DFW05FA020

NTSB accident investigation · Piper PA-31-350 · San Antonio, TX · November 14, 2004

Accident · FatalField investigationFinal report
Date
November 14, 2004, 17:18 local (23:18 UTC)
Place
San Antonio, TX
Injuries
5 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N40731Piper PA-31-350
Weather
Instrument (IMC) · Dusk
Status
Completed · report July 7, 2005
Report
Approved by Office Director
Parties
Federal Aviation Administration, National Transportation Safety Board
FAA report
20041114032489A
Case key
60542

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 during an ILS approach. Contributing factors were the prevailing instrument meteorological conditions( clouds, low ceiling and drizzle/mist), and the pilot's spatial disorientation.

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 flightApproach - faf/outer marker to threshold (ifr)
Aircraft control - not maintainedPilot in commandCause
Spatial disorientationPilot in commandFactor
Weather condition - low ceilingFactor
Weather condition - drizzle/mistFactor
In flight collision with objectDescent - uncontrolled
Object - residence
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - ground

Analysis

The twin-engine airplane collided with a residential structure and terrain following a loss of control after the pilot experienced difficulties maintaining course during an Instrument Landing System (ILS) approach while on instrument meteorological conditions. The impact occurred approximately 3.7 miles short of the approach end of the runway. Radar data depicted that after the 8,700-hour commercial pilot was vectored to the ILS Runway 3 approach, the airplane remained left throughout the approach before turning right of the localizer approximately 2 miles before the final approach fix (FAF). Radar then showed the aircraft turn to the left of course line. When the aircraft was abeam the FAF, it was approximately 1 mile left of the course line. As the aircraft closed to approximately 1.5 miles from the runway threshold, the aircraft had veered about 1.3 miles left of the course line (at which time air traffic control instructed the pilot to turn left to a heading of 270 degrees). The aircraft continued to turn left through the assigned heading and appeared to be heading back to the ILS course line. According to the radar, another aircraft was inbound on the ILS course line and Air Traffic Control Tower (ATCT) instructed the pilot to turn left immediately. Thereafter, the aircraft went below radar coverage. A witness, located approximately 1.25 miles northwest of the accident site, reported that he heard a very loud noise, and then observed an airplane flying toward a building, approximately 60 feet in height. The airplane was observed to have pitched-up approximately 45 - 90 degrees just before the building and disappeared into the clouds. A second witness located approximately 1 mile northwest of the accident site reported that he heard a low flying aircraft, and then observed a white twin-engine airplane banking left out of the clouds. The airplane leveled out, and flew into the clouds again a few seconds later. The witness stated that the airplane was at an altitude of 100-200 feet above the ground. A third witness located adjacent to the accident site reported that they heard the sound of a low flying airplane in the distance. As the sound became louder and louder, they looked up and observed the airplane in a near vertical attitude as it impacted trees and the side of an apartment complex. Examination of the airplane did not reveal any pre-impact mechanical anomalies. A weather observation taken approximately 15 minutes after the accident included a visibility 4 statue miles, light drizzle and mist, and an overcast ceiling at 400 feet.

Factual narrative

History of flight

On November 14, 2004, approximately 1718 central standard time, a Piper PA-31-350 twin-engine airplane, N40731, registered to and operated by Dash Air Charter Inc., of San Antonio, Texas, was destroyed when it impacted a multi-unit residential building and the ground following a loss of control while on an instrument approach to runway 3 at the San Antonio International Airport (SAT), San Antonio, Texas. The commercial pilot and four passengers were fatally injured. Instrument meteorological conditions (IMC) prevailed, and an instrument flight plan was filed for the 14 Code of Federal Regulations Part 91 personal flight. The 499-nautical mile cross-country flight originated from the Dodge City Regional Airport (DDC), near Dodge City, Kansas, approximately 1345, with the intended destination of SAT.

According to information provided to the NTSB investigator-in-charge (IIC) by friends and family members, the passengers on board the aircraft were returning home after a hunting trip. Information provided by the FAA and weather reporting services revealed that the en route portion of the flight from Dodge City was flown in instrument meteorological conditions. There were no reports of problems from the pilot during the approximate 3 1/2-hour en route portion of the flight. As the airplane neared its intended destination of San Antonio, the pilot established communications with San Antonio Air Traffic Control Tower (ATCT) and maneuvered to execute the Instrument Landing System (ILS) Runway 3 instrument approach.

The following are excerpts of radio communications between the pilot of N40731 and approach controllers (ATCT) in the minutes prior to the accident.

Agencies Making Transmissions: Abbreviations:

Piper PA-31-250, N40731: N40731

San Antonio Approach Control, Radar South: A/C

San Antonio ATCT, Local Control 2: ATCT

2301:01 N40731

approach navajo seven three one five thousand

2301:05 A/c

navajo seven three one san antonio approach roger

2304:16 A/c

navajo seven three one turn right heading one eight zero

2304:20 N40731

right turn to one eight zero

2307:15 A/c

navajo seven three one descend and maintain four thousand

2307:19 N40731

five for four seven three one

2309:39 A/c

navajo seven three one descend and maintain uh oh disregard just three thousand five hundred for navajo seven three one heading zero nine zero

2309:47 N40731

three thousand five hundred zero nine zero

2310:18 A/c

navajo seven three one is uh three miles from resoc turn left heading zero six zero maintain three thousand five hundred til resoc cleared ils runway three maintain maximum forward speed

2310:28 N40731

okay uh left turn zero six zero join the localizer maintain three point five til resoc

2314:04 A/c

low

2314:05 ATCT

uh local is uh navajo seven three one going around we're not talking to navajo seven three one if you thought he was on us

2314:12 A/c

navajo seven three one san antonio

2314:13 N40731

(unintelligible)

2314:14 A/c

okay navajo seven three one looks like you've lost the localizer uh turn left heading two seven zero climb and maintain three thousand five hundred

2314:22 N40731

left turn two seven zero three thousand five hundred

2315:16 A/c

navajo seven three one say altitude

2315:18 N40731

climbing to three thousand

2315:20 A/c

say altitude now

2315:22 N40731

two thousand climbing

2315:24 A/c

navajo seven three one looks like you're in a left turn northeast bound you got traffic one o'clock and a mile a hard left turn now heading three zero zero hard left turn

2315:42 A/c

navajo three thou navajo seven three one maintain three thousand five hundred i show you at one thousand eight hundred

2315:52 A/c

navajo seven three one i've lost your transponder

2315:58 A/c

navajo seven three one san antonio

2316:02 ATCT

local

2316:04 A/c

do you see that navajo anywhere

2316:05 ATCT

no we don't are you talking to him

2316:07 A/c

he he answered me one time and now he's not talking to me

2316:09 ATCT

well i we broke out one mike echo he's one two zero heading to three thousand he says he's low on fuel we'll put him back on you

2316:14 A/c

all right

2316:18 A/c

navajo seven three one san antonio

2316:22 A/c

navajo seven three one san antonio approach

No further communications were received from N40731.

Radar data received from the FAA showed that the aircraft remained initially left of the localizer course line before turning right of the localizer approximately 2 miles before the final approach fix (FAF). Radar then showed the aircraft turn to the left of course line. When the aircraft was abeam the FAF, it was approximately 1 mile left of the course line. As the aircraft closed to approximately 1.5 miles from the runway threshold, the aircraft had veered about 1.3 miles left of the course line (at which time ATCT instructed the pilot to turn left to a heading of 270 degrees). The aircraft continued to turn left through the assigned heading and appeared to be heading back to the ILS course line. According to the radar, another aircraft was inbound on the ILS course line and ATCT instructed the pilot to turn left immediately. Thereafter, the aircraft went below radar coverage (approximately 1200 feet msl).

A witness, located approximately 1.25 miles northwest of the accident site, reported to the NTSB investigator-in-charge (IIC) that he heard a very loud noise, and then observed a small white airplane flying toward a building, approximately 60 feet in height. The airplane pitched up approximately 45 - 90 degrees just before the building and disappeared into the clouds. A second witness located approximately 1 mile northwest of the accident site reported to the IIC that he heard a low flying aircraft, and then observed a white twin-engine airplane banking left out of the clouds. The airplane leveled out, and flew into the clouds again a few seconds later. The witness added that he "saw no indications of problems, smoke, or visible damage to the airplane." The witness stated that the airplane was at an altitude of 100-200 feet above the ground. A third witness located adjacent to the accident site reported that they heard the sound of a low flying airplane in the distance. As it became louder and louder, they looked up and observed the airplane in a near vertical attitude as it impacted trees and the side of an apartment complex.

Personnel information

The pilot held a commercial pilot certificate with airplane single-engine land, airplane multi-engine land, and instrument ratings. The pilot was last issued a second-class medical certificate on December 9, 2003, with the limitation stated "must wear corrective lenses and posses glasses for near and interim vision." The pilot had reported on his medical application he had accumulated a total flight time of 8,700 hours. The pilot's logbook was located during the on-scene investigation. At the last entry recorded on August 24, 2003, the pilot had accumulated 8,426.4 hours of flight. Entries observed within an aircraft flight log, kept by the pilot, stated that between October 21, 2003, and November 13, 2004, the pilot had accumulated an additional 164.3 hours of flight, totaling 8590.7 hours.

The pilot's most recent flight review was on July 17, 2003, in a PA-31.

Aircraft information

The 1981-model Piper PA-31-350, serial number 31-8152003, was a low wing, twin-engine semimonocoque design airplane, with a retractable landing gear, configured for a maximum of eight occupants. The airplane was powered by two normally aspirated, direct drive, air-cooled, horizontally opposed, fuel injected, six-cylinder engines driving a four bladed "Q-tip" Hartzell propeller. The left engine was a Lycoming TSIO-540-J2B engine (serial number RL-1298-68A) and the right engine was a Lycoming LTIO-540-J2B engine (serial number L-6186-61A

Aircraft

Registration
N40731
Reported as
Piper PA-31-350
Category
Airplane
Serial number
31-8152003
Airframe hours
2,248.7
Engines
Lycoming LTIO-540-J2B, 350 horsepower, reciprocatingLycoming TSIO-540-J2B, 350 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Registered owner
Dash Air Charter Inc.
Airworthiness certificate
Standard, Normal
Last inspection
Annual · July 31, 2004
Departed
DDC · Dodge City, KS
Destination
SAT · San Antonio, TX
Flight plan
IFR
Airport
SAT · San Antonio Intl, runway 3, 7,505 × 150 ft

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
58
Injuries
Fatal
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Last flight review
July 31, 2004
Seat
Left
Flight hours
8,590 total

Weather

Conditions
Instrument (IMC) · Dusk
Wind
50° at 9 knots
Visibility
4 statute miles
Lowest ceiling
400 ft overcast
Temperature
54 °F, dew point 52 °F
Altimeter
30.28 inHg
Observed at
SAT, 3 nm away

Docket · 15

The files NTSB released with the investigation on May 9, 2005, on NTSB’s docket system: statements, records, photos and specialists’ reports. 8.1 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.