CHI95FA018

NTSB accident investigation · Piper PA-23-250 · Sellersburg, IN · October 20, 1994

Accident · FatalField investigationFinal report
Date
October 20, 1994, 00:35 local (05:35 UTC)
Place
Sellersburg, IN
Injuries
5 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N40509Piper PA-23-250
Weather
Instrument (IMC) · Night/dark
Status
Completed · report July 31, 1995
Report
Approved by Office Director
FAA report
19941020035159A
Case key
9718

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

Failure of the pilot to follow IFR procedures by allowing the aircraft to deviate left of the ILS localizer course, by not maintaining the proper ILS glide path, and by continuing descent below the ILS decision height.

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 terrain/waterApproach - faf/outer marker to threshold (ifr)
Light condition - dark night
Weather condition - fog
Flight to destination alternate - performedPilot in command
Ifr procedure - not followedPilot in commandCause
Proper glidepath - not maintainedPilot in commandCause
Decision height - not usedPilot in commandCause

Analysis

Due to weather, the pilot made a missed approach at an airport about 10 miles southeast of the alternate airport. He then diverted to the alternate, where he was cleared for an ILS runway 18 approach. After passing the final approach fix, the pilot was cleared to contact the airport's advisory service. As the airplane continued inbound, it collided with a quarry wall about 2 miles north of the airport and 1/4 mile east of the localizer centerline. Elevation at the top of the quary wall was 480' MSL; airport elevation was 474' MSL; decision height for the approach was 674' MSL. An examination of the airplane revealed no preimpact failure, but the airplane was extensively damaged by impact and ground fire. A friend reported that the pilot began his work day at 0830 EST.

Factual narrative

History of Flight

On October 20, 1994, at 0035 eastern standard time (est), a Piper PA-23-250, N40509, registered to All American Air, Incorporated, of Louisville, Kentucky, and piloted by an instrument rated commercial pilot, was destroyed during a collision with a stone quarry wall. The airplane had been given radar vectors for an ILS runway 18 approach at the Clark County Airport, Jeffersonville, Indiana, shortly before the accident. Instrument meteorological conditions prevailed at the time of the accident. The airplane had been operating on an IFR flight plan. The pilot and four passengers were fatally injured. The flight departed Dayton, Ohio, at 2347 est.

During the afternoon of October 19, 1994, the pilot of N40509 had made an IFR flight from Louisville, Kentucky, to Dayton, Ohio. Before this flight he obtained a weather briefing from the Federal Aviation Administration's (FAA) Louisville, Kentucky, Flight Service Station (FSS). During the conversation the pilot said he would "...be back tonight before midnight... ." The pilot was told that a frontal system was moving from the northwest and that it would be going "...through the Cincinnati, Ohio, and Louisville, Kentucky, area around eight to ten o'clock..." in the evening.

The briefer gave the current weather conditions for Louisville, Kentucky, and Dayton, Ohio. The information showed instrument meteorological conditions for both locations. The pilot then filed two IFR flight plans for flights between the two cities.

Before departing Dayton, the pilot called the FAA's Dayton FSS for a weather update briefing. The update consisted of current weather for Dayton International Airport, Bowman, and Standiford Airport in Louisville, Kentucky. He was told that the visibility at Standiford and Bowman was two and three miles respectively. Both airports were reporting fog, according to the briefer. The pilot made minor changes to a previously filed IFR flight plan and concluded the briefing. He did not ask for surface weather trends at either airport. The briefer did not supply temperature/dew point spreads for either airport.

At 2359, N40509 approached the Louisville, Kentucky, area. The FAA Approach Control (ATC) at the Standiford Airport advised the pilot that Bowman Airport's ceiling and visibility were "...sky partially obscured, visibility a half mile fog... ." The pilot told ATC that he'll "...try the VOR 24 at Bowman and then upon the miss we'll have to come into Standiford." At 0001:52, ATC told the pilot, "...Standiford is below minimums right now...expect a VOR 24 approach at ...Bowman and I'll have the ...missed approach instructions for you momentarily." The pilot replied that if he could not complete the instrument approach and landing at Bownman Airport he "...wanted to try the ILS 18 at Clark County... ."

About 10 minutes later, N40509 was cleared for the Bowman Airport VOR 24 approach. N40509 shot and reported the missed VOR approach to ATC. The ATC controller acknowledged the pilot's missed approach report and asked if the pilot wanted to do the runway 18 ILS at the Clark County Airport. The pilot confirmed his desire to do the approach.

N40509 was given heading and altitude instructions followed by the Standiford Airport's current weather: "...measured 800 overcast, visibility a quarter mile, fog, winds calm." The pilot was then given radar vectors toward the Clark County Airport. About two minutes after receiving the weather, the pilot of N40509 was told to turn the airplane to a heading 200 degrees, that he was two miles from the final approach fix, and to maintain 2,500 feet above mean sea level. He was cleared for the ILS 18 approach at Clark County Airport, Jeffersonville, Indiana. Two minutes later ATC told the pilot he was "...just inside Happs [final approach fix], now change to advisory approved... ." The pilot acknowledged ATC's communication.

Personnel Information

The pilot's logbook records were not at the accident scene. According to the pilot's wife he always kept the logbooks in his flight case that he took with him when he flew. She said she looked for the logbooks and could not locate them.

According to the FAA airman certification records, the pilot had 1,041 hours as of May 10, 1993. The records showed he had 15 hours total time in the Piper PA-23-250, 1 hour was shown as pilot-in-command flight time. The actual amount of flight time in the Piper PA-23-250 and his recency of experience were not able to be determined.

FAA records showed the pilot had received two notices of disapproval for his multi-engine commercial certificate with an instrument rating. The records showed he had been issued the notices of disapproval on June 28, 1992, and May 10, 1993. The June 28, 1992, notice said, "Upon reapplication you will be reexamined on the following: Area of operation VI all tasks, first failure." The second notice said, "Upon reapplication you will be reexamined on the following: pilot operation 4, 5, 6, 8, 9. Single engine ILS approach, Pilot operation 6, task B." The pilot received his commercial pilot certificate with a multi-engine and instrument rating on May 19, 1993.

Aircraft Information

N40509's airframe logbook showed it received an annual inspection on August 25, 1994. At that time its total airframe time was 7,198.1 hours (tach time). The entry showed 1,195.2 hours hobbs meter reading.

N40509's left engine logbook entry dated August 20, 1994, showed it had 2,149 hours since major overhaul. Its right engine logbook entry dated August 20, 1994, showed it had 2,395 hours since major overhaul. According to the airframe logbook N40509 had a pitot-static and transponder check on November 2, 1993. Records showing a VOR accuracy check were not located in the wreckage or aircraft logbook.

Wreckage and Impact Information

N40509's wreckage was located in a stone quarry approximately two miles north of the Clark County Airport, Jeffersonville, Indiana. The airplane had collided at the midpoint of a 60-foot high quarry wall. Its wreckage was found at the base of this wall, burnt and covered with stone fragments.

The empennage's right side was fire damaged, its left side showed sooting. No evidence of airflow sooting was found on the empennage's rivets. The fuselage and wings had been consumed by fire. Portions of the wing's main spar were found with fire and collision damage. Both engines were damaged by collision with the quarry wall and subsequent fire. The major portions of both engine cases had been melted.

N40509's right engine vacuum pump drive shaft was torsionally separated at its junction with the engine case. Its rotor vanes were cracked, the pumps housing was oblong shaped. The left engine's vacuum pump had been destroyed by fire.

The left engine case was melted, exposing an intact crankshaft and camshaft. The crankshaft propeller extension end had separated aft of its main bearing journal. Both propeller blades were separated from their hub. One blade was curved forward, the outer half of the blade had separated. The second blade was bent aft about 70 degrees at its mid-span position. The outer portion of the blade was curved 45 degrees outward at its mid-span position. Both propeller blades had various sized knicks and gouges in their leading edges. The front cylinders were bent aft, one of them separated from its piston. Crush and fire damage was observed on the front cylinders fins.

The right engine case was melted, exposing an intact crankshaft and camshaft. The number 1 cylinder had separated from the engine case. The number 2 cylinder was bent aft about 2 degrees; its cooling fins showed collision and fire damage. The propeller crankshaft extension had separated from its crankshaft mounting. The propeller blades displayed multiple forward and aft bends along their span. The leading edges of the blades

Aircraft

Registration
N40509
Reported as
Piper PA-23-250
Category
Airplane
Serial number
27-7405240
Engine
Lycoming IO-540-C4B5, 250 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Registered owner
All American Air, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
Annual · August 25, 1994
Departed
DAY · Dayton, OH
Destination
LOU · Louisville, KY
Flight plan
IFR
Airport
JVY · Jeffersonville/Clark Co., runway 18, 5,500 × 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
43
Certificates
Commercial, Flight instructor
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Toxicology
Performed
Flight hours
1,041 total

Weather

Conditions
Instrument (IMC) · Night/dark
Visibility
0.25 statute miles
Lowest ceiling
None
Temperature
63 °F, dew point 63 °F
Altimeter
30.00 inHg
Observed at
JVY, 2 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.