NEW HAVEN, CT, USA
N1488X
PIPER PA-28R-200
ABOUT 30 MIN BEFORE THE ACCIDENT THE PILOT WAS ADVISED TO EXPECT AN ILS RWY 2, AND HE BEGAN RECEIVING VECTORS FOR THE FINAL APPROACH COURSE. AT 8 MIN BEFORE THE ACCIDENT, AND ABOUT 12 MI FROM THE INITIAL APPROACH FIX, THE PILOT WAS CLEARED FOR ILS RWY 2 TO CIRCLE TO RWY 20. AT ABOUT 2 MI FROM THE INITIAL APPROACH FIX THE PILOT WAS AGAIN CLEARED FOR THE ILS RWY 2 TO CIRCLE TO RWY 20. WHILE ON THE LOCALIZER THE PILOT ACKNOWLEDGED 'CIRCLING TO AH TO TWO ZERO.' THE AIRPLANE IMPACTED THE WATER 4.5 MI FROM THE AIRPORT. AN ATR-42 PILOT WHO HAD JUST LANDED STATED THAT CONDITIONS WERE 'ROUGH AND TURBULENT, ESPECIALLY AT TRAFFIC PATTERN ALTITUDE.' THE PILOT HAD OBTAINED HIS INSTRUMENT RATING 4-1/2 MOS BEFORE THE ACCIDENT.
HISTORY OF FLIGHT On Saturday, December 4, 1993, at 1857 eastern standard time, a Piper PA-28R-200, N1488X, registered to the University of New Haven, and piloted by John D. Lapinski, was destroyed by impact with the water during an approach to the Tweed-New Haven Airport, New Haven, Connecticut. The three passengers were fatally injured. The body of the pilot was not recovered, but he was presumed to have received fatal injuries. Instrument meteorological conditions prevailed, and an IFR flight plan was filed. The flight was being conducted under 14 CFR 91. The airplane departed Nantucket, Massachusetts at 1722, destined for New Haven. At 1827, the pilot of N1488X contacted New York TRACON and was provided with a series of vectors to the ILS. The TRACON switched N1488X to the New Haven Control Tower for landing instructions. Several transmissions occurred between the pilot of N1488X and the tower controller regarding the approach to be performed. The last transmission from N1488X was at 1856:32, when the pilot stated: "okay circling to ah to two zero." The tower controller attempted to contact N1488X several times after this radio call, but without any response. The tower controller heard no distress calls. There was no radar available to the tower controller, and he had no visual contact with the airplane. Captain Matt Falkner was the pilot of an ATR-42 that landed on runway 02 at the Tweed-New Haven Airport approximately 3 minutes prior to the time N1488X commenced the approach. Captain Falkner stated that the flight conditions were "rough and turbulent, especially at traffic pattern altitude." He said that the control tower initially cleared him for the ILS approach with a circle to land runway 20. He advised the controller that he wanted to land straight-in runway 02, from the ILS approach. This was approved by the tower. He stated that he "broke out of the clouds at about 700 feet and landed without problems." He indicated that it was raining when he landed. After landing, Captain Falkner heard the pilot of N1488X make radio contact with the tower. He recalled that the pilot was cleared for a circling approach to runway 20. He stated that the pilot of N1488X did not sound confident. He said that he even considered suggesting to the pilot of N1488X that he request the straight-in ILS and land runway 02, rather than accept the circling approach. He rejected this idea, after deciding that it was not "professional" for him to interfere with the communications. A search of the area was conducted, and on December 20, 1993, the airplane wreckage was located in 65 feet of water, approximately 4.5 miles southwest of the airport. The left wing was located in the water approximately 2.25 miles from the main wreckage on a magnetic heading of 300 degrees. The main wreckage was salvaged from the water, but due to adverse weather conditions, the left wing was not recovered. The accident occurred during the hours of darkness, at about 41 degrees, 10 minutes North; 72 degrees, 52 minutes West. PERSONNEL INFORMATION Mr. Lapinski held a Private Pilot's Certificate, with a single engine land rating. He was enrolled as a student in the University of New Haven's Flight Operations Program, where he was receiving instruction towards a Commercial Pilot's Certificate. Mr. Lapinski's flight time log book was not located. Based upon training records, it was estimated that he had a total flight time of approximately 228 hours. His most recent FAA Medical Certificate was a 3rd Class, with no limitations, issued on January 11, 1993. Mr. Lapinski had obtained an instrument rating on July 26, 1993. METEOROLOGICAL INFORMATION The New Haven Automatic Terminal Information Service (ATIS) SIERRA, recorded at 1745, reported the weather as "measured ceiling eight hundred overcast visibility three light rain fog temperature four seven dewpoint missing wind one one zero at eight altimeter two niner niner eight." The ATIS TANGO, recorded at 1845, reported the weather as "five hundred scattered measured ceiling one thousand one hundred overcast visibility four light rain fog temperature four seven dewpoint missing wind one two zero at one zero altimeter two niner niner five." These weather reports were determined by the Tweed-New Haven Tower Local Controller, as part of his duties. AIDS TO NAVIGATION At the time of the accident, there was no published approach for runway 20 at the Tweed-New Haven Airport. The ceiling and visibility minimums for an ILS to runway 02 with a circling approach to runway 20 were 800 feet and 1 mile visibility. The ILS to runway 02 was inspected and found to be operating satisfactorily by an Federal Aviation Administration technician on December 4, 1993 and by an FAA flight check on December 5, 1993. WRECKAGE The airplane wreckage, except for the left wing, was recovered on December 20, 1993, and examined at the Tweed-New Haven Airport. In order to transport the wreckage from the boat pier to an examination facility, the fuselage cut aft of the passenger cabin. The left wing was separated from the fuselage at the wing root. There was no evidence of corrosion or fatigue on the spar or remaining support structure. The left horizontal stabilizer leading edge was crushed, and the outer 1/3 of the stabilizer was missing, outboard from the trim tab. There was no evidence of corrosion or fatigue on the remaining stabilizer support structure. The left side of the cockpit was crushed, and the windshield was shattered and missing. The fuselage was partially separated from the cockpit instrument panel. The right main landing gear was in the down and locked position. The left main landing gear was not with the wreckage, but it was located on a beach near Riverhead, New York, on December 12, 1993. The nose gear was attached to the fuselage and was partially extended. The wing flaps were in the up position, as verified by both the jackscrew position and the cockpit switch. The NAV 1 frequency selector was set to the New Haven VORTAC, and the NAV 2 was set to the New Haven LOCALIZER. The three-bladed propeller was intact and the blades were bent in the aft direction. The propeller was rotated and continuity was verified through the valve train to the accessory section. There was compression to the four cylinders. The engine magnesium oil sump was partially corroded. The vacuum pump was intact and suction was evident when the shaft was rotated. The shear shaft was intact. The electric fuel pump was in the ON position. The engine fuel pump was fractured, but the diaphragm moved when the shaft was rotated. Both magnetos impulse couplings operated. The fuel manifold was fractured, but there was the smell of AVGAS when the "spider" manifold was removed. Flight control continuity was established from the rudder and the elevator to the cockpit rudder pedals and control yokes. Except for the left wing, investigators accounted for all flight control surfaces. MEDICAL AND TOXICOLOGICAL INFORMATION The body of the pilot was not recovered, therefore; no autopsy or toxicological tests were accomplished. ADDITIONAL INFORMATION The National Transportation Safety Board Air Traffic Control Group Chairman's Factual Report stated: At 2327:16 [times in this report are Universal Coordinated Time], the pilot of N1488X made initial radio contact with the Beads arrival controller at the New York TRACON, advising, "New York approach ah Arrow or november one four eight uh xray with you at six thousand." The controller replied, "Arrow one four eight xray good evening New York approach Islip altimeter two niner niner one." The pilot acknowledged. At 2328:04, the radar controller transmitted, "Arrow eight eight xray expect I-L-S two at New Haven advise if you have information sierra." At 2328:09, the pilot responded, "Ah eight eight xray expecting I-L-S two into New Haven with information ah do have information sierra." At 2328:29, the controller advised, "And Arrow eight eight xray fly heading two eight zero will be vectors for the I-L-S two final approach course." At 2328:34, the pilot responded, "okay we'll be flying a heading of two eight zero understand vectors for the final approach course eight eight xray." At 2334:11, the radar controller issued a descent clearance to 4000 feet. At 2334:26, the pilot responded, "ah descending to four thousand eight eight xray." At 2348:48, the radar controller transmitted, "Arrow one four eight eight xray contact approach on one two six point niner five twenty six ninety five good night." [the pilot acknowledged this change] At 2343:01, the radar controller at the Loves arrival position called the controller at the New Haven tower advising, "New Haven tower approach two inbounds." When the tower controller answered his call, at 2343:06, the Loves controller advised, "Blue Ridge four forty a Jet- stream and Cherokee one four eight eight xray." At 2343:10, the pilot of N1488X made initial contact with the controller at Loves radar position advising, "New York approach ah Arrow er November one four eight eight xray with you ah four thousand feet." The Loves radar controller, who was at that moment still talking to the controller at New Haven then advised, "[unintelligible] tell you what after Blue Ridge will be a Jet Link thirty seven eight an A-T-R then Cherokee eight eight xray." The Loves controller then advised the pilot of N1488X, "...fly heading two seven zero." At 2343:39, the pilot responded, "fly heading two seven zero eight eight xray." At 2346:28, the controller transmitted, "Cherokee eight eight xray descend and maintain two thousand." At 2346:31, the pilot advised, "descending to two thousand eight eight xray." At 2348:34, the radar controller advised, "Cherokee eight eight xray you're about twelve miles from SALLT [the initial approach fix for the ILS to runway 02 at New Haven] turn right heading three five zero maintain two thousand until established on the localizer course cleared the I-L-S two circle two zero." At 2348:45, the pilot responded, "okay turning to three five zero ah or established on the localizer cleared for the I-L-S two eight eight xray." [At this point, the ATIS for New Haven had been changed from Sierra to Tango. There were no recorded transmissions indicating that the pilot of N1488X was aware of this change. Tango changed the landing runway from 02, to a circling approach to runway 20.] At 2349:34, the Loves controller advised, "Cherokee eight eight xray ah I'm I'm gonna have to vector you a little bit for spacing from the aircraft in front of you cancel the approach clearance fly heading ah two seven zero again be vectors across the localizer." At 2349:45, the pilot replied, "going back to two seven zero eight eight xray." The controller then explained, "roger ah cause he has to circle and will need a little bit of extra room there." At 2349:50, the pilot responded, "no problem eight eight xray." At 2351:38 the radar controller transmitted, "Cherokee eight eight xray turn right heading zero five zero join the localizer." At 2351:43, the pilot responded, "turning right zero five zero we'll join the localizer eight eight xray." At 2353:17, the radar controller advised, "Cherokee eight eight xray continue on around to a ninety heading zero none zero." At 2353:22, the pilot responded, "continuing on to a ah zero ah eight eight xray." [Recorded radar data indicated that N1488X's flight path at this point was approximately 360 degrees. Also, the data showed that N1488X's altitude was 1300 feet. The published altitude to cross SALLT was 1500 feet] At 2353:25, the controller transmitted, "roger maintain one thousand five hundred eight eight xray the ah New Haven altimeter two nine nine five." At 2353:28, the pilot replied, "okay we'll maintain one thousand five hundred eight eight xray." At 2353:44, the pilot advised, "and we have the localizer ah New York eight eight xray." At 2353:47, the controller replied, "eight xray ah I'll give yah a turn in just another few sweeps of the radar here." The pilot acknowledged. At 2354:20, the controller advised, "Cherokee eight eight xray turn left heading zero five zero you're about ah two miles from SALLT maintain one thousand five hundred until established cleared the I-L-S two circle two zero." At 2354:28, the pilot acknowledged by advising, "okay turning to zero five zero eight eight xray." At 2354:56, the controller advised, "Cherokee eight eight xray report established on the localizer." At 2354:49, the pilot replied, "understand [unintelligible] localizer eight eight xray." At 2355:00, the radar controller advised, "Cherokee eight eight xray radar service terminated contact the tower one two four point eight so long." At 2355:05, the pilot acknowledged the frequency change." In the Group Chairman's Radar Data Report, it stated: Using the data from the Islip radar sensor, the flight track indicates that N1488X was about 2.3 miles south- west of PEPER [an intersection 4.4 miles southwest of SALLT] when the pilot was instructed to turn right to a heading of 050. When the pilot was instructed to turn right to a heading of 090, the airplane was about 4.3 miles southwest of SALLT. At about 2354:20 UTC, the airplane was about 2.3 miles southwest of SALLT. The airplane passed about 1.5 miles west of SALLT while inbound to the airport on the approach. At 2355:10, the pilot of N1488X made initial contact with the local controller at the New Haven tower, advising, "ah New Haven tower ah Cherokee one four eight xray with you at ah ah not on the lo just to the left of the localizer." At 2355:25, the local controller responded, "Cherokee one four eight eight xray New Haven tower roger are you ah are you cleared for the ILS runway two approach." At 2355:31, the pilot replied, "I understand I am cleared for the ILS eight eight xray." At 2355:34, the local controller transmitted, "Arrow one four eight eight xray roger report crossing SALLT and verify you have ATIS tango." At 2355:40, the pilot replied, "ah crossing SALLT already ah do not have tango sir." At 2355:46, the local controller responded, "Arrow eight eight xray the wind is one four zero at eight altimeter two niner niner four circle for the left downwind runway two zero report midfield." At 2355:56, the pilot replied, "we'll report midfield eight eight xray." At 2356:14, the pilot advised, "ah New Haven tower one four eight eight xray is on the localizer now at ah one thousand feet ah what were the final instructions." At 2356:25, the local controller transmitted, "Arrow eight eight xray at your discretion circle for the left downwind runway two zero and report midfield." At 2356:32, the pilot replied, "circling to ah to two zero." [Recorded radar data showed N1488X was in a descending left turn. The airplane's altitudes were recorded as follows: 2356:29.....800 feet 2356:38.....700 " 2356:43.....600 " 2356:48.....500 " This was the last radar contact with N1488X] The Group Chairman interviewed the controllers. The interview with the TRACON controller was reported as follows: On the night of the accident, he acknowledged that he had two commuter aircraft that would precede N1488X to the New Hav
THE PILOT'S FAILURE TO MAINTAIN CONTROL OF THE AIRPLANE DURING A NIGHT APPROACH IN ADVERSE WEATHER CONDITIONS. FACTORS WHICH CONTRIBUTED TO THE ACCIDENT WERE THE WEATHER CONDITIONS AND DARK NIGHT. IN ADDITION, THE RADAR CONTROLLER'S VECTORING OF THE PILOT TO THE FINAL APPROACH COURSE WAS NOT IN ACCORDANCE WITH ATC PROCEDURES, THE RADAR CONROLLER ISSUED THE PILOT AN ALTITUDE WHICH WAS NOT IN ACCORDANCE WITH PROCEDURES, AND THE RADAR CONTROLLER FAILED TO PROVIDE RADAR MONITORING AS OUTLINED IN IN ATC HANDBOOK 7110.65H.
Source: NTSB Aviation Accident Database
Aviation Accidents App
In-Depth Access to Aviation Accident Reports
