# NTSB IAD03FA032: Cessna 421, N421TJ, Ferguson, KY, February 17, 2003 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: February 16, 2003, 20:02 local (Feb 17, 2003, 01:02 UTC) - Place: Ferguson, KY - Coordinates: 37.073055, -84.584167 - Nearby events: https://openairdocs.org/map.md?lat=37.0731&lon=-84.5842&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 3 fatal, 4 serious - Status: Completed, report October 28, 2004 - Report: Approved by Office Director - Parties: Griffith Aviation, Inc., Cessna Aircraft Company, FAA/FSDO, Teledyne Continental Motors - NTSB case key (mKey): 56502 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=IAD03FA032 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/56502/pdf - Page: https://openairdocs.org/ntsb/IAD03FA032 ## Probable cause The pilot's failure to follow the instrument approach procedure, which resulted in an early descent into trees and terrain. Factors included the low ceiling and the night lighting conditions. ## Analysis The airplane joined the inbound course for the GPS instrument approach between the intermediate approach fix and the final approach fix, and maintained an altitude about 200 feet below the sector minimum. The last radar return revealed the airplane to be about 3/4 nautical miles beyond the final approach fix, approximately 1,000 feet left of course centerline. An initial tree strike was found about 1 nautical mile before the missed approach point, about 700 feet left of course centerline, at an elevation about 480 feet below the minimum decent altitude. Witnesses reported seeing the airplane flying at a "very low altitude" just prior to its impact with hilly terrain, and also described the sound of the airplane's engines as "really loud" and "a constant roar." Night instrument meteorological conditions prevailed at the time of the accident. There was no evidence of mechanical malfunction. ## Factual narrative HISTORY OF FLIGHT On February 16, 2003, at 2002 eastern standard time, a Cessna 421, N421TJ was destroyed when it impacted trees and terrain in Ferguson, Kentucky, while on an instrument approach to Somerset-Pulaski County Airport - J.T. Wilson Field (SME), Somerset, Kentucky. The certificated commercial pilot, a pilot-rated passenger, and one other passenger were fatally injured. Four additional passengers were seriously injured. Night instrument meteorological conditions prevailed for the flight, which originated at Griffith-Merrillville Airport (05C), Griffith, Indiana. An instrument flight rules (IFR) flight plan was filed for the corporate flight, conducted under 14 CFR Part 91. A review of the air traffic control transcript revealed that at 1944, the pilot contacted the London Sector Radar position of Indianapolis Center, while descending out of 12,000 feet, and requested the GPS RWY 22 approach at Somerset. The controller responded that he had the request, and that the altimeter setting at London was 29.86. The controller then asked the pilot if he had the current weather at Somerset, and the pilot responded that he did. The controller then confirmed with the pilot, which fix he was proceeding to, and reconfirmed that the pilot wanted the GPS RWY 22 approach. At 1945, the controller cleared the airplane down to 5,000 feet, and advised the pilot that he'd have the approach clearance in a couple of minutes. At 1948, the controller asked the pilot if he had the current NOTAMS (Notices to Airmen). The pilot responded that he did, and that the pilot-controlled runway lighting was out. The pilot then asked the controller for any additional items, and the controller responded that the airport beacon was out, as well as the pilot controlled lighting. At 1949, the pilot responded, "yes we're aware of all of the (unintelligible) thank you." The controller then cleared the pilot to maintain 3,600 feet until established on the approach, cleared him for the approach, and requested that the pilot report the field in sight, which the pilot acknowledged. About 30 seconds later, the pilot asked for a clearance outbound from the airport, stating that he would be on the ground for no longer than 10 minutes. At 1957:06, the controller requested that the pilot report "established on the approach," and 10 seconds later, the pilot stated "actually we're established right now." At 1957:24, the controller gave the pilot his outbound clearance, which the pilot read back. At 1958:22, the controller stated, "change to advisory frequency approved," to which the pilot responded, "(unintelligible), thank you." There were no further communications from the airplane. The final three fixes for the instrument approach, the GPS RWY 22 approach, from northeast to southwest, were AZLEC, HITFO, and BABME. The inbound course from AZLEC, through HITFO, to BABME, was 241 degrees magnetic. The minimum descent altitude between AZLEC and HITFO was 2,800 feet above mean sea level (msl), and between HITFO and BABME, was 1,700 feet msl. The distance between AZLEC and HITFO was 5.0 nautical miles, and between HITFO and BABME was 5.3 nautical miles. Runway 22 was 0.5 nautical miles beyond BABME. Along the approach path, traveling northeast to southwest, there was a hill that rose to an elevation of about 1,240 feet, then descended down toward the airport. The top of the hill was about 1.5 nautical miles from the airport, and there were saddlebacks on each side, leading to other hills. Radar data revealed that the airplane joined the GPS RWY 22 inbound course between AZLEC and HITFO, at 2,600 feet. The last radar return, received at 2002:04, indicated that the airplane was 3/4 of a nautical mile beyond HITFO, about 1,000 feet left of course centerline, at 2,500 feet. Two witnesses, who lived northeast of the accident site, stated that they saw the airplane through the back window of their house. One witness stated that the lights of the airplane were approximately the same level as the house. The sound of the airplane was "really loud," and the house shook as the airplane approached, then passed low overhead. The witness then ran out the front door of the house, and watched the airplane pass over the crest of the hill and disappear from view. Immediately thereafter, there was a loud explosion and a fireball. When asked about the sounds of the engines, the witness stated that they were "smooth, continuous, and a constant roar." The second witness stated that she was sitting on her couch and observed what appeared to be two headlights. She repeated several times that the airplane was "really low" as it passed over the house. The airplane then disappeared from view, and exploded. The witness also noted, that from her vantage point, she could only have seen the airplane if it had been close to the ground. When asked about the sound of the engines, she stated that they were "really loud. It sounded like a normal plane, just really loud." A third witness, driving on a nearby road, reported that she saw the airplane traveling "unusually low" and "very fast" in a westerly direction. The airplane crossed the road in front of her, and its lights were "bright and flashing." The witness remarked to her daughter that the airplane "would not make the airport," and after it disappeared from view, "an orange glow appeared in the trees." When asked to describe the airplane's altitude above the ground, the witness stated that she could see it by looking "straight out" of her windshield. The Pulaski County Sheriff's Department received a 911 emergency call at 2003. At 2131:16, after the accident had occurred, a Louisville Flight Service Station specialist confirmed, during a recorded review of Somerset NOTAMs, that, "airport beacon out of service," and shortly after that, he stated, "somerset four and two two pilot controlled lighting out of service medium intensity continuous." According to excerpts from the surviving adult passenger's interrogatory, as provided by her attorney, she was asleep at the time of the accident. She remembered hearing a loud noise, then the sensations of being thrown violently and finding herself outside the airplane, in pain. The accident occurred during the hours of darkness, in the vicinity of 37 degrees, 04.37 minutes north latitude, 84 degrees, 35.08 minutes west longitude. PERSONNEL INFORMATION The pilot held a commercial pilot certificate with ratings for airplane single engine land, multi-engine land, and instrument airplane. He also held a flight instructor certificate with ratings for airplane single engine land, multi-engine land, and instrument airplane. His most recent second class medical certificate on file with the Federal Aviation Administration (FAA) was issued on November 30, 2001. However, on an insurance form provided by the pilot's employer, dated December 18, 2002, the pilot reported that his most recent second class medical certificate was issued on November 17, 2002. The pilot's logbook was not located. On the insurance form obtained from the pilot's employer, the pilot listed 11,732 total hours of flight experience, 518 hours of which were in the Cessna 421. Within the previous 90 days of that date, the pilot recorded 280 hours of flight experience, 46 hours of which were in the Cessna 421. The surviving adult passenger stated, in her interrogatory, that the pilot was flying the airplane when the accident occurred. The pilot-rated passenger's employer reported that he was not acting as a crewmember, and was only "along for the ride." The pilot-rated passenger held a private pilot certificate with ratings for airplane single-engine land, multi-engine land, and instrument airplane. His most recent FAA first-class medical certificate was issued on April 30, 2002. Examination of his logbook revealed that he had accrued 249 total hours ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight collision with terrain/water, approach - faf/outer marker to threshold (ifr) - ifr procedure - not followed, pilot in command (cause) - minimum descent altitude - not maintained, pilot in command (cause) - weather condition - low ceiling (contributing factor) - terrain condition - mountainous/hilly - light condition - night (contributing factor) - object - tree(s) ## Aircraft - Registration: [N421TJ](https://openairdocs.org/deregistered/N421TJ-2010-11-09), registration cancelled 2010-11-09, S/N 421-0051, built 1968 (OpenAirDocs) - Reported make and model: Cessna 421 - Registry model: [Cessna 421](https://openairdocs.org/model/cessna-421) (registry code 2076010) (OpenAirDocs) - Registry engine: [Continental GTSIO-520-C](https://openairdocs.org/engine/continental-gtsio-520-c) (registry code 17035, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 421-0051 - Airframe hours: 4129 - Engines: Continental GTSIO-520-C 375 horsepower reciprocating; Continental GTSIO-520-C 375 horsepower reciprocating - Damage: Destroyed - Flight: Executive/Corporate, Part 91 - Operator: Shalabh N. Agarwal - Registered owner: Great Northern Aircraft, Inc - Airworthiness certificate: Standard, Normal - Last inspection: Annual, February 1, 2002, 210 hours before - Departed: 05C, Griffith-Merril, IN - Destination: SME, Somerset, KY - Flight plan: IFR - Airport: SME, Somerset-Pulaski County, runway 22, 5,600 × 100 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 32; injuries: fatal; flight instructor, commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, valid medical--no waivers/lim.; last flight review March 29, 2002; seat: left; toxicology performed; flight hours: 11,732 total, 518 in this make and model ## Weather - Conditions: Instrument (IMC), Night - Wind: calm - Visibility: 7 statute miles - Lowest ceiling: 700 ft overcast - Temperature: 36 °F, dew point 34 °F - Altimeter: 29.87 inHg - Observed at: SME, 2 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 20030216001879A](https://openairdocs.org/incident/20030216001879A), Feb 16, 2003: Cessna 421, Ferguson, KY, Substantial damage, 3 fatal. (-23) On 2-16-03, at approximately 2000 local time, N421TJ crashed into a wooded ridge while conducting a GPS rwy 22 instrument approach to somerset, KY… 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.