# NTSB NYC94FA033: Piper PA-28R-200, N1488X, New Haven, CT, December 4, 1993 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: December 4, 1993, 18:57 local (23:57 UTC) - Place: New Haven, CT - Location: 41.1919° N, 72.8994° W: Placed by OpenAirDocs from NTSB’s distance and direction from TWEED/NEW HAVEN (HVN), within about a mile (OpenAirDocs) - Nearby events: https://openairdocs.org/map.md?lat=41.1919&lon=-72.8994&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 4 fatal - Status: Completed, report December 2, 1994 - Report: Approved by Office Director - NTSB case key (mKey): 38664 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC94FA033 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/38664/pdf - Page: https://openairdocs.org/ntsb/NYC94FA033 ## Probable cause THE PILOT'S FAILURE TO MAINTAIN CONTROL OF THE AIRPLANE DURING A NIGHT APPROACH IN ADVERSE WEATHER CONDITIONS. FACTORS WHICH CONTRIBUTED TO THE ACCIDENT WERE THE WEATHER CONDITIONS AND DARK NIGHT. IN ADDITION, THE RADAR CONTROLLER'S VECTORING OF THE PILOT TO THE FINAL APPROACH COURSE WAS NOT IN ACCORDANCE WITH ATC PROCEDURES, THE RADAR CONROLLER ISSUED THE PILOT AN ALTITUDE WHICH WAS NOT IN ACCORDANCE WITH PROCEDURES, AND THE RADAR CONTROLLER FAILED TO PROVIDE RADAR MONITORING AS OUTLINED IN IN ATC HANDBOOK 7110.65H. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, approach - faf/outer marker to threshold (ifr) - light condition - dark night (contributing factor) - weather condition - fog (contributing factor) - weather condition - rain (contributing factor) - weather condition - low ceiling (contributing factor) - weather condition - turbulence (contributing factor) - aircraft control - not maintained, pilot in command (cause) - lack of total experience in type operation, pilot in command (contributing factor) - artcc service - inadequate, atc personnel(artcc) (contributing factor) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - water ## Analysis ABOUT 30 MIN BEFORE THE ACCIDENT THE PILOT WAS ADVISED TO EXPECT AN ILS RWY 2, AND HE BEGAN RECEIVING VECTORS FOR THE FINAL APPROACH COURSE. AT 8 MIN BEFORE THE ACCIDENT, AND ABOUT 12 MI FROM THE INITIAL APPROACH FIX, THE PILOT WAS CLEARED FOR ILS RWY 2 TO CIRCLE TO RWY 20. AT ABOUT 2 MI FROM THE INITIAL APPROACH FIX THE PILOT WAS AGAIN CLEARED FOR THE ILS RWY 2 TO CIRCLE TO RWY 20. WHILE ON THE LOCALIZER THE PILOT ACKNOWLEDGED 'CIRCLING TO AH TO TWO ZERO.' THE AIRPLANE IMPACTED THE WATER 4.5 MI FROM THE AIRPORT. AN ATR-42 PILOT WHO HAD JUST LANDED STATED THAT CONDITIONS WERE 'ROUGH AND TURBULENT, ESPECIALLY AT TRAFFIC PATTERN ALTITUDE.' THE PILOT HAD OBTAINED HIS INSTRUMENT RATING 4-1/2 MOS BEFORE THE ACCIDENT. ## Factual narrative HISTORY OF FLIGHT On Saturday, December 4, 1993, at 1857 eastern standard time, a Piper PA-28R-200, N1488X, registered to the University of New Haven, and piloted by John D. Lapinski, was destroyed by impact with the water during an approach to the Tweed-New Haven Airport, New Haven, Connecticut. The three passengers were fatally injured. The body of the pilot was not recovered, but he was presumed to have received fatal injuries. Instrument meteorological conditions prevailed, and an IFR flight plan was filed. The flight was being conducted under 14 CFR 91. The airplane departed Nantucket, Massachusetts at 1722, destined for New Haven. At 1827, the pilot of N1488X contacted New York TRACON and was provided with a series of vectors to the ILS. The TRACON switched N1488X to the New Haven Control Tower for landing instructions. Several transmissions occurred between the pilot of N1488X and the tower controller regarding the approach to be performed. The last transmission from N1488X was at 1856:32, when the pilot stated: "okay circling to ah to two zero." The tower controller attempted to contact N1488X several times after this radio call, but without any response. The tower controller heard no distress calls. There was no radar available to the tower controller, and he had no visual contact with the airplane. Captain Matt Falkner was the pilot of an ATR-42 that landed on runway 02 at the Tweed-New Haven Airport approximately 3 minutes prior to the time N1488X commenced the approach. Captain Falkner stated that the flight conditions were "rough and turbulent, especially at traffic pattern altitude." He said that the control tower initially cleared him for the ILS approach with a circle to land runway 20. He advised the controller that he wanted to land straight-in runway 02, from the ILS approach. This was approved by the tower. He stated that he "broke out of the clouds at about 700 feet and landed without problems." He indicated that it was raining when he landed. After landing, Captain Falkner heard the pilot of N1488X make radio contact with the tower. He recalled that the pilot was cleared for a circling approach to runway 20. He stated that the pilot of N1488X did not sound confident. He said that he even considered suggesting to the pilot of N1488X that he request the straight-in ILS and land runway 02, rather than accept the circling approach. He rejected this idea, after deciding that it was not "professional" for him to interfere with the communications. A search of the area was conducted, and on December 20, 1993, the airplane wreckage was located in 65 feet of water, approximately 4.5 miles southwest of the airport. The left wing was located in the water approximately 2.25 miles from the main wreckage on a magnetic heading of 300 degrees. The main wreckage was salvaged from the water, but due to adverse weather conditions, the left wing was not recovered. The accident occurred during the hours of darkness, at about 41 degrees, 10 minutes North; 72 degrees, 52 minutes West. PERSONNEL INFORMATION Mr. Lapinski held a Private Pilot's Certificate, with a single engine land rating. He was enrolled as a student in the University of New Haven's Flight Operations Program, where he was receiving instruction towards a Commercial Pilot's Certificate. Mr. Lapinski's flight time log book was not located. Based upon training records, it was estimated that he had a total flight time of approximately 228 hours. His most recent FAA Medical Certificate was a 3rd Class, with no limitations, issued on January 11, 1993. Mr. Lapinski had obtained an instrument rating on July 26, 1993. METEOROLOGICAL INFORMATION The New Haven Automatic Terminal Information Service (ATIS) SIERRA, recorded at 1745, reported the weather as "measured ceiling eight hundred overcast visibility three light rain fog temperature four seven dewpoint missing wind one one zero at eight altimeter two niner niner eight." The ATIS TANGO, recorded at 1845, reported the weather as "five hundred scattered measured ceiling one thousand one hundred overcast visibility four light rain fog temperature four seven dewpoint missing wind one two zero at one zero altimeter two niner niner five." These weather reports were determined by the Tweed-New Haven Tower Local Controller, as part of his duties. AIDS TO NAVIGATION At the time of the accident, there was no published approach for runway 20 at the Tweed-New Haven Airport. The ceiling and visibility minimums for an ILS to runway 02 with a circling approach to runway 20 were 800 feet and 1 mile visibility. The ILS to runway 02 was inspected and found to be operating satisfactorily by an Federal Aviation Administration technician on December 4, 1993 and by an FAA flight check on December 5, 1993. WRECKAGE The airplane wreckage, except for the left wing, was recovered on December 20, 1993, and examined at the Tweed-New Haven Airport. In order to transport the wreckage from the boat pier to an examination facility, the fuselage cut aft of the passenger cabin. The left wing was separated from the fuselage at the wing root. There was no evidence of corrosion or fatigue on the spar or remaining support structure. The left horizontal stabilizer leading edge was crushed, and the outer 1/3 of the stabilizer was missing, outboard from the trim tab. There was no evidence of corrosion or fatigue on the remaining stabilizer support structure. The left side of the cockpit was crushed, and the windshield was shattered and missing. The fuselage was partially separated from the cockpit instrument panel. The right main landing gear was in the down and locked position. The left main landing gear was not with the wreckage, but it was located on a beach near Riverhead, New York, on December 12, 1993. The nose gear was attached to the fuselage and was partially extended. The wing flaps were in the up position, as verified by both the jackscrew position and the cockpit switch. The NAV 1 frequency selector was set to the New Haven VORTAC, and the NAV 2 was set to the New Haven LOCALIZER. The three-bladed propeller was intact and the blades were bent in the aft direction. The propeller was rotated and continuity was verified through the valve train to the accessory section. There was compression to the four cylinders. The engine magnesium oil sump was partially corroded. The vacuum pump was intact and suction was evident when the shaft was rotated. The shear shaft was intact. The electric fuel pump was in the ON position. The engine fuel pump was fractured, but the diaphragm moved when the shaft was rotated. Both magnetos impulse couplings operated. The fuel manifold was fractured, but there was the smell of AVGAS when the "spider" manifold was removed. Flight control continuity was established from the rudder and the elevator to the cockpit rudder pedals and control yokes. Except for the left wing, investigators accounted for all flight control surfaces. MEDICAL AND TOXICOLOGICAL INFORMATION The body of the pilot was not recovered, therefore; no autopsy or toxicological tests were accomplished. ADDITIONAL INFORMATION The National Transportation Safety Board Air Traffic Control Group Chairman's Factual Report stated: At 2327:16 [times in this report are Universal Coordinated Time], the pilot of N1488X made initial radio contact with the Beads arrival controller at the New York TRACON, advising, "New York approach ah Arrow or november one four eight uh xray with you at six thousand." The controller replied, "Arrow one four eight xray good evening New York approach Islip altimeter two niner niner one." The pilot acknowledged. At 2328:04 ## Aircraft - Registration: [N1488X](https://openairdocs.org/deregistered/N1488X-1994-06-27), registration cancelled 1994-06-27, S/N 28R7535297 (OpenAirDocs) - Reported make and model: PIPER PA-28R-200 - Registry model: [Piper PA-28R-200](https://openairdocs.org/model/piper-pa-28r-200) (registry code 7102811) (OpenAirDocs) - Category: Airplane - Serial number: 28R-7535297 - Airframe hours: 3198 - Engines: LYCOMING IO-360-C1C 200 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Registered owner: University Of New Haven - Airworthiness certificate: Standard, Normal - Last inspection: Annual, September 9, 1993 - Departed: ACK, NANTUCKET, MA - Flight plan: IFR - Airport: HVN, Tweed-New Haven, runway 20, 5,600 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 42; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, valid medical--no waivers/lim.; seat: left; flight hours: 228 total, 14 in the last 90 days, 9 in the last 30 days, 3 in the last 24 hours ## Weather - Conditions: Instrument (IMC), Night/dark - Wind: 120° at 10 knots - Visibility: 4 statute miles - Lowest ceiling: 1,100 ft overcast - Temperature: 46 °F - Altimeter: 29.00 inHg - Observed at: HVN ## 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 19931204045949A](https://openairdocs.org/incident/19931204045949A), Dec 4, 1993: Piper PA28R200, New Haven, CT, Destroyed, 4 fatal. Lost control circling over water after ILS. Turbulence night time rain and fog. Descended into water off shore. 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.