NYC01FA005

NTSB accident investigation · Mitsubishi MU-2B-26A · Edgartown, MA · October 7, 2000

Accident · FatalField investigationFinal report
Date
October 6, 2000, 21:58 local (Oct 7, 2000, 01:58 UTC)
Place
Edgartown, MA
Injuries
4 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N60BTMitsubishi MU-2B-26A
Weather
Instrument (IMC) · Night/dark
Status
Completed · report February 7, 2002
Report
Approved by Office Director
Parties
Mitsubishi Heavy Industries, Honeywell, Massachusetts Aeronautical Commission
FAA report
20001006014999A
Case key
51292

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The pilot's failure to follow instrument flight procedures resulting in a collision with a tree. A factor related to the accident was the low cloud ceiling.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

In flight collision with objectApproach - faf/outer marker to threshold (ifr)
Light condition - dark night
Ifr procedure - not followedPilot in commandCause
Object - tree(s)
Weather condition - low ceilingFactor

Analysis

The pilot departed on a night cross-country flight without obtaining a weather briefing or flight plan. Arriving in the area of the destination airport, the weather was reported as, 2 statute miles of visibility and mist; overcast cloud layer at 100 feet. The pilot requested an instrument flight rules clearance from the approach controller, and was vectored and cleared for the ILS 24 approach. The clearance included an altitude restriction of 1,500 feet msl, until the airplane was established on the localizer. As the pilot contacted the control tower, the tower controller issued a low altitude alert to the pilot. The pilot replied that he was climbing and the tower controller cleared the pilot to land, which the pilot acknowledged. No further pertinent radio transmissions were received from the airplane. The airplane came to rest in a wooded area about 3/4-mile from the runway threshold, and about 50 feet right of the extended centerline. Review of the approach plate for the ILS 24 approach revealed that the minimum glide slope intercept altitude at the beginning of the final approach segment on the precision approach was 1,500 feet. The glide slope altitude at the final approach fix for the non-precision approach, which was located about 4 miles from the approach end of the runway, was 1,407 feet. The glide slope altitude at the middle marker, which was located about 0.6 miles from the approach end of the runway, was 299 feet. Review of radar data revealed that the airplane was observed at 700 feet, about 4 miles from the airport, and at 300 feet, about 1.5 miles from the airport. The pilot had accumulated about 1,946 hours of total flight experience, with about 252 hours in make and model. The pilot had attended initial and recurrent training for the make and model airplane; however, did not complete the training.

Factual narrative

History of flight

On October 6, 2000, about 2158 eastern daylight time, a Mitsubishi MU-2B-26A, N60BT, was destroyed when it impacted terrain while conducting an instrument approach to the Vineyard Haven Airport (MVY), Edgartown, Massachusetts. The certificated commercial pilot and three passengers were fatally injured. Night instrument meteorological conditions prevailed at the accident site. No flight plan was filed for the personal flight conducted under 14 CFR Part 91.

According to Federal Aviation Administration (FAA) air traffic control transcripts and radar data, the airplane had departed the Trenton Mercer Airport (TTN), Trenton, New Jersey, about 2101, and proceeded in an easterly direction. The last communication from the airplane to the TTN air traffic control tower was about 2103. The next radio communication from the airplane was received by Cape Approach Control, about 2138, in the vicinity of MVY. The pilot requested an instrument flight rules clearance from the approach controller, and was vectored for the ILS Runway 24 approach at MVY. The approach controller issued the pilot an approach clearance about 4 miles from BORST intersection. The clearance included a left hand turn to 230 degrees, and an altitude restriction of 1,500 feet msl, until the airplane was established on the localizer. The pilot acknowledged the clearance and requested the approach controller to repeat the heading for the left turn. The approach controller replied "continue left turn heading of" 220 degrees.

About 7 miles from the airport, the pilot was instructed to contact the MVY air traffic control tower. The pilot contacted the MVY control tower and announced that he was on the ILS 24 approach. The tower controller replied to the pilot to report BORST intersection inbound, which the pilot acknowledged. At 2153:14, the approach controller contacted the tower controller to issue a low altitude alert warning for the accident airplane. The tower controller advised the pilot, "and uh six zero bravo tango approach advises low altitude alert check your altitude immediately altimeter two niner eight seven." The pilot replied "bravo tango climbing up." The tower controller then queried the pilot about what type of aircraft he was, and how long he would be staying on the island. The pilot replied that he was a Mitsubishi and that he would be staying until Monday. At 2154:54, the pilot stated that he was "crossing" BORST intersection. The tower controller cleared the pilot to land, which the pilot acknowledged. No further radio transmissions were received from the airplane.

The airplane came to rest in a wooded area about 3/4-mile from the runway 24 threshold, and about 50 feet right of the extended centerline.

The accident occurred during the hours of darkness, at 41 degrees, 24.40 minutes north latitude, 70 degrees, 35.90 minutes west longitude, at an elevation of 55 feet.

Personnel information

The pilot held a commercial pilot certificate with ratings for multi-engine land and single-engine land airplanes. The pilot was also instrument rated. His most recent application for a FAA second-class medical certificate was dated on December 9, 1999.

According to the pilot's logbook, he had accumulated about 1,946 hours of total flight experience, with about 252 hours in make and model. The pilot had also accumulated about 178 hours of night flying experience and about 209 hours of actual instrument flight experience. His last instrument competency check was completed on January 2, 1999.

Further review of the pilot's logbook revealed a remark, entered during the month of April 1999, stating that the pilot had "completed flight safety MU-2 initial course." A certified flight instructor signed the entry.

A flight instructor, who was employed by the Flight Safety (FS) Houston Learning Center, Houston, Texas, stated that the pilot had attended MU-2 ground school and simulator training early in 1999. At that time, the flight instructor estimated that the pilot arrived at FS with about 1470 hours of total time, and his only experience with turbine aircraft was in a Vampire Jet. During the ground school, the pilot had a positive attitude, but did not meet the minimum standards of FS during the simulator sessions and left without completing the course.

The pilot returned to FS about August 1999, for recurrent training. The flight instructor was tasked with conducting the simulator portion of the training with the pilot. During the simulator training, the pilot needed to be "spoon fed" procedures and techniques, "step by step," in the simulator. He was not near the minimum standards set by FS. The pilot was able to fly the simulator if the weather was VFR and no emergencies occurred. However, when the weather was low or an emergency occurred, the pilot "could not keep the airplane right side up." As the simulator sessions progressed the flight instructor observed the pilot improving in his abilities; however, "he was still a 100 knot pilot in a 300 knot airplane." The pilot did not complete the recurrent training, and departed FS. The flight instructor advised the pilot prior to his departure that he should secure a second qualified pilot to fly with him, and avoid flying in bad weather.

Aircraft information

The airplane's maintenance logbooks were not recovered during the investigation.

According to records from a maintenance facility in Rhode Island, the airplane was last maintained on October 4, 2000. The maintenance included a 100-hour inspection, and the repair of the turn and bank indicator. The owner of the maintenance facility stated that the pilot picked up the airplane on October 5, 2000. The maintenance facility owner advised the pilot that the pilot's side horizontal situation indicator (HSI) was still inoperative and suggested that it be removed for repair prior to departing. The pilot replied to the maintenance facility owner that he would have it fixed by another maintenance facility, and that he would fly the airplane as it was. The pilot also added that the upcoming weekend was very important and he did not want the problem with the HSI to ruin it.

An individual, who sold the accident airplane to the pilot, stated that he had conversed with the pilot about 1 week prior to the accident. The conversation included the subject of the pilot's side HSI installed in the airplane. The pilot stated to the salesman that the HSI had been inoperative for about the last 4-5 trips and he was utilizing the instruments on the right pilot's side to fly the airplane during inclement weather conditions. The salesman advised the pilot of several facilities that could fix the HSI, but the pilot replied that he would have the maintenance facility in Rhode Island check it the next time maintenance was performed.

Copies of discrepancies, or "squawks," which were in the pilot's handwriting, outlined problems that included, "Pilot's side HSI does not slave to fluxgate. (Right side HSI slaves fine!) (Pilot's HSI works fine except slaving.) Pilot side ball and needle is frozen inop. (I would prefer a turn coordinator anyway but it sits in a 2 ½ hole." "Autopilot no problems at all."

Meteorological information

The weather reported from MVY, at 2153 was, winds from 340 degrees at 12 knots; 2 statute miles of visibility and mist; overcast cloud layer at 100 feet; temperature and dew point of 55 degrees Fahrenheit; and an altimeter setting of 29.86 inches of mercury.

Aids to navigation

About 3 minutes prior to the accident, a "Citation X" jet airplane landed uneventfully at MVY, after conducting the ILS Runway 24 approach. According to an FAA inspector, the runway 24 ILS system was "flight checked" the day after the accident, and no abnormalities were noted.

Review of the approach plate for the ILS Runway 24 approach revealed that the minimum glide slope altitude at the beginnin

Aircraft

Registration
N60BT
Reported as
Mitsubishi MU-2B-26A
Category
Airplane
Serial number
358SA
Airframe hours
5,400
Engine
Garrett TPE-331, 665 horsepower, turbo prop
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Registered owner
Keith Corp
Airworthiness certificate
Standard, Normal
Last inspection
Annual · October 5, 2000 · 2 hours before
Departed
TTN · Trenton, NJ
Destination
MVY · Edgartown, MA
Flight plan
IFR
Airport
MVY · Vineyard Haven Airport, runway 24, 5,500 × 100 ft, asphalt

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
61
Injuries
Fatal
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Last flight review
January 6, 1999
Seat
Left
Toxicology
Performed
Flight hours
1,946 total · 253 in this make and model · 1,755 as pilot in command · 39 in the last 90 days · 2 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Night/dark
Wind
340° at 12 knots
Visibility
2 statute miles
Lowest ceiling
100 ft overcast
Temperature
55 °F, dew point 55 °F
Altimeter
29.86 inHg
Observed at
MVY, 1 nm away

Docket · 24

The files NTSB released with the investigation on January 15, 2002, on NTSB’s docket system: statements, records, photos and specialists’ reports. 6.9 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.