# NTSB MIA04FA045: Piper PA-28-181, N298PA, Fort Pierce, FL, January 19, 2004 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: January 19, 2004, 01:06 local (06:06 UTC) - Place: Fort Pierce, FL - Coordinates: 27.485834, -80.384445 - Nearby events: https://openairdocs.org/map.md?lat=27.4858&lon=-80.3844&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal, 1 serious - Status: Completed, report July 7, 2005 - Report: Approved by Office Director - Parties: Pan Am International Flight Academy, Textron Lycoming, New Piper Aircraft, FAA, Orlando FSDO - NTSB case key (mKey): 58642 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=MIA04FA045 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/58642/pdf - Page: https://openairdocs.org/ntsb/MIA04FA045 ## Probable cause The flight instructor's failure to comply with the instrument approach procedure in that he descended prematurely below decision height resulting in an in-flight collision with trees, power lines and the ground. Contributing factors were the dark night light condition and the low ceiling. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight encounter with weather, approach - ifr procedure - not followed, pilot in command(cfi) (cause) - weather condition - low ceiling (contributing factor) - light condition - dark night (contributing factor) - In flight collision with object, approach - faf/outer marker to threshold (ifr) - object - tree(s) - object - wire,transmission - In flight collision with terrain/water, descent - uncontrolled - terrain condition - ground ## Analysis The airplane was on a night instrument training flight in actual instrument meteorological conditions, with a flight instructor, a private pilot-rated student, and a private pilot-rated passenger on board. The flight was cleared for an instrument landing system (ILS) approach to runway 09. As part of the clearance, the controller assigned the flight an altitude of 1,800 feet to be maintained until established on the approach. The pilot read back the altitude incorrectly as 1,200 feet, and the controller did not correct the error. Radar service was terminated, and the pilot was cleared to change frequencies. The pilot told the controller that he planned to make a full stop landing. There were no further transmissions from the airplane. According to the passenger, the flight instructor had taken control of the airplane "due to the fact that the visibility was so poor." The passenger stated that "there was no visibility." The last thing the passenger recalled prior to impact was that "the VSI [vertical speed indicator] was dropping more than 500 ft per min." Radar data showed the airplane tracking the ILS course. The data showed the airplane crossing the outer marker at a mode C altitude of about 1,300 feet (corresponding to an altitude of 1,200 feet when corrected for local altimeter setting). This was below the 1,800 foot glideslope intercept altitude at the outer marker shown on the approach plate. The airplane remained at 1,300 feet for the next 49 seconds and then began to descend. The last radar return was recorded 1 minute 27 seconds later and showed the airplane at a mode C altitude of 400 feet (300 feet when corrected for local altimeter setting), approximately 1/4 mile west of the accident site. The accident occurred approximately 1/2 nautical mile west of the threshold of runway 09. The airplane was approximately 300 feet left of the extended runway centerline when it initially struck trees and then power lines about 50 feet above the ground (agl). The decision height for the approach was 223 feet msl, or 200 feet agl. Reported weather conditions at the airport near the time of the accident were overcast ceiling at 100 feet, surface visibility 5 statute miles in mist, and surface wind from the west at 7 knots. The ILS approach was flight checked by the FAA two days after the accident, and the localizer, glide slope, distance measuring equipment, locator outer marker, and middle marker all inspected satisfactory. No evidence of any pre-impact mechanical discrepancies were found with the airframe, engine, avionics or instruments that would have prevented successful completion of the approach. ## Factual narrative HISTORY OF FLIGHT On January 19, 2004, about 0106 eastern standard time, a Piper PA-28-181, N298PA, registered to Merrill Lynch Business Financial Services Inc., and operated by Pan Am International Flight Academy Inc., impacted with trees, a power line and the ground while on an instrument landing system (ILS) approach to the Saint Lucie County Airport, Fort Pierce, Florida. Instrument meteorological conditions prevailed at the time and an instrument flight rules flight plan was filed for the 14 CFR Part 91 instructional flight. The airplane was destroyed. The certified flight instructor and the private pilot-rated student were fatally injured. The private-pilot rated passenger received serious injuries. The flight departed from West Palm Beach, Florida, at 2345 on January 18, 2004. The instrument training flight departed Fort Pierce about 2100 on January 18 and flew to Palm Beach International Airport to practice instrument approaches. After landing at Palm Beach, the airplane was refueled with 28 gallons of 100 LL aviation fuel and departed for the return flight to Fort Pierce via Vero Beach. The flight executed a practice approach, but did not land at Vero Beach Municipal Airport. At 0053:46, the controller cleared the flight for the ILS approach to runway 09 at Fort Pierce by stating, "two niner eight papa alpha yes sir seven west of lucie heading one two zero maintain one thousand eight hundred until established cleared i l s runway nine approach into fort pierce airport." The pilot responded, "heading one zero heading one two zero maintain a thousand two hundred and then cleared for the i l s niner." The controller did not challenge the pilot's incorrect read back of the altitude to be maintained. The controller then cleared the flight to execute a missed approach at the completion of the ILS approach. The pilot read back this clearance. At 0054:20, the controller told the pilot that radar service was terminated, and the pilot was cleared to change radio frequency. At 0054:40, the pilot responded, "miami center two nine eight papa alpha we will try to do a uh make this a full stop if not we'll come back to you." The controller acknowledged and reminded the pilot that he needed to close his flight plan upon landing. The last transmission from the pilot recorded by air traffic control was at 0054:57. According to the passenger, who was seated in the right rear seat, "due to the fact that the visibility was so poor [the flight instructor] took control of the plane to land it." The passenger stated that "there was no visibility." The last thing the passenger recalled prior to impact was that "the VSI [vertical speed indicator] was dropping more than 500 ft per min." The passenger lost consciousness during the crash sequence. When she regained consciousness, the passenger climbed out of the airplane and was going to get help when the driver of a car saw the accident scene and stopped. Radar data for the flight was obtained from the FAA radar sites at Melbourne, Florida and Tamiami, Florida. From 0055:21 to 0056:32, the flight proceeded along the ILS inbound course heading (094 degrees) from a point about two nautical miles west of the outer marker to the vicinity of the outer marker and descended from a mode C altitude of 2,000 feet to a mode C altitude of 1,300 feet. (Note: To correct the Mode C altitudes (which are based on a fixed altimeter setting of 29.92 inches) for the local altimeter setting (29.84 inches), reduce mode C altitudes by 100 feet.) From 0056:32 to 0057:21, the flight continued along the ILS course and maintained a mode C altitude of 1,300 feet. The flight then began to descend, and at 0058:48, when the last radar return was recorded, had reached a mode C altitude of 400 feet and was about 1/4 nautical mile west of the accident site. The accident occurred during dark night conditions approximately 1/2 nautical mile from the threshold of runway 09. The airplane was approximately 300 feet left of the extended runway centerline when it initially struck trees and then power lines about 50 feet above the ground. The main wreckage was found at 27:29.855 N latitude and 080:23.404 W longitude at an elevation of 54 feet msl as measured using a hand held GPS unit. PERSONNEL INFORMATION The flight instructor, who was seated in the right front seat, held a commercial pilot certificate with airplane single and multi-engine land and instrument ratings. Additionally, he held a flight instructor certificate with airplane single and multi-engine land and instrument ratings. He held a first class medical dated November 21, 2001, with no limitations. The flight instructor received the flight training for all of his ratings at Pan Am International Flight Academy from January 2002 to February 2003. He began working as a flight instructor for Pan Am in June 2003. Review of the instructor's flight logbook revealed that the last entry had been made on January 13, 2004. As of that date, the instructor had accumulated 528 hours total flight time, 245 hours acting as an instructor, and 78 hours total instrument flight experience of which 32 hours were in actual instrument meteorological conditions. The student pilot, who was seated in the left front seat, held a private pilot certificate with an airplane single engine land rating, issued on December 12, 2003. He held a first class medical certificate dated September 4, 2003, with no limitations. He received flight training towards his private pilot certificate at Pan Am International Flight Academy from September 27, 2003, to December 12, 2003. He enrolled in a 14 CFR Part 61 instrument flight training course at Pan Am International Flight Academy on December 15, 2003. Review of the student's Pan Am instrument course records indicated that the accident flight would probably have been Mission 25 in the course's flight training syllabus. The stated objectives of this lesson were, "review of previously practiced procedures in the airplane. Subject to the equipment available in the airplane, the student will review the GPS, ILS, and VOR approaches. The student will also be introduced to partial panel approaches." Review of the student's flight logbook revealed that the last entry had been made on January 17, 2004. As of that date, the student had accumulated 132 hours total flight time of which 10 hours were in simulated instrument conditions. AIRCRAFT INFORMATION Examination of the airplane's maintenance records revealed that the 2002 model Piper Archer III had been operated by Pan Am International Flight Academy since it was new. The airplane was placed on Pan Am's progressive inspection program on December 26, 2002, at which time it had accumulated a total airframe time of 558.7 hours. It received its most recent inspection, an Event Number 3 inspection, on January 14, 2004, at a total airframe time of 1,780.6 hours. As of this inspection, the engine, a Lycoming O-360-A4M, S/N L-38496-36A, had accumulated 1,780.6 hours total time. When the accident occurred, the airplane had been flown about 25 hours since this inspection. Review of the checklist for the Event Number 3 inspection revealed that it was similar in scope and detail to a 100 hour inspection of the engine combined with a detailed inspection of the wings and landing gear. The checklist did not list any discrepancies found with the airplane during the inspection. The most recent transponder test required by FAR 91.413 was performed on February 5, 2002, and the most recent altimeter and static system test required by FAR Part 91.411 was performed on March 16, 2002. Review of the discrepancy log kept in the airplane revealed no evidence of any uncorrected maintenance discrepancies. A discrepancy dated December 29, 2003, indicated the vacuum pump was inoperative. The corrective action block for this discrepancy stated that the vacuum pump was remove ## Aircraft - Registration: [N298PA](https://openairdocs.org/deregistered/N298PA-2004-08-24), registration cancelled 2004-08-24, S/N 2843507, built 2002 (OpenAirDocs) - Reported make and model: Piper PA-28-181 - Registry model: [Piper PA-28-181](https://openairdocs.org/model/piper-pa-28-181) (registry code 7102807) (OpenAirDocs) - Registry engine: [Lycoming O-360 series](https://openairdocs.org/engine/lycoming-o-360-series) (registry code 41575, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 2843507 - Airframe hours: 1805 - Engines: Lycoming O-360-A4M 180 horsepower reciprocating - Damage: Destroyed - Flight: Instructional, Part 91 - Operator: Pan Am International Flight Academy Inc. - Registered owner: Merrill Lynch Business Financial Services Inc. - Airworthiness certificate: Standard, Normal - Last inspection: AAIP, January 14, 2004, 25 hours before - Departed: PBI, WEST PALM BEACH, FL - Destination: FPR, Fort Pierce, FL - Flight plan: IFR - Airport: FPR, St. Lucie County International, runway 09, 6,492 × 150 ft ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 29; injuries: fatal; flight instructor, commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; last flight review February 17, 2003; seat: right; toxicology performed; flight hours: 528 total, 395 as pilot in command, 102 in the last 90 days, 28 in the last 30 days - Student pilot; age 20; injuries: fatal; private; airplane ratings: single-engine land; medical: class 1, valid medical--no waivers/lim.; last flight review December 12, 2003; seat: left; toxicology performed; flight hours: 132 total, 35 as pilot in command, 125 in the last 90 days, 25 in the last 30 days ## Weather - Conditions: Instrument (IMC), Night - Wind: 240° at 7 knots - Visibility: 5 statute miles - Lowest ceiling: 100 ft overcast - Temperature: 63 °F, dew point 63 °F - Altimeter: 29.84 inHg - Observed at: FPR, 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 20040119011119A](https://openairdocs.org/incident/20040119011119A), Jan 19, 2004: Piper PA28181, Fort Pierce, FL, Substantial damage, 2 fatal. (-23) At 0106 (local) on January 19, 2004, while on an ILS approach to st. Lucie county airport, N298PA, a PA-28-181 struck trees with its left wing and… 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.