# NTSB NYC95FA033: Piper PA-28-181, N2949Q, Doylestown, PA, November 22, 1994 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: November 21, 1994, 20:00 local (Nov 22, 1994, 01:00 UTC) - Place: Doylestown, PA - Coordinates: 40.320198, -75.060546 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=40.3202&lon=-75.0605&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal, 1 serious - Status: Completed, report July 31, 1995 - Report: Approved by Office Director - NTSB case key (mKey): 38845 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC95FA033 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/38845/pdf - Page: https://openairdocs.org/ntsb/NYC95FA033 ## Probable cause the pilot's descent below the published minimum circling altitude, and his failure to execute the published missed approach procedure during a night IFR instrument approach, which resulted in an in-flight collision with trees. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight collision with object, circling (ifr) - light condition - night - weather condition - low ceiling - weather condition - fog - ifr procedure - not followed, pilot in command (cause) - object - tree(s) ## Analysis THE PILOT AND PASSENGER WERE ON THE RETURN LEG OF A FLIGHT FOR COMPENSATION. THE EN ROUTE FLIGHT WAS UNEVENTFUL. DURING THE NIGHT WEATHER VOR APPROACH TO THE DESTINATION AIRPORT, THE PILOT DESCENDED 300 FEET BELOW THE MINIMUM DESCENT ALTITUDE. AFTER FLYING OVER THE RUNWAY, THE PILOT CIRCLED THE AIRPORT TWICE, BETWEEN 300 AND 500 FEET BELOW THE MINIMUM CIRCLING ALTITUDE. DURING THE THIRD CIRCLE, THE AIRPLANE STRUCK TREES ABOUT 1/4 MILE FROM THE RUNWAY. AN AIRPORT 8 MILES FROM THE ACCIDENT SCENE REPORTED THE WEATHER AS INDEFINITE 100 FOOT SKY OBSCURED, VISIBILITY 1/4 MILE, WITH LIGHT DRIZZLE AND FOG. NEITHER OF THE TWO VOR RECEIVERS IN THE AIRPLANE WERE TUNED TO THE FREQUENCY USED FOR THE VOR FINAL APPROACH COURSE, OR THE MISSED APPROACH PROCEDURE. DURING THE PREVIOUS 12 MONTHS THE PILOT HAD LOGGED ONE INSTRUMENT APPROACH. ## Factual narrative HISTORY OF FLIGHT On November 21, 1994, at 2000 eastern standard time, a Piper PA-28-181, N2949Q, co-owned and piloted by Harry E. Gee, was substantially damaged when it collided with trees during a night instrument approach to the Doylestown Airport, Doylestown, Pennsylvania. The pilot was fatally injured, and the passenger received serious injuries. Instrument meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan had been filed for the flight conducted under 14 CFR Part 91. The pilot, Mr. Harry Gee, was hired by the passenger, Mr. James C. Dalton, to fly him from Doylestown to Elmira, New York, and return, on November 21, 1994. Mr. Gee departed Robbinsville, New Jersey, where N2949Q was based, about 0830, destined for Doylestown to pick up Mr. Dalton. Mr. Dalton stated that he met Mr. Gee at the Doylestown Airport (N88), and they departed about 0900 for the Elmira- Corning Regional Airport (ELM). Upon arrival at ELM, Mr. Dalton left the airport to conduct his business and returned, about 1750. Mr. Gee advised Mr. Dalton that, due to weather, the departure had to be delayed. Mr. Dalton believed that Mr. Gee then left to check the weather. When Mr. Gee returned, he stated that "they had a break in the weather," and were fueled and ready to go. They departed for N88 about 1830. Mr. Dalton stated that the flight was conducted between cloud layers, and he described the flight as routine. Mr. Dalton could hear Mr. Gee talking on the radio, but could not hear clearly enough to understand what was said. Later in the flight, while the airplane was descending, Mr. Dalton was able to visually see the ground and recognize where they were. Mr. Dalton was able to maintain visual contact with the ground and recognize N88 when they flew over it. They circled the airport and flew over the runway twice, when he thinks they started a third circle. Mr. Dalton did not recall the last circle and the accident. Mr. Dalton was not concerned when they circled the airport, and assumed that Mr. Gee was just getting his orientation to the airport and runway. The runway lights at N88 were visible during some of the circling. Mr. Dalton stated that Mr. Gee did not appear to be upset or worried, and he appeared to be concentrating on flying the airplane and the approach to the airport. Mr. Gee was talking on the radio while they were circling the airport. Prior to the takeoff from ELM, Mr. Dalton observed Mr. Gee use a flashlight to look at charts on his lap because the airplane dome light did not work. He did not recall whether Mr. Gee used the flashlight at any other point during the flight. Mr. Dalton did not recall any problems with the airplane or the engine during the flight to ELM, or on the return flight. According to the Elmira Flight Service Station (FSS) records and briefer statements, Mr. Gee received three in-person weather briefings at the Elmira FSS pilot briefing counter. These occurred at 1328, 1713, and 1805. Each briefing was a complete, standard weather briefing. At the completion of the 1713 briefing, Mr. Gee filed an IFR flight plan with the FSS. During the 1805 briefing, the FSS briefer recommended that the pilot take along all the weather information he had printed out, and for the pilot to consider delaying his flight until the next morning, when the weather was expected to improve. Mr. Gee took the weather information and indicated he would be leaving soon. According to air traffic control records, N2949Q was issued an IFR clearance from ELM to N88 and was cleared to takeoff, at 1831, by ELM tower. The en route flight from ELM to N88 was unremarkable, and N2949Q arrived in the Philadelphia Approach Control area, at 1941. During the initial contact with the controller, N2949Q reported level at 5,000 feet. A clearance for the VOR RWY 23 instrument approach to N88 was issued to N2949Q, at 1949. This was followed by a frequency change to the advisory frequency for the airport, at 1950. N2949Q responded to the frequency change with, "Roger right now we are still in clouds." No further transmissions were received from N2949Q. Several members of the local Civil Air Patrol (CAP) chapter were at N88 at the time of the accident. One witness was the Squadron Commander. She stated in a telephone interview that between 1950 and 2000, she and several of the CAP members observed an airplane make low passes to N88. She was standing on the west side of runway 23. The airplane was approaching N88 from northeast to southwest, flying low and slow. As the airplane flew overhead, the engine sounds increased, and the airplane performed a climbing left turn to the east. She stated that it did this twice. She further stated she could see the airplane and the navigation lights located on the wings. She also thought the landing light was on during these low passes. Each time the airplane climbed and turned east away from N88, she was able to maintain visual contact with the airplane as it maneuvered for another approach. It appeared to her that the pilot was attempting to remain below the clouds. During the last go- around, she lost sight of the airplane in the clouds. A short time later she heard a "cracking" sound when the airplane crashed. She estimated that the airplane was flying between 300 and 500 feet above the ground. She heard no unusual noises from the engine. The airplane struck 60 to 70 foot high trees and impacted the ground 1/4 mile northeast of N88's runway 23. The accident occurred during the hours of darkness at approximately 40 degrees, 20 minutes north latitude, and 75 degrees, 8 minutes west longitude. PERSONNEL INFORMATION The pilot, Mr. Harry E. Gee, held an Airline Transport Pilot Certificate with a rating for airplane multiengine land, and a Commercial Pilot Certificate with a rating for airplane single engine land. His most recent Federal Aviation Administration (FAA) Second Class Medical Certificate was issued on April 12, 1994. Mr. Gee's pilot log book indicated that his total flight time was approximately 2,500 hours, of which 1,400 hours were in single engine airplanes, and about 40 hours in this make and model. During the previous 12 months, Mr. Gee had logged 10 hours of actual weather flight and 1 instrument approach. METEOROLOGICAL INFORMATION The weather forecasts provided to Mr. Gee, by the ELM FSS consisted of: North Philadelphia (PNE) Until 2100 EST - ceiling 1,500 overcast, light rain showers, winds from 180 degrees at 10 knots, gusting to 20 knots, low level wind shear; occasional 700 overcast, 3 miles visibility, rain showers and fog. Philadelphia (PHL) Until 2100 EST - ceiling 900 broken, 4,000 overcast, light rain showers, winds from 180 degrees at 10 knots, gusting to 22 knots, low level wind shear; occasional 900 scattered, ceiling 3,000 broken 2 miles visibility, light rain showers and fog. Atlantic City (ACY) Until 2200 EST - ceiling 500 overcast, winds from 160 degrees at 15 knots, gusting to 25 knots, low level wind shear; occasional 500 scattered, ceiling 2,000 overcast 5 miles visibility, light rain showers and fog. Weather reported in the area at the time of the accident was: Navy Willow Grove, (8 miles southwest): 1955 EST - Indefinite 100 foot sky obscured, 1/4 mile visibility, light drizzle and fog, winds calm. Trenton-Mercer County, (14 miles southeast): 1950 EST - Measured 400 foot overcast, 2 miles visibility, rain and fog, winds from 320 degrees at 5 knots. Allentown, (24 miles northwest): 1957 EST - 400 scattered, measured 1,500 foot overcast, 1 1/ 2 miles visibility, light rain and fog, winds from 250 degrees at 4 knots. AERODROME INFORMATION Runway 23 at Doylestown was equipped with a Simplified Abbreviated Visual Approach Slope Indicator (SAVASI), with a glide slope set ## Aircraft - Registration: [N2949Q](https://openairdocs.org/deregistered/N2949Q-2018-01-18), registration cancelled 2018-01-18, S/N 28-7790428, built 1977 (OpenAirDocs) - Reported make and model: PIPER PA-28-181 - Registry model: [Piper PA-28-181](https://openairdocs.org/model/piper-pa-28-181) (registry code 7102807) (OpenAirDocs) - Registry engine: [Lycoming O&VO-360 series](https://openairdocs.org/engine/lycoming-o-vo-360-series) (registry code 41514, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-7790428 - Airframe hours: 3997 - Engines: LYCOMING O-360-A1M 180 horsepower reciprocating - Damage: Substantial damage - Flight: Part 91 - Registered owner: Alcom Business Systems, Inc. - Airworthiness certificate: Standard, Normal - Last inspection: Annual, September 28, 1994, 56 hours before - Departed: ELM, ELMIRA, NY - Destination: N88, PA - Flight plan: IFR - Airport: N88, Doylestown, runway 23, 3,004 × 60 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 51; commercial, airline transport; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, valid medical--w/ waivers/lim; seat: left; toxicology performed; flight hours: 2,500 total, 40 in this make and model, 2,200 as pilot in command, 35 in the last 90 days, 28 in the last 30 days, 3 in the last 24 hours ## Weather - Conditions: Instrument (IMC), Night/dark - Wind: calm - Visibility: 0.25 statute miles - Lowest ceiling: 100 ft - Temperature: 63 °F, dew point 61 °F - Altimeter: 29.00 inHg - Observed at: NXX, 8 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 19941121038679A](https://openairdocs.org/incident/19941121038679A), Nov 21, 1994: Piper PA28181, Doylestown, PA, Substantial damage, 1 fatal. Made VOR to N88 but unable land due below minimums. Struck trees on third try to land visually. Not IFR current. 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.