CHI06FA232

NTSB accident investigation · Piper PA-23-250 · Sault Ste Marie, MI · August 14, 2006

Accident · FatalField investigationFinal report
Date
August 14, 2006, 09:18 local (13:18 UTC)
Place
Sault Ste Marie, MI
Injuries
4 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N133BHPiper PA-23-250
Weather
Instrument (IMC) · Day
Status
Completed · report May 28, 2008
Report
Approved by Office Director
Parties
Piper Aircraft Company, Inc., Textron Lycoming, Federal Aviation Administration, Grand Rapids FSDO
FAA report
20060814026539A
Case key
64360

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 aircraft control during the circling approach and his failure to perform a missed approach when the airplane was no longer in a position to land using normal flight maneuvers. Contributing to the accident was the pilot's decision to operate below the approach's authorized minimum descent altitude (MDA) before having the airport/runway environment visible. Additional factors were the low cloud ceiling and visibility.

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 flightCircling (ifr)
Minimum descent altitude - continued belowPilot in commandFactor
Circling approach - performedPilot in command
Missed approach - not performedPilot in commandCause
Aircraft control - not maintainedPilot in commandCause
Stall - encountered
Weather condition - low ceilingFactor
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - ground

Analysis

While en route, about 23 minutes before the accident, the pilot reported that he had the current weather at the destination airport. At that time, the reported weather was scattered clouds at 900 feet above ground level (agl), an overcast ceiling at 3,500 feet agl, and a visibility of 3 miles. At the time of the accident, the airport's reported weather was 300 feet agl overcast ceiling and a 1-1/4 mile visibility. The flight was cleared for the VOR-A instrument approach procedure, circle to land runway 27. According to aircraft radar track data, the airplane descended below the approach's authorized minimum descent altitude (MDA) about 2.6 miles northeast of the airport. The airplane leveled off about 175 feet below the MDA until crossing over the intersection of the airport's two runways. The airplane then made a left turn to the east, and paralleled runway 27 about 600 feet south of the runway. The airplane's last radar return was at 185 feet agl and about 0.5 miles east of the runway threshold. The point-of-impact was about 725 feet north of the final radar return. Numerous witnesses reported seeing the airplane traveling eastbound approximately 150 and 200 feet agl, and then perform a left turn back towards the airport before impacting nose first into the terrain. Several of those witnesses reported that the airplane reached a bank angle of approximately 90 degrees during the turn. The airplane's altitude and proximity to the runway prevented an approach to landing using normal flight maneuvers. A majority of the airframe was destroyed during a post-impact ground fire. Examination of the recovered wreckage revealed no evidence of a pre-impact mechanical malfunction. According to FAA regulations," no pilot may continue below the authorized MDA unless the airplane is continuously in a position from which a descent to a landing on the intended runway can be made at a normal rate of descent using normal maneuvers, the flight visibility is not less than the visibility prescribed for the instrument approach procedure, and the runway environment is distinctly visible and identifiable to the pilot."

Factual narrative

History of flight

On August 14, 2006, at 0918 eastern daylight time (all referenced times are eastern daylight time), a Piper PA-23-250 Aztec, N133BH, operated by Spring City Aviation, Inc., Waukesha, Wisconsin, was destroyed during an explosion and ground fire following an in-flight collision with terrain while attempting to land at the Chippewa County International Airport (CIU), Sault Ste. Marie, Michigan. Instrument meteorological conditions (IMC) prevailed at the time of the accident. The instructional flight was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 91 while on an instrument flight plan. The flight instructor, dual student, and two passengers were fatally injured. The flight departed the Waukesha County Airport (UES), Waukesha, Wisconsin, at approximately 0711.

At 0624, the flight instructor contacted Green Bay Automated Flight Service Station (AFSS) to file an instrument flight rule (IFR) flight plan and to obtain a weather briefing. The planned route of flight was to depart UES, then proceed direct to the Escanaba (ESC) VHF Omni-directional Range (VOR), and then direct to the Sault Ste. Marie (SSM) VOR. The SSM VOR was an initial approach fix for the destination airport. The requested cruise altitude was 11,000 feet mean sea level (msl).

The briefer told the flight instructor that marginal visual meteorological conditions (VMC) prevailed along the route of flight, with areas of IMC near Escanaba, Michigan, and Manistique, Michigan. The briefer told the pilot that the forecast weather near the destination airport was VMC, with periods of reduced ground visibility of 5 miles due to light rain and mist. The destination forecast called for scattered clouds between 2,000 and 2,500 feet above ground level (agl) and an overcast ceiling at 10,000 feet agl.

At 0711, the accident airplane was cleared for departure from UES. At 0713, the pilot established radio communications with the Milwaukee Departure Control. The flight was cleared to climb to 11,000 feet msl and to fly direct to ESC VOR, then to continue as filed. At 0729, the airplane was handed off to Chicago Air Route Traffic Control Center (ARTCC) who verified that the airplane was flying direct to ESC VOR. At 0741, the airplane was handed off to Minneapolis ARTCC. At 0837, the pilot requested and was cleared to descend to 7,000 feet msl. At 0840, the pilot reported having the current weather at the destination airport (CIU). At 0848, the airplane was handed off to Toronto ARTCC.

At 0849, the pilot established radio communications with Toronto ARTCC and reported being level at 7,000 feet msl. Toronto ARTCC cleared the airplane to descend to 5,000 feet msl and inquired which instrument approach procedure the pilot wanted. The pilot requested the VOR-A approach into CIU, landing runway 27.

At 0855:41 (hhmm:ss), Toronto ARTCC cleared the airplane for the VOR-A approach into CIU and instructed the pilot to report when established inbound on the approach. At 0859:37, the airplane was cleared to descend to 3,000 feet msl.

At 0908:26, the pilot reported crossing the SSM VOR inbound on the approach. At 0908:34, Toronto ARTCC told the pilot to change to the CIU Unicom frequency and to cancel his flight plan after landing. At 0908:43, the pilot acknowledged the clearance and stated "I'll cancel on the ground, still IMC." No additional communications were received from the accident airplane.

According to aircraft radar track data, the accident airplane tracked the 218-degree radial inbound to CIU. The airplane descended below the approach's authorized minimum descent altitude (MDA) of 1,260 feet msl about 2.6 miles northeast of the airport. The airplane then leveled off at 1,085 feet msl until crossing over the intersection of runway 9/27 and runway 16/34. The airplane then made a left turn to the east, and paralleled runway 27 about 600 feet south of the runway at 985 feet msl.

At 0916:29, the last radar return associated with the accident airplane was recorded at 985 feet msl, about 0.5 miles east of the runway 27 threshold. The airplane impacted immediately adjacent to a prison perimeter fence located north of extended runway centerline, and about 725 feet north of the last recorded radar return.

Numerous witnesses reported seeing the airplane traveling eastbound approximately 150 and 200 feet agl, and then perform a left turn back toward airport before impacting nose first into the terrain. Several of those witnesses reported that the airplane reached a bank angle of approximately 90 degrees during the turn.

Personnel information

Flight Instructor --

According to Federal Aviation Administration (FAA) records, the flight instructor, age 23, held a commercial pilot certificate with single and multi-engine land airplane, and instrument airplane ratings. He also held a flight instructor certificate with single and multi-engine airplane, and instrument airplane ratings. His last aviation medical examination was completed on October 13, 2005, when he was issued a first-class medical certificate with no restrictions or waivers.

The flight instructor's most recent logbook entry was dated August 12, 2006, at which time he had accumulated 998.3 hours total flight time. Of that total, 937.5 hours were in single-engine airplanes and 60.8 hours were in multi-engine airplanes. He had accumulated 134.5 hours at night, 35.5 hours in actual instrument conditions, and 46.1 hours in simulated instrument conditions. He had flown 32.5 hours in a Piper PA-23-250. The flight instructor had provided 572.4 hours of flight instruction, of which 564.4 hours were in single-engine airplanes and 8.0 hours were in multi-engine airplanes.

During the 30-day period prior to the accident, the flight instructor had flown 62.6 hours total flight time. Of that flight time, 57.9 hours were in single-engine airplanes and 4.7 hours were in multi-engine airplanes. The 4.7 hours of multi-engine time were accumulated in the accident airplane. He had flown 0.2 hours at night and 3.5 hours in actual instrument conditions, including 8 instrument approaches. An additional 10 instrument approaches were logged without any corresponding instrument time for the particular flight.

During the 90-day period prior to the accident, the flight instructor had accumulated 247.5 hours total flight time. Of that flight time, 239.3 hours were in single-engine airplanes and 8.2 hours were in multi-engine airplanes. A total of 4.7 hours were flown in the accident airplane. He had flown 4.2 hours at night and 9.6 hours in actual instrument conditions, including 21 instrument approaches. An additional 57 instrument approaches were logged without any corresponding instrument time for the particular flight.

During the 6-month period prior to the accident, he had flown 488.5 hours total flight time. Of that flight time, 464.4 hours were in single-engine airplanes and 24.1 hours were in multi-engine airplanes. A total of 17.6 hours were flown in the accident airplane. He had flown 30.8 hours at night and 22.5 hours in actual instrument conditions, including 47 instrument approaches. An additional 95 instrument approaches were logged without any corresponding instrument time for the particular flight.

Dual Student --

According to FAA records, the dual student, age 30, held a private pilot certificate with a single-engine land airplane rating. He was not instrument rated. His last aviation medical examination was completed on September 12, 2005, when he was issued a third-class medical certificate with no restrictions or waivers.

The dual student's logbook was not recovered and is presumed to have been destroyed during the accident. His private pilot certificate was issued on May 24, 2006, at which time he had accumulated 70.8 hours total flight time. Of that flight time, 18.4 hours were as pilot-in-command, 52.4 hours were du

Aircraft

Registration
N133BH
Reported as
Piper PA-23-250
Category
Airplane
Serial number
27-3198
Airframe hours
1,806.4
Engine
Lycoming IO-540-C4B5, 250 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Instructional · Part 91
Registered owner
Spring City Aviation, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · June 1, 2006
Departed
UES · Waukesha, WI
Destination
CIU · Sault Ste Marie, MI
Flight plan
IFR
Airport
CIU · Chippewa County International, runway 27, 5,000 × 75 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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Flight instructor
Age
23
Injuries
Fatal
Certificates
Flight instructor, Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
April 1, 2006
Seat
Left
Toxicology
Performed
Flight hours
998 total · 33 in this make and model · 936 as pilot in command · 247 in the last 90 days · 63 in the last 30 days
Role
Student pilot
Age
30
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Without waivers/limitations
Last flight review
May 1, 2006
Seat
Right
Toxicology
Performed
Flight hours
71 total · 0 in this make and model · 18 as pilot in command

Weather

Conditions
Instrument (IMC) · Day
Wind
210° at 4 knots
Visibility
1.25 statute miles
Lowest ceiling
300 ft overcast
Temperature
63 °F, dew point 61 °F
Altimeter
29.69 inHg
Observed at
CIU

Docket · 22

The files NTSB released with the investigation on May 9, 2008, on NTSB’s docket system: statements, records, photos and specialists’ reports. 6.4 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.