and instrument airplane. The pilot's logbook was not recovered and presumed destroyed in the post-crash fire. On the pilot's last application for a FAA second class medical certificate dated August 20, 1998, he reported 350 hours of total flight experience. The pilot had an Authorization for Special Issuance Medical Certificate for diabetes mellitus requiring oral medication. The authorization for a second-class airman medical certificate was issued by the manager of the Aeromedical Certification Division on September 23, 1998, with a scheduled expiration of August 31, 1999. As part of the submission supporting this Authorization, the pilot included a letter from his personal physician dated September 10, 1998, which noted: "I've been treating this patient since 1997 currently the patient is taking two tablets of Glyburide 5 mg twice and glucophage 500 mg two times a day. Patient has zero side effects from this medication since onset. ...[The pilot] is also maintaining satisfactory control of his diabetes as demonstrated through his last glycohemoglobin .... Patient is seen in our office on a regular basis. Patient has no signs of cardiovascular, neurological or renal diseases. Ophthalmic examinations are performed once a year. Presently the ophthalmic examination of [the pilot] is normal...." MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was preformed on the pilot, by Dr. Donald A. Nicklas, M.D. on January 10, 2000, at the Medical Examiners Office in Brandywine, Pennsylvania. A toxicological test was performed on the pilot and the pilot rated passenger by the FAA Toxicology and Accident Research Laboratory, Oklahoma City, Oklahoma, on March 15, 2000. According to the toxicological report, the pilot had 180 mg/dl of glucose in vitreous and 7182 mg/dl of glucose in urine. AIDS TO NAVIGATION The final approach course for the ILS Runway 29 approach into Chester County was 293 degrees magnetic. The glide slope intercept altitude was 2,400 feet. At the outer marker, glide slope altitude was 2,320 feet. (Radar data depicted the airplane at 1,900 feet.) Decision height for the ILS straight-in to Runway 29, all categories, was 911 feet, or 250 feet agl. Minimum visibility for the approach was 3/4 mile. Minimum decent altitude for the localizer straight-in to Runway 29, all categories, was 960 feet, or 299 feet agl. Minimum visibility for this approach was 1 mile. The missed approach procedure for both approaches was climbing left turn (southwest) to 2,400 feet, direct Modena VOR and hold. The day after the accident, an in-flight inspection of the localizer, glide slope, and outer maker were conducted. All preformed satisfactorily. METEOROLOGICAL INFORMATION At 0550, an automated weather station at Chester County reported a ceiling of 200 feet and a visibility of 3/4 mile in mist. WRECKAGE AND IMPACT INFORMATION The airplane impacted the ground approximately 1 mile north of the airport on the opposite side of the missed approach procedure. The debris path was oriented on a northeast heading. It was 650 feet long and 80 feet wide at the end. In addition, the center of the debris path was broken down into 1-foot increments called stations. The start of the debris path, station 1, was marked by freshly broken branches on top of a 35-foot tree. At station 30, two trees about 10 feet apart, and approximately 30 feet tall were burned and sooted. The tree on the left had a fresh vertical-scrape mark on the southwest side. The mark was approximately 2 feet long and started about 3 feet from the base of the tree. At station 34, were fresh ground scars on a 3-foot drop-off that bordered a four-lane highway. The angle from the first broken branches to the ground scars was approximately 30 degrees. The debris path crossed the highway perpendicular. The guardrail that separated the east and west lanes had fresh impact marks, and was sooted. Lying on the highway at station 90 was the right engine propeller. At station 110 was a third set of trees. These trees were also sooted and burned. At the base of the trees were sections of the cabin, left wing, and right wing, along with melted aluminum. The vertical stabilizer was also located in this area. At station 120 was the left engine propeller minus one of its three blades, which was located about 5 feet away. The horizontal stabilizer was located at station 170, and sections of the cockpit were located at station 320. The cockpit area was comprised of portions o ## Aircraft - Registration: [N905DK](https://openairdocs.org/deregistered/N905DK-2013-08-13), registration cancelled 2013-08-13, S/N 61P-0308-081 (OpenAirDocs) - Reported make and model: Aerostar 601P - Registry model: [Smith AEROSTAR 601P](https://openairdocs.org/model/smith-aerostar-601p) (registry code 8360608) (OpenAirDocs) - Category: Airplane - Serial number: 61P-0308-081 - Engines: Lycoming IO-540 290 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Positioning, Part 91 - Registered owner: N3193x Bonanza Corp - Airworthiness certificate: Standard, Normal - Last inspection: Annual, March 9, 1999 - Departed: MIV, MILLVILLE, NJ - Destination: 40N - Flight plan: IFR - Airport: 40N, Chester County G O Carlso, runway 29, 5,400 × 100 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 66; commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, invalid medical for flight; seat: left; toxicology performed; flight hours: 350 total ## Weather - Conditions: Visual (VMC), Night/dark - Wind: 130° at 6 knots - Visibility: 0.75 statute miles - Lowest ceiling: 200 ft overcast - Temperature: 43 °F, dew point 39 °F - Altimeter: 29.00 inHg - Observed at: 40N, 2 nm away ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20000110006219A](https://openairdocs.org/incident/20000110006219A), Jan 10, 2000: Coatesvilla, PA, No damage, 2 fatal. (-23) On Monday, 1-10-00, at approx. 0519Z, an Aerostar, N905DK with two pilots on board began an ILS 29 approach to Chester county airport (40N), PA. This a/c… From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.