Accident Details
Probable Cause and Findings
The pilot's failure to maintain the proper glidepath during an instrument-landing-system (ILS) approach. Contributing to the accident were the pilot's decision to initiate the ILS approach with weather below the published minimums, and the pilot's self-induced pressure to expeditiously transport an organ recipient to a hospital.
Aircraft Information
Registered Owner (Historical)
Analysis
HISTORY OF FLIGHT
On November 7, 2008, at 0246 eastern standard time, a Partenavia SPA P68C, N681KW, operated by Florida Aero Charter Inc., doing business as Air Key West, crashed during approach to the Gainesville Regional Airport (GNV), Gainesville, Florida. The on-demand air taxi flight was conducted under the provisions of 14 Code of Federal Regulations Part 135. Night instrument meteorological conditions (IMC) prevailed, and an instrument flight rules (IFR) flight plan was filed. The certificated airline transport pilot and two passengers were killed and the airplane received substantial damage. The flight originated from Key West International Airport (EYW), Key West, Florida, at 0037.
The pilot worked for Air Key West and was based out of EYW. According to the pilot's girlfriend, the pilot previously flew on Monday, November 3. He was then off-duty on Tuesday and Wednesday, November 4 and 5. The pilot was on-duty Thursday, November 6; however, no flights were scheduled. The pilot went to bed early Thursday night, as he had a flight scheduled for 0600 on Friday, November 7. At 2223 on Thursday night, the pilot received a telephone call from an individual, who was on an organ recipient waiting list. The individual stated that an organ was available in Gainesville, and that he’d have to get there quickly for surgery the following morning. The pilot then called the airplane owner/operator, and the owner/operator decided to fly the 0600-trip so that the pilot could conduct the flight to GNV.
According to data from Lockheed Martin, the pilot telephoned about 2336 on November 6, 2008, and filed two IFR flight plans with the Miami Flight Service Station (FSS). The first IFR flight plan was for a direct flight from EYW to GNV, with three persons on board. The pilot advised the FSS specialist that he was transporting a kidney transplant patient and although he was not a Lifeguard or Angel Flight, he was requesting priority handling. The pilot indicated that he would be at GNV for only a short time and filed a second IFR flight plan for a return to EYW, with one person on board.
The accident flight checked in with Jacksonville terminal radar approach control (TRACON) at 0215, approximately 75 miles south of GNV. The controller provided the pilot with the Jacksonville altimeter and advised that no weather information was available at GNV. The pilot advised, “the weather looks like it’s going up and down…like a real thin fog layer,” and added, “we’re kind of a priority trying to get a kidney transplant ah but if it’s undoable at Gainesville we’re probably be looking at Saint Augustine, just to give you a heads-up.”
At 0216, the controller asked the pilot if he wanted an instrument landing system (ILS) approach to GNV. The pilot responded that he wanted an ILS approach to runway 29. At 0242, 6 miles from the WYNDS initial approach fix (IAF), the controller cleared the flight for the ILS runway 29 approach. At 0243, the controller terminated radar services and approved a radio frequency change to the common traffic advisory frequency (CTAF). The pilot acknowledged the CTAF frequency and advised “…we’ll talk to ya on the way out…”
At 5 miles from runway 29, just prior to the WYNDS IAF, the pilot radioed on the CTAF and reported a 5-mile final leg for runway 29. Gainesville FSS advised that automated GNV weather observation was indicating an indefinite ceiling of 100 feet vertical visibility, 1/4 mile visibility in fog, wind calm, temperature 11 degrees Celsius, dew point 10 degrees Celsius, altimeter 30.02 inches of mercury, and that no known airport traffic information was available. The pilot acknowledged the weather and traffic information. There was no further air traffic control or FSS communication with the flight.
According to an employee at a fixed based operator (FBO) located at GNV, the pilot contacted him via radio between 0200 and 0300, and asked about the weather and runway lighting conditions. The employee replied that the visibility was low due to fog, and he could not see the terminal lights from the FBO. The employee also stated that the runway lights were pilot-controlled-lighting, and they were not currently on the highest setting. The pilot then asked about which was a closer alternate airport, Leesburg Florida or St. Augustine Florida, and the employee stated that he did not know. The employee then heard the pilot “click” the runway lights and contact Gainesville Radio. He did not hear any further communications from the accident airplane.
According to radar data provided by the Federal Aviation Administration (FAA), the flight intercepted and tracked the localizer about 0243, and intercepted the glideslope about 0244. There were a few radar targets without altitude data, due to intermittent Mode C transponder returns. The last recorded radar target with altitude was at 0246:30, which indicated the airplane was at 600 feet and on glideslope; however, the three subsequent and final targets did not have altitude information. The last recorded radar target was at 0246:44, about 1.4 miles from the runway threshold.
PERSONNEL INFORMATION
The pilot, age 45, held an airline transport pilot certificate, with a rating for airplane multiengine land. He held a commercial pilot certificate, with ratings for airplane single-engine land, rotorcraft helicopter, and instrument helicopter. His most recent FAA second-class medical certificate was issued on November 21, 2007. At that time, the pilot reported a total flight experience of 8,300 hours.
The pilot's logbooks were not recovered; however, the operator was able to provide his flight experience. According to the operator, of the 8,300 total hours of flight experience, 7,400 hours were in multiengine airplanes, 1,500 hours were in the same make and model as the accident airplane, 1,100 hours were at night, and 1,800 hours were in actual IMC. The pilot flew 50 hours and 130 hours during the 30-day period and 90-day period preceding the accident, respectively.
AIRCRAFT INFORMATION
The seven-seat, high-wing, fixed-gear airplane, serial number 273, was manufactured in 1983. It was powered by two Lycoming IO-360, 200-horsepower engines, equipped with Hartzell propellers. The operator stated that the airplane was in “good shape,” and he used the airplane the previous week for an FAA-checkride. The airplane’s most recent 100-hour inspection was completed on September 19, 2008. The operator further stated that the airplane was equipped with an IFR-certified Apollo GX50 global positioning system. The airplane was not equipped with a radar altimeter, ground proximity warning system, or a terrain awareness and warning system.
METEOROLOGICAL INFORMATION
During the telephone call with Miami FSS, the pilot received an abbreviated weather briefing, which included airmen's meteorological information (AIRMET) Sierra for IFR conditions north of Tampa Bay, up through Daytona and points north, developing through the evening. Specifically, the IFR conditions were forecast as ceilings below 1,000 feet and visibility below 3 miles due to mist and fog. At the time of the briefing, the FSS specialist noted he has seen some of the lower visibilities during the past hours; however, Gainesville was visual flight rules with clear skies, 10 miles visibility, and calm winds.
The reported weather at GNV, at 0153, was: wind calm; visibility 1/2 mile in fog; overcast ceiling at 100 feet; temperature 11 degrees Celsius; dew point 10 degrees Celsius; altimeter 30.03 inches of mercury.
The reported weather at GNV, at 0253, was: wind calm; visibility 1/4 mile in fog; vertical visibility 100 feet; temperature 11 degrees Celsius; dew point 10 degrees Celsius; altimeter 30.02 inches of mercury.
The reported weather at GNV, at 0353, was: wind calm; visibility 1/4 mile in fog; broken ceiling at 100 feet and overcast ceiling at 900 feet; temperature 10 degrees Celsius; dew point 9 degrees Celsius; altimeter 30.02 inches of mercury.
The reported weather at St. Augustine Airport (SJG), at 0155, was: wind calm; visibility 7 miles; scattered clouds at 100 feet; temperature 13 degrees Celsius; dew point 12 degrees Celsius; altimeter 30.04 inches of mercury.
The reported weather at SJG, at 0255, was: wind from 280 degrees at 3 knots; visibility 8 miles; broken ceiling at 100 feet; temperature 12 degrees Celsius; dew point 11 degrees Celsius; altimeter 30.02 inches of mercury.
The reported weather at SJG, at 0355, was: wind from 290 degrees at 3 knots; visibility 7 miles; few clouds at 200 feet; temperature 12 degrees Celsius; dew point 12 degrees Celsius; altimeter 30.02 inches of mercury.
AERODROME INFORMATION
A non-federal air traffic control tower was located at GNV. The tower was open from 0645 to 2230.
Runway 29 at GNV was 7,504 feet long, 150 feet wide, and constructed of grooved asphalt. Runway 29 was equipped with an ILS approach, a high intensity runway light system, and a four-light precision approach path indicator light system. It was also equipped with a medium intensity approach light system with runway alignment indicator lights.
Review of a terminal instrument procedure chart for the ILS runway 29 approach at GNV revealed that the decision height for the approach was 322 feet msl (200 feet agl). The minimum visibility requirement was 2,400 feet (1/2 mile).
WRECKAGE AND IMPACT INFORMATION
The wreckage was located in a wooded area about 0700, approximately 3,575 feet from the runway 29 threshold. The wreckage was examined on November 7 and 8, and all major components of the airplane were accounted for at the scene. An approximate 575-foot debris path was observed, that originated with tree strikes. The debris path extended on a course of approximately 290 degrees magnetic, and terminated at the main wreckage. Freshly cut tree branches were recovered along the debris path. They varied in diameter up to about 6 inches, and were cut at approximately 45-degr...
Data Source
Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# ERA09FA039