New Windsor, NY, USA
N108GD
CIRRUS DESIGN CORP SR20
The pilot was attempting his second instrument landing system approach in night instrument meteorological conditions, below the published approach weather minimums (which were not a regulatory limit for the flight) when the accident happened. After the first approach resulted in a missed approach, the pilot reported that he established the airplane on the localizer course and that the airplane was then cleared to land, which the pilot acknowledged. No further transmissions were received from the accident airplane, which impacted trees and uneven terrain about 2 miles from the approach end of the runway. The pilot did not survive, but both passengers did. The passengers stated that the airplane was flying in foggy conditions; however, the flight seemed normal until the airplane impacted trees. Examination of the airplane did not reveal any preimpact malfunctions. The pilot woke up about 19 hours prior to the accident and the investigation revealed that he did not sleep between the start of his day and the accident. The pilot was not issued a minimum safe altitude warning (MSAW) by air traffic control because the radar sensor being used to track the airplane did not provide sufficient coverage to trigger an MSAW alarm. A different system was available to the controller that if selected would have sounded an MSAW.
HISTORY OF FLIGHT On November 21, 2007, about 0145 eastern standard time, a Cirrus Design Corp. SR20, N108GD, was substantially damaged when it impacted terrain in New Windsor, New York, while on approach to the Stewart International Airport (SWF), Newburgh, New York. The certificated private pilot was fatally injured, and two passengers were seriously injured. Instrument meteorological conditions prevailed and an instrument flight rules (IFR) flight plan was filed for the flight that departed the Lynchburg Regional Airport (LYH), Lynchburg, Virginia. The personal flight was conducted under 14 Code of Federal Regulations (CFR) Part 91. The airplane was based at the Wings Field Airport (LOM), near Philadelphia, Pennsylvania. According to the pilot's wife, the pilot flew to Lynchburg, Virginia, where he watched their son play a basketball game. He then intended to fly to SWF, with his son, who was seated in the right front seat, and a passenger, who was seated in the right rear seat. According to information obtained from the Federal Aviation Administration (FAA), the pilot departed LOM about 1550, on November 20th, and landed at LYH about 1800. The pilot and two passengers departed LYH about 2250, and the airplane proceeded to SWF without incident. At about 0120, the pilot was cleared for an instrument landing system (ILS) approach to runway 9, a 11,818-foot-long, 150-foot-wide, asphalt runway, which resulted in a missed approach. The pilot was subsequently directed by air traffic control for a second ILS approach to runway 9. At 0141, the pilot reported that he was established on the runway 9 localizer. The airplane was cleared to land at 0141:53. The pilot acknowledged the landing clearance. There were no further communications from the airplane. The airplane's radar target descended from about 1,500 feet to 700 feet, and its groundspeed slowed from about140 knots to 102 knots, during the minute before radar contact was lost at 0144:49. The airplane was subsequently located about 1/10 mile further east of the last radar target. The airplane impacted trees and uneven terrain within Stewart State forest, about 2 miles from the approach end of runway 9. Both passengers stated that the flight seemed normal; however, the airplane encountered fog while on approach to land. The rear passenger stated "On the first descent, we got into fog. We circled around the airport and came back for a second try. We hit extreme fog, and we hit a tree..." The pilot's son reported that he had flown was his father "100 times or more" and that everything seemed normal during both approaches until the airplane crashed. PERSONNEL INFORMATION The pilot, age 49, held a private pilot certificate, with ratings for airplane single-engine land and instrument airplane. He reported 445 hours of total flight experience on his most recent application for a FAA third-class-medical certificate, which was issued on January 22, 2007. He received his instrument rating during January 2006. According to the pilot's logbook, at the time of the accident he had accumulated about 572 hours of total flight experience, of which, 9.7 and 49.1 hours were accumulated during the 30 days and 90 days preceding the accident; respectively. Of the total flight experience, about 500 hours were in the accident airplane, and 108 hours were logged as in "actual" instrument meteorological conditions. The pilot had logged 5.2 hours and 8.1 hours as in "actual" instrument meteorological conditions during the 30 days and 90 days preceding the accident; respectively. The pilot received an "SR20 Transition Training" sign-off from a certified flight instructor on July 18, 2005. According to the pilot's wife, the pilot went to bed around 2130 on November 19th, and woke up around 0630 to 0700, the morning of November 20th. After eating breakfast, the pilot went to work. AIRCRAFT INFORMATION The airplane, serial number 1290, was manufactured in 2003, constructed primarily of composite materials, and equipped with a Teledyne Continental Motors IO-360-ES engine. According to an FAA bill of sale, the airplane was purchased by the pilot and a co-owner during June 2005. The airplane's maintenance logbooks were not recovered. According to a maintenance invoice, the airplane's most recent annual inspection was performed on December 26, 2006. The airplane and engine had been operated for about 1,030 hours at the time of the accident. Review of fueling records from a fixed-base operator at LYH revealed that the airplane was "topped-off" with 22.5 gallons of 100 low lead aviation gasoline, prior to takeoff. METEOROLOGICAL INFORMATION A weather observation taken at SWF, at 0145, reported: winds calm; visibility 1/4 mile in fog; ceiling 400 feet overcast; temperature and dew point 4 degrees Celsius; altimeter 30.07 inches of mercury. Airman's Meteorological Information (Airmet) Sierra was valid until 0400, and included the area around SWF. The Airmet called for ceilings below 1,000 feet and visibility below 3 statute miles with mist and fog. The conditions were expected to develop between 2300 to 0100 and continue beyond 0400 to 1000 on November 21, 2007. COMMUNICATIONS Review of the New York terminal radar approach control (TRACON) transcript revealed that after the missed approach, about 0130, the controller stated that the visibility at SWF was reported as three quarters of a mile, but was "probably below that" and asked the pilot if he wanted to wait or attempt the approach again. At 0130:38, the pilot stated, "no I'll go ahead and shoot it again." Review of the SWF control tower transcript for the flight revealed that during the pilot's first approach, the local tower controller (LC) advised the pilot that "the visibility is dropping like a rock." At 0128:08, the controller stated "eight golf delta guess you didn't land," and the pilot responded "eight golf delta nope I'm gona go around can you give me vectors." At 0141:43, the pilot reported he was at 3,000 feet, inbound to runway 9. At 0141:53, the controller replied, "eight golf delta stewart tower runway nine rvr five thousand feet runway nine cleared to land." At 0142:00, the pilot replied "cleared to land runway nine thanks." The pilot was not issued a minimum safe altitude warning (MSAW) by air traffic control. According to an FAA representative, the airplane was being worked by the TRACON's "LIB-E" departure position, which was utilizing the "HPN (03) ASR-9" radar sensor. A MSAW warning was not provided to the pilot because the MSAW audio and visual alarms did not activate, and the controller was not aware of the airplane's low altitude. The MSAW audio and visual alarms did not activate because as the airplane progressed toward SWF and descended, it's primary and beacon targets went below the radar coverage of the HPN (03) sensor, which resulted in the loss of the airplane's track. After the accident, air traffic controllers working "CATSKIL" area airports were advised that arrivals need to be associated with the "ASR-9 SWF (04)" sensor in order to maintain MSAW coverage. AIRPORT INFORMATION Stewart International Airport was positioned at 41 degrees, 30 minutes, 14.7 seconds, north latitude; 74 degrees, 06 minutes, 17.4 seconds, west longitude, at an elevation of 491 feet above sea level. Runway 9 was equipped with an instrument landing system, and a high intensity approach lighting system with touchdown zone and runway centerline lighting. Review of a current approach chart for the ILS runway 9 approach at SFW revealed that the decision altitude for a straight-in approach was 682 feet msl, and the runway touchdown zone elevation was 482 feet. WRECKAGE AND IMPACT INFORMATION The airplane came to rest about 65 feet from an initial tree strike, and was inverted, on a magnetic heading of 210 degrees, and on a 070-degree bearing to the runway. All major components of the airplane were accounted for at the accident site. The right wing remained intact and attached to the airframe. It displayed leading edge damage consistent with tree strikes. The right aileron was detached at the inboard hinge, but remained attached via the outboard hinge. The left wing structure had separated from its flap outboard, exposing the main spar. The left aileron was located on the ground near the initial tree strike. Both wing fuel tanks were compromised; however, fuel was observed leaking from the right wing. The right elevator was bent upward about 45 degrees, and the left elevator and horizontal stabilizer were bent upward about mid-span. The rudder was separated at its upper hinge. Flight control continuity was confirmed from the cockpit to all flight controls except the left aileron, due to impact damage. Measurement of the flap control actuator corresponded to a 50-percent (16-degree) flap setting. The airplane's left main landing gear remained attached; however, the right main, and nose gear were separated. The engine was separated from its mounts and remained attached to the airframe via hoses and cables. The complete propeller assembly was separated at the crankshaft flange and located at the base of a tree, adjacent to the main wreckage. All three propeller blades were twisted, and displayed varying degrees of chordwise scratches and tip bending. The crankshaft displayed a 45-degee shear lip at the point of the propeller assembly separation and was bent slightly. The crankshaft could not be rotated; however, there was no external evidence of a catastrophic engine failure. Both magnetos were separated from the engine and produced spark from all towers when rotated by hand. All top sparkplugs except for the No. 1 cylinder were removed. The No. 1 cylinder top sparkplug could not be removed due to impact damage; however, the bottom sparkplug was removed for examination. The electrodes of all the removed sparkplugs were intact. The engine driven fuel pump contained fuel, it rotated freely and its drive shaft was intact. The airplane was equipped with a Cirrus Airplane Parachute System (CAPS). The CAPS handle in the cabin was displaced from its holder; however, it was noted that the ceiling structure around the handle was buckled. The CAPS access cover was intact and the parachute was found in the stowed position. A handheld Garmin Global Positioning System (GPS) 396 receiver was located in the cockpit and forwarded to the Safety Board's Vehicle Recorders Division, Washington, D.C. The airframe and engine were recovered to storage facility in Clayton, Delaware. Additional examination of the engine, which included rotating the crankshaft after the front crankcase through bolts were loosened, and a borescope inspection of each cylinder, did not reveal any preimpact mechanical malfunctions. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was performed on the pilot by order of the Orange County, New York Coroner's Office, on November 21, 2007. The autopsy report revealed the cause of death as multiple blunt force traumatic injuries that were sustained in an accident. Toxicological testing was conducted on the pilot at the FAA Toxicology Accident Research Laboratory, Oklahoma City, Oklahoma, with no anomalies noted. TESTS AND RESEARCH Examination of the handheld Garmin 396 GPS receiver that was recovered from the cockpit revealed the unit sustained significant impact damage. The internal backup battery was separated from the main printed circuit board and was missing. The "FLASH" memory chip was cracked and rendered inoperable. No data was recovered from the unit.
The pilot's failure to maintain the proper glidepath during an instrument-landing-system approach in fog. Contributing to the accident were pilot fatigue and air traffic control's failure to issue a minimum safe altitude warning.
Source: NTSB Aviation Accident Database
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