N1488X – Piper Aircraft Corp PA-28R-200 – 1993-12-04 NTSB Accident Report

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 Haven Airport. He initially issued an approach clearance to the pilot of N1488X and then cancelled the clearance because he wanted to put the "faster guy" (commuter) ahead on the approach. He believed that N1488X was east of the localizer and about 10 to 15 miles southeast of SALLT when he instructed the pilot to fly a heading of 270. When he instructed the pilot to turn to a heading of 050, the airplane was about 5 miles west of the localizer. In his opinion, he had turned the pilot from a heading of 270 to 050, "pretty quick." He said that he instructed the pilot to fly a heading of 090 because he thought that the pilot would join the localizer, "too close to the final approach fix."

When he observed the mode C readout of the airplane indicating the airplane was at an altitude of 1300 feet, he called the New Haven tower, asked for their current altimeter. He then instructed the pilot to maintain 1500 feet and issued the current altimeter. When the pilot advised him, "we have the localizer," it appeared to him that the pilot was turning onto the localizer on his own. He advised the pilot he would give him another turn in another 2 sweeps of the radar because, "the pilot was still west of the localizer and the map (radar video map) is off by one-half mile... it doesn't line up with the actual depiction on the map because of the distance from the radar antenna. When he issued the heading of 050 to the pilot of N1488X, in his judgement, the airplane was just about on it [localizer]. When he asked the pilot to verify that he was on the localizer, he said that he did so, "out of habit." He said that when the pilot verified he was on the localizer, the airplane was about 1 mile south of SALLT. He then advised the pilot that radar service was terminated and instructed the pilot to contact the tower at New Haven. He did not recall observing the mode C readout (airplane altitude) at that time, but believed that he might have been performing coordination and therefore would have taken his eyes off the radar display.

It appeared to him at the time he instructed the pilot to turn to a heading of 090, he believed that the pilot had started a turn to the "north" on his own. He then reissued a heading of 050 because it was the required heading for the intercept angle to the final approach course and that the minimum intercept angle is 30 degrees. When questioned about the vectors provided to the pilot of N1488X and the radar track plot which indicated the airplane was not depicted on radar during this period, he replied, "...radar data is worthless and inaccurate." He went on to say that he had been shown the radar plots and that they, "did not coincide with what I saw that day." In his opinion, the radar data was not an accurate record of the occurrence, because it could be derived from any position of the [beacon] target. He affirmed that up to the point at which he advised the pilot of N1488X that radar service was terminated, the target was "most likely" shown as both a primary and secondary target.

In the Federal Aviation Administration Advisory Circular (AC) 61-27, Instrument Flying Handbook, revised 1980, unusual attitudes and recoveries are discussed. The AC states:

An unusual attitude is any airplane attitude not normally required for instrument flight. Unusual attitudes may result from a number of conditions, such as turbulence, disorientation, instrument failures, confusion, preoccupation with cockpit duties, carelessness in cross-checking, errors in instrument interpretation, or lack of proficiency in aircraft control. Since unusual attitudes are not intentional maneuvers during instrument flight, except in training, they are often unexpected, and the reaction of an inexperienced or inadequately trained pilot to an unexpected abnormal flight attitude is usually instinctive rather than intelligent and deliberate. This individual reacts with abrupt muscular effort, which is purposeless and even hazardous in turbulent conditions, at excessive speeds, or at low altitudes.

The airplane wreckage was released to Mr. Walter J. Liona, Assistant Vice President for United States Associated Underwriters, on December 20, 1993.