# NTSB DFW05FA020: Piper PA-31-350, N40731, San Antonio, TX, November 14, 2004 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: November 14, 2004, 17:18 local (23:18 UTC) - Place: San Antonio, TX - Coordinates: 29.533611, -98.469718 - Nearby events: https://openairdocs.org/map.md?lat=29.5336&lon=-98.4697&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 5 fatal - Status: Completed, report July 7, 2005 - Report: Approved by Office Director - Parties: Federal Aviation Administration, National Transportation Safety Board - NTSB case key (mKey): 60542 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=DFW05FA020 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/60542/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=60542 - Page: https://openairdocs.org/ntsb/DFW05FA020 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, approach - faf/outer marker to threshold (ifr) - aircraft control - not maintained, pilot in command (cause) - spatial disorientation, pilot in command (contributing factor) - weather condition - low ceiling (contributing factor) - weather condition - drizzle/mist (contributing factor) - In flight collision with object, descent - uncontrolled - object - residence - In flight collision with terrain/water, descent - 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](https://openairdocs.org/deregistered/N40731-2005-10-06), registration cancelled 2005-10-06, S/N 31-8152003, built 1980 (OpenAirDocs) - Reported make and model: Piper PA-31-350 - Registry model: [Piper PA-31-350](https://openairdocs.org/model/piper-pa-31-350) (registry code 7103110) (OpenAirDocs) - Registry engine: [Lycoming TI0-540 series](https://openairdocs.org/engine/lycoming-ti0-540-series) (registry code 41533, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: 31-8152003 - Airframe hours: 2248.7 - Engines: Lycoming LTIO-540-J2B 350 horsepower reciprocating; Lycoming 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 58; injuries: fatal; 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 ## 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 20041114032489A](https://openairdocs.org/incident/20041114032489A), Nov 14, 2004: Piper PA31350, San Antonio, TX, Destroyed, 5 fatal. (-23) The pilot and four passengers were fatally injured when the twin engine aircraft impacted the ground. ## Docket (15 files) The files NTSB released with the investigation on May 9, 2005, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=60542. 8.1 MB in all. - Meteorology 5 - Factual Report of Group Chairman (item 1, .PDF, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40230241&FileExtension=.PDF&FileName=Meteorology%205%20-%20Factual%20Report%20of%20Group%20Chairman-Master.PDF - Witness Statements (item 2, .PDF, 122 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40430595&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - Maps or Charts of Accident Area, Wreckage Diagrams (item 3, .PDF, 124 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40230869&FileExtension=.PDF&FileName=Maps%20or%20Charts%20of%20Accident%20Area,%20Wreckage%20Diagrams-Master.PDF - Maps or Charts of Accident Area, Wreckage Diagrams (item 4, .PDF, 34 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40230871&FileExtension=.PDF&FileName=Maps%20or%20Charts%20of%20Accident%20Area,%20Wreckage%20Diagrams-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 5, .PDF, 202 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40430596&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Toxicological Report (item 6, .PDF, 51 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40430597&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF - Photo 1 - Overview of wreckage area (item 7, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40230875&FileExtension=.PDF&FileName=Photo%201%20-%20Overview%20of%20wreckage%20area-Master.PDF - Photo 2 - Overview of Wreckage Area (item 8, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40230876&FileExtension=.PDF&FileName=Photo%202%20-%20Overview%20of%20Wreckage%20Area-Master.PDF - Photo 3 - Overview of Wreckage Area (item 9, .PDF, 706 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40230877&FileExtension=.PDF&FileName=Photo%203%20-%20Overview%20of%20Wreckage%20Area-Master.PDF - Photo 4 - Cutout in the Apartment Roof by the left wing tip and winglet (item 10, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40230881&FileExtension=.PDF&FileName=Photo%204%20-%20Cutout%20in%20the%20Apartment%20Roof%20by%20the%20left%20wing%20tip%20and%20winglet-Master.PDF - Photo 5 - View of the left wingtip and winglet located inside the apartment building (item 11, .PDF, 305 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40230886&FileExtension=.PDF&FileName=Photo%205%20-%20View%20of%20the%20left%20wingtip%20and%20winglet%20located%20inside%20the%20apartment%20building-Master.PDF - Photo 6 - View of Right Engine (item 12, .PDF, 404 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40230895&FileExtension=.PDF&FileName=Photo%206%20-%20View%20of%20Right%20Engine-Master.PDF - Photo 7 - View of the right propeller and tree trunk (item 13, .PDF, 495 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40230897&FileExtension=.PDF&FileName=Photo%207%20-%20View%20of%20the%20right%20propeller%20and%20tree%20trunk-Master.PDF - Photo 8 - View of the left engine (item 14, .PDF, 378 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40230900&FileExtension=.PDF&FileName=Photo%208%20-%20View%20of%20the%20left%20engine-Master.PDF - Photo 9 - View of the left engine (item 15, .PDF, 348 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40230902&FileExtension=.PDF&FileName=Photo%209%20-%20View%20of%20the%20left%20engine-Master.PDF 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.