# NTSB NYC01FA005: Mitsubishi MU-2B-26A, N60BT, Edgartown, MA, October 7, 2000 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: October 6, 2000, 21:58 local (Oct 7, 2000, 01:58 UTC) - Place: Edgartown, MA - Coordinates: 41.411109, -70.416664 - Nearby events: https://openairdocs.org/map.md?lat=41.4111&lon=-70.4167&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 4 fatal - Status: Completed, report February 7, 2002 - Report: Approved by Office Director - Parties: Mitsubishi Heavy Industries, Honeywell, Massachusetts Aeronautical Commission - NTSB case key (mKey): 51292 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC01FA005 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/51292/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=51292 - Page: https://openairdocs.org/ntsb/NYC01FA005 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight collision with object, approach - faf/outer marker to threshold (ifr) - light condition - dark night - ifr procedure - not followed, pilot in command (cause) - object - tree(s) - weather condition - low ceiling (contributing factor) ## 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](https://openairdocs.org/deregistered/N60BT-2001-04-12), registration cancelled 2001-04-12, S/N 358SA (OpenAirDocs) - Reported make and model: Mitsubishi MU-2B-26A - Registry model: [Mitsubishi MU-2B-26A](https://openairdocs.org/model/mitsubishi-mu-2b-26a) (registry code 5780414) (OpenAirDocs) - Category: Airplane - Serial number: 358SA - Airframe hours: 5400 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 61; injuries: fatal; 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 ## 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 20001006014999A](https://openairdocs.org/incident/20001006014999A), Oct 6, 2000: Mtsbsi MU2B26A, Marthas Vineyar, MA, No damage, 4 fatal. (-23) Weather 100 feet overcast visibility 2 miles. Cleared for mvy ILS rwy 24. Given a low altitude alert outside borst, the final approach fix, for altitude… ## Docket (24 files) The files NTSB released with the investigation on January 15, 2002, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=51292. 6.9 MB in all. - Supplement C (item 1, .PDF, 439 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40155750&FileExtension=.PDF&FileName=Supplement%20C-Master.PDF - Supplement D (item 2, .PDF, 530 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40155764&FileExtension=.PDF&FileName=Supplement%20D-Master.PDF - Pilot Logbook Excerpts (item 3, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40406298&FileExtension=.PDF&FileName=Pilot%20Logbook%20Excerpts-Redacted.PDF - Materials Laboratory 15 - Factual Report of Group Chairman (item 4, .PDF, 229 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40406292&FileExtension=.PDF&FileName=Materials%20Laboratory%2015%20-%20Factual%20Report%20of%20Group%20Chairman-Redacted.PDF - Maps or Charts of Accident Area, Wreckage Diagrams (item 5, .PDF, 105 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40155751&FileExtension=.PDF&FileName=Maps%20or%20Charts%20of%20Accident%20Area,%20Wreckage%20Diagrams-Master.PDF - Approach Chart (item 6, .PDF, 355 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40155766&FileExtension=.PDF&FileName=Approach%20Chart-Master.PDF - Records of Memorandum (item 7, .PDF, 162 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40155768&FileExtension=.PDF&FileName=Records%20of%20Memorandum-Master.PDF - Flight Plan (item 8, .PDF, 45 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40155769&FileExtension=.PDF&FileName=Flight%20Plan-Master.PDF - FAA Flight Inspection Report (item 9, .PDF, 583 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40406280&FileExtension=.PDF&FileName=FAA%20Flight%20Inspection%20Report-Redacted.PDF - Radar Data (item 10, .PDF, 723 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40406293&FileExtension=.PDF&FileName=Radar%20Data-Redacted.PDF - ATC Package (item 11, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40406282&FileExtension=.PDF&FileName=ATC%20Package-Redacted.PDF - Airport Inspection Reports (item 12, .PDF, 156 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40406281&FileExtension=.PDF&FileName=Airport%20Inspection%20Reports-Redacted.PDF - Maintenance Discrepancy Excerpts (item 13, .PDF, 145 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40406285&FileExtension=.PDF&FileName=Maintenance%20Discrepancy%20Excerpts-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 14, .PDF, 97 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40406277&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 15, .PDF, 99 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40406278&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Toxicological Report (item 16, .PDF, 69 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40406279&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF - Photo of Left Engine. (item 17, .PDF, 49 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40155756&FileExtension=.PDF&FileName=Photo%20of%20Left%20Engine.-Master.PDF - Photo of Right Engine Propeller. (item 18, .PDF, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40155757&FileExtension=.PDF&FileName=Photo%20of%20Right%20Engine%20Propeller.-Master.PDF - Photo of Empennage. (item 19, .PDF, 43 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40155758&FileExtension=.PDF&FileName=Photo%20of%20Empennage.-Master.PDF - Photo of Main Wreckage. (item 20, .PDF, 49 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40155759&FileExtension=.PDF&FileName=Photo%20of%20Main%20Wreckage.-Master.PDF - Photo of Main Wreckage Site. (item 21, .PDF, 44 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40155760&FileExtension=.PDF&FileName=Photo%20of%20Main%20Wreckage%20Site.-Master.PDF - Photo of Left Horizontal Stab. Section. Note Impact Damage. (item 22, .PDF, 30 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40155761&FileExtension=.PDF&FileName=Photo%20of%20Left%20Horizontal%20Stab.%20Section.%20Note%20Impact%20Damage.-Master.PDF - Photo of HSI. (item 23, .PDF, 37 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40155762&FileExtension=.PDF&FileName=Photo%20of%20HSI.-Master.PDF - Photo of Right Wing. (item 24, .PDF, 49 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40155763&FileExtension=.PDF&FileName=Photo%20of%20Right%20Wing.-Master.PDF 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.