# NTSB NYC96FA002: Cessna 172N, N9461E, Caton, NY, October 4, 1995 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: October 4, 1995, 19:34 local (23:34 UTC) - Place: Caton, NY - Coordinates: 42.140651, -77.050315 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=42.1407&lon=-77.0503&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report February 26, 1997 - Report: Approved by Office Director - NTSB case key (mKey): 39072 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC96FA002 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/39072/pdf - Page: https://openairdocs.org/ntsb/NYC96FA002 ## Probable cause The pilot's improper IFR procedure by failing to maintain proper altitude, while on the initial approach for an ILS. A factor relating to the accident was: failure of the tower controller to issue a safety advisory. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight collision with terrain/water, approach - iaf to faf/outer marker (ifr) - light condition - dark night - weather condition - low ceiling - flight/nav instruments,heading indicator - undetermined - ifr procedure - improper, pilot in command (cause) - proper altitude - not maintained, pilot in command (cause) - safety advisory - not issued, atc personnel(lcl/gnd/clnc) (contributing factor) ## Analysis During arrival at night, the pilot contacted approach control (located in the control tower) and received vectors for an ILS runway 6 approach. During the first approach, the radar controller observed that the airplane drifted left of course and descended below the glideslope. This resulted in a low-altitude aural alarm, and the radar controller issued a low-altitude alert. The pilot made a missed approach and stated that he 'had a mismatch of the two compasses.' He was vectored for a second approach and was instructed to maintain 3,000 feet until established on the approach. The pilot was then transfered to tower frequency and was cleared to land. About 6 miles from the runway, the airplane again drifted left of course and another low-altitude alert was activated. The tower controller stated that he did not hear the low-altitude aural alarm, because he was focused on another airplane that was landing. A supervisor controller, situated on the other side of the control cab, heard the alarm and prompted the tower controller to take remedial action. However, the airplane crashed into an open field outside the outer marker in a wings-level attitude. Impact occurred at an elevation of 1,500 feet. The ILS glideslope crossing altitude at the outer marker was 2,800 feet. The extent of a 'mismatch of the two compasses' was not verified; no preimpact mechanical malfunction of the airplane was found. The pilot had flown nine instrument approaches since receiving an instrument competency check on 4/27/95 and had logged 15.7 hours of night flight time. ## Factual narrative HISTORY OF FLIGHT On October 4, 1995, at 1934 eastern daylight time, a Cessna 172N, N9461E, was destroyed by impact with the terrain in Caton, New York, while performing an instrument approach to the Elmira/Corning Regional Airport, Elmira, New York. The private pilot and one passenger were fatally injured. Instrument meteorological conditions prevailed, and an instrument flight plan (IFR) had been filed for the flight, which departed Dunkirk, New York. The personal flight was being conducted under 14 CFR Part 91. N9461E was returning to Elmira from Dunkirk, after having dropped off another passenger. At the Dunkirk Airport, the airplane's fuel tanks were filled, by adding 29.4 gallons of aviation fuel. The pilot had earlier filed an IFR flight plan for the flight to Dunkirk and return to Elmira. At 1818, the pilot contacted ATC that he was airborne, and the airplane was radar identified and provided with vectors and assigned an altitude of 5,000 feet. The pilot of N9461E contacted Elmira Approach Control at 1910, and acknowledged that he had the Airport Terminal Information Service (ATIS) "Mike." This reported the Elmira weather as: 1300 scattered, measured ceiling 3300 broken, visibility 7 miles and the wind from 040 degrees at 7 knots. The Elmira Approach Controller vectored N9461E for the ILS approach to runway 06, and assigned the pilot an altitude of 3,000 feet to intercept the approach course. The NTSB Air Traffic Control Group Chairman's Factual Report stated: (Times are expressed in UTC.) During his first attempt, he declared a missed approach after declaring a problem with his compasses. The radar controller received a low altitude alert and observed a course deviation from the final approach course. The pilot was vectored for a second approach. About 6 miles from touchdown, the local controller observed a course deviation and lost radio and radar contact with the airplane. At 2323:24, the radar controller transmitted, "cessna six one echo looks like you went through the localizer turn left heading zero three zero to join." The pilot replied, "six one echo zero three zero to join." At 2324:58, the radar controller transmitted, "...are you established."....the pilot replied, "...that's a negative we would like to declare a missed approach please and take vectors...for the ILS six again."...the...controller responded, "...climb immediately maintain three thousand there is a low altitude alert minimum vectoring altitude in your area in three thousand." ...the...controller inquired,"is there a reason why you went through the localizer twice."...the pilot replied, "no sir uh I just had a mismatch of the two compasses and was trying to re-establish them and uh got out of whack and decided to try again." After issuing several changes in the heading...the... controller transmitted, "cessna...six miles from CHEMU turn left heading zero niner zero maintain three thousand til established on the localizer cleared I-L-S runway six approach." ...the pilot acknowledged... ...the pilot established radio contact with the local controller and advised, "Elmira tower six one echo is with you on the I-L-S six." ...the local controller transmitted, "cessna six one echo...runway six cleared to land wind zero three zero at six." At 2333:58, the local controller transmitted, "cessna six one echo verify you're established on the localizer." ...the pilot replied, "six one echo has drifted is re-establishing." At 2334:15, the local controller transmitted, "cessna six one echo say your altitude." ...There was no response. A search was initiated, and the wreckage was found by use of the emergency locator transmitter (ELT) in the airplane. The accident occurred during the hours of darkness, about 42 degrees, 10 minutes North, 76 degrees, 53 minutes West. PERSONNEL INFORMATION The pilot was issued an FAA Private Pilot Certificate on November 21, 1972, with a rating for single engine land. He was issued an instrument rating on November 14, 1994. He was issued an FAA Airman's Third Class Medical Certificate on February 21, 1995, with the limitation that he must wear corrective lenses. According to his logbook, he had a total of 406 hours. It was reported that all of his flight time was in this make and model. On April 27, 1995, he received an instrument competency flight check. Since that date, his logbook indicated 9 instrument approaches, and 13.5 hours of hood or instrument time. The logbook showed a total of 15.7 hours of night time, with his most recent night flight on September 28, 1995. METEOROLOGICAL INFORMATION A special weather observation at the airport was taken at 1949, which reported: ceiling measured 1100 overcast, visibility 4 miles with haze, winds from 040 degrees at 8 knots. AIDS TO NAVIGATION The ILS to runway 06, at the Elmira/Corning Regional Airport, was ground checked immediately after the accident. No discrepancies were noted. There were no published notices to airmen (NOTAMS) for this approach. The FAA conducted a flight check of the runway 06 ILS, on October 6, 1995. The Flight Inspection Report stated, "Facility performance was satisfactory." WRECKAGE The airplane wreckage was examined at the accident site on October 5, 1995. There were ground scars on the top of a hill, in an open field. Two of these scars matched the width of the landing gear, and two of them matched the width of the airplane wing tips. These scars were about 300 feet left of the ILS extended centerline, as investigators observed other airplanes conduct approaches to the airport. Pieces of wingtip navigation light frames were located near the outer ground scars. The wreckage path continued on a magnetic heading of 090 degrees. Approximately 70 feet beyond the initial ground scars, there were pieces of the fuel system, including parts of the carburetor and fuel strainer. More pieces of the carburetor were located about 150 feet further along the path. The main wreckage came to rest about 323 feet from the initial scars, along a line of trees at the end of the open field. The wreckage was on a magnetic heading of about 010 degrees. Both wings had separated from the fuselage attach points. The fuselage was laying on its left side. There was no evidence of fire. The elevation of the impact site was estimated at 1500 feet above mean sea level (MSL). The airport elevation was listed as 955 feet MSL. The fuel selector was slightly left of the BOTH position; however, there was impact damage to this area. The wing flap position was estimated at 10 degrees. The actuator was measured at 7 degrees. All flight control surfaces were accounted for at the site, and control continuity was established to the ailerons, elevator and rudder. Examination of the seat tracks indicated no malfunctions. The wreckage was removed from the accident site on October 5, 1995, and additional examination was conducted on October 6, 1995, at a hangar at the Elmira/Corning Regional Airport. The vacuum pump was examined and no discrepancies were observed. The gyroscopic instruments were also examined and no malfunctions noted. The engine was partially disassembled. There was impact damage to the forward cylinders, including the number 1 intake pushrod, and the oil sump area. Engine was rotated and compression was noted in all cylinders, using the thumb method. Continuity was confirmed to the accessory drive train. The carburetor was in pieces and scattered along the wreckage path. Spark was obtained ## Aircraft - Registration: [N9461E](https://openairdocs.org/deregistered/N9461E-1996-10-03), registration cancelled 1996-10-03, S/N 17272271 (OpenAirDocs) - Reported make and model: CESSNA 172N - Registry model: [Cessna 172N](https://openairdocs.org/model/cessna-172n) (registry code 2072434) (OpenAirDocs) - Category: Airplane - Serial number: 17272271 - Airframe hours: 4610 - Engines: LYCOMING O-320-H2AD 160 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Registered owner: George O. Cowburn - Airworthiness certificate: Standard, Utility; Standard, Normal - Last inspection: Annual, September 1, 1995, 19 hours before - Departed: DKK, DUNKIRK, NY - Destination: ELM, ELMIRA, NY - Flight plan: IFR - Airport: ELM, Elmira/Corning Regional, runway 6, 6,999 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 53; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, valid medical--w/ waivers/lim; seat: left; toxicology performed; flight hours: 406 total, 406 in this make and model, 363 as pilot in command, 47 in the last 90 days, 13 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Instrument (IMC), Night/dark - Wind: 40° at 8 knots - Visibility: 4 statute miles - Lowest ceiling: 1,100 ft overcast - Temperature: 61 °F, dew point 55 °F - Altimeter: 29.00 inHg - Observed at: ELM, 6 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 19951004030909A](https://openairdocs.org/incident/19951004030909A), Oct 4, 1995: Cessna 172N, Elmira, NY, Destroyed, 2 fatal. Descended below mda on ILS night approach. Impacted in open field. Generated too low altitude alerts prior approach 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.