CHI02FA197

NTSB accident investigation · Piper PA-60 · Columbus, IN · July 18, 2002

Accident · FatalField investigationFinal report
Date
July 18, 2002, 03:45 local (08:45 UTC)
Place
Columbus, IN
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N158GAPiper PA-60
Weather
Visual (VMC) · Night
Status
Completed · report December 30, 2003
Report
Approved by Office Director
Parties
Lycoming, The New Piper Aircraft Company, FAA-Indianapolis FSDO
Case key
55259

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

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Probable cause

The pilot's failure to maintain control of the airplane during a missed approach. Additional factors included the operator's inadequate oversight, the pilot's improper in-flight decision, conditions conducive to pilot fatigue, fog, and night.

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.

Loss of control - in flightMissed approach (ifr)
Aircraft control - not maintainedPilot in commandCause
In-flight planning/decision - improperPilot in commandFactor
Improper decisionPilot in commandFactor
Inadequate surveillance of operationCompany/operator mgmtFactor
Fatigue (conditions conducive to pilot fatigue)Pilot in commandFactor
Light condition - dark nightFactor
Weather condition - fogFactor
In flight collision with terrain/waterDescent - uncontrolled
Airport facilities,runway/landing area condition - runway

Analysis

The airplane was destroyed by impact forces and fire after it impacted the intersection of runway 23 and 32 while attempting a missed-approach. The pilot's crew day started at 1300 and the 14 hour duty limit was 0300 the following morning. The second leg of the flight was delayed 1 hour and 36 minutes due to a freight delay. The operator reported the pilot exceeded his 14 hour crew day by 45 minutes as a result of the freight delay. The flight was cleared for the runway 23 ILS instrument approach. A witness, who was monitoring the Unicom radio frequency, reported that he heard clicking sounds on the Unicom frequency (to bring up the runway light intensity), but the pilot did not make any radio transmissions. The witness reported the ground fog was very thick. Two witnesses reported they heard the airplane's engines. They then heard the engines go to "full power," and then they heard the airplane impact the ground. They saw an initial flash, but could not see the airplane on fire from 2,500 feet away. FAR 135.213 requires that, "Weather observations made and furnished to pilots to conduct IFR operations at an airport must be made at the airport where those IFR operations are conducted." The destination did not have authorized weather reporting, and the operator's Operating Specifications did not list an alternate weather reporting source. At 0253, the observed weather 20 miles to the north, indicated the following: winds 190 at 4 knots, 1/4 statute mile visibility, fog, indefinite ceilings 100 feet, temperature 22 degrees C, dew point 22 degrees C, altimeter 30.00. From the initial point of impact (POI), the wreckage path continued for about 210 feet on a heading of about 180 degrees. The outboard section of the left wing outboard of the nacelle was found on runway 32, about 85 feet from the POI. Separated, unburned, portions of the left aileron and left flap were also found on the runway. The remaining pieces of the left wing were located with the main wreckage. The right wing was located with the main wreckage and the entire span of the right wing from the wing root to the wingtip exhibited continuity. The inspection of the airplane revealed no preexisting anomalies.

Factual narrative

History of flight

On July 18, 2002, at 0345 eastern standard time, a Piper PA-60, N158GA, operated by Grand Aire Express, Inc., was destroyed when it impacted runway 23 (6,401 feet by 150 feet, asphalt) at the Columbus Municipal Airport (BAK), Columbus, Indiana. The commercial pilot received fatal injuries. The 14 CFR Part 135 cargo flight departed Cleveland-Hopkins International Airport (CLE), Cleveland, Ohio, at 0225. The flight was on an instrument flight rules (IFR) flight plan. Night visual meteorological conditions were being reported at Indianapolis International Airport (IND), Indianapolis, Indiana, located approximately 33 miles northwest of BAK.

The pilot reported for duty at 1300 on July 17, 2002. His first flight was as an additional crewmember (ACM) that was scheduled to depart at 1400. After he completed the first ACM flight at 2150, the pilot accepted to fly as pilot-in-command on a second trip.

The pilot received a flight briefing and a printout of the DUATS weather for the first leg of the scheduled trip from the company's non-licensed dispatcher. The first flight leg of the flight had a scheduled departure time of 2300 from Toledo Express Airport (TOL), Toledo, Ohio, on July 17, 2002. The destination was CLE with a scheduled time en route of 49 minutes. The flight from TOL to CLE was uneventful.

The second leg of the flight was scheduled to depart Cleveland one hour later at 0049. However, the operator reported that due to a freight delay in Cleveland, the cargo was not loaded on the airplane as scheduled. Instead of departing at 0049, the flight departed CLE at 0225. The final destination airport was BAK with a scheduled time en route of 1 hour and 35 minutes. Due to the freight delay, the flight did not arrive at BAK until 0345.

The pilot contacted the Indianapolis Air Traffic Control (ATC) at 0328:28. He requested radar vectors for the ILS RWY 23 instrument approach to BAK.

At 0337:36, N158GA was 10 miles from the ILS outer marker and ATC cleared N158GA for the approach.

At 0341:07, ATC informed N158GA that radar service was terminated.

At 0341:16, the pilot responded, "Roger, change to the (unintelligible) and we'll call you for cancellation, Golf Alpha." There were no further radio transmissions from N158GA.

A witness, who was working at the terminal building at BAK, was monitoring the Unicom radio frequency. He had been notified that N158GA would be arriving at BAK for a cargo delivery. He reported that he heard clicking sounds on the Unicom frequency (to bring up the runway light intensity), but he reported that the pilot did not make any radio transmissions. He walked outside to wait for the airplane. He, along with another witness who was waiting for N158GA's arrival, reported that at the time of the accident, the ground fog was very thick. He reported that the light on the windsock located 100 yards away was "just a glow," and that the runway lights could not be seen. The witness reported that he made the comment, "He's gonna go missed," because the fog was so thick. Both witnesses reported they heard the airplane's engines. They then heard the engines go to "full power," and then they heard the airplane impact the ground. They saw an initial flash, but could not see the airplane on fire from 2,500 feet away.

Two Indiana State Police troopers, who were on duty at the Columbus Airport, heard the sound of the airplane impacting the ground. A trooper reported, "We drove down the runways and tried to find the plane crash. We got within 50-75 yards of the crash before we were able to see the flames from the crash due to the heavy fog in the area."

The airplane impacted the runway at the northeast corner of the intersection of runways 23/05 and 32/14, approximately 2,600 feet from the approach end of runway 23.

Personnel information

The 25-year old pilot was a commercial pilot with single and multi-engine land ratings. He was a certified flight instructor with ratings as a single and multi-engine land instructor and as an instrument instructor. He held a First Class medical certificate. He had a total of about 2,378 hours of flight time, with about 281 hours in multi-engine aircraft and about 150 hours of instrument time.

Company records indicated the pilot started his company ground school courses on May 11, 2002. He completed courses in Basic Indoctrination, Hazardous Materials, General Emergency Situations, and Aircraft Ground instruction. He flew 9.5 hours during his PA-60 flight training. The pilot completed an initial pilot-in-command flight check from a company check airman on May 23, 2002. The pilot's date of hire at the company was May 24, 2002. Flight and duty records indicate the pilot flew 29.3 hours in June and 11.9 hours in July. The pilot had a total of about 51 hours of flight time in PA-60 airplanes.

Aircraft information

The airplane was a twin engine Piper PA-60. The airplane was utilized in cargo operations that seated two, and had a maximum gross weight of 5,520 pounds. The engines were 300 horsepower Lycoming IO-520-S1A5 engines. The last airplane inspection was conducted on June 27, 2002. The airplane had flown 12.5 hours since the last inspection and had a total of 6,288 hours.

Meteorological information

The control tower at BAK provides weather information between 0700 and 2200 when the tower is in operation. After 2200, there is no weather reporting available at BAK since the airport is not equipped with an Automated Weather Observing System (AWOS) or an Automated Surface Observing System (ASOS).

The last BAK weather observation available to N158GA on July 17 was the 2150 observation, which was: winds calm, 8 statute miles visibility, scattered clouds 15,000 feet, temperature 24 degrees C, altimeter 30.04.

The first BAK weather observation on July 18 when the tower opened at 0700, was: winds calm, 2 statute miles visibility, mist, overcast 600 feet, temperature 21 degrees, altimeter 30.04

At 0253, the weather observation at GEZ, Shelbyville, Indiana, located 20 miles to the north of BAK, indicated the following: winds 190 at 4 knots, 1/4 statute mile visibility, fog, indefinite ceilings 100 feet, temperature 22 degrees C, dew point 22 degrees C, altimeter 30.00.

At 0353, the weather observation at GEZ indicated the following: winds 180 at 5 knots, 1/4 statute mile visibility, fog, indefinite ceilings 100 feet, temperature 21 degrees C, dew point 21 degrees C, altimeter 29.99.

At 0255, the weather observation at IND, located about 33 miles to the northwest of BAK, indicated the following: winds 220 at 6 knots, 6 statute miles visibility, mist, few clouds 6,000 feet, broken clouds 8,500 feet, temperature 22 degrees C, dew point 22 degrees C, altimeter 30.00.

At 0355, the weather observation at IND indicated the following: winds 210 at 4 knots, 5 statute miles visibility, mist, few clouds 6,000 feet, scattered clouds 8,500 feet, temperature 21 degrees C, dew point 21 degrees C, altimeter 30.00.

The following hand written weather information was found in the pilot's flight planning documents:

"High pressure one Columbus India mist fog 250/5 7 mile (illegible writing) 3000 Columbus calm 2 ½ mist 22/22 3002 TAF 06Z 0900 VRR 5 mist OCC 2 mist 0900 2 miles (illegible writing) 270/9 (illegible writing)."

The weather package provided to the pilot by the dispatcher prior to the first leg of the flight did not include an area forecast or a terminal forecast. The area forecast that was valid for the northern portions of Illinois, Indiana, and Kentucky was the following:

"Scattered clouds 12,500 feet, isolated light rain showers, light rain and thunderstorms, cumulonimbus tops 40,000 feet, occasional visibility 3-5 statute miles, mist. Outlook marginal VFR mist becoming VFR at 1600Z."

Wreckage and impact information

The initial point of impact (POI) was at the

Aircraft

Registration
N158GA
Reported as
Piper PA-60
Category
Airplane
Serial number
6006087961195
Airframe hours
6,288
Engine
Lycoming IO-520-S1A5, 300 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Part 135
Registered owner
Grand Aire Express Inc
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · June 27, 2002 · 12.5 hours before
Departed
CLE · Cleveland, OH
Destination
BAK · Columbus, IN
Flight plan
IFR
Airport
BAK · Columbus Municipal Airport, runway 23, 6,400 × 150 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
25
Injuries
Fatal
Certificates
Flight instructor, Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Last flight review
May 24, 2002
Seat
Left
Toxicology
Performed
Flight hours
2,378 total · 51 in this make and model

Weather

Conditions
Visual (VMC) · Night
Wind
220° at 6 knots
Visibility
6 statute miles
Lowest ceiling
8,500 ft broken
Temperature
72 °F, dew point 72 °F
Altimeter
30.00 inHg
Observed at
IND, 33 nm away

Docket · 52

The files NTSB released with the investigation on October 21, 2003, on NTSB’s docket system: statements, records, photos and specialists’ reports. 12.7 MB in all.

Supplement AItem 1 · .PDF · 105 KBSupplement BItem 2 · .PDF · 139 KBRecord of Interview & Witness StatementsItem 3 · .PDF · 181 KBWreckage DiagramItem 4 · .PDF · 415 KBWeather InformationItem 5 · .PDF · 301 KBATC TranscriptItem 6 · .PDF · 425 KBIndiana State Police Report ExcerptsItem 7 · .PDF · 110 KBPilot Training InformationItem 8 · .PDF · 494 KBTrip Details ReportItem 9 · .PDF · 600 KBGrand Aire Express Operational InformationItem 10 · .PDF · 1.0 MBProp Slash CalculationsItem 11 · .PDF · 225 KBFAR 135.213Item 12 · .PDF · 191 KBEngine Inspection InformationItem 13 · .PDF · 110 KBToxicological ReportItem 14 · .PDF · 66 KBStatement of Party Representatives to NTSB InvestigationItem 15 · .PDF · 348 KBWreckage ReleaseItem 16 · .PDF · 50 KBPhoto 1. Overhead View of Wreckage PathItem 17 · .PDF · 219 KBPhoto 2. Wreckage Path. Heading About 180 DegreesItem 18 · .PDF · 214 KBPhoto 3. Initial Point of ImpactItem 19 · .PDF · 219 KBPhoto 4. Propeller StrikesItem 20 · .PDF · 218 KBPhoto 5. Green GlassItem 21 · .PDF · 219 KBPhoto 6. Scrape Marks on RunwayItem 22 · .PDF · 216 KBPhoto 7. Outboard Section of Left WingItem 23 · .PDF · 219 KBPhoto 8. View of WreckageItem 24 · .PDF · 213 KBPhoto 9. View of Inverted Right Wing and Burned Runway SignItem 25 · .PDF · 215 KBPhoto 10. Nose Section of the AirplaneItem 26 · .PDF · 219 KBPhoto 11. View of Wreckage and EmpannageItem 27 · .PDF · 218 KBPhoto 12. View of Empannage and Burned CabinItem 28 · .PDF · 215 KBPhoto 13. Right Wing and Extended Right Main Landing GearItem 29 · .PDF · 217 KBPhoto 14. Left Engine and Burned CockpitItem 30 · .PDF · 227 KBPhoto 15. Left Propeller and Cargo (Round Pulleys)Item 31 · .PDF · 225 KBPhoto 16. Left Engine and EmpennageItem 32 · .PDF · 216 KBPhoto 17. Cockpit InstrumentsItem 33 · .PDF · 225 KBPhoto 18. Burned Right WingtipItem 34 · .PDF · 216 KBPhoto 19. Sections of Left Wing PiecesItem 35 · .PDF · 218 KBPhoto 20. Power QuadrantItem 36 · .PDF · 215 KBPhoto 21. Scraping on Left Side of Nose and Cockpit FuselageItem 37 · .PDF · 221 KBPhoto 22. Turn Coordinator Gyro RotorItem 38 · .PDF · 221 KBPhoto 23. Right Engine and Right PropellerItem 39 · .PDF · 221 KBPhoto 24. Leading Edge Gouges and Nicks in Right Propeller BladeItem 40 · .PDF · 220 KBPhoto 25. Artificial Horizon Gyro Housing and RotorItem 41 · .PDF · 227 KBPhoto 26. Horizontal Situation Indicator Gyro Rotor and CoverItem 42 · .PDF · 226 KBPhoto 27. Right Propeller Blade With Leading Edge Knicks and Chordwise ScratchingItem 43 · .PDF · 225 KBPhoto 28. Left PropellerItem 44 · .PDF · 216 KBPhoto 29. Left Propeller Blade With Tip CurlItem 45 · .PDF · 215 KBPhoto 30. Left Propeller Blade With Leading Edge Gouges and About 360 Degrees of Blade CurlItem 46 · .PDF · 218 KBPhoto 31. Left Blade 360 Degree Blade CurlItem 47 · .PDF · 216 KBPhoto 32. Right Propeller Blade With Chordwise Scratching and Tip CurlItem 48 · .PDF · 227 KBPhoto 33. EmpennageItem 49 · .PDF · 217 KBPhoto 34. Right WingItem 50 · .PDF · 217 KBPhoto 35. Left Wing Spar Attach PointsItem 51 · .PDF · 219 KBPhoto 36. Left Wing Spar Attach PointsItem 52 · .PDF · 217 KB