N298PA

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 removed and replaced. Further investigation revealed that the vacuum pump had not been replaced. According to a written statement, provided by the mechanic who worked the discrepancy, he started the airplane's engine and performed a ground check of the normal and auxiliary vacuum systems and found both systems operated normally with no anomalies. He released the airplane back to service, signed off the discrepancy in a computerized record keeping system (CASSi), but forgot to sign off the discrepancy log in the airplane. On December 30, 2003, a student pilot noted the unsigned off discrepancy and questioned a dispatcher about it. The dispatcher checked in CASSi, found that the discrepancy had been corrected, and made the assumption that the vacuum pump had been replaced. The dispatcher made the entry in the corrective action block and entered the mechanic's name in the corrected by block of the discrepancy log. There were no further reports of discrepancies with the vacuum system.

METEOROLOGICAL INFORMATION

The National Weather Service surface analysis chart for 0100 showed a trough of low pressure extending from the southwest Atlantic Ocean to the vicinity of Miami, Florida. Then the trough curved southward through the Florida Keys. A weak pressure gradient was indicated over Florida. The plotted stations indicated patchy fog and haze with generally light and variable winds throughout the state.

At 0053, the weather conditions at Saint Lucie County Airport reported by the unaugmented Automated Surface Observing System (ASOS) were wind 270 degrees at 7 knots, visibility 5 statute miles, present weather - mist, sky condition - overcast 100 feet, temperature 17 degrees C, dew point 17 degrees C, altimeter setting 29.84 inches.

At 0053, the weather conditions at Vero Beach Municipal Airport, located approximately 10 nautical miles north of the accident site, reported by the augmented ASOS were wind 250 degrees at 7 knots, visibility 4 statute miles, present weather - mist, sky co...