# NTSB DEN02FA004: Cessna T337G, N45E, Palmer Lake, CO, October 28, 2001 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: October 27, 2001, 20:06 local (Oct 28, 2001, 02:06 UTC) - Place: Palmer Lake, CO - Coordinates: 39.174446, -104.970558 - Nearby events: https://openairdocs.org/map.md?lat=39.1744&lon=-104.9706&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report August 26, 2003 - Report: Approved by Office Director - Parties: Federal Aviation Administration - NTSB case key (mKey): 53675 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=DEN02FA004 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/53675/pdf - Page: https://openairdocs.org/ntsb/DEN02FA004 ## Probable cause the pilot intentionally restricting his external vision (turning his cabin lights up bright to practice night instrument approaches), and his subsequent failure to maintain clearance of the mountain. A contributing factor was the Air Traffic Controller’s failure to provide appropriate safety alerts for rising terrain. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight collision with terrain/water, maneuvering - visual lookout - restricted, pilot in command (cause) - altitude/clearance - not maintained, pilot in command (cause) - procedures/directives - not followed, atc personnel(dep/apch) (contributing factor) ## Analysis The pilot departed Centennial Airport (elevation 5,883 feet) VFR to practice multiple instrument approaches at night. He told his wife that he would turn the cockpit lights up bright to facilitate instrument training. After two ILS approaches, he requested, from ATC, two turns in the holding pattern before flying additional approaches. The ATC controller cleared him for the practice holding, and assigned him to fly at 9,000 feet. During the inbound track (347 degrees), radar data indicated that the airplane descended from its assigned altitude to 7,600 feet with no ATC intervention. Next, the pilot requested to depart the initial approach fix to the southeast for approximately 15 nm at 8,500 feet. The ATC controller cleared the request, but didn't terminate radar services. The pilot flew south for approximately 8nm, then turned to 210 degrees. He impacted the mountain approximately 5 minutes later. ## Factual narrative HISTORY OF FLIGHT On October 27, 2001, at 2006 mountain daylight time, a Cessna T337G, N45E, was destroyed during impact with terrain near Palmer Lake, Colorado. The instrument rated private pilot, the sole occupant in the airplane, was fatally injured. The flight was being conducted under Title 14 CFR Part 91. Visual meteorological conditions prevailed for the local, night flight that originated at 1905 from Centennial Airport, Englewood, Colorado. The pilot had not filed a flight plan. The pilot's wife said the purpose of his flight was to practice instrument approaches in preparation for an instrument proficiency check ride, for insurance purposes, on October 29, 2001. She said she was planning to fly with him as a safety pilot (which she frequently did), but on this day he wanted to fly alone. The pilot told her that he would not wear a visual restricting device (for instrument training), but "he would turn the cabin lights up bright" to restrict his external vision. The Federal Aviation Administration (FAA) Denver TRACON (Terminal Radar Approach Control) voice tape indicates that the pilot said "I will be airborne for a couple of hours, and I'd like to practice various approaches." The controller told him to squawk 5230 (a VFR discreet code with no associated MSAW [minimum safe altitude warning] capability) and climb to 8,500 feet msl (mean sea level). He was then cleared to fly the full ILS (Instrument Landing System) approach to runway 35R. The pilot flew two complete ILS approaches; his first clearance was at 1918 and his second clearance was at 1936. During the first approach, the pilot came out of the procedure turn and flew through the localizer. He said to the controller, "I can't seem to get on the localizer." The controller assisted him with a heading of 020 degrees [or a 30 degree localizer intercept angle]. At 1946, the pilot requested to fly two turns in the holding pattern before flying a third approach; the controller cleared him to fly direct to Casse (the outer marker) and climb to 9,000 feet msl. At 1948, the controller conducted a position relief briefing and transferred position responsibility to the relieving controller. At 1950, the pilot was flying inbound on the first holding pattern and he departed his assigned altitude. Radar data indicates that he descended approximately 1,400 feet with no controller intervention. Next, the pilot requested to depart 15 nautical miles (nm) to the southeast to "get out of the way of the approach course for awhile." The controller cleared him, with no further instructions. The pilot requested an altitude of 8,500 feet; the controller cleared him for that altitude. No mention of visual flight rules (VFR) or changing his discreet transponder squawk were made by the controller. At 2000:31, the radar data indicates that the airplane was west of the localizer (approximately 8 nm south of Casse) flying approximately 170 degrees, and made a 35 degree turn to the west towards rising terrain. Radar data indicates that this straight course was held for approximately 5 minutes, at which time radar contact was lost. At 2300, the pilot's wife reported to local authorities that the airplane was overdue. A search was commenced, and the airplane was located at approximately 0730 the next morning. PERSONNEL INFORMATION The pilot took his last FAA flight medical exam (third class) on March 29, 2001, and at that time he reported on his application that he had 9,793 hours of flight experience, with 54 hours during the last 6 months. The pilot's wife reported that the pilot was instrument current per regulations; his personal flight logbook was never located. It could not be determined if he had a current flight review. AIRCRAFT INFORMATION The airplane was a twin engine, propeller-driven, five seat, pressurized cockpit, centerline thrust airplane, which was manufactured by Cessna Aircraft Company, in 1973. It was powered by two Teledyne Continental Motors TSIO-360-C5B, six cylinder, reciprocating, horizontally opposed, direct drive, air cooled, fuel injected, turbo-charged engines, which had a maximum takeoff rating of 210 horsepower at sea level. At the last annual inspection on November 11, 2000, the documented airframe total time was 5,498 hours. The front engine was installed on March 3, 1997, and was a zero time engine. It received an oil change on October 5, 2001, 86.5 hours since the last annual inspection; it had a total of 495 hours of operation. On October 5, 2001, the rear engine's oil was also changed; it had 1,140 hours since major over haul. A Bill of Sale was located which indicated that the pilot purchased the airplane on September 29, 1981. The airplane manufacturer's records indicate that the airplane was fully equipped for instrument flight. The airplane's NAVCOM was a Bendix-King KX-175B with a KCS-55A Horizontal Situation Indicator (HSI) system. The manufacturer of this system said the d-bar polarity indicator (the ILS localizer signal indicator) does not reverse itself for back course approaches. They said "the correct procedure for flying a back course with the HSI is to set the Course Selector to the inbound front course approach bearing. The d-bar indication is always a fly-to the needle, never away from it." The airplane was "topped off" with fuel on October 22, 2001; it received 80 gallons of avgas 100LL. METEOROLOGICAL INFORMATION At 1953, the weather conditions at Centennial Airport (elevation 5,883 feet), 020 degrees 18 nautical miles (nm) from the accident site, were as follows: wind 180 degrees at 7 knots; visibility 10 statute miles; cloud condition 12,000 feet few, 15,000 feet scattered, and 25,000 feet broken; temperature 55 degrees Fahrenheit; dew point 16 degrees Fahrenheit; altimeter setting 30.18 inches. At 1954, the weather conditions at the City of Colorado Springs Municipal Airport (elevation 6,184 feet), Colorado Springs, Colorado, 120 degrees 27 nm from the accident site, were as follows: wind 070 degrees at 7 knots; visibility 10 sm; cloud condition 12,000 feet few; temperature 54 degrees Fahrenheit; dew point 16 degrees Fahrenheit; altimeter setting 30.24 inches. The moon was waxing gibbous with 82 percent of its visible disk illuminated; it rose at 1626. AERODROME INFORMATION Centennial Airport (elevation 5,883 feet), Englewood, Colorado, is a tower controlled field that has three runways, but only one precision instrument approach. The ILS (Instrument Landing System, 111.3 MHz) to runway 35R has an initial approach altitude of 8,000 feet msl (2,817 feet agl), to the outer marker (Casse). The final approach course is 347 degrees, the decision height is 6,083 feet msl, and the touchdown zone's elevation is 5,883 feet msl. The distance from Casse to the approach end of runway 35R is 6.3 nm. WRECKAGE AND IMPACT INFORMATION The airplane was found (N39 degrees, 10.46'; W104 degrees, 58.24'; elevation 8,512 feet) on a heavily forested mountain slope. The terrain was, at first impact, sloping up at approximately 20 degrees; the up slope condition leveled off and transitioned to a slightly down slope condition. The conifer trees were 40 to 60 feet in height. The longitudinal track through the trees was approximately 210 degrees, and was approximately 250 feet in length. The postimpact fire consumed much of the airplane, and it started a small forest fire. All of the airplane's major components were accounted for at the accident site. The flight control surfaces were all identified. Impact damage and postimpact fire precluded any flight control cable continuity confirmation, or any documentation of cockpit controls, avionics, and instrumentation. The landing gear was found extended, and the wing flaps were in the up position. The two engines were found lying in their respective positions, in relation to the fire consumed fuselage. The front engine was ## Aircraft - Registration: [N45E](https://openairdocs.org/deregistered/N45E-2002-03-19), registration cancelled 2002-03-19, S/N P3370136, built 1973 (OpenAirDocs) - Reported make and model: Cessna T337G - Registry model: [Cessna T337G](https://openairdocs.org/model/cessna-t337g) (registry code 2075726) (OpenAirDocs) - Registry engine: [Continental IO-360 series](https://openairdocs.org/engine/continental-io-360-series) (registry code 17025, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: P3370136 - Airframe hours: 5585 - Engines: Continental TSIO-360-C 210 horsepower reciprocating; Continental TSIO-360-C 210 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Registered owner: Leo J. Miller - Airworthiness certificate: Standard, Normal - Last inspection: Annual, November 11, 2000, 87 hours before - Departed: APA, Centennial Arpt, CO ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 76; injuries: fatal; private; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 3, valid medical--w/ waivers/lim; seat: left; toxicology performed; flight hours: 9,793 total, 5,351 in this make and model, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Night/dark - Wind: 180° at 7 knots - Visibility: 10 statute miles - Lowest ceiling: 25,000 ft broken - Temperature: 55 °F, dew point 16 °F - Altimeter: 30.18 inHg - Observed at: APA, 18 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 20011027030979A](https://openairdocs.org/incident/20011027030979A), Oct 27, 2001: Cessna T337G, Palmerlake, CO, No damage, 1 fatal. (-23) Aircraft N45E was destroyed during impact with terrain at approximately 8500 feet elevation. 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.