NTSB Factual Report

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 Approach Fix (IAF), WHIPS Intersection, was determined by reference to the 007 degree radial of the Nantucket VOR (116.2). The IAF was 4.1 nautical miles from the missed approach point (MAP) on the bearing of 114 degrees. The approach chart indicated a time of 4:06 from the IAF to MAP at a ground speed of 60 Knots.

The published Minimum Descent Altitude (MDA), when the pilot was utilizing the Hyannis Airport altimeter, was 580, which was 512 feet above ground level (68 feet airport elevation). When the OTIS Air National Guard Base altimeter was used, the MDA was 640 feet. The approach was not authorized when neither of these altimeters was received.

METEOROLOGICAL INFORMATION

The Hyannis (HYN) 1945 weather observation was; measured ceiling 300 overcast, visibility 2 miles, light rain fog, temperature 61 degrees F, dew point 59 degrees F, wind 130 degrees, 15 knots, altimeter 30.03 inches Hg.

The HYN 2045 weather observation was; indefinite ceiling 100 sky obscured, visibility 1 1/4 miles, light rain fog, temperature 60 degrees F, dew point 58 degrees F, wind 140 degrees, 12 knots, gusts to 22 knots, altimeter 30.00 inches Hg.

WRECKAGE AND IMPACT INFORMATION

The wreckage was examined at the accident site on November 19-20, 1994. All the major components of the airplane were accounted for within the accident site. A crater approximately 3 feet deep was located within the confines of the wreckage area. The trees surrounding the wreckage were approximately 100 feet in height, and only tree branch ends that had been located directly over the crash site were cut at a 45 degree angle and broken. The wreckage came to rest heading in a northeasterly direction. Impact forces rendered all the instruments and switches unreadable. Control continuity could not be established to the ailerons because of impact damage, but continuity was established to the elevators and rudder.

The engine was buried in the crater, to a depth of the fire wall. The engine and firewall were compressed together crushing all the accessories located between them including the magnetos. The vacuum pump, along with the other accessories located at the rear of the engine were crushed and intermingled with the damaged instrument panel. The combination of the damage to the accessory section of the engine and the instrument panel precluded any determination of the vacuum pump's condition prior to impact.

The forward left cylinder was broken open, exposing the rocker arms. Lubrication was observed on the exposed rocker arms and pools of oil were found in the crater. The impact damage to the flange prevented rotation of the engine.

The propeller had separated from the flange. Examination of the propeller revealed that one of the blades had separated from the hub, and displayed twists and bending damage. The other blade was buried in the crater and was bent rearward at the tip, and a gouge was found in the outboard section of the trailing edge. No chordwise marks were observed on either of the propeller blades.

PERSONNEL INFORMATION

Mr. David H. Roe held Commercial Pilot Certificate, No. 47663656, with single engine land, instrument airplane and glider ratings.

Mr. Roe was issued a Second Class Airman Medical Certificate on March 31, 1994, with no limitations.

Mr. Roe's log book indicated that at the time of the accident he had 1,080 total flight hours, of which 609 hours were in Mooney M20J aircraft. He had accumulated about 189 hours of instrument flight time.

The pilot's log book revealed the following:

Last 90 Days- 43 hours total 7 hours night 5 hours actual instruments

Last 30 days- 21 hours total 4 hours night no instrument hours logged

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was performed on Mr. David Roe, on November 20, 1994, at the Medical Examiner's Office, in Patchiest, Massachusetts, by Dr. James Whiner.

The toxicological tests were conducted at the Armed Forces Institute of Pathology, Washington, DC, and "...no drugs or alcohol were found."

ADDITIONAL INFORMATION

According to the ATC transcripts, the specialist at Cape TRACON did not provide or determine if the pilot had been issued the Hyannis or Otis altimeter setting. Safety Board Investigators found no evidence that the pilot requested or received either of these altimeter settings prior to or during the approach. Additionally, the transcript revealed that the pilot did not request the weather.

Records indicate that the last altimeter setting issued to the pilot of N5681Y was at 1923, which was the Providence altimeter of 30.04 inches Hg.

According to FAA Order 7110.65, a controller should:

Provide current approach information to arriving aircraft at airports where your facility/sector provides approach control services on first radio contact or as soon as possible thereafter. Approach information contained in the ATIS [Automated Terminal Information Service] broadcast may be omitted if the pilot states the appropriate ATIS code; otherwise issue approach information....surface winds...ceiling and visibility if the ceiling at the intended landing is reported below 1,000 feet or below the highest circling minimum, whichever is greater, or the visibility is less the 3 miles...altimeter setting for the airport of intended landing...controllers without access to current airport weather data shall inform pilots that the weather is not available and the frequency where automated weather data may be obtained....

In a personnel statement, the specialist said that she received a "low altitude alert" on the airplane and attempted to call the pilot. The transcript revealed that the specialist reestablished radio communications with the pilot of N5681Y, but did not transmit a "low altitude alert" warning.

FAA Order 7110.65, stated that controllers should:

Issue a safety alert to an aircraft if you are aware the aircraft is at an altitude which, in your judgement, places it in unsafe proximity to terrain, obstructions, or other aircraft. Once the pilot informs you action is being taken to resolve the situation, you may discontinue the issuance of further alerts. Do not assume that because someone else has responsibility for the aircraft that the unsafe situation has been observed and the unsafe alert issued; inform the appropriate controller.

The controller-in-charge (CIC) of the Cape Tracon wrote the following in a personnel statement:

I was the CIC for the evening shift at Cape Approach (K90). At approximately 0055Z [local time 1955], (PW) [the specialist controlling N5681Y] asked to be relieved to go to the bathroom. After receiving a position brief...N5681Y reported established on the NDB-A final to Chatham. I cleared N5681Y for the approach. When [PW] returned, I gave her a position relief briefing and continued my CIC duties. At approximately 0116 UTC [2116 local], I was informed of radar contact lost with N5681Y.

The airplane was released to the owner's wife, Mrs. E. J. Roe on November 19, 1994.

NTSB 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.