# NTSB NYC04FA100: Piper PA-28R-180, N4686J, Harrietstown, NY, April 3, 2004 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: April 2, 2004, 19:25 local (Apr 3, 2004, 00:25 UTC) - Place: Harrietstown, NY - Coordinates: 44.409168, -74.194999 - Nearby events: https://openairdocs.org/map.md?lat=44.4092&lon=-74.1950&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report October 27, 2005 - Report: Approved by Office Director - Parties: Piper Aircraft, Lycoming Engines, FAA - NTSB case key (mKey): 58989 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC04FA100 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/58989/pdf - Page: https://openairdocs.org/ntsb/NYC04FA100 ## Probable cause The pilot's failure to follow instrument flight rules procedures resulting in a collision with a tree. Factors related to the accident were the dark night conditions, low visibility, and low cloud ceiling. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight collision with object, approach - faf/outer marker to threshold (ifr) - object - tree(s) - ifr procedure - not followed, pilot in command (cause) - light condition - dark night (contributing factor) - weather condition - low ceiling (contributing factor) - weather condition - snow (contributing factor) ## Analysis Arriving in the area of the destination airport, the weather was reported as, 1-3/4 statute miles of visibility; light snow, mist; overcast cloud layer at 200 feet; temperature of 34 degrees Fahrenheit; dew point of 32 degrees Fahrenheit. The pilot performed an ILS procedure towards the runway. An employee at the airport received a radio transmission from the accident airplane, requesting a current altimeter setting. The employee replied back with the current altimeter setting. Moments later, the employee heard a transmission from the airplane that it was on a 4 mile final for the ILS approach. No further transmissions were received from the airplane. The airplane came to rest in a wooded area, about 3/4-mile from the runway threshold, about 300 feet right of the extended centerline. Review of the approach plate for the ILS approach revealed that the minimum glide slope intercept altitude at the beginning of the final approach segment on the precision approach was 4,300 feet msl. The glide slope altitude at the final approach fix for the non-precision approach, which was located about 4 miles from the approach end of the runway, was 3,619 feet msl. The glide slope altitude at the middle marker, which was located about 0.4 miles from the approach end of the runway, was 1,853 feet msl. Review of recovered GPS data revealed that about 1.75 miles from the runway, the airplane turned to the left of the final approach course. When the airplane was about 1/2 mile left of the final approach course, it began a turn to the right towards the final approach course. The last GPS data point was recorded about 5,073 feet from the runway threshold, along the final approach course, at an altitude of 1,765 feet msl. The elevation at the airport was 1,663 feet msl. Review of the pilot's logbook revealed times spans in excess of 6 months, where the pilot did not record 6 instrument approaches or IFR holding procedures. The pilot's last recorded instrument flight proficiency flight was dated October 26, 1996. According to Federal Aviation Regulations, Part 61.57 Recent flight experience, pilot-in-command, "...no person may act as pilot in command under IFR or in weather conditions less than the minimums prescribed for VFR, unless within the preceding 6 calendar months, that person has...performed and logged under actual or simulated instrument conditions, at least six instrument approaches, holding procedures, and intercepting and tracking courses through the use of navigation systems...a person who does not meet the instrument experience requirements within the prescribed time, or within 6 calendar months after the prescribed time, may not serve as pilot in command under IFR or in weather conditions less than the minimums prescribed for VFR until that person passes an instrument proficiency check..." ## Factual narrative HISTORY OF FLIGHT On April 2, 2004, about 1925 eastern standard time, a Piper PA-28R-180, N4686J, was substantially damaged after impacting terrain during an approach to the Adirondack Regional Airport (SLK), Harrietstown, New York. The certificated private pilot and passenger were fatally injured. Night instrument meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan was filed for the flight that originated from the Leesburg Executive Airport (JYO), Leesburg, Virginia. The personal flight was conducted under 14 CFR Part 91. According to a Federal Aviation Administration (FAA) inspector, the airplane arrived at JYO the day before the accident, and was fueled with 25.9 gallons of aviation fuel. On the day of the accident, the pilot received a weather briefing from the Leesburg Flight Service Station (FSS), and subsequently filed an IFR flight plan. He then departed JYO about 1530. The flight proceeded uneventfully towards SLK, and was cleared for the ILS runway 23 approach at SLK at 1858. At 1909, the radar services were terminated. An employee at the SLK airport received a radio transmission from the accident airplane, requesting a current altimeter setting. The employee replied back with the current altimeter setting. Moments later, the employee heard a transmission from the airplane that it was on a 4 mile final for the ILS runway 23 approach. No further transmissions were received from the airplane. The airplane was located the following day by rescue personnel. It came to rest inverted, in a wooded area, about 3/4-mile from the runway 23 threshold, and about 300 feet right of the extended centerline. Review of radar data revealed that the airplane crossed the SLK VOR, which was co-located on the airport, at 6,000 feet msl, and proceeded outbound on a course of approximately 050 degrees. The airplane also began a descent to 5,000 feet msl after crossing the VOR. About 9 miles from the SLK VOR, the airplane made a left hand turn. Approximately 10 seconds later, the airplane turned to the right. The turn continued until intercepting the final approach course for the runway 23 localizer, where a gradual descent began. The last target observed was about 2.25 miles prior to the SLK VOR, at an altitude of 2,500 feet msl. A hand-held global positioning system (GPS) was found in the wreckage, and was forwarded to the manufacturer for data extraction. The data revealed that the airplane departed from JYO, and proceeded in a northerly direction towards SLK at an average airspeed of 153 mph. About 5 minutes after passing the SLK VOR at 5,555 feet msl, the airplane reversed course, and began to track the final approach course inbound towards the runway. About 1.75 miles from the runway, the airplane turned to the left of the final approach course. When the airplane was about 1/2 mile left of the final approach course, it began a turn to the right towards the final approach course. The last data point was recorded about 5,073 feet from the runway threshold, along the final approach course, at an altitude of 1,765 feet msl. The accident occurred during the hours of darkness, at 44 degrees, 24.336 minutes north longitude, 74 degrees, 11.42 minutes west latitude, at an elevation of 1,640 feet. PERSONNEL INFORMATION The pilot held a private pilot certificate with ratings for airplane single engine land, and instrument airplane. The pilot's most recent application for a Federal Aviation Administration (FAA) third class medical certificate was dated on May 14, 1996. Review of the pilot's logbook revealed that he had accumulated about 1,215 hours of total flight experience, of which 285 hours were recorded as "actual instrument." During the previous 6-month period, the pilot recoded 5 instrument approaches, and 14.9 hours of "actual instrument." The pilot did not record any IFR holding procedures during the 6-month period. Further review of the pilot's logbook revealed times spans in excess of 6 months, where the pilot did not record 6 instrument approaches or IFR holding procedures. The pilot's last recorded instrument flight proficiency flight was dated October 26, 1996. AIRCRAFT INFORMATION A review of the airframe and engine records did not reveal any abnormalities with the engines or the airframe. The airplane's most recent annual inspection was completed on March 31, 2004, at a total aircraft time of 3,108 hours. METEOROLOGICAL INFORMATION The weather reported at SLK, at 1924, included winds from 090 at 5 knots; 1-3/4 statute miles of visibility; light snow, mist; overcast cloud layer at 200 feet; temperature of 34 degrees Fahrenheit; dew point of 32 degrees Fahrenheit; and an altimeter setting of 29.75 inches of mercury. An AIRMET, issued at 1545, and valid until 2200, called for moderate rime and mixed icing in clouds and in precipitation, between the freezing level and 15,00 feet. The freezing level was expected to be between 4,000 and 6,000 feet. AIDS TO NAVIGATION Review of the approach plate for the ILS Runway 23 approach at SLK revealed that the outbound minimum altitude from the SLK VOR, for the full approach, was 5,000 feet msl. The outbound course was 047 degrees, and continued to the initial approach fix (IAF). Upon crossing the IAF, the outbound course was 049 degrees, and the minimum descent altitude was 4,800 feet msl. Upon completion of the course reversal, the inbound course was 229 degrees. The glide slope crossing altitude at the beginning of the final approach segment on the precision approach was 4,300 feet. The glide slope altitude at BRIEL intersection, which was located about 5.8 miles from the approach end of the runway, was 3,619 feet. The glide slope altitude at the middle marker, which was located about 0.4 miles from the approach end of the runway, was 1,853 feet. The minimums for the full approach were 1/2 statute mile visibility, and a decision height of 200 feet agl. The airport elevation at SLK was 1,663 feet msl. WRECKAGE AND IMPACT INFORMATION Examination of the accident site on April 3-4, revealed terrain which consisted of evergreen and hardwood trees reaching a height of about 40 feet. The ground surrounding the accident site was covered with about 4 feet of snow. The wreckage path was oriented on a 230-degree heading, with the main fuselage coming to rest on a 235-degree heading. The first tree strike area was located about 150 feet prior to the main fuselage. A 48-inch section of the outer left wing was located about 60 feet beyond the first tree strike. About 10 feet from the outer left wing, the remaining section of the inboard left wing was located. A large section of a 9-inch diameter hardwood tree was found lying on the ground about 4 feet past the wing section. About 35 feet beyond the fallen tree was a 6-foot wide, 15-foot long, and 1-foot deep, crater. About 40 feet beyond the crater was the main wreckage. The right wing, and empennage section remained attached to the fuselage. All flight control surfaces were accounted for at the accident site. The left wing main landing gear assembly was located under the fuselage. When the outer left wing was examined, a 12-inch deep "u"-shaped dent on the leading edge were noted. Tree bark was observed in the dent compression mark. When the inboard left wing was examined, two large, deep, dents on the leading edge was noted. Tree bark was observed in the dent compression marks. The engine was removed from the airframe and examined. The crankshaft was rotated freely through the accessory drive section. Thumb compression and valve train continuity was attained on all cylinders. The top and bottom spark plugs were removed; their electrodes were intact and light gray in color. The left and right magnetos were removed from the engine, and when rotated by hand, produced spark on all four towers. The fuel line co ## Aircraft - Registration: [N4686J](https://openairdocs.org/deregistered/N4686J-2013-09-16), registration cancelled 2013-09-16, S/N 28R-30587, built 1968 (OpenAirDocs) - Reported make and model: Piper PA-28R-180 - Registry model: [Piper PA-28R-180](https://openairdocs.org/model/piper-pa-28r-180) (registry code 7102809) (OpenAirDocs) - Registry engine: [Lycoming I0360 series](https://openairdocs.org/engine/lycoming-i0360-series) (registry code 41515, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28R-30587 - Airframe hours: 3108 - Engines: Lycoming IO-360 180 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Registered owner: Paul N. Gurlich - Airworthiness certificate: Standard, Normal - Last inspection: Annual, March 1, 2004, 6 hours before - Departed: JYO, Leesburg, VA - Destination: SLK, Harriettstown, NY - Flight plan: IFR - Airport: SLK, Adirondack Regional Airport, runway 23 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 57; injuries: fatal; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, expired; last flight review October 26, 1996; seat: left; toxicology performed; flight hours: 1,218 total ## Weather - Conditions: Instrument (IMC), Night/dark - Wind: 90° at 5 knots - Visibility: 1.75 statute miles - Lowest ceiling: 200 ft overcast - Temperature: 34 °F, dew point 32 °F - Altimeter: 29.75 inHg - Observed at: SLK, 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 20040402004129A](https://openairdocs.org/incident/20040402004129A), Apr 2, 2004: Piper PA28R180, Saranac Lake, NY, Destroyed, 2 fatal. (-23) N4686J departed jyo at approximately 1550 local and flew non-stop to slk on 04/02/2004. The aircraft was cleared for an ILS approach to rwy 23 at slk by… 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.