# NTSB MIA03FA025: Raytheon 58, N241JG, Fort Myers, FL, December 6, 2002 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: December 6, 2002, 15:41 local (20:41 UTC) - Place: Fort Myers, FL - Coordinates: 26.55611, -81.825836 - Nearby events: https://openairdocs.org/map.md?lat=26.5561&lon=-81.8258&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report December 20, 2005 - Report: Approved by Office Director - Parties: Raytheon Aircraft Company, Federal Aviation Administration - NTSB case key (mKey): 56179 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=MIA03FA025 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/56179/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=56179 - Page: https://openairdocs.org/ntsb/MIA03FA025 ## Probable cause the pilot's spatial disorientation during instrument meteorological conditions, which resulted in his failure to maintain aircraft control. Contributing factors included the pilot's distraction to the low fuel status and the low cloud conditions. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, missed approach (ifr) - spatial disorientation, pilot in command (cause) - aircraft control - not maintained, pilot in command (cause) - diverted attention, pilot in command (contributing factor) - weather condition - low ceiling (contributing factor) - fluid,fuel - low level (contributing factor) - In flight collision with object, descent - uncontrolled - object - residence ## Analysis The twin-engine airplane impacted a residential area after a loss of aircraft control during a missed approach in instrument meteorological conditions (IMC). The flight departed Alabama and made its way to Florida uneventfully where it made a non-precision approach at Naples with 500-foot ceilings and a visibility of two statute miles in mist. The pilot executed a missed approach after descending to the minimum descent altitude of 500 feet. After conducting the missed approach, the pilot requested to divert to Fort Meyers where they had a precision approach. Fort Meyers was reporting 300-foot ceilings and 3 statute miles of visibility at the time of the accident. The pilot conducted three approaches to Fort Meyers. The pilot was unable to obtain/maintain the final approach course and conducted a teardrop course reversal on the first two approaches to Fort Meyers before reaching the final approach fix. The pilot indicated he was experiencing "very big difficulties out here" and mentioned instrument problems, but was going to try to fly the next approach manually. The controller asked the pilot about his fuel status, to which the pilot reported it was in the yellow range. When the controller asked how much time that was, the pilot responded it was "practically nil." The controller then set the pilot up for another precision approach attempt and eventually converted it to a surveillance approach when it became apparent the pilot was having trouble obtaining and maintaining the final approach course. The airplane's radar track was over the final approach course during the final approach attempt; however, the airplane's minimum altitude was 300 feet over the approach end of the runway. The airplane overflew the runway and began a climb to 600 feet. The airplane then descended to 300 feet again as it began a left turn. The controller instructed the pilot to climb and maintain 1,500 feet and provided two vectors, neither of which the aircraft followed. The maximum altitude the airplane attained during the last missed approach was 1,200 feet before it began its final, uncontrolled descent. The last communication obtained from the pilot was during the initiation of the missed approach. The airplane departed controlled flight and impacted a garage and terrain. Wreckage was strewn 350 feet. The airplane was observed descending out of the clouds heading south at a low altitude, with the landing gear retracted, full power and a high rate of speed. Additional witnesses heard engine noise emanating from the airplane prior to both engines going silent. The propellers separated from the engines and the engines separated from the airplane. The right engine proceeded through another house before coming to rest in its attic. Post-accident examination of the engines' throttle bodies and fuel metering units revealed that the right fuel metering unit fuel flows were in excess of those specified by the manufacturer. The left fuel metering unit was substantially damaged and could not be flow tested. No additional pre-impact anomalies were noted with the airframe, its engines, or propellers that would have precluded their normal operation. The damage sustained by the cockpit was enough to preclude functional testing of any of the navigation equipment and instruments. The accident flight lasted 3 hours and 21 minutes and the pilot's flight plan indicated he had about 4 hours and 15 minutes of fuel on board. The left fuel selector was found in the ON position and the right fuel selector was found in the OFF position. ## Factual narrative HISTORY OF FLIGHT On December 6, 2002, about 1541 eastern standard time, a Raytheon 58 twin-engine airplane, N241JG, was destroyed when it departed controlled flight and impacted private homes in a residential area near Fort Myers, Florida. The airplane was registered to KC Services Inc., and operated by the pilot. Instrument meteorological conditions prevailed at the time and an instrument flight rules (IFR) flight plan was filed for the 14 CFR Part 91 personal cross-country flight. There were no injuries to anyone on the ground. The instrument-rated private pilot and one passenger were fatally injured. The flight departed from Centerville, Alabama, about 1220 (1120 central standard time). The flight had originally departed from Rosecrans Memorial Airport (KSTJ), St. Joseph, Missouri, at 0903 (0803 central standard time), en route to Naples, Florida, with an intermediate fuel stop at the Centerville Airport (0A8), Centerville, Alabama. While in Centerville, the pilot contacted the Anniston Flight Service Station (FSS) and filed the IFR flight plan to Naples and obtained an abbreviated weather briefing for the flight. According to the filed flight plan, the pilot intended to fly at 200 knots at 7,000 feet. His planned route had him going from 0A8 to SZW (Seminole, Florida), CTY (Cross City, Florida), PIE (St. Petersburg, Florida), SRQ (Sarasota, Florida), and ending in APF (Naples, Florida). According to the pilot's family, the pilot did not want to fly direct because the airplane was not equipped for extended operations over water. According to the pilot's flight plan, he estimated the flight would last 2 hours and 30 minutes and he had 4 hours and 15 minutes of fuel on board. The pilot did not file an alternate destination. After departure from 0A8 the flight proceeded to Naples without incident. Aircraft radar data was obtained from the Federal Aviation Administration's (FAA) terminal radar approach control located at Southwest Florida International Airport (RSW), Fort Meyers, Florida. The facility is equipped with an Airport Surveillance Radar-8 radar system, which supplies data to an Automated Radar Terminal System (ARTS) model IIE at RSW. Radar targets for the accident airplane were recorded by the ARTS from 1434 to 1540. Transcripts of the pilot's communications with air traffic controllers were also obtained. The pilot attempted four instrument approaches (one at Naples, and three at Fort Meyers Page Field) prior to the accident. A NTSB air traffic control specialist overlayed the aircraft's radar data onto the various approach plates to provide a bird's-eye view of the airplane's flight track in relation to the final approach courses. The following is a summary of the aforementioned radar data and communications. Approach #1 (1440 to 1510) At 1440:05, the pilot contacted the Southwest Florida International Air Traffic Control (ATC) departure facility and informed the controller that they were at 7,000 feet. The controller provided the altimeter setting (30.06 inches of mercury) and asked the pilot to report when he had ATIS (automatic terminal information services) Sierra for Naples. He also informed the pilot he could expect the VOR (very high omni-directional range navigation aid) Runway 23 approach with a circle to land on runway 32. At 1441:28, the pilot called back and informed the controller he had ATIS information Sierra and confirmed the approach information. At 1444:52, the controller made a general radio announcement to all aircraft indicating ATIS information Tango was current at Naples. He then provided the updated weather, which at the time was reported as visibility two statute miles in light rain and mist with an overcast ceiling of 500 feet above ground level (agl). The wind was from 320 degrees at 7 knots and the altimeter setting was 30.04 inches of mercury. The controller informed all aircraft to expect the VOR runway 23 approach with a circle to land runway 32 at Naples. At 1446:01, the controller cleared the airplane direct to Naples and to descend to 5,000 feet. At 1447:22, the controller provided the pilot with a vector of 190 degrees for the VOR 23 approach. At 1450:44, the controller instructed the pilot to switch to Fort Meyers control (Southwest Florida International ATC south radar position) on another frequency after providing him a vector of 180 degrees. Once the pilot switched frequencies, that controller instructed the pilot to descend to 3,000 feet and to fly a heading of 130 degrees for sequencing. At 1456:58, the controller provided the pilot with a vector of 180 degrees and informed the pilot to "expect vectors across the final approach course for sequence" to which the pilot acknowledged. The controller then informed the pilot to expect vectors back toward the final approach in five miles, to which he responded, "I'll be waiting." At 1459:43, the controller gave the pilot a vector of 330 degrees and asked him to descend to 2,000 feet. At 1501:25, the controller provided the pilot a left vector to 270 degrees to join the VOR 23 approach. Thirty five seconds later, the controller asked the pilot to reduce his final approach speed and informed him he was 12 miles from the airport. He instructed the pilot to maintain 2,000 feet until he was established on final approach and cleared him for the VOR 23 approach circle to land runway 32. The pilot acknowledged and reported he was established. At 1502:16, the controller informed the pilot that two aircraft went missed on their approaches and one Piper Comanche just landed and a Westwind was ahead of his flight. One minute and 40 seconds later, the controller informed the pilot that the Westwind conducted a missed approach, and his radar services were terminated. He then instructed the pilot to switch frequencies to the Naples control tower, which he did. Examination of the aircraft's radar data for that approach revealed the pilot flew through the final approach (radial 055 from the Cypress VOR) about eight miles from the VOR. The aircraft's track then paralleled the final course on the northwest side of the course starting about four miles out. The aircraft remained on that parallel track until it passed the VOR where the pilot initiated the missed approach. The radar data for that approach indicates that the aircraft descended to about 500 feet (the minimum descent altitude for the VOR 23 approach circle to land was 500 feet). Approach #2 (1511 to 1527) Upon conducting the missed approach at Naples, the pilot contacted the Southwest Florida International ATC departure facility and requested to divert to Page Field, Fort Meyers, Florida (located 26.5 nautical miles north of Naples). The controller then provided radar vectors to Page Field and cleared the pilot back up to 3,000 feet. At 1513:37, the controller provided Page Field's weather information, which was reporting the wind from 020 degrees at 13 knots, visibility 3 statute miles in light rain and mist, an overcast ceiling at 300 feet, and an altimeter setting of 30.06 inches of mercury. At 1515:05, the controller transferred the pilot to Fort Myers approach control. At 1522:22, the approach controller informed the pilot he was five miles from Caloo (the locator outer marker and initial approach fix for the instrument landing system [ILS] runway 5). He was given a vector of 030 degrees and told to maintain 2,000 feet until established on the localizer and was cleared for the ILS runway 5 approach. The pilot acknowledged the clearance. At 1523:26, the pilot was instructed to contact the control tower. The pilot then contacted Fort Meyer's control tower and was cleared to land. The controller asked the pilot whether he was established on the approach, to which the pilot responded "yeah, I'm not quite established yet. I'm comin up on Caloo, but I'm not actually on the glide slope yet. Looks like I should interce ## Aircraft - Registration: [N241JG](https://openairdocs.org/deregistered/N241JG-2004-09-23), registration cancelled 2004-09-23, S/N TH-1987, built 2001 (OpenAirDocs) - Reported make and model: Raytheon 58 - Registry model: [Raytheon 58](https://openairdocs.org/model/raytheon-58) (registry code 7150003) (OpenAirDocs) - Registry engine: [Continental IO-550 series](https://openairdocs.org/engine/continental-io-550-series) (registry code 17042, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: TH-1987 - Airframe hours: 186.1 - Engines: Teledyne Continental IO-550-C reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Operator: Laurence G. Casey - Registered owner: KC Services Inc. - Airworthiness certificate: Standard, Normal - Last inspection: Annual, May 1, 2002, 66.7 hours before - Departed: OA8, Centerville, AL - Destination: APF, Naples, FL - Flight plan: IFR - Airport: FMY, Page Field Airport, runway 5 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 69; injuries: fatal; private; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 3, without waivers/limitations; last flight review May 1, 2001; seat: left; toxicology performed; flight hours: 911 total, 212 in this make and model ## Weather - Conditions: Instrument (IMC), Day - Wind: 40° at 11 knots - Visibility: 3 statute miles - Lowest ceiling: 300 ft overcast - Temperature: 61 °F, dew point 61 °F - Altimeter: 30.06 inHg - Observed at: FMY, 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 20021206036179A](https://openairdocs.org/incident/20021206036179A), Dec 6, 2002: Beech 58, Ft Myers, FL, Destroyed, 2 fatal. (-23) On December 06, 2002, at 15:39 EDT, a ratheon model 58 baron, N241JG, registered to kc services, inc. being flown by the owner laurence g. casey on a… ## Docket (31 files) The files NTSB released with the investigation on September 23, 2005, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=56179. 19.3 MB in all. - ATC 3 - Radar Study (item 1, .PDF, 977 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40426327&FileExtension=.PDF&FileName=ATC%203%20-%20Radar%20Study-Redacted.PDF - ATC 3 - RSW Radar Data File (item 2, ZIP, 2.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40238313&FileExtension=zip&FileName=ATC%203%20-%20RSW%20Radar%20Data%20File-Master - Witness Statements (item 3, .PDF, 166 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40426328&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - ATC Statements and Transcripts (item 4, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40426329&FileExtension=.PDF&FileName=ATC%20Statements%20and%20Transcripts-Redacted.PDF - Audio File: Anniston AFSS Briefing (item 5, MP3, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40238342&FileExtension=mp3&FileName=Audio%20File%3A%20Anniston%20AFSS%20Briefing-Master - FAA Approach Flight Test Results (item 6, .PDF, 176 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40426330&FileExtension=.PDF&FileName=FAA%20Approach%20Flight%20Test%20Results-Redacted.PDF - Approach Charts (item 7, .PDF, 321 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40238344&FileExtension=.PDF&FileName=Approach%20Charts-Master.PDF - Fuel Information (item 8, .PDF, 84 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40426331&FileExtension=.PDF&FileName=Fuel%20Information-Redacted.PDF - Aircraft and Maintenance Information 1 (item 9, .PDF, 842 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40426332&FileExtension=.PDF&FileName=Aircraft%20and%20Maintenance%20Information%201-Redacted.PDF - Aircraft and Maintenance Information 2 (item 10, .PDF, 209 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40426333&FileExtension=.PDF&FileName=Aircraft%20and%20Maintenance%20Information%202-Redacted.PDF - Aircraft and Maintenance Information 3 (item 11, .PDF, 3.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40426334&FileExtension=.PDF&FileName=Aircraft%20and%20Maintenance%20Information%203-Redacted.PDF - Pilot's Logbook (item 12, .PDF, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40426335&FileExtension=.PDF&FileName=Pilot%27s%20Logbook-Redacted.PDF - Fuel Metering Unit Exams (item 13, .PDF, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40426336&FileExtension=.PDF&FileName=Fuel%20Metering%20Unit%20Exams-Redacted.PDF - Reports from Parties to the Investigation - Raytheon (item 14, .PDF, 7 photos, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40426340&FileExtension=.PDF&FileName=Reports%20from%20Parties%20to%20the%20Investigation%20-%20Raytheon-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 15, .PDF, 47 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40426337&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 16, .PDF, 60 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40426338&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Toxicological Report (item 17, .PDF, 91 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40426339&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF - Photo 1: Initial impact with garage NTSB (negative) (item 18, .PDF, 312 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40238366&FileExtension=.PDF&FileName=Photo%201%3A%20Initial%20impact%20with%20garage%20NTSB%20(negative)-Master.PDF - Photo 2: Debris field & impacted house containing right engine & propeller NTSB (negative) (item 19, .PDF, 275 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40238367&FileExtension=.PDF&FileName=Photo%202%3A%20Debris%20field%20%26%20impacted%20house%20containing%20right%20engine%20%26%20propeller%20NTSB%20(negative)-Master.PDF - Photo 3: Debris Field NTSB (negative) (item 20, .PDF, 344 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40238369&FileExtension=.PDF&FileName=Photo%203%3A%20Debris%20Field%20NTSB%20(negative)-Master.PDF - Photo 4: Right Propeller NTSB (negative) (item 21, .PDF, 215 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40238370&FileExtension=.PDF&FileName=Photo%204%3A%20Right%20Propeller%20NTSB%20(negative)-Master.PDF - Photo 5: Engine Controls NTSB (negative) (item 22, .PDF, 275 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40238371&FileExtension=.PDF&FileName=Photo%205%3A%20Engine%20Controls%20NTSB%20(negative)-Master.PDF - Photo 6: Empennage NTSB (negative) (item 23, .PDF, 278 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40238372&FileExtension=.PDF&FileName=Photo%206%3A%20Empennage%20NTSB%20(negative)-Master.PDF - Photo 7: Empennage NTSB (negative) (item 24, .PDF, 293 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40238373&FileExtension=.PDF&FileName=Photo%207%3A%20Empennage%20NTSB%20(negative)-Master.PDF - Photo 8: Left Propeller NTSB (negative) (item 25, .PDF, 207 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40238374&FileExtension=.PDF&FileName=Photo%208%3A%20Left%20Propeller%20NTSB%20(negative)-Master.PDF - Photo 9: Right Propeller NTSB (negative) (item 26, .PDF, 197 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40238375&FileExtension=.PDF&FileName=Photo%209%3A%20Right%20Propeller%20NTSB%20(negative)-Master.PDF - Photo 10: Left Engine NTSB (negative) (item 27, .PDF, 285 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40238376&FileExtension=.PDF&FileName=Photo%2010%3A%20Left%20Engine%20NTSB%20(negative)-Master.PDF - Photo 11: Right Engine NTSB (negative) (item 28, .PDF, 269 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40238377&FileExtension=.PDF&FileName=Photo%2011%3A%20Right%20Engine%20NTSB%20(negative)-Master.PDF - Photo 12: Fuel Selectors Raytheon (no negative) (item 29, .PDF, 290 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40238378&FileExtension=.PDF&FileName=Photo%2012%3A%20Fuel%20Selectors%20Raytheon%20(no%20negative)-Master.PDF - Photo 13: Airspeed Indicator Raytheon (no negative) (item 30, .PDF, 286 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40238379&FileExtension=.PDF&FileName=Photo%2013%3A%20Airspeed%20Indicator%20Raytheon%20(no%20negative)-Master.PDF - Photo 14: VSI Raytheon (no negative) (item 31, .PDF, 289 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40238380&FileExtension=.PDF&FileName=Photo%2014%3A%20VSI%20Raytheon%20(no%20negative)-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.