NTSB Factual Report

HISTORY OF FLIGHT

On December 6, 2002, about 1541 eastern standard time, a Raytheon 58 twin-engine airplane, N241JG, was destroyed when it departed controlled flight and impacted private homes in a residential area near Fort Myers, Florida. The airplane was registered to KC Services Inc., and operated by the pilot. Instrument meteorological conditions prevailed at the time and an instrument flight rules (IFR) flight plan was filed for the 14 CFR Part 91 personal cross-country flight. There were no injuries to anyone on the ground. The instrument-rated private pilot and one passenger were fatally injured. The flight departed from Centerville, Alabama, about 1220 (1120 central standard time).

The flight had originally departed from Rosecrans Memorial Airport (KSTJ), St. Joseph, Missouri, at 0903 (0803 central standard time), en route to Naples, Florida, with an intermediate fuel stop at the Centerville Airport (0A8), Centerville, Alabama. While in Centerville, the pilot contacted the Anniston Flight Service Station (FSS) and filed the IFR flight plan to Naples and obtained an abbreviated weather briefing for the flight. According to the filed flight plan, the pilot intended to fly at 200 knots at 7,000 feet. His planned route had him going from 0A8 to SZW (Seminole, Florida), CTY (Cross City, Florida), PIE (St. Petersburg, Florida), SRQ (Sarasota, Florida), and ending in APF (Naples, Florida). According to the pilot's family, the pilot did not want to fly direct because the airplane was not equipped for extended operations over water. According to the pilot's flight plan, he estimated the flight would last 2 hours and 30 minutes and he had 4 hours and 15 minutes of fuel on board. The pilot did not file an alternate destination. After departure from 0A8 the flight proceeded to Naples without incident.

Aircraft radar data was obtained from the Federal Aviation Administration's (FAA) terminal radar approach control located at Southwest Florida International Airport (RSW), Fort Meyers, Florida. The facility is equipped with an Airport Surveillance Radar-8 radar system, which supplies data to an Automated Radar Terminal System (ARTS) model IIE at RSW. Radar targets for the accident airplane were recorded by the ARTS from 1434 to 1540. Transcripts of the pilot's communications with air traffic controllers were also obtained. The pilot attempted four instrument approaches (one at Naples, and three at Fort Meyers Page Field) prior to the accident. A NTSB air traffic control specialist overlayed the aircraft's radar data onto the various approach plates to provide a bird's-eye view of the airplane's flight track in relation to the final approach courses. The following is a summary of the aforementioned radar data and communications.

Approach #1 (1440 to 1510)

At 1440:05, the pilot contacted the Southwest Florida International Air Traffic Control (ATC) departure facility and informed the controller that they were at 7,000 feet. The controller provided the altimeter setting (30.06 inches of mercury) and asked the pilot to report when he had ATIS (automatic terminal information services) Sierra for Naples. He also informed the pilot he could expect the VOR (very high omni-directional range navigation aid) Runway 23 approach with a circle to land on runway 32. At 1441:28, the pilot called back and informed the controller he had ATIS information Sierra and confirmed the approach information.

At 1444:52, the controller made a general radio announcement to all aircraft indicating ATIS information Tango was current at Naples. He then provided the updated weather, which at the time was reported as visibility two statute miles in light rain and mist with an overcast ceiling of 500 feet above ground level (agl). The wind was from 320 degrees at 7 knots and the altimeter setting was 30.04 inches of mercury. The controller informed all aircraft to expect the VOR runway 23 approach with a circle to land runway 32 at Naples.

At 1446:01, the controller cleared the airplane direct to Naples and to descend to 5,000 feet. At 1447:22, the controller provided the pilot with a vector of 190 degrees for the VOR 23 approach. At 1450:44, the controller instructed the pilot to switch to Fort Meyers control (Southwest Florida International ATC south radar position) on another frequency after providing him a vector of 180 degrees.

Once the pilot switched frequencies, that controller instructed the pilot to descend to 3,000 feet and to fly a heading of 130 degrees for sequencing. At 1456:58, the controller provided the pilot with a vector of 180 degrees and informed the pilot to "expect vectors across the final approach course for sequence" to which the pilot acknowledged. The controller then informed the pilot to expect vectors back toward the final approach in five miles, to which he responded, "I'll be waiting." At 1459:43, the controller gave the pilot a vector of 330 degrees and asked him to descend to 2,000 feet. At 1501:25, the controller provided the pilot a left vector to 270 degrees to join the VOR 23 approach. Thirty five seconds later, the controller asked the pilot to reduce his final approach speed and informed him he was 12 miles from the airport. He instructed the pilot to maintain 2,000 feet until he was established on final approach and cleared him for the VOR 23 approach circle to land runway 32. The pilot acknowledged and reported he was established. At 1502:16, the controller informed the pilot that two aircraft went missed on their approaches and one Piper Comanche just landed and a Westwind was ahead of his flight. One minute and 40 seconds later, the controller informed the pilot that the Westwind conducted a missed approach, and his radar services were terminated. He then instructed the pilot to switch frequencies to the Naples control tower, which he did.

Examination of the aircraft's radar data for that approach revealed the pilot flew through the final approach (radial 055 from the Cypress VOR) about eight miles from the VOR. The aircraft's track then paralleled the final course on the northwest side of the course starting about four miles out. The aircraft remained on that parallel track until it passed the VOR where the pilot initiated the missed approach. The radar data for that approach indicates that the aircraft descended to about 500 feet (the minimum descent altitude for the VOR 23 approach circle to land was 500 feet).

Approach #2 (1511 to 1527)

Upon conducting the missed approach at Naples, the pilot contacted the Southwest Florida International ATC departure facility and requested to divert to Page Field, Fort Meyers, Florida (located 26.5 nautical miles north of Naples). The controller then provided radar vectors to Page Field and cleared the pilot back up to 3,000 feet. At 1513:37, the controller provided Page Field's weather information, which was reporting the wind from 020 degrees at 13 knots, visibility 3 statute miles in light rain and mist, an overcast ceiling at 300 feet, and an altimeter setting of 30.06 inches of mercury. At 1515:05, the controller transferred the pilot to Fort Myers approach control.

At 1522:22, the approach controller informed the pilot he was five miles from Caloo (the locator outer marker and initial approach fix for the instrument landing system [ILS] runway 5). He was given a vector of 030 degrees and told to maintain 2,000 feet until established on the localizer and was cleared for the ILS runway 5 approach. The pilot acknowledged the clearance. At 1523:26, the pilot was instructed to contact the control tower.

The pilot then contacted Fort Meyer's control tower and was cleared to land. The controller asked the pilot whether he was established on the approach, to which the pilot responded "yeah, I'm not quite established yet. I'm comin up on Caloo, but I'm not actually on the glide slope yet. Looks like I should intercept it here in just about a minute." The controller then informed the pilot that most of the other airplanes had been breaking out of the cloud bases around 300 feet and they were reporting 3 statute miles visibility in light rain and mist.

At 1526:15, the controller called the pilot, and the pilot responded with, "yeah, I missed it. Uh, I'm going back up to two thousand and uh can you bring me back around?"

Review of the aircraft's radar data for that approach revealed the airplane tracked toward the ILS on an approximate 030 degree heading and intercepted the localizer (231-degree radial) about one mile outside (southwest of) Caloo. The airplane maintained that 030-degree track for about another mile before it turned back toward the localizer. The airplane's track then paralleled the final course for about one mile before it made a teardrop turn to the right before rolling out on a westerly heading (making a turn to reverse course). It was at this point that the controller called the pilot. This all took place within 2.5 miles of Caloo. During the course reversal, the airplane track was observed descending from 1,100 feet (lowest point during the parallel leg of the inbound portion), to a low of 200 feet (as the airplane's track made the right turn to the west).

At 1526:24, the tower controller began coordinating with the approach controller regarding N241JG's status. The tower controller informed the approach controller that the pilot initiated a turn outbound on his own and asked on what heading the approach controller wanted N241JG. At 1526:54, the tower controller instructed the pilot to fly a heading of 270 degrees, maintain 2,000 feet and contact the approach controller. The tower controller then informed the pilot that he needed to let someone know if he was going to initiate a missed approach.

Approach #3 (1528 to 1535)

At 1528:02, the approach controller asked the pilot for his intentions. The pilot responded by stating he would like to try the ILS for runway 5 again. The controller provided another vector toward the south and the localizer frequency, to which the pilot responded that he had it.

At 1530:09, the controller instructed the pilot to fly a heading of 080 degrees and maintain 2,000 feet until he was established on the localizer. He also informed the pilot that he was about three miles from Caloo. At 1531:01, the controller informed the pilot that he was "just about ready to be established sir." Nine seconds later the controller informed the pilot he was going left of course and asked if he was picking up the localizer, to which the pilot responded he was "through the localizer." The controller asked if he was not receiving the localizer or if the pilot was just getting on it right now. The pilot answered he had flown through the localizer. However, the radar data depicted the airplane's track flying southeast toward the localizer, but turning toward the northeast (parallel to the course). The airplane never crossed over the final course. The track diverted from the course further, but then paralleled the final course for a few miles. At 1531:33, the controller instructed the pilot to turn to a heading of "070 [degrees] and reintercept. Your over the marker now." The pilot responded by repeating the heading and stating "I'm on it now." The airplane's track displayed it turning toward the final course. However, before the airplane's track met that of the localizer, the airplane made a left teardrop shaped turn, reversing its course. The controller asked the pilot to inform him when he had the localizer "locked" but received no response, he then asked the pilot to confirm whether he was on the localizer. The pilot stated, "Sir, I'm having very big difficulties out here. I've gone through it again and I'm climbing back to 2,000." The lowest the airplane got on this attempt was 1,400 feet, which occurred while in the teardrop shaped turn.

The controller informed the pilot that the approach clearance was cancelled and instructed him to fly a heading of 310 degrees. He then informed the pilot to "just fly straight...ahead sir, fly straight ahead." The pilot asked if the controller wanted him on a 310-degree heading, to which the controller responded, "fly straight ahead. Just whatever heading you have now. Maintain 2,000 feet." The controller then informed the pilot to expect radar vectors the ILS runway 5 approach.

At 1533:24, the controller asked the pilot what his fuel status was, to which the pilot responded, "it's down in the yellow." The controller asked the pilot how much that was in time and the pilot responded "practically nil." The controller acknowledged and asked the pilot to turn to a heading of 300 degrees. He then asked the pilot to report his flight weather conditions, to which the pilot stated, "I'm above the clouds at the moment turning two one oh over to 300."

The controller informed the pilot that he could set him up for the NDB (non-directional beacon) approach, but the minimum descent altitude was higher. The pilot said no, and that he was trying to fly the approach, "with my automatic" and he was going to "have to fly it manual. I've got some kind of instrument problem."

Approach #4 (1535 to 1540)

At 1535:38, while the airplane was flying a southern track, the controller informed the pilot that he was going to turn him onto a base leg and would monitor his progress. He also informed the pilot that he was four miles from Caloo, gave the pilot a vector of 040 degrees, and cleared him for the ILS runway 5 approach. Following this communication, the approach controller contacted Fort Meyer's control tower and asked what the weather was at the airport. The tower controller informed the approach controller that the visibility was three statute miles and that most of the airplanes are breaking out of the cloud bases around 300 feet, which is what the tower was reporting the cloud bases.

At 1536:51, the controller informed the pilot that he was flying through the localizer again and suggested he turn right to a heading of 060 degrees to recapture the localizer. Nine seconds later, the controller instructed the pilot to descend and maintain 1,500 feet and informed him he was over the outer marker and he was going to initiate the pilot's descent early. At 1537:18, the pilot repeated the clearance.

At 1537:33, the controller instructed the pilot to fly a heading of 050 degrees and informed the pilot that he was going to convert the ILS approach to a surveillance approach to runway 5. He informed the pilot that the published missed approach point was one mile from the runway threshold and the minimum descent altitude was 500 feet. At 1538:01, the approach controller instructed the pilot to fly a heading of 070 degrees and descend and maintain 900 feet, and informed the pilot he was 3.5 miles from the runway and "very slightly left of course."

The controller provided additional vectors and altitudes bringing the airplane down to 500 feet along the final course at the missed approach point. The controller cleared the pilot to land if he could see the runway; however, he also provided missed approach instructions (climb straight ahead to 2,000 feet) in the event the pilot could not see the runway environment.

At 1539:20, the controller informed the pilot that he was less than a mile from the threshold at an indicated altitude of 300 feet. He instructed the pilot that if he did not see the runway, to go around.

The radar data depicted the airplane on course for the last three miles of the approach. The airplane's altitude descended to 300 feet near the runway threshold. The airplane's track over flew the runway as the altitude increased to 600 feet. As the airplane's track neared the end of the runway, the airplane began a left turn and another descent to 300 feet.

At 1539:52, the controller informed the pilot that he had radar contact with his aircraft and he was to maintain 1,500 feet if he could. At, 1540:12, the controller asked the pilot how he could hear him, to which the pilot responded, "I hear ya." The controller then instructed the pilot to climb and maintain 1,500 feet and fly a heading of 180 degrees. The radar data depicted the airplane track straighten along a southe

NTSB Probable Cause

the pilot's spatial disorientation during instrument meteorological conditions, which resulted in his failure to maintain aircraft control. Contributing factors included the pilot's distraction to the low fuel status and the low cloud conditions.