CHI01FA025

NTSB accident investigation · Piper PA-28R-200 · Gaylord, MI · October 25, 2000

Accident · FatalField investigationFinal report
Date
October 24, 2000, 20:10 local (Oct 25, 2000, 00:10 UTC)
Place
Gaylord, MI
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N15900Piper PA-28R-200
Weather
Instrument (IMC) · Night
Status
Completed · report June 18, 2002
Report
Approved by Office Director
Parties
Federal Aviation Administration, Grand Rapids FSDO, The New Piper Aircaft, Inc., Textron Lycoming
FAA report
20001024043079A
Case key
50708

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The pilot not maintaining proper glideslope and localizer alignment during the precision instrument approach, the pilot continuing flight below the decision height, the pilot not performing a missed approach, and the pilot not maintaining altitude/clearance from the trees and terrain. Contributing factors to the accident were the air traffic controller not issuing the current weather conditions to the pilot prior to the approach clearance, the weather conditions being below the instrument approach landing minimums, the pilot's lack of recent experience in instrument flight rules (IFR) operations and the pilot disregarding federal regulations regarding instrument currency.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

In flight collision with objectApproach - faf/outer marker to threshold (ifr)
In-flight weather advisories - not issuedAtc personnel(artcc)Factor
Weather condition - below approach/landing minimumsFactor
Procedures/directives - disregardedPilot in commandFactor
Lack of recent experience in type operationPilot in commandFactor
Proper glidepath - not maintainedPilot in commandCause
Proper alignment - not maintainedPilot in commandCause
Decision height - continued belowPilot in commandCause
Missed approach - not performedPilot in commandCause
Altitude/clearance - not maintainedPilot in commandCause
Object - tree(s)Factor
In flight collision with terrain/waterDescent - uncontrolled

Analysis

The airplane was destroyed when it impacted trees and terrain during a precision instrument approach. The wreckage was located 0.66 nautical miles (nm) left of the course centerline and 2.44 nm from the runway threshold. Instrument meteorological conditions prevailed at the time of the accident with a visibility of 1/4 statute mile (sm) and a vertical visibility of 100 feet above ground level (agl). No anomalies were found with the airplane, engine, and systems that could be identified as existing prior to impact. Subsequent to the accident, the instrument approach was flight-tested and was fully operational with no discrepancies. The landing minimums for the instrument approach were a cloud height of 200 feet agl and a visibility of 1/2 statute mile. Air traffic control (ATC) did not issue the current weather conditions to the pilot or verify that the pilot had the current weather conditions prior to issuing the clearance for the instrument approach. The pilot was not current for operations in instrument meteorological conditions.

Factual narrative

History of flight

On October 24, 2000, at 2010 eastern daylight time (edt), a Piper PA-28R-200, N15900, owned and piloted by a private pilot, was destroyed during an in-flight collision with trees and subsequent collision with terrain while executing the Instrument Landing System (ILS) runway 9 approach to the Otsego County Airport (GLR), Gaylord, Michigan. Instrument meteorological conditions prevailed at the time of the accident. The business flight was operating under the provisions of 14 CFR Part 91 on an instrument flight plan. The pilot and his single passenger were fatally injured. The flight departed the Gerald R. Ford International Airport, Grand Rapids, Michigan, at 1856.

According to a Federal Aviation Administration (FAA) Air Traffic Control (ATC) accident report, the accident airplane was issued vectors to intercept the final approach course for the ILS runway 9 approach to GLR. The accident airplane was cleared for the ILS runway 9 approach and the pilot was instructed to cancel his flight plan through another airplane, a Piper Navajo (N59815), which was holding at the Gaylord VHF omni-directional range/distance measuring equipment (GLR VOR/DME). The GLR VOR/DME is located within the airport's perimeter and provides navigation assistance for visual and instrument flight operations.

Aircraft radar track data for the period before and after the reported accident time was obtained from the FAA. The aircraft radar track data was plotted using commercial software. The plot is appended to this factual report along with a copy of the source data.

According to the supplied radar track data, the accident airplane's first radar return was a reinforced discrete beacon code 12.235 nautical miles (nm) southwest of GLR at 2001:29 (hhmm:ss). The radar track data indicated the airplane continued heading north until 2005:05 when a right turn was initiated. The last radar return was recorded 7.631 nm west of GLR. The wreckage was located approximately 3 nm west-northwest of GLR.

Personnel information

The pilot held a private pilot certificate with ratings for airplane single engine land and instrument airplane operations. The pilot's last medical examination was conducted on June 16, 1999, and he was issued a third-class medical certificate with the limitation, "Must wear corrective lenses."

According to the pilot's flight logbook, the pilot had a total flight time of 918.2 hours, all of which were in single engine land airplanes. The pilot's last biennial flight review, as required by Federal Aviation Regulation (FAR) 61.56, was completed on August 18, 1998.

The pilot had logged a total of 60.9 hours in actual instrument meteorological conditions (IMC) and 69.3 hours as simulated IMC. The pilot's last recorded instrument proficiency check (IPC) was completed on April 17, 1998. The pilot's last recorded holding procedure was completed on August 18, 1998. During the 6 month period following the last IPC the pilot logged 8 approaches and 1 holding pattern. Between August 18, 1998, and February 18, 1999, the pilot logged 6 approaches and 1 holding pattern. Between February 18, 1999, and August 18, 1999, the pilot logged 4 approaches and no holding patterns. The pilot did not record an IPC subsequent to August 18, 1999. During the 6 month period prior to the accident, the pilot logged 9 instrument approaches and no holding procedures.

The pilot logged 57.0 hours in the last 90 days, all of which were in the accident airplane. During the last 90 days the pilot recorded 7.6 hours in actual IMC and 6 instrument approaches.

The pilot logged 41.9 hours in the last 60 days, during which time he recorded 4.4 hours in actual IMC and 3 instrument approaches.

The pilot logged 17.3 hours in the last 30 days, during which time he did not record any instrument time or instrument approaches.

There were no flight logbook entries within 24 hours of the accident.

Aircraft information

The airplane was a Piper PA-28R-200, serial number 28R-7335103. The Piper PA-28R-200 is a low-wing monoplane of all metal construction and is equipped with a constant-speed propeller, wing flaps, and retractable landing gear. The PA-28R-200 can accommodate a pilot and up to three passengers.

The airplane was issued a Standard Airworthiness Certificate on December 27, 1972, and was certified for normal category operations. The airframe had accumulated a total flight time of 5,358.40 hours. The last annual inspection was performed on April 1, 2000, and the airplane had accumulated 117.66 hours since the inspection.

According to the maintenance logbooks, the last transponder test, as required by FAR 91.413, was completed on September 18, 1998.

According to the maintenance logbooks, the last altimeter system test, as required by FAR 91.411, was completed on January 19, 1995.

The last recorded VOR equipment check, as required by FAR 91.171, was completed on August 9, 1994.

The engine was a 200 horsepower Textron Lycoming IO-360-C1C, serial number L-6235-51A. The engine had accumulated 1,584.90 hours since the last major overhaul, which was completed on April 9, 1985. The last inspection of the engine was on April 1, 2000, and the engine had accumulated 117.66 hours since the inspection.

The propeller was a two-bladed Hartzell HC-C2YR-1BF, serial number CH11457.

Meteorological information

An Automated Surface Observing System (ASOS), located at the Otsego County Airport, Gaylord, Michigan, recorded the weather as follows:

Observation Time: 2001 edt

Wind: 330 degrees magnetic at 4 knots

Visibility: 1/2 statute mile with fog

Sky Condition: Overcast layer at 200 feet above ground level (agl)

Temperature: 11 degrees Celsius

Dew Point: 11 degrees Celsius

Pressure: 30.35 inches-of-mercury

Observation Time: 2010 edt

Wind: Variable direction at 3 knots

Visibility: 1/4 statute mile with fog

Sky Condition: Vertical visibility 100 feet agl

Temperature: 11 degrees Celsius

Dew Point: 11 degrees Celsius

Pressure: 30.35 inches-of-mercury

At 1841 edt a pilot representing the accident airplane contacted the Lansing Automated Flight Service Station (AFSS) and requested a weather briefing. The AFSS briefer issued a standard weather briefing and at the completion of the weather briefing the pilot filed an IFR flight plan. According to a memorandum provided by the FAA, "All services provided by Lansing AFSS were normal and there were no pertinent transmissions."

Aids to navigation

On October 25, 2000, the ILS runway 9 approach to GLR was flight tested by the Battle Creek Flight Inspection Field Office. According to the Flight Inspection Report, the ILS runway 9 approach was fully operational and tested satisfactory. The Flight Inspection Report is appended to this factual report.

Communications

The voice transmissions between the accident aircraft (N15900), Minneapolis Air Route Traffic Control Center (ZMP-ARTCC), and the holding airplane (N59815) were transcribed in part as follows:

1951:22 (hhmm:ss)

ZMP-ARTCC: november one five niner zero zero descend maintain three thousand five hundred

1951:25

N15900: out of six three point five nine zero zero

1951

1952

1953

1954

1955

1956

1957

1957:01

ZMP-ARTCC: november one five niner zero zero turn further ten degree left

1957:06

N15900: ten degrees left nine zero zero

1957:40

ZMP-ARTCC: november one five niner zero zero maintain three thousand two hundred please

1957:46

N15900: three point two nine zero zero

1957:49

ZMP-ARTCC: and what is your new heading going to be once your turn further left

1957:52

N15900: fifteen degrees nine zero zero

1957:52

ZMP-ARTCC: okay make the heading of zero zero five please for nine zero zero

1957:51

N15900: zero zero five nine zero zero

1958

1959

2000

2001

2002

2003

2004

2004:38

ZMP-ARTCC: november one five niner niner zero zero

Aircraft

Registration
N15900
Reported as
Piper PA-28R-200
Category
Airplane
Serial number
28R-7335103
Airframe hours
5,358.4
Engine
Textron Lycoming IO-360-C1C, 200 horsepower, reciprocating
Damage
Destroyed
Flight
Business · Part 91
Registered owner
Dirty Side Down
Airworthiness certificate
Standard, Normal
Last inspection
Annual · April 1, 2000 · 117.66 hours before
Departed
GRR · Grand Rapids, MI
Destination
GLR · Gaylord, MI
Flight plan
IFR
Airport
GLR · Otsego County Airport, runway 09, 6,500 × 100 ft, asphalt

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
47
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Valid Medical--w/ waivers/lim
Last flight review
August 18, 1998
Seat
Left
Toxicology
Performed
Flight hours
918 total · 838 as pilot in command · 57 in the last 90 days · 17 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Night
Wind
Variable at 3 knots
Visibility
0.25 statute miles
Lowest ceiling
100 ft
Temperature
52 °F, dew point 52 °F
Altimeter
30.00 inHg
Observed at
GLR, 3 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.