# NTSB FTW97FA044: Piper PA-28R-200, N1394T, Fort Worth, TX, November 20, 1996 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: November 20, 1996, 05:31 local (11:31 UTC) - Place: Fort Worth, TX - Coordinates: 32.820075, -97.360664 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=32.8201&lon=-97.3607&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report July 17, 2001 - Report: Approved by Office Director - NTSB case key (mKey): 20014 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=FTW97FA044 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/20014/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=20014 - Page: https://openairdocs.org/ntsb/FTW97FA044 ## Probable cause the pilots' continued descent of the aircraft below decision height. Factors contributing to the accident were the fog, the dark night illumination, one of the pilot's impairment due to use of marihuana, and both pilots' fatigue. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight collision with object, approach - faf/outer marker to threshold (ifr) - object - wire,transmission - light condition - dark night (contributing factor) - weather condition - below approach/landing minimums - weather condition - fog (contributing factor) - decision height - continued below, flightcrew (cause) - impairment(drugs), pilot in command (contributing factor) - fatigue (conditions conducive to pilot fatigue), flightcrew (contributing factor) ## Analysis During dark night instrument meteorological flight conditions, the pilots (a CFI and a private pilot) of the single-engine airplane executed a missed approach after reaching decision height during an ILS approach with the airport below landing weather minimums (visibility 1/8 of a mile in fog). During a second ILS approach attempt, the airplane collided with power lines approximately 3/4 of a mile short of the runway threshold. The airplane, configured with the landing gear extended and the flaps extended 10 degrees, impacted the ground and a highway guardrail approximately 300 feet south of the power lines. No distress calls were received from the airplane. No discrepancies were found with the airplane or engine that could have prevented normal operation. Toxicological tests for the private pilot were positive for marihuana. The CFI had worked all day preceding the flight, and the private pilot had taken a 'nap' in the afternoon preceding the flight. ATC voice recordings revealed that both pilots were acknowledging radio transmissions prior to and during the approach, and it could not be determined which pilot was at the controls. ## Factual narrative HISTORY OF FLIGHT On November 20, 1996, at 0531 central standard time, a Piper PA-28R-200 single engine airplane, N1394T, registered to a private individual, and operated by Delta Aeronautics of Fort Worth, Texas, was destroyed following impact with power lines and the ground during an instrument landing system (ILS) approach to runway 16L at the Meacham Field Airport (FTW), near Fort Worth, Texas. The instrument rated commercial pilot, who also was a certified flight instructor (CFI), and the instrument rated private pilot were both fatally injured. Dark night instrument meteorological conditions prevailed for the 14 Code of Federal Regulations Part 91 personal flight, for which an instrument flight plan was filed. The cross-country flight originated from Abilene, Texas, approximately 1 hour and 30 minutes before the accident. According to several friends of the pilots, who were interviewed after the accident, the general intent of the flight was for the pilots to "take advantage" of the prevailing low ceilings in the area to log some "actual" instrument flight time. The flight was not "instructional." The private pilot had rented the airplane to accumulate actual instrument flight time. According to Air Traffic Control (ATC) records, the airplane departed Meacham Field about 0200, and had an uneventful flight to Abilene, Texas, where it made several practice approaches and a full stop landing. Subsequently, the pilots planned the return flight to Meacham and departed Abilene about 0345. At 0511, one of the pilots on board N1394T called a missed approach to Meacham Airport, and then requested to try the approach once more. At 0527, N1394T reported inbound on the ILS, and the controller cleared the aircraft to land and to report on the runway or missed approach. At 0531, Meacham Tower advised DFW TRACON that electrical power was lost in the tower facility and that N1394T would be transferred back to TRACON control. Meacham Tower then attempted to contact N1394T with no response. At 0532, DFW TRACON informed Meacham Tower that they had no primary or secondary radar indication for N1394T. At 0533, Meacham Tower dispatched an airport security vehicle to search the airport for N1394T. At 0537, the Tarrant County Sheriff's Department called the tower to advise them of an aircraft accident just north of the airport. Local emergency response personnel identified the aircraft as N1394T. The emergency response personnel also reported downed power lines about 300 feet north of the wreckage. Throughout the entire aforementioned sequence, no distress calls were received from the airplane. PERSONNEL INFORMATION Note: The private pilot occupied the left front seat of the airplane, and the commercial pilot (CFI) occupied the right front seat. It could not be determined which pilot was at the controls at the time of the accident. Review of recorded radio transmissions between the aircraft and ATC personnel prior to the accident revealed that both pilots made ATC acknowledgments prior to and during the final approach. According to entries in the CFI's pilot logbook, he had accumulated a total of 328.4 flight hours, 61 hours of simulated instrument time, and 5.0 hours of actual instrument time. He had 316 total hours in single engine airplanes and had accumulated 10 hours as a certified flight instructor. His last biennial flight review was completed in August 21, 1996, in the same type of airplane as the accident airplane. A friend of the CFI reported that she had dinner with him late on the night prior to the accident. She stated that the CFI had worked all day and seemed tired. She also stated that he got a weather brief by telephone and told her that "the weather was going to be bad" and he was not sure if he wanted to go on the flight. It was her impression that he went on the flight to accommodate a request by the other pilot to practice in actual instrument meteorological weather conditions. The CFI left her apartment at about 0030, November 20th, to meet the other pilot at the airport. The private pilot had accumulated a total of 325 flight hours, all in single-engine airplanes. He had accrued a total of 28 hours of simulated instrument time and 7 hours of actual instrument time. This pilot's roommate stated that the pilot took a "nap" in the afternoon on November 19th. After the nap, the pilot showered and ate dinner about 2200. He stated that the pilot told him that he was going to fly late that night because the ceilings were forecast to be "low" and he wanted to practice approaches in instrument meteorological conditions. He stated that the pilot seemed very relaxed and happy prior to leaving his apartment at about 2330, and told him that he would return home about 0530, the next morning after the flight. AIRCRAFT INFORMATION The 1972 Piper PA-28R-200, serial number 28R-7238276, had accumulated a total of 6,602 hours. The engine, a Lycoming IO-360-C1C, serial number L-9314-51A, had accumulated 570 hours since it was last overhauled on December 18, 1993. Review of entries in the airplane's maintenance records revealed no evidence of uncorrected discrepancies with the airplane's radios, navigational equipment, encoding transponder, or altimeter. Current calibration documentation for the VOR receiver and altimeter was present in the records. METEOROLOGICAL INFORMATION At 0511, Meacham Airport was reporting wind from 180 degrees at 8 knots, visibility of one-eighth of a mile in fog, vertical visibility zero, temperature and dew point at sixteen degrees centigrade, with an altimeter setting of 29.68 inches of mercury. At 0521, approach control informed the pilots that the runway visual range (RVR) for runway 16L was reported at 1,800 feet, variable to 2,200 feet. According to data obtained from the U.S. Naval Observatory, the sunrise occurred at 0702, on the morning of the accident. AIDS TO NAVIGATION Following the aircraft accident, the ILS serving runway 16L at Meacham was evaluated by FAA facility technicians. All performance parameters were found to be in tolerance and no obstructions were found in the ILS critical area. Additionally, FAA Flight Inspections dispatched a facility check aircraft to functionally check the localizer, glide slope, middle marker, and outer marker of the approach. All ground and flight approach performance parameters were found in tolerance, and the system was re-certified for continued use. COMMUNICATIONS The transcripts of all the recorded communications between the pilots and FAA ATC personnel are included in the public docket as supporting documentation to this report. AERODRROME INFORMATION The published landing minimums for the straight-in ILS approach to runway 16L are 200 foot ceiling with a visibility of one-half mile. The airport elevation is 710 feet MSL. The decision height altitude for the approach is established at 910 feet MSL (RVR 2,400 feet). WRECKAGE AND IMPACT INFORMATION The wreckage was located adjacent to a southbound entrance lane to Highway 820 West, Forth Worth, Texas, about 3/4 miles short of the threshold of runway 16L. Evidence at the site showed that the initial impact point was a high-tension power line running perpendicular to the flight path of the airplane. The airplane pulled the power lines for about 300 feet prior to coming to rest against a guardrail adjacent to the highway. The airplane sustained limited fire damage to the top of the right wing and the right side of the forward fuselage. The fire appeared to have originated due to arcing from the electrical power cable that was severed by the airplane during the accident sequence. A portion of the left wing tip was found lodged in a support pole for an overhead road sign, and the left wing was found severed from the fuselage. The right wing remained attached to the airframe, and fuel was found in the right wing fu ## Aircraft - Registration: [N1394T](https://openairdocs.org/deregistered/N1394T-1998-06-10), registration cancelled 1998-06-10, S/N 28R7235276 (OpenAirDocs) - Reported make and model: Piper PA-28R-200 - Registry model: [Piper PA-28R-200](https://openairdocs.org/model/piper-pa-28r-200) (registry code 7102811) (OpenAirDocs) - Category: Airplane - Serial number: 28R-7235276 - Airframe hours: 3355 - Engines: Lycoming IO-360-C1C 200 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Operator: Delta Aeronautics - Registered owner: K. M. Miloud - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, July 22, 1996, 83 hours before - Departed: ABI, ABILENE, TX - Destination: FTW - Flight plan: IFR - Airport: FTW, Fort Worth Meacham, runway 16L, 7,501 × 150 ft, concrete ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 31; flight instructor, commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, valid medical--no waivers/lim.; seat: right; toxicology performed; flight hours: 328 total, 38 in this make and model, 214 as pilot in command, 14 in the last 90 days, 11 in the last 30 days ## Weather - Conditions: Instrument (IMC), Night/dark - Wind: 180° at 8 knots - Visibility: 0.12 statute miles - Temperature: 61 °F, dew point 61 °F - Altimeter: 29.00 inHg - Observed at: FTW, 1 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 19961120036099A](https://openairdocs.org/incident/19961120036099A), Nov 20, 1996: Piper PA28R200, Fort Worth, TX, Destroyed, 2 fatal. Descended below ILS glide slope and da. Struck high voltage powerline short of runway. Impacted terrain. (-23) on November 20, 1996, at approximately 0531 CST,… ## Other investigations on N1394T (2) 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. - [NTSB FTW95LA265](https://openairdocs.org/ntsb/FTW95LA265), Jun 29, 1995: Piper PA-28R-200 (N1394T), Denton, TX, substantial damage. Probable cause: INADEQUATE SUPERVISION BY THE FLIGHT INSTRUCTOR (CFI), AND THE RESULTANT LOSS OF DIRECTIONAL CONTROL. A FACTOR RELATING TO THE ACCIDENT WAS: THE LACK OF BRAKE CONTROLS FOR THE RIGHT SEAT OCCUPANT. - [NTSB CHI78FEP20](https://openairdocs.org/ntsb/CHI78FEP20), Feb 16, 1978: Piper PA-28R (N1394T), Pewaukee, WI, substantial damage ## Docket (20 files) The files NTSB released with the investigation on June 11, 2001, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=20014. 6.7 MB in all. - Supplement A - Wreckage Documentation (item 1, .PDF, 249 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40141485&FileExtension=.PDF&FileName=Supplement%20A%20-%20Wreckage%20Documentation-Master.PDF - Supplement B - Cockpit Documentation (item 2, .PDF, 368 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40141486&FileExtension=.PDF&FileName=Supplement%20B%20-%20Cockpit%20Documentation-Master.PDF - Supplement E - Second Pilot Information (item 3, .PDF, 124 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478311&FileExtension=.PDF&FileName=Supplement%20E%20-%20Second%20Pilot%20Information-Master.PDF - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 4, .PDF, 365 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478312&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Maps and Charts (item 5, .PDF, 218 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40141488&FileExtension=.PDF&FileName=Maps%20and%20Charts-Master.PDF - Radar Data and Plots (item 6, .PDF, 308 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40141489&FileExtension=.PDF&FileName=Radar%20Data%20and%20Plots-Master.PDF - Weather Reports (item 7, .PDF, 413 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40141490&FileExtension=.PDF&FileName=Weather%20Reports-Master.PDF - Witness Statements (item 8, .PDF, 456 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478313&FileExtension=.PDF&FileName=Witness%20Statements-Master.PDF - Airport Facility Tests and FAA Flight Check (item 9, .PDF, 173 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478314&FileExtension=.PDF&FileName=Airport%20Facility%20Tests%20and%20FAA%20Flight%20Check-Master.PDF - Airplane Records (item 10, .PDF, 209 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478315&FileExtension=.PDF&FileName=Airplane%20Records-Master.PDF - Excerpts from Maintenance Records (item 11, .PDF, 2.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478316&FileExtension=.PDF&FileName=Excerpts%20from%20Maintenance%20Records-Master.PDF - FAA Report of Aircraft Accident (item 12, .PDF, 241 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478317&FileExtension=.PDF&FileName=FAA%20Report%20of%20Aircraft%20Accident-Master.PDF - ATC Communication Transcripts (item 13, .PDF, 585 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478318&FileExtension=.PDF&FileName=ATC%20Communication%20Transcripts-Master.PDF - Report from Party (Piper) (item 14, .PDF, 297 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478319&FileExtension=.PDF&FileName=Report%20from%20Party%20(Piper)-Master.PDF - Report from Party (Lycoming) (item 15, .PDF, 272 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40141498&FileExtension=.PDF&FileName=Report%20from%20Party%20(Lycoming)-Master.PDF - Toxicology Reports (item 16, .PDF, 86 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478320&FileExtension=.PDF&FileName=Toxicology%20Reports-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 17, .PDF, 139 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478321&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Photo 01: Resting place of wreckage against guardrail (item 18, .PDF, 138 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40141501&FileExtension=.PDF&FileName=Photo%2001%3A%20Resting%20place%20of%20wreckage%20against%20guardrail-Master.PDF - Photo 02: Forground of accident site. Arrow shows broken high-tension power line in the background (item 19, .PDF, 67 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40141502&FileExtension=.PDF&FileName=Photo%2002%3A%20Forground%20of%20accident%20site.%20Arrow%20shows%20broken%20high-tension%20power%20line%20in%20the%20background-Master.PDF - Photo 03: Power lines in relationship to the approach path (item 20, .PDF, 48 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40141503&FileExtension=.PDF&FileName=Photo%2003%3A%20Power%20lines%20in%20relationship%20to%20the%20approach%20path-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.