# NTSB NYC95FA031: Mooney M20J, N5681Y, Brewster, MA, November 19, 1994 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: November 18, 1994, 20:16 local (Nov 19, 1994, 01:16 UTC) - Place: Brewster, MA - Location: 41.7996° N, 70.0325° W: Placed by OpenAirDocs from NTSB’s distance and direction from CHATHAM MUNI (CQX), within about 2 miles (OpenAirDocs) - Nearby events: https://openairdocs.org/map.md?lat=41.7996&lon=-70.0325&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report September 24, 1995 - Report: Approved by Office Director - NTSB case key (mKey): 38844 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC95FA031 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/38844/pdf - Page: https://openairdocs.org/ntsb/NYC95FA031 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, missed approach (ifr) - light condition - dark night - weather condition - low ceiling - weather condition - rain - missed approach - initiated, pilot in command - aircraft control - not maintained, pilot in command (cause) - In flight collision with terrain/water, descent - 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](https://openairdocs.org/deregistered/N5681Y-1995-04-04), registration cancelled 1995-04-04, S/N 241399 (OpenAirDocs) - Reported make and model: MOONEY M20J - Registry model: [Mooney M20J](https://openairdocs.org/model/mooney-m20j) (registry code 5870219) (OpenAirDocs) - Category: Airplane - Serial number: 24-1399 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 48; 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 (OpenAirDocs). - [Accident 19941118038529A](https://openairdocs.org/incident/19941118038529A), Nov 18, 1994: Mooney M20J, Chatham, MA, Destroyed, 1 fatal. Departed into hurricane weather. Severe at destination. Crashed in trees. Vertically. NOTAMS on weather. 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.