# NTSB FTW04FA172: Piper PA-32-300, N4123R, Hot Springs, AR, July 2, 2004 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: July 2, 2004, 10:43 local (15:43 UTC) - Place: Hot Springs, AR - Coordinates: 34.526668, -93.024719 - Nearby events: https://openairdocs.org/map.md?lat=34.5267&lon=-93.0247&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report June 8, 2005 - Report: Approved by Office Director - Parties: The New Piper Aircraft Company, FAA FSDO, SW11 - NTSB case key (mKey): 59547 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=FTW04FA172 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/59547/pdf - Page: https://openairdocs.org/ntsb/FTW04FA172 ## Probable cause The pilot's failure to fly a stabilized, published instrument approach procedure, which resulted in a collision with mountainous terrain. Factors were the clouds and the air traffic controllers' failure to provide known information that may have assisted the pilot in determining whether to continue with the approach or take alternate action. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight collision with terrain/water, maneuvering - ifr procedure - not followed, pilot in command (cause) - remedial action - not advised, atc personnel(artcc) (contributing factor) - proper altitude - not maintained, pilot in command (cause) - terrain condition - mountainous/hilly - weather condition - clouds (contributing factor) ## Analysis The 1,765-hour instrument rated private pilot was executing the ILS RWY 5 instrument approach when he over flew the airport, then made a left turn and collided with mountainous terrain approximately five miles northeast of the airport. A witness was in her home when she heard the sound of an airplane "flying really low." She said the engine sounded normal, and then the sound of the engine stopped very "abruptly." The pilot was vectored by air traffic control (ATC) to intercept the localizer course for the ILS RWY 5 approach. A review of ATC communications and radar data revealed at 1035:53, when the airplane was approximately 5.5 miles southwest of HOSSY intersection, an approach controller instructed the pilot to, "fly heading 020 degrees intercept the localizer and maintain 3,000 feet until established." The pilot acknowledged, and began a right turn towards the airport. Over the next two minutes, the airplane tracked a 020 degree heading but remained south of the final approach course. At 1038:10, the airplane was just southeast of HOSSY at an altitude of 3,000 feet msl. At this point, the airplane was 700 feet above the published approach altitude, which was 2,300 feet msl, and the pilot had not reported established on the final approach course. At 1039:25, the approach controller conducted a position relief briefing and discussed the airplane's approach with the relief controller. The controller stated to the relief controller, "he's probably going to miss...I turned him on too late probably gonna miss yeah he's too high he's missed it now." At 1039:25, the pilot reported established on the final approach course. The airplane was 2.5 miles past HOSSY and three miles from the runway at an altitude of 3,000 feet msl. The relief controller responded, "roger change to advisory approved report your arrival time this frequency." The pilot acknowledged. The relief controller then replied, "well just make sure you got this approach you are cleared for the i l s runway five approach and change to advisory approved report your arrival time this frequency." The pilot responded, "two three romeo cleared for the i l s runway five I'll report to you when I am down." No further transmissions were received from the pilot. Both controllers acknowledged the pilot's abnormal approach and failed to provide known information that may have assisted the pilot in determining whether to continue with the approach or take alternate action as required per FAA Order 7110.65, "Air Traffic Control" paragraph 5-9-2, Final Approach Course Interception. Examination of the airplane and engine revealed no mechanical deficiencies. ## Factual narrative HISTORY OF FLIGHT On July 2, 2004, at 1043 central daylight time, a Piper PA-32-300 single-engine airplane, N4123R, was substantially damaged after colliding with mountainous terrain while maneuvering near Indian Mountain, Hot Springs, Arkansas. The instrument rated private pilot/owner, the sole occupant of the airplane, was fatally injured. An instrument flight rules (IFR) flight plan was filed for the cross-country flight that originated at Lebanon-Springfield Airport (6I2), near Springfield, Kentucky, about 0700, destined for Hot Springs/Memorial Airport (HOT), near Hot Springs, Arkansas. Visual meteorological conditions prevailed for the personal flight conducted under 14 Code of Federal Regulations Part 91. A witness was in her home located on Indian Mountain. She was talking on the telephone, when she heard the sound of an airplane "flying really low" near her home. The witness said the engine sounded normal and "it wasn't sputtering or anything like that...then the sound of the engine stopped very abruptly." A review of air traffic control communications revealed that the pilot received radar vectors to intercept the localizer course for the ILS RWY 5 approach. At 1007:39, the pilot contacted the Memphis Air Route Traffic Control Center and advised he was at an altitude of 5,000 feet mean sea level (msl). An approach controller acknowledged the transmission and instructed the pilot to fly a heading of 200 degrees. The pilot responded, "heading two zero zero." At 1017:29, the controller instructed the pilot to fly a heading of 230 degrees, and the pilot acknowledged. At 1020:37, the controller asked the pilot, "and four one two three romeo can you reduce your speed about fifteen knots or so", which the pilot responded, "roger." At 1024:05, the controller requested the pilot's indicated airspeed, which the pilot advised, "three romeo is indicating a hundred and twenty five knots." The controller stated, "roger." At 1032:18, the controller instructed the pilot to fly a heading of 290 degrees, and the pilot acknowledged. At 1034:50, the controller instructed the pilot to descend and maintain 4,000 feet msl, and the pilot acknowledged. At 1035:22, the controller stated, "four one two three romeo fly heading zero one zero and intercept the localizer." The pilot acknowledged by stating, "zero one zero intercept the localizer two three romeo." The controller responded, "and two three romeo, I'm gonna bring you in just a bit high if that's okay." The pilot responded, "two three romeo okay." At 1035:53, the controller stated, "november four one two three romeo your position is eight miles southeast of Hossy, fly heading zero two zero, intercept the localizer, maintain three thousand till established." The pilot acknowledged the instructions and stated, "two three romeo, maintain three thousand, intercept the local, I'll let you know when I'm established." At 1038:49, the controller handling the airplane was relieved by another controller. The controller conducted a position relief briefing with the relief controller and had a short discussion regarding the airplane's approach. The controller said to the relief controller, "he's probably gonna miss", which the relief controller responded by saying, " turn him on too early late." The controller replied, "I turned him on too late, probably gonna miss, yeah he's too high, he's missed it now he missed it he's too high." At 1039:25, the pilot stated, "memphis center two three romeo is established." The relief controller instructed the pilot to, "change to advisory approved report your arrival time this frequency." The pilot acknowledged, and stated, "three romeo switching to advisory." The relief controller stated, "ah well just make sure you got this ah approach you are cleared for the ILS runway five approach and change to advisory approved report your arrival time this frequency." The pilot responded by saying, "two three romeo cleared for the ILS runway five I'll report to you when I am down." No further transmissions were received from the pilot. Data downloaded from a hand-held global positioning system (GPS) found at the crash site revealed that the airplane departed Springfield about 0700 and proceeded westbound toward Hot Springs. A review of the last eight minutes of recorded data revealed the airplane approached Hot Springs Airport from the southwest, and was abeam HOSSY, the final approach fix, at 1038:08 at an altitude of 3,055 feet mean sea level (msl), and a groundspeed of 127 knots. The airplane made a series of left and right turns as it proceeded along the localizer course toward the airport. Two minutes and 36 seconds later, the airplane was abeam the missed approach point at an altitude of 2,536 feet msl, and a ground speed of 114 knots. For the next two minutes and 30 seconds, the airplane continued to descend as it proceeded on a northeasterly heading away from the airport. A review of the last 11 seconds of recorded data revealed that the airplane began a left turn to the north before the data ended at 1043:30 at an altitude of 970 feet, and a ground speed of 111 knots. The last GPS coordinate was recorded at 34 degrees, 31 minutes north latitude, and 93 degrees, 01 minutes west longitude, approximately five miles northeast of the airport. PERSONNEL INFORMATION The pilot held a private pilot certificate for airplane single-engine land and instrument airplane. His most recent Federal Aviation Administration (FAA) third class medical was issued on August 27, 2002. A review of the pilot's logbooks revealed he had accumulated a total of approximately 1,765 flight hours, of which 115 hours were in simulated instrument conditions and 58 hours were in actual instrument conditions. The pilot was current for instrument flight conditions and had completed a biennial flight review on October 18, 2002. METEOROLOGICAL INFORMATION Hot Springs Airport was equipped with an automated surface observation system (ASOS). At 1035, the weather was reported as wind from 220 degrees at 8 knots, visibility 8 statute miles, overcast clouds at 7,000 feet agl, broken clouds at 4,200 feet agl, and scattered clouds at 1,200 feet agl. The temperature was 79 degrees Fahrenheit and the dewpoint was 72 degrees Fahrenheit. At 1053, the wind was from 220 degrees at 4 knots, visibility 7 statute miles, overcast clouds at 2,100 feet agl, broken clouds at 1,300 feet agl, and scattered clouds at 800 feet agl. The temperature was 76 degrees Fahrenheit, and the dewpoint 73 degrees Fahrenheit. The barometric pressure setting was 30.03 inches Mercury, with remarks of lightning northeast of the airport, and that rain began at 1016 and ended at 1020. A review of weather radar information indicated a line of rain showers northwest of the airport along with scattered areas of precipitation around the area of the Hot Springs Airport at the time of the accident. AIRPORT INFORMATION Hot Springs/Memorial Airport was a non-towered airport with an elevation of 540 feet msl. Runway 5 is a 6,595-foot-long and 150-foot-wide asphalt runway, with no displaced threshold. The runway is equipped with high intensity runway edge lights, and a 1,400-foot medium intensity approach lighting system, with runway alignment indicator lights. The pilot also had the capability of turning on the runway lights via the push-to-talk mechanism on the airplane's radio. The airport elevation is 540 feet msl. A review of the published approach procedure revealed the inbound course for the ILS RWY 5 approach was 050 degrees magnetic, and the missed approach point was 715 feet msl. The crossing altitude at HOSSY, the final approach fix, was 2,300 feet msl. The distance between HOSSY and the missed approach point, which was located a half nautical mile from the end of the runway, was 5.1 nautical miles. The published missed approach ## Aircraft - Registration: [N4123R](https://openairdocs.org/deregistered/N4123R-2004-10-01), registration cancelled 2004-10-01, S/N 32-40441, built 1968 (OpenAirDocs) - Reported make and model: Piper PA-32-300 - Registry model: [Piper PA-32-300](https://openairdocs.org/model/piper-pa-32-300) (registry code 7103212) (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: 32-40441 - Airframe hours: 4339 - Engines: Lycoming IO-540 250 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Registered owner: Larry D. Sanders - Airworthiness certificate: Standard, Normal - Last inspection: Annual, January 2, 2004 - Departed: 6I2, Springfield, KY - Destination: HOT, Hot Springs, AR - Flight plan: IFR - Airport: HOT, Hot Springs/Memorial Field, runway 5, 6,595 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 54; injuries: fatal; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, valid medical--w/ waivers/lim; last flight review October 18, 2002; seat: left; toxicology performed; flight hours: 1,765 total ## Weather - Conditions: Visual (VMC), Day - Wind: 220° at 4 knots - Visibility: 7 statute miles - Lowest ceiling: 1,300 ft broken - Temperature: 77 °F, dew point 73 °F - Altimeter: 30.03 inHg - Observed at: HOT, 5 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 20040702014069A](https://openairdocs.org/incident/20040702014069A), Jul 2, 2004: Piper PA32300, Hot Springs, AR, Destroyed, 1 fatal. (-23) On July 2, 2004, at 1043 central daylight time, a Piper PA-32-300 single-engine airplane, N4123R, was substantially damaged while maneuvering near Hot… 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.