# NTSB CHI01FA043: Piper PA-28R-180, N4541J, Danville, IL, November 27, 2000 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: November 27, 2000, 16:50 local (22:50 UTC) - Place: Danville, IL - Coordinates: 40.139678, -87.609046 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=40.1397&lon=-87.6090&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 4 fatal - Status: Completed, report January 2, 2002 - Report: Approved by Office Director - NTSB case key (mKey): 50686 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CHI01FA043 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/50686/pdf - Page: https://openairdocs.org/ntsb/CHI01FA043 ## Probable cause The pilot's failure to maintain altitude/clearance during the instrument approach. Factors were the low ceilings, the pilot's failure to maintain proper alignment and glidepath during the approach, his lack of recent instrument experience, and his failure to perform the missed approach. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight collision with terrain/water, approach - weather condition - low ceiling (contributing factor) - proper glidepath - not maintained, pilot in command (contributing factor) - lack of recent instrument time, pilot in command (contributing factor) - missed approach - not performed, pilot in command (contributing factor) - proper alignment - not maintained, pilot in command (contributing factor) - altitude/clearance - not maintained, pilot in command (cause) ## Analysis The airplane was destroyed when it impacted the ground about 6 miles from the airport while on an ILS approach. The pilot was instrument rated. No logbook entry was found to indicate that the holding procedures requirements listed in FAR 61.57 (c) were performed. In addition, the pilot had only logged 1.3 hours of simulated instrument flight time and 0.9 hours of actual instrument flight time in the previous 6 months. No preexisting anomalies were found with respect to the accident airplane. Reported weather at the time of the accident was 500 foot overcast with 5 miles of visibility. Radar data along with voice transcripts show that the aircraft was given a right turn to a 180-degree heading to intercept the ILS 21 approach. The data shows that the aircraft turned left prior to intercepting the localizer course, and then proceeded through the localizer course before commencing a right turn to intercept the 209-degree approach bearing. The data indicates that when the aircraft was about 9.6 nautical miles from the localizer antenna, it was about 0.7 miles left of the localizer course. The aircraft altitude returns from the radar data indicate that the aircraft remained below the 3-degree glide slope path during the approach. The last radar return shows that the aircraft was about 400-feet below the standard 3-degree glide slope. The aircraft wreckage was located about 0.3 nautical miles and 196 degrees from the ILS outer marker antenna ## Factual narrative HISTORY OF FLIGHT On November 27, 2000, at about 1650 central standard time (cst), a Piper PA-28R-180, N4541J, piloted by a private pilot, was destroyed on impact with terrain about 6 nautical miles and 030 degrees magnetic from the Vermillion County Airport (DNV), Danville, Illinois. The aircraft had been cleared for the ILS approach to runway 21 at DNV. The 14 CFR Part 91 personal flight was on an instrument flight rules flight plan and was operating in instrument meteorological conditions. The pilot and three passengers received fatal injuries. The flight originated from the Maury County Airport, Mount Pleasant, Tennessee at about 1400 cst. PERSONNEL INFORMATION The pilot was the holder of a private pilot certificate with single engine land and instrument airplane ratings. He was also the holder of a second-class aviation medical certificate issued on December 28, 1998. According to the pilot's logbook, he had accumulated the following flight times as of the last entry dated November 19, 2000: Total Time 499.8 Pilot in Command 440.6 Single-Engine Land 499.8 Night 68.2 Actual Instrument 40.3 Simulated Instrument 71.3 The logbook indicates that the pilot accumulated 1.3 hours simulated instrument flight time and 0.9 hours of actual instrument flight time within the 6 months preceding the accident. The logbook entry dated November 11, 2000 indicates that the pilot accumulated 1.0 hours simulated instrument flight time with a safety pilot, 1.4 hours total flight time, 3 landings, and 6 instrument approaches. No logbook entry was found to indicate that the holding procedures requirements listed in FAR 61.57 (c) were performed. The flight dated November 11, 2000 was performed in the accident airplane. FAR 61.57 (c) states: 61.57 (c) Instrument experience. Except as provided in paragraph (e) of this section, no person may act as pilot in command under IFR or in weather conditions less than the minimums prescribed for VFR, unless within the preceding 6 calendar months, that person has: (1) For the purpose of obtaining instrument experience in an aircraft (other than a glider), performed and logged under actual or simulated instrument conditions, either in flight in the appropriate category of aircraft for the instrument privileges sought or in a flight simulator or flight training device that is representative of the aircraft category for the instrument privileges sought - (i) At least six instrument approaches; (ii) Holding procedures; and (iii) Intercepting and tracking courses through the use of navigation systems. A written endorsement within the pilot logbook indicates that the pilot completed the flight review requirements of FAR 61.56 on October 09, 1999. A review of FAA records shows that the pilot received two disapprovals prior to the issuance of his private pilot certificate on August 03, 1995. The records also show that the pilot received 3 disapprovals prior to the issuance of his instrument rating on June 16, 1997. The first disapproval notice for the instrument rating, dated March 06, 1997, indicated the following items for reexamination: Preflight preparation - Cross-country flight planning The second disapproval notice for the instrument rating, dated April 04, 1997, indicated the following items for reexamination: Flight by reference to instruments - Steep turns Flight by reference to instruments - Recovery from unusual flight attitudes Instrument approach procedures - Precision ILS instrument approach Instrument approach procedures - Missed approach The third disapproval notice for the instrument rating, dated May 13, 1997, indicated the following items for reexamination: Flight by reference to instruments - Change of airspeed Flight by reference to instruments - Constant airspeed climbs and descents Flight by reference to instruments - Rate climbs and descents Flight by reference to instruments - Steep turns Instrument approach procedures - Precision ILS instrument approach Instrument approach procedures - Missed approach AIRCRAFT INFORMATION The airplane was a Piper PA-28R-180, serial number 28R-30400. A Lycoming IO-360-B1E engine that produced 180 horsepower powered it. The aircraft logbooks indicate that the last annual inspection was performed on January 22, 2000. At the time of the accident, the airframe had accumulated 8,363.9 hours time in service. The engine had accumulated 328.5 hours time in service since it's last major overhaul on December 18, 1996. The airframe logbook indicates that the most recent altimeter, static and transponder inspection, as required by FAR 91.411, was performed on September 05, 1998. FAR 91.411 states: 91.411 Altimeter system and altitude reporting equipment tests and inspections. (a) No person may operate an airplane, or helicopter, in controlled airspace under IFR unless - (1) Within the preceding 24 calendar months, each static pressure system, each altimeter instrument, and each automatic pressure altitude reporting system has been tested and inspected and found to comply with appendix E of part 43 of this chapter METEOROLOGICAL INFORMATION The weather reporting station located at DNV recorded the following: Time 2245 UTC (1645 cst) Wind direction 240 degrees magnetic Wind speed 8 knots Visibility 5 statute miles Ceiling 500 feet, overcast Temperature 29 degree Fahrenheit Dewpoint 29 degree Fahrenheit Altimeter setting 29.98 inches of mercury COMMUNICATIONS The aircraft was in communication with the Champaign, Illinois, Air Traffic Control Tower, East Radar position (ER). The following excerpts are from transcripts of the recorded conversations between ER and N4541J. All times listed below are UTC. The full transcripts are appended to this report. 2223:59 N4541J five four juliet with you at four 2224:01 ER november four one juliet champaign approach altimeter two niner niner five 2224:05 N4541J altimeter two niner niner five 2234:57 ER november four one juliet fly heading three six zer zero vector i l s two one approach 2235:05 N4541J three six zero 2235:08 ER november four one juliet affirmative three six zero for the heading 2235:11 N4541J roger three six zero for four one juliet 2235:41 ER november four one juliet descend and maintain three thousand 2235:45 N4541J roger four one juliet descend and maintain three thousand 2236:09 ER arrow four five four one juliet advise you have danville weather 2236:16 N4541J four one juliet has the danville weather 2236:21 ER november four one juliet thank you 2236:51 ER November four one juliet turn right heading zero correction turn right heading one zero zero 2236:57 N4541J repeat one zero zero four one juliet 2238:21 ER arrow four one juliet eight miles form julip turn right heading one eight zero maintain three thousand till established on the localizer cleared i l s runway two (unintelligible) two one approach 2238:36 ER arrow four one juliet eight miles form julip fly heading one eight zero maintain three thousand till established on the localizer cleared i l s runway two --- runway two one approach 2238:54 ER arrow four one juliet champaign approach 2239:35 ER arrow four one juliet if you hear this transmission ident 2240:10 ER arrow four one juliet report cancelling your i f r on the ground through one two one point seven change to advisory approved if you understand this transmission ident 2241:24 ER arrow four one juliet if you sh ## Aircraft - Registration: [N4541J](https://openairdocs.org/deregistered/N4541J-2017-04-13), registration cancelled 2017-04-13, S/N 28R-30400, built 1968 (OpenAirDocs) - Reported make and model: Piper PA-28R-180 - Registry model: [Piper PA-28R-180](https://openairdocs.org/model/piper-pa-28r-180) (registry code 7102809) (OpenAirDocs) - Registry engine: [Lycoming I0360 series](https://openairdocs.org/engine/lycoming-i0360-series) (registry code 41515, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28R-30400 - Airframe hours: 8364 - Engines: Lycoming IO-360-B1E 180 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Registered owner: Dennis M. Kriewaldt - Airworthiness certificate: Standard, Normal - Last inspection: Annual, January 22, 2000, 85 hours before - Departed: MRC, MOUNT PLEASANT, TN - Destination: DNV - Flight plan: IFR - Airport: DNV, Vermillion County Airport, runway 21, 5,399 × 100 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 50; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 2, valid medical--w/ waivers/lim; seat: left; toxicology performed; flight hours: 500 total, 405 in this make and model, 441 as pilot in command, 16 in the last 90 days, 9 in the last 30 days ## Weather - Conditions: Instrument (IMC), Dusk - Wind: 240° at 8 knots - Visibility: 5 statute miles - Lowest ceiling: 500 ft overcast - Temperature: 84 °F, dew point 84 °F - Altimeter: 29.00 inHg - Observed at: DNV, 6 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 (OpenAirDocs). - [Accident 20001127043099A](https://openairdocs.org/incident/20001127043099A), Nov 27, 2000: Piper PA28R180, Danville, IL, Destroyed, 4 fatal. (-23) N4541J, a PA-28 was being vectored by champaign ATC, for an ILS approach to runway 21 at the Danville, Illinois airport. The aircraft intercepted the… From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.