FTW97FA299

During arrival, the pilot contacted 'Springs Approach' & was provided a vector to join the localizer for an ILS DME Runway 17L Approach. He was advised that runway RVR was 4,000 feet (about 3/4 mile visibility), but was not provided other current weather or airport information. In preparation for the ILS, he was instructed to descend & maintain 9,000 feet, then to reduce his speed 20 knots as he was closing on an MD-80, 3 miles ahead. About 2 minutes later (without issuing a clearance for the ILS approach), the pilot was transferred to tower frequency. Soon thereafter, the tower controller advised the pilot that radar showed he had deviated from the localizer course & inquired about his intentions. The pilot said he was going to make a missed approach. To ensure separation from other traffic, the controller told the pilot to turn left to 090 degrees, climb, & maintain 9,000 feet. Seconds later, the controller noted the pilot was below minimum vectoring altitude & told him to start his climb. The pilot acknowledged. About a minute later, the controller asked the pilot for his heading; the pilot replied '...190 heading to 090.' The controller told him to 'Start a left turn now. You're headed towards the mountains.' The pilot acknowledged, but moments later, radio & radar contact with the airplane were lost. The airplane impacted a small hill about 5 miles north of the airport on a magnetic heading of 080 degrees. Although the pilot was certificated to fly multiengine airplanes in instrument meteorological conditions, FAA records revealed he had once failed the instrument practical test; had made an inadvertent wheels up landing in the airplane; had failed an instrument procedures refresher course; and had once failed the multiengine practical test. These events occurred 18, 10, 7, and 6 months before the accident, respectively.

History of flight

On August 5, 1997, at 1058 mountain daylight time, a Beech 58P, N258W, was destroyed when it collided with terrain during a missed approach at Colorado Springs, Colorado. The private pilot and passenger were fatally injured. Instrument meteorological conditions prevailed, and an IFR flight plan had been filed for the business flight being conducted under Title 14 CFR Part 91. The flight originated at Broomfield, Colorado, at 1027.

At 0836, the pilot contacted the Denver Automated Flight Service Station (AFSS) and requested "an IFR briefing, BJC (Broomfield-Jefferson County Airport) to Colorado Springs." The pilot was provided a standard briefing. He then filed an IFR flight plan, indicating his airplane was equipped with RNAV (area navigation) and a transponder with altitude encoding capability. His proposed takeoff time was 1000, and he indicated that he planned to fly at 200 KTAS (knots true airspeed) at 10,000 feet to Colorado Springs via V-81. He estimated his time en route to be 30 minutes, and that he had 5 hours of fuel on board. The pilot also filed an IFR flight plan for his return trip to Broomfield. The conversation terminated at 0844.

At 1017, the pilot contacted BJC ground control and was issued his IFR clearance to Colorado Springs (COS). The pilot failed to obtain a taxi clearance and ground control advised him of the mistake when they observed him taxiing on taxiway A. He was subsequently cleared to continue taxiing to runway 29R. At 1027, the pilot was cleared for takeoff. At 1030, the pilot contacted Denver departure control and was given radar vectors to join V-81. At 1047, the pilot contacted COS approach control and was vectored to join the runway 17L localizer and was advised to expect the ILS DME (instrument landing system/distance measuring equipment) approach to runway 17L. He was also advised that the runway visual range (RVR) was 4,000 feet (about 3/4-mile visibility). In his written statement, the controller said the airplane "flew what appeared to be a normal ILS."

At 1054, the pilot contacted COS tower. At 1056:27, after observing the target moving away from the localizer in a southeast direction, the local controller asked the pilot, "Are you showing yourself on the localizer? I show you east of it, proceeding away." The pilot concurred and when asked what his intentions were, he replied: "Do a missed approach." The pilot was instructed to turn left to a heading of 090 degrees and climb and maintain 9,000 feet. At 1056:43, after noting the airplane was at an encoded altitude of 8,000, the local controller instructed the pilot to "start your climb to niner thousand (feet). You're well below the minimum vectoring altitude in that area." The pilot acknowledged.

At 1057:08, the local controller instructed the pilot of N58LC, a Cessna 501 Citation jet that was following N258W, to "climb and maintain one zero thousand. Start the climb now. Traffic twelve o'clock, two miles. I can't tell what he's going to do...That Baron's at seven thousand, eight hundred, needs to be climbing...Just fly the localizer for right now. I can't exactly tell where that Baron's going." The pilot of N58LC replied, "Yeah, we have him off and on the TCAS (terminal collision avoidance system). He looks like he's going to pass underneath us here." The local controller then advised the approach controller, "I'm climbing Lima Charlie to ten. That Baron's making a reverse course. I don't know what he's doing...He's supposed to be going on a ninety heading, but I don't know...I'm trying to do something with him."

At 1057:46, the local controller asked the pilot of N258W for his heading and he replied, "...one nine zero heading to zero nine zero." The controller then told the pilot, "Start a left turn now. You're headed towards the mountains." The pilot acknowledged. This was the last known contact with N258W. At 1058:50, after noting that the data block for N258W had disappeared from the radarscope, the local controller told the approach controller: "I think that Baron just augured in up there. I can't talk to him." Search and rescue procedures were then initiated (see transcripts of radio communications, attached).

The captain of N58LC was asked to submit a written statement as to his observations. The captain wrote, "Just prior to glideslope interception, I noticed on our TCAS (Terminal Collision and Avoidance System) that the Baron was west of the localizer, as was pointed out by the controller. The pilot of the Baron responded and, as I recall, indicated that he would correct. The controller has stated as a reminder that 'there are mountains to the west.'

"Our TCAS indicated that the Baron was correcting, but to such an extent that he was proceeding more east than south. Further, I observed on the TCAS that he was climbing and separation from him was becoming an issue. I elected to maintain altitude rather than continue with the descent on the glideslope just as the controller instructed me to maintain an altitude that I think was 10,000 feet. On the TCAS we observed the Baron pass under and behind to the east. I abandoned the approach and went around for a successful ILS and landing."

The captain said that during this entire time, he was in instrument meteorological conditions and never had a visual sighting of N258W. He believed there was "stress" in the voice of the pilot of N258W that sounded like "controlled panic."

A City of Colorado Springs employee told investigators he was sitting in his truck about 3 to 4 miles north of the accident site when he heard a low flying twin engine airplane. Although he did not see the airplane or hear the sounds of impact, he did hear the engines being "powered up and down." He described the weather conditions as being "foggy."

The accident occurred during the hours of daylight at a location of 30 degrees, 54 minutes north latitude and 104 degrees, 41 minutes west longitude.

Personnel information

The pilot's logbook was made available for examination. He began taking flying lessons on April 21, 1994, and soloed on May 22, 1994, in a Cessna 172. He received his private pilot license on August 17, 1994, flying a Cessna T206.

On December 17, 1994, the pilot began taking instrument flight instruction. He took the instrument rating practical test on March 30, 1995, and failed. The Notice of Disapproval cited deficient instrument approach procedures. He passed the instrument practical test on April 15, 1996, flying a Cessna T206.

The pilot first flew the Beech 58P on July 10, 1996. He purchased N258W and began taking multiengine flight instruction on August 22, 1996. On October 15, the pilot inadvertently landed wheels up at Colorado Springs. While the airplane was being repaired, the pilot flew single engine airplanes.

The pilot's insurance company required that he attend an approved Beech 58 training facility of his choice. Between January 20 and 24, 1997, the pilot attended a Beech 58 initial training course at SIMCOM in Prescott, Arizona. He received 15.5 hours of ground school, 12.8 hours of simulator training, and 10.0 hours of briefings/debriefings. According to SIMCOM's training records, simulator sessions 1, 2, 3, 7, and 8 were satisfactory. Sessions 4, 5, 6, 9, and 10 contained unsatisfactory grades. The pilot was marked deficient in the following areas: balked landing; departure, en route, and arrival procedures; ILS approach; VOR approach; NDB approach; circling approach; engine failure in flight; engine inoperative go-around. The instructor wrote, "VFR only. Could not do IFR very well --- in fact, terrible!" His graduation certificate was marked, "VFR only."

On February 14, 1997, the pilot began an accelerated multiengine flight course in the Beech 95 at Red Bird Airport, Dallas, Texas. He failed the practical test on February 17, then passed it on February 28. He began