NTSB Factual Report

HISTORY OF FLIGHT

On October 27, 2001, at 2006 mountain daylight time, a Cessna T337G, N45E, was destroyed during impact with terrain near Palmer Lake, Colorado. The instrument rated private pilot, the sole occupant in the airplane, was fatally injured. The flight was being conducted under Title 14 CFR Part 91. Visual meteorological conditions prevailed for the local, night flight that originated at 1905 from Centennial Airport, Englewood, Colorado. The pilot had not filed a flight plan.

The pilot's wife said the purpose of his flight was to practice instrument approaches in preparation for an instrument proficiency check ride, for insurance purposes, on October 29, 2001. She said she was planning to fly with him as a safety pilot (which she frequently did), but on this day he wanted to fly alone. The pilot told her that he would not wear a visual restricting device (for instrument training), but "he would turn the cabin lights up bright" to restrict his external vision.

The Federal Aviation Administration (FAA) Denver TRACON (Terminal Radar Approach Control) voice tape indicates that the pilot said "I will be airborne for a couple of hours, and I'd like to practice various approaches." The controller told him to squawk 5230 (a VFR discreet code with no associated MSAW [minimum safe altitude warning] capability) and climb to 8,500 feet msl (mean sea level). He was then cleared to fly the full ILS (Instrument Landing System) approach to runway 35R. The pilot flew two complete ILS approaches; his first clearance was at 1918 and his second clearance was at 1936. During the first approach, the pilot came out of the procedure turn and flew through the localizer. He said to the controller, "I can't seem to get on the localizer." The controller assisted him with a heading of 020 degrees [or a 30 degree localizer intercept angle].

At 1946, the pilot requested to fly two turns in the holding pattern before flying a third approach; the controller cleared him to fly direct to Casse (the outer marker) and climb to 9,000 feet msl. At 1948, the controller conducted a position relief briefing and transferred position responsibility to the relieving controller. At 1950, the pilot was flying inbound on the first holding pattern and he departed his assigned altitude. Radar data indicates that he descended approximately 1,400 feet with no controller intervention. Next, the pilot requested to depart 15 nautical miles (nm) to the southeast to "get out of the way of the approach course for awhile." The controller cleared him, with no further instructions. The pilot requested an altitude of 8,500 feet; the controller cleared him for that altitude. No mention of visual flight rules (VFR) or changing his discreet transponder squawk were made by the controller.

At 2000:31, the radar data indicates that the airplane was west of the localizer (approximately 8 nm south of Casse) flying approximately 170 degrees, and made a 35 degree turn to the west towards rising terrain. Radar data indicates that this straight course was held for approximately 5 minutes, at which time radar contact was lost.

At 2300, the pilot's wife reported to local authorities that the airplane was overdue. A search was commenced, and the airplane was located at approximately 0730 the next morning.

PERSONNEL INFORMATION

The pilot took his last FAA flight medical exam (third class) on March 29, 2001, and at that time he reported on his application that he had 9,793 hours of flight experience, with 54 hours during the last 6 months. The pilot's wife reported that the pilot was instrument current per regulations; his personal flight logbook was never located. It could not be determined if he had a current flight review.

AIRCRAFT INFORMATION

The airplane was a twin engine, propeller-driven, five seat, pressurized cockpit, centerline thrust airplane, which was manufactured by Cessna Aircraft Company, in 1973. It was powered by two Teledyne Continental Motors TSIO-360-C5B, six cylinder, reciprocating, horizontally opposed, direct drive, air cooled, fuel injected, turbo-charged engines, which had a maximum takeoff rating of 210 horsepower at sea level. At the last annual inspection on November 11, 2000, the documented airframe total time was 5,498 hours. The front engine was installed on March 3, 1997, and was a zero time engine. It received an oil change on October 5, 2001, 86.5 hours since the last annual inspection; it had a total of 495 hours of operation. On October 5, 2001, the rear engine's oil was also changed; it had 1,140 hours since major over haul.

A Bill of Sale was located which indicated that the pilot purchased the airplane on September 29, 1981. The airplane manufacturer's records indicate that the airplane was fully equipped for instrument flight. The airplane's NAVCOM was a Bendix-King KX-175B with a KCS-55A Horizontal Situation Indicator (HSI) system. The manufacturer of this system said the d-bar polarity indicator (the ILS localizer signal indicator) does not reverse itself for back course approaches. They said "the correct procedure for flying a back course with the HSI is to set the Course Selector to the inbound front course approach bearing. The d-bar indication is always a fly-to the needle, never away from it."

The airplane was "topped off" with fuel on October 22, 2001; it received 80 gallons of avgas 100LL.

METEOROLOGICAL INFORMATION

At 1953, the weather conditions at Centennial Airport (elevation 5,883 feet), 020 degrees 18 nautical miles (nm) from the accident site, were as follows: wind 180 degrees at 7 knots; visibility 10 statute miles; cloud condition 12,000 feet few, 15,000 feet scattered, and 25,000 feet broken; temperature 55 degrees Fahrenheit; dew point 16 degrees Fahrenheit; altimeter setting 30.18 inches. At 1954, the weather conditions at the City of Colorado Springs Municipal Airport (elevation 6,184 feet), Colorado Springs, Colorado, 120 degrees 27 nm from the accident site, were as follows: wind 070 degrees at 7 knots; visibility 10 sm; cloud condition 12,000 feet few; temperature 54 degrees Fahrenheit; dew point 16 degrees Fahrenheit; altimeter setting 30.24 inches.

The moon was waxing gibbous with 82 percent of its visible disk illuminated; it rose at 1626.

AERODROME INFORMATION

Centennial Airport (elevation 5,883 feet), Englewood, Colorado, is a tower controlled field that has three runways, but only one precision instrument approach. The ILS (Instrument Landing System, 111.3 MHz) to runway 35R has an initial approach altitude of 8,000 feet msl (2,817 feet agl), to the outer marker (Casse). The final approach course is 347 degrees, the decision height is 6,083 feet msl, and the touchdown zone's elevation is 5,883 feet msl. The distance from Casse to the approach end of runway 35R is 6.3 nm.

WRECKAGE AND IMPACT INFORMATION

The airplane was found (N39 degrees, 10.46'; W104 degrees, 58.24'; elevation 8,512 feet) on a heavily forested mountain slope. The terrain was, at first impact, sloping up at approximately 20 degrees; the up slope condition leveled off and transitioned to a slightly down slope condition. The conifer trees were 40 to 60 feet in height. The longitudinal track through the trees was approximately 210 degrees, and was approximately 250 feet in length. The postimpact fire consumed much of the airplane, and it started a small forest fire.

All of the airplane's major components were accounted for at the accident site. The flight control surfaces were all identified. Impact damage and postimpact fire precluded any flight control cable continuity confirmation, or any documentation of cockpit controls, avionics, and instrumentation. The landing gear was found extended, and the wing flaps were in the up position.

The two engines were found lying in their respective positions, in relation to the fire consumed fuselage. The front engine was inverted, and forced back into its firewall. The propeller remained attached to the flange; rotation of the engine was not possible due to thermal damage. One blade was bent back around the engine and exhibited heavy longitudinal gouging with underlying chordwise scratching. The second blade was "S" bent, with leading edge damage. The rear engine was resting on its left cylinders, and its firewall was crushed around it. Crankshaft rotation was not possible, due to fire damage, and the propeller remained attached to its flange. One blade was bent aft and the other was bent forward, and both exhibited extensive thermal damage.

No preimpact engine or airframe anomalies, which might have affected the airplane's performance were identified.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was performed on the pilot by an independent forensic pathologist for the Douglas County Coroner's Office, Castle Rock, Colorado, on October 29, 2001.

The FAA's Civil Aeromedical Institute (CAMI) in Oklahoma City, Oklahoma, performed toxicology tests on the pilot. According to CAMI's report (#200100305001), the blood was tested for carbon monoxide, cyanide, volatiles (ethanols), and drugs, with negative results.

TESTS AND RESEARCH

The pilot had departed VFR and requested to do practice multiple instrument approaches with Denver Terminal Radar Approach Control. With the aid of ATC personnel (FAA Order 7110.65, paragraph 4-8-11) he flew two complete ILSs. After the second ILS, he requested from ATC to fly two turns in the published holding pattern, and then fly another ILS approach. The ATC controller cleared him to do this at 9,000 feet msl. During the inbound track (347 degree bearing) of the first holding pattern, radar data indicates the pilot descended approximately 1,300 to 1,400 feet without ATC controller intervention. The controller's responsibilities under these conditions are dictated under the definition of "Additional Services":

***"Advisory information provided by ATC which includes but is not limited to the following: traffic advisories; vectors, when requested by the pilot; altitude deviation information of 300 feet or more from an assigned altitude as observed on a verified automatic altitude readout (Mode C); advisories that traffic is no longer a factor; weather and chaff information; weather assistance; bird activity information and holding pattern surveillance."

***"Additional services are provided to the extent possible contingent upon the controller's capability to fit them into the performance of higher priority duties and on the basis of limitations of radar, volume of traffic, frequency congestion, and controller workload."

At 1957, the pilot requested to proceed 15 miles southeast at 8,500 feet. The ATC controller cleared him, but did not terminate radar services. FAA Order 7110.65, paragraph 7-6-1 (Basic Radar Services), and paragraph 2-6-1 (Safety Alerts) requires the controller to provide:

7-6-1

"Basic radar services are provided for VFR aircraft by all commissioned terminal radar facilities and include safety alerts, traffic advisories, and limited radar vectoring when requested by the pilot."

2-6-1

"Issue a safety alert to an aircraft if you are aware the aircraft is in a position/altitude, which, in your judgment, places it in unsafe proximity to terrain, obstructions, or other aircraft."

Radar data indicates that the pilot flew south approximately 8 nm, and then turned to approximately 210 degrees and flew directly into rising terrain, with no controller advisories.

The ATC controller's radar equipment (Automated Radar Terminal System IIIE) was equipped with Minimum Safe Altitude Warning (MSAW). To avoid excessive false alerts, FAA Order 7110.65, paragraph 5-15-7 permits the use of transponder code subsets that suppress the MSAW functionality for VFR aircraft unless the pilot requests the service. The pilot had not requested this service.

ADDITIONAL DATA

The airplane, including all components and logbooks, was released to a representative of the owner's insurance company on December 7, 2001.

NTSB Probable Cause

the pilot intentionally restricting his external vision (turning his cabin lights up bright to practice night instrument approaches), and his subsequent failure to maintain clearance of the mountain. A contributing factor was the Air Traffic Controller’s failure to provide appropriate safety alerts for rising terrain.