Accident Details
Probable Cause and Findings
The pilot not maintaining proper glideslope and localizer alignment during the precision instrument approach, the pilot continuing flight below the decision height, the pilot not performing a missed approach, and the pilot not maintaining altitude/clearance from the trees and terrain. Contributing factors to the accident were the air traffic controller not issuing the current weather conditions to the pilot prior to the approach clearance, the weather conditions being below the instrument approach landing minimums, the pilot's lack of recent experience in instrument flight rules (IFR) operations and the pilot disregarding federal regulations regarding instrument currency.
Aircraft Information
Registered Owner (Historical)
Analysis
HISTORY OF FLIGHT
On October 24, 2000, at 2010 eastern daylight time (edt), a Piper PA-28R-200, N15900, owned and piloted by a private pilot, was destroyed during an in-flight collision with trees and subsequent collision with terrain while executing the Instrument Landing System (ILS) runway 9 approach to the Otsego County Airport (GLR), Gaylord, Michigan. Instrument meteorological conditions prevailed at the time of the accident. The business flight was operating under the provisions of 14 CFR Part 91 on an instrument flight plan. The pilot and his single passenger were fatally injured. The flight departed the Gerald R. Ford International Airport, Grand Rapids, Michigan, at 1856.
According to a Federal Aviation Administration (FAA) Air Traffic Control (ATC) accident report, the accident airplane was issued vectors to intercept the final approach course for the ILS runway 9 approach to GLR. The accident airplane was cleared for the ILS runway 9 approach and the pilot was instructed to cancel his flight plan through another airplane, a Piper Navajo (N59815), which was holding at the Gaylord VHF omni-directional range/distance measuring equipment (GLR VOR/DME). The GLR VOR/DME is located within the airport's perimeter and provides navigation assistance for visual and instrument flight operations.
Aircraft radar track data for the period before and after the reported accident time was obtained from the FAA. The aircraft radar track data was plotted using commercial software. The plot is appended to this factual report along with a copy of the source data.
According to the supplied radar track data, the accident airplane's first radar return was a reinforced discrete beacon code 12.235 nautical miles (nm) southwest of GLR at 2001:29 (hhmm:ss). The radar track data indicated the airplane continued heading north until 2005:05 when a right turn was initiated. The last radar return was recorded 7.631 nm west of GLR. The wreckage was located approximately 3 nm west-northwest of GLR.
PERSONNEL INFORMATION
The pilot held a private pilot certificate with ratings for airplane single engine land and instrument airplane operations. The pilot's last medical examination was conducted on June 16, 1999, and he was issued a third-class medical certificate with the limitation, "Must wear corrective lenses."
According to the pilot's flight logbook, the pilot had a total flight time of 918.2 hours, all of which were in single engine land airplanes. The pilot's last biennial flight review, as required by Federal Aviation Regulation (FAR) 61.56, was completed on August 18, 1998.
The pilot had logged a total of 60.9 hours in actual instrument meteorological conditions (IMC) and 69.3 hours as simulated IMC. The pilot's last recorded instrument proficiency check (IPC) was completed on April 17, 1998. The pilot's last recorded holding procedure was completed on August 18, 1998. During the 6 month period following the last IPC the pilot logged 8 approaches and 1 holding pattern. Between August 18, 1998, and February 18, 1999, the pilot logged 6 approaches and 1 holding pattern. Between February 18, 1999, and August 18, 1999, the pilot logged 4 approaches and no holding patterns. The pilot did not record an IPC subsequent to August 18, 1999. During the 6 month period prior to the accident, the pilot logged 9 instrument approaches and no holding procedures.
The pilot logged 57.0 hours in the last 90 days, all of which were in the accident airplane. During the last 90 days the pilot recorded 7.6 hours in actual IMC and 6 instrument approaches.
The pilot logged 41.9 hours in the last 60 days, during which time he recorded 4.4 hours in actual IMC and 3 instrument approaches.
The pilot logged 17.3 hours in the last 30 days, during which time he did not record any instrument time or instrument approaches.
There were no flight logbook entries within 24 hours of the accident.
AIRCRAFT INFORMATION
The airplane was a Piper PA-28R-200, serial number 28R-7335103. The Piper PA-28R-200 is a low-wing monoplane of all metal construction and is equipped with a constant-speed propeller, wing flaps, and retractable landing gear. The PA-28R-200 can accommodate a pilot and up to three passengers.
The airplane was issued a Standard Airworthiness Certificate on December 27, 1972, and was certified for normal category operations. The airframe had accumulated a total flight time of 5,358.40 hours. The last annual inspection was performed on April 1, 2000, and the airplane had accumulated 117.66 hours since the inspection.
According to the maintenance logbooks, the last transponder test, as required by FAR 91.413, was completed on September 18, 1998.
According to the maintenance logbooks, the last altimeter system test, as required by FAR 91.411, was completed on January 19, 1995.
The last recorded VOR equipment check, as required by FAR 91.171, was completed on August 9, 1994.
The engine was a 200 horsepower Textron Lycoming IO-360-C1C, serial number L-6235-51A. The engine had accumulated 1,584.90 hours since the last major overhaul, which was completed on April 9, 1985. The last inspection of the engine was on April 1, 2000, and the engine had accumulated 117.66 hours since the inspection.
The propeller was a two-bladed Hartzell HC-C2YR-1BF, serial number CH11457.
METEOROLOGICAL INFORMATION
An Automated Surface Observing System (ASOS), located at the Otsego County Airport, Gaylord, Michigan, recorded the weather as follows:
Observation Time: 2001 edt
Wind: 330 degrees magnetic at 4 knots
Visibility: 1/2 statute mile with fog
Sky Condition: Overcast layer at 200 feet above ground level (agl)
Temperature: 11 degrees Celsius
Dew Point: 11 degrees Celsius
Pressure: 30.35 inches-of-mercury
Observation Time: 2010 edt
Wind: Variable direction at 3 knots
Visibility: 1/4 statute mile with fog
Sky Condition: Vertical visibility 100 feet agl
Temperature: 11 degrees Celsius
Dew Point: 11 degrees Celsius
Pressure: 30.35 inches-of-mercury
At 1841 edt a pilot representing the accident airplane contacted the Lansing Automated Flight Service Station (AFSS) and requested a weather briefing. The AFSS briefer issued a standard weather briefing and at the completion of the weather briefing the pilot filed an IFR flight plan. According to a memorandum provided by the FAA, "All services provided by Lansing AFSS were normal and there were no pertinent transmissions."
AIDS TO NAVIGATION
On October 25, 2000, the ILS runway 9 approach to GLR was flight tested by the Battle Creek Flight Inspection Field Office. According to the Flight Inspection Report, the ILS runway 9 approach was fully operational and tested satisfactory. The Flight Inspection Report is appended to this factual report.
COMMUNICATIONS
The voice transmissions between the accident aircraft (N15900), Minneapolis Air Route Traffic Control Center (ZMP-ARTCC), and the holding airplane (N59815) were transcribed in part as follows:
1951:22 (hhmm:ss)
ZMP-ARTCC: november one five niner zero zero descend maintain three thousand five hundred
1951:25
N15900: out of six three point five nine zero zero
1951
1952
1953
1954
1955
1956
1957
1957:01
ZMP-ARTCC: november one five niner zero zero turn further ten degree left
1957:06
N15900: ten degrees left nine zero zero
1957:40
ZMP-ARTCC: november one five niner zero zero maintain three thousand two hundred please
1957:46
N15900: three point two nine zero zero
1957:49
ZMP-ARTCC: and what is your new heading going to be once your turn further left
1957:52
N15900: fifteen degrees nine zero zero
1957:52
ZMP-ARTCC: okay make the heading of zero zero five please for nine zero zero
1957:51
N15900: zero zero five nine zero zero
1958
1959
2000
2001
2002
2003
2004
2004:38
ZMP-ARTCC: november one five niner niner zero zero you're three from bangu right heading zero six zero maintain three thousand two hundred until established on localizer cleared i l s nine approach to gaylord airport
2004:48
N15900: okay zero three zero ah cleared on the i l s zero niner Gaylord three thousand until established nine zero zero
2004:54
ZMP-ARTCC: november nine zero zero fly heading zero six zero and ah cleared for approach
2004:59
N15900: zero six zero niner zero zero
2005
2005:37
ZMP-ARTCC: november one five niner zero zero change to advisory frequency is approved and try and cancel through a five niner eight one five he's right on top of you ah outbound in the holding
2005:53
ZMP-ARTCC: november niner zero zero change to advisory frequency approved relay your down time through a ah five niner eight one five if I don't hear ya he's above waiting to get in
2006:00
N15900: yeah we got him in sight we'll stay with you for a bit nine zero zero
2007
2008
2009
2010
2011
2012
2012:06
ZMP-ARTCC: november eight one five did you hear from nine zero zero yet he should be ah should be touching down any second
2012:11
N59815: negative i haven't heard anything from him
2013
2014
2014:41
ZMP-ARTCC: november eight one five wanta go over to unicom real quick and see if one five niner zero zero is on the ground he should be down by now
2014:46
N59815: alright stand by one
2015
2016
2016:33
ZMP-ARTCC: november eight one five did you hear from him at all
2016:44
N59815: eight one five negative ah unicom hadn't from him either
2016:47
ZMP-ARTCC: okay he should have been down a couple of minutes ago expect further clearance at zero zero two five [2025 edt] now for november five niner eight one five
2016:54
N59815: zero zero two five eight one five
2017
2018
2018:18
ZMP-ARTCC: november eight one five unicom hadn't heard from him at all if you would go back over to frequency ah over to Unicom there and see if they can ah scare him up otherwise we'll have our guys um call and see if we can find him here and expect further clearance at ah zero zero four zero [2040 edt] now
2018:34
N59815: okay further clearance...
Data Source
Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# CHI01FA025