MIA08FA163

The instrument rated pilot was a volunteer pilot for a charity organization that connects pilots and aircraft owners with individuals in need of transportation primarily for medical purposes. The pilot was not instrument current. In addition, the charity did not verify instrument currency of volunteer pilots nor were they required to. After takeoff, the flight proceeded towards the destination airport on an instrument flight rules clearance and was vectored onto the downwind and base legs for sequencing. The pilot made two errors related to incorrect heading changes both of which were not immediately detected by the controller, but neither were significant. While on the base leg and approximately 1.5 miles west of the final approach course for runway 4R, the controller instructed the pilot to fly heading 060 degrees to intercept the final approach course. Radar data depicted a large radius turn towards the left, and the airplane flying through the final approach course. When the flight was approximately 1.6 miles east of the final approach course, the controller advised the pilot he had passed through the course and instructed him to turn to a heading of 010 degrees to re-intercept. Radar depicted a tight radius turn past the assigned heading, while the airplane descended below the assigned altitude of 3,000 feet. The airplane then turned to the north, then southeast with altitude deviations descending so low the controller issued several low altitude alerts. The airplane then entered a final descent, immerged from the base of clouds, and impacted into a parking lot. Examination of the engine, airframe, and avionics did not reveal any preimpact failures or malfunctions.

History of flight

On August 12, 2008, about 1017 eastern daylight time, a Beech G35, N4615D, registered to a private individual, operated by the pilot as "Angel Flight 15 Delta" experienced an in-flight loss of control while maneuvering to re-intercept a final approach course, and then crashed into a parking lot of a shopping center located in South Easton, Massachusetts. Instrument meteorological conditions prevailed at the time and an instrument flight rules (IFR) flight plan was filed for the 14 Code of Federal Regulations (CFR) Part 91 personal flight that departed Francis S. Gabreski Airport (FOK), Westhampton, New York, about 0909, destined for General Edward Lawrence Logan International Airport (BOS), Boston, Massachusetts. The airplane was destroyed, and the certificated commercial pilot and the two passengers were killed.

The pilot was flying the passengers to BOS so one of the passengers could receive medical treatment in the Boston area.

After takeoff the pilot established contact with New York Terminal Radar Approach Control, and then with Providence Air Traffic Control Tower, while proceeding towards the destination airport. Air traffic control (ATC) communications were then transferred to Boston Consolidated Terminal Radar Approach Control (Boston Consolidated TRACON).

According to a transcription of communications with Boston Consolidated TRACON Initial Departure Position, the pilot contacted the facility at 0954:05, and advised the controller that he had automated terminal information service (ATIS) information Papa. The controller instructed the pilot to expect the instrument landing system (ILS) approach to runway 4R, and provided the altimeter setting. The flight continued towards the destination airport and the controller instructed the pilot to turn 10 degrees left from his current heading of 030 degrees. The pilot responded that he was turning to heading 040 degrees, but the controller did not correct the incorrect readback. The flight was given several more heading changes, and the controller informed the pilot to expect to be turned onto the downwind leg. At 1008:08, the controller vectored the pilot to fly heading 220 degrees, which the pilot acknowledged.

Air traffic control communications were transferred to the Boston Consolidated TRACON Final 1 position and on the pilot’s first contact at 1008:30, he informed the controller he was turning to heading 210 degrees, though approximately 22 seconds earlier he was previously instructed to fly heading 220 degrees. Approximately 1 minute 49 seconds later the controller instructed the pilot to turn 10 degrees to the right and descend and maintain 4,000 feet. The pilot acknowledged the heading and altitude clearances and radar data depicted the airplane flying the heading and descending with a ground speed of approximately 170 knots. At 1013:01, when the flight was approximately 21 nautical miles southwest of BOS flying at 4,200 feet msl, the controller instructed the pilot to turn to heading 170 degrees. The pilot acknowledged and radar data depicted the heading change.

The transcription of communications further indicates that at 1013:42, the controller instructed the pilot to turn to heading 130 degrees and then instructed him to descend and maintain 3,000 feet msl; the pilot acknowledged both clearances and recorded radar data reflects the airplane flying in a southeasterly heading. At 1014:44, when the flight was about 3,500 feet msl and approximately 1.5 statute miles west of the ILS 4R localizer at 170 knots ground speed, the controller instructed the pilot to turn left heading 060 degrees and to intercept the localizer. The pilot acknowledged the instructions and recorded radar data indicates a large radius turn to the left but the pilot flew thru the localizer flying in a east-northeasterly direction. At 1015:46, while flying at 3,300 feet msl on a heading of approximately 072 degrees approximately 1.6 statute miles east of the ILS 4R localizer, the controller instructed the pilot, “…you’re passing through the localizer turn left heading zero one zero intercept localizer.” The pilot responded with "one five Delta." After the pilot's truncated transmission, radar data indicated the flight turned left to a heading of approximately 320 degrees and descended to 2,800 feet msl then climbed to 2,900 feet msl. The recorded radar data depicted that between 1016:27, and 1016:39, the flight descended to 2,800 feet msl and turned to the right flying in a northerly direction. At 1016:39, the controller asked the pilot if he was joining the localizer; there was no response. At 1016:46, the controller instructed the pilot that the altitude indicated 2,300 feet, then immediately informed him radar contact was lost and ended the transmission with the partial call sign of the flight. The pilot responded with, "one five Delta with you."

The recorded radar data indicates that between 1016:39, and 1016:54, the airplane turned to the right heading in a southeasterly direction and descended to 1,900 feet msl. At 1016:57, the controller instructed the pilot that the flight was at 1,200 feet, issued a low altitude alert, and instructed the pilot twice to "climb immediately." The pilot responded "one five Delta’s climbing", and the recorded radar data indicates the flight turned to the left flying in a northwesterly direction and climbed to 2,200 feet msl. The controller advised the pilot to maintain 3,000 feet; and to state his heading. While the transcription of communications indicates the transmission from the pilot was unintelligible, review of the voice communication tape by the National Transportation Safety Board (NTSB) revealed the pilot responded, “15 Delta’s ah 020.”

The recorded radar data indicated that at 1017:27, the flight was at 2,700 feet msl and approximately 4 seconds later at 1017:31, the airplane was at 2,100 feet msl. The controller again instructed the pilot to maintain 3,000 feet and to state heading; there was no response. The controller then instructed the pilot that, "… your altitude is going up and down are you all right sir." There was no response. The controller then issued a low altitude alert again, instructed the pilot to climb immediately, and that radar contact was lost. The controller asked nearby aircraft if they heard a signal from an emergency locator transmitter; no signal was heard.

A witness who was on Route 106 reported to law enforcement seeing the airplane climbing and descending from the clouds.

A pilot-rated witness who was located .41 nautical mile north-northwest from the crash site reported hearing a low flying airplane, heading west to east, with high rpm. He ran outside but did not see the airplane. The noise faded then returned, and he observed the airplane descending vertically out of the clouds. The witness's first view of the airplane was the top of the airplane. He did not recall if he saw the landing gear, but did not see any smoke trailing the airplane during the time he saw it. The airplane spun 2.5 times to the left, went out of sight behind trees, and he heard an impact and saw smoke. He drove to the scene arriving there about 1 minute later. The witness added that the engine was running with a constant sound prior to impact, and that there was no missing or sputtering. The weather conditions at the time consisted of a ceiling at 800 feet, with no rain or wind.

One witness located adjacent to the accident site reported hearing the airplane then seeing it flying in a southerly direction at the base of or partially in the clouds. The airplane climbed into the clouds then heard it flying eastbound. About 15 to 20 seconds later he heard “coughing sounds,” followed by seeing the airplane emerge from the base of the clouds with no engine no operating. He then reported the engine began operating but was sputtering while the airplane was descending with the nose at an angle of about 45