NYC95FA031

NTSB accident investigation · Mooney M20J · Brewster, MA · November 19, 1994

Accident · FatalField investigationFinal report
Date
November 18, 1994, 20:16 local (Nov 19, 1994, 01:16 UTC)
Place
Brewster, MA
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N5681YMooney M20J
Weather
Instrument (IMC) · Night/dark
Status
Completed · report September 24, 1995
Report
Approved by Office Director
FAA report
19941118038529A
Case key
38844

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

Failure of the pilot to maintain control of the airplane during a missed approach. A factor related to the accident was: the deteriorating weather condition with a low ceiling and rain.

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.

Loss of control - in flightMissed approach (ifr)
Light condition - dark night
Weather condition - low ceiling
Weather condition - rain
Missed approach - initiatedPilot in command
Aircraft control - not maintainedPilot in commandCause
In flight collision with terrain/waterDescent - uncontrolled

Analysis

Before takeoff, the pilot obtained a weather briefing for an IFR flight & was told the weather was being influenced by a stationary hurricane over the atlantic ocean. He was advised of 3 airmet's, with a forecast of rain, drizzle, fog, moderate isolated severe turbulence below 15,000' & icing above 12,000' along the route of flight. There was no weather station at the destination, but at the time of the briefing, the hyannis weather was in part: 3300' overcast, visibility 7 mi with occasional light drizzle & wind 110 deg at 12 KTS. During arrival, the pilot encountered deteriorating weather while on an NDB approach. He elected to divert to an alternate & initiated a missed approach. The airplane climbed 800' in 12 seconds (to 1600' MSL), then radar & radio contact were lost. The airplane crashed in a wooded area, while in a steep descent. No preimpact mechanical failure was evident. The 2045 EST weather at hyannis was in part: 100' obscured, visibility 1-1/4 mi with light rain & fog, temperature 60 degrees, dew point 58 degrees & wind 140 deg at 12 KTS.

Factual narrative

History of flight

On November 18, 1994, about 2016 eastern standard time, a Mooney M20J, N5681Y, owned and piloted by David H. Roe, collided with the terrain, after discontinuing a non-precision approach at Chatham Municipal Airport, near Brewster, Massachusetts. The airplane was destroyed, and the pilot was fatally injured. Instrument meteorological conditions prevailed, and an IFR flight plan had been filed for the flight conducted under 14 CFR Part 91.

At 1737, the pilot of N5681Y called the Automated Flight Service Station (AFSS), Millville, New Jersey. The pilot requested and received a pre-flight pilot briefing for weather conditions between Morristown, New Jersey, and Chatham, Massachusetts.

The pilot was given a summary by the AFSS Specialist of, "pertinent adverse conditions, synoptic conditions and current and forecasted weather along his route of flight." In addition, the pilot was told there were no pertinent en route NOTAM's or destination airport NOTAM's.

At 1738:28, the specialist provided the pilot the following weather information:

...up to the north now the high is centered now east of Maine...even up that way they do have a east northeast wind flow so conditions really not improving too much...goin' up towards Chatham as far as um the hurricane Gordon that looks like pretty well stationary if anything it may even be moving southward at this time so for the route...that northeast easterly wind flow bringing in low ceilings visibilities [sic] and rain drizzle and fog...there is airmet sierra for those conditions for the entire route of flight...airmet tango for moderate isolated severe turbulence below fifteen thousand feet that's also for the route...airmet zulu...for icing but uh the freezing level right now and these forecasts will be throughout the afternoon en route should be twelve thousand feet or higher.

The pilot was also provided the current Morristown weather conditions: "estimated ceiling five hundred overcast visibility a mile and a half in light drizzle fog temperature five six dew point missing wind from zero two zero at six altimeter three zero zero six...."

The specialist told the pilot that the nearest weather information available for his destination at Chatham was Hyannis (located approximately 15 NM west of Chatham). Based on the pilot's estimated arrival time, the following Hyannis weather forecast was issued:

... they're reporting two thousand scattered measured ceiling three thousand three hundred overcast visibility seven temperature six one dew point five seven wind from one one zero at one two altimeter three zero one zero...occasional light drizzle. Martha's Vineyard...about the same two thousand five hundred scattered ceiling three thousand five hundred overcast...visibility six miles in light drizzle and fog...rain shower light rain and rain shower activity all the way up but nothing convective...and they are saying now through zero three hundred [2200] one thousand five hundred scattered ceiling four thousand five hundred broken...wind from one five zero at one five gust two five occasional ceiling of one thousand five hundred overcast.

The pilot filed an IFR flight plan and departed from Morristown, at 1835.

At 1945, the pilot established radio contact with the Air Traffic Control (ATC) Specialist at the HIGH Arrival Radar position, located at Cape TRACON, Otis Air National Guard Base (ANGB), Massachusetts.

The pilot initially checked-in at 7000 feet and was issued radar vectors for the Non-Directional Beacon "A" (NDB A) approach at Chatham (CQX).

In the specialist's personal statement, she wrote:

I broke him off the approach twice; once he was too high, the second time he did not intercept final until inside the final approach fix. When he was established on final I switched him to advisory frequency. I observed N5681Y deviate from the final approach course and descend. The low altitude alert went off, and I tried to call the pilot even though he had changed frequencies. He responded saying that he was encountering rough weather and didn't think he could see the airport. I climbed him to 2000' and issued a heading. [He] requested a clearance to...HYA; I told him to expect it in a few miles. I observed the aircraft's Mode C [transponder] altitude at 2000' and cleared him to HYA Airport. There was no response and the target disappeared from my scope....

According to the ATC Transcript of Communications, at 1958:25, N5681Y was located 7 miles from the final approach fix, and the pilot was cleared for his first attempt at the NDB A approach. The pilot repeated the clearance and asked, "...oh do you have any missed approach instructions for me...."

The specialist responded at 1958:38, "...in the event of a missed approach enter controlled airspace heading zero six zero to maintain two thousand...."

At 2000:05, specialist called N5681Y, and asked "...are you going to be okay at make[ing] the approach at that altitude...." The pilot replied, "I'm going to see if I can get down a little faster and probably but if not I'll ah ask you again." The specialist asked the pilot if he wanted a 360 degree turn, which he accepted and performed.

The specialist instructed the pilot to break off the approach at 2007:16. This time the specialist advised the pilot that he was inside Whips Intersection, the final approach fix (FAF), and asked if he wanted to make another 360 degree turn. The pilot requested a turn to the right. This was approved, and the pilot performed the turn. At the completion of the turn, the pilot was cleared for the approach again and told to report established on final.

At 2012:43, the pilot said, "...established on the approach," and the specialist told the pilot to, "...change to advisory frequency...[and] cancellation with me...on the ground...."

The pilot called at 2015:12, "...I'm in uh pretty rough weather here and I don't think I'm going to ah get down to uh be able to see the ground."

The specialist responded, "...81Y now I would uh climb back up to about two thousand feet if I were you and uh fly heading zero six zero and uh then you can say intentions either if you want to try again or uh go somewhere else."

The pilot stated, "...I'd like to try uh Hyannis if anybody's been getting in there." The ATC Specialist responded, "...everyone [was] getting into Hyannis and you can expect your clearance there in a few more miles."

At 2016:29, the specialist issued the pilot a clearance to Hyannis, which the pilot never acknowledged. The specialist tried several calls, but radio contact was never reestablished.

The NTSB Radar Study showed that, between 2016:47, and the last radar hit at 2016:59, N5681Y climbed 800 feet in 12 seconds. The last radar hits showed the airplane at 1600 feet MSL, turning to the left and heading in a northerly direction.

The accident occurred during the hours of darkness, approximately 41 degrees, 44 minutes north, and 70 degrees, 01 minutes west.

Aircraft information

The aircraft and engine log books were not found in the wreckage. The pilot's family searched for these items, but were unable to locate them.

Aerodrome information

The Chatham Airport had one runway, 06/24, which was 3,000 feet long. The runway was equipped with medium-intensity runway edge lights (MIRL), which were pilot controlled by microphone keying, on frequency, 122.95. There were no approach lights, runway end identification lights (REIL), nor visual approach slope indicator system (VASI).

The NDB approach to the airport utilized the Nauset Radio Beacon (279), which was located on the airport. This was a circling approach only. The Initial Ap

Aircraft

Registration
N5681Y
Reported as
Mooney M20J
Category
Airplane
Serial number
24-1399
Engine
Lycoming IO-360, 200 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Registered owner
David Roe
Airworthiness certificate
Standard, Normal
Departed
MMU · Morristown, NJ
Destination
CQX · Chatham, MA
Flight plan
IFR
Airport
CQX · Chatham Municipal, runway 24, 3,000 × 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
48
Certificate
Commercial
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--no waivers/lim.
Seat
Left
Toxicology
Performed
Flight hours
1,080 total · 609 in this make and model · 984 as pilot in command · 43 in the last 90 days · 21 in the last 30 days

Weather

Conditions
Instrument (IMC) · Night/dark
Wind
140° at 12 knots, gusting 22
Visibility
1.25 statute miles
Lowest ceiling
100 ft overcast
Temperature
61 °F, dew point 57 °F
Altimeter
30.00 inHg
Observed at
HYA, 9 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.