NTSB Factual Report

HISTORY OF FLIGHT

On November 27, 2000, at about 1650 central standard time (cst), a Piper PA-28R-180, N4541J, piloted by a private pilot, was destroyed on impact with terrain about 6 nautical miles and 030 degrees magnetic from the Vermillion County Airport (DNV), Danville, Illinois. The aircraft had been cleared for the ILS approach to runway 21 at DNV. The 14 CFR Part 91 personal flight was on an instrument flight rules flight plan and was operating in instrument meteorological conditions. The pilot and three passengers received fatal injuries. The flight originated from the Maury County Airport, Mount Pleasant, Tennessee at about 1400 cst.

PERSONNEL INFORMATION

The pilot was the holder of a private pilot certificate with single engine land and instrument airplane ratings. He was also the holder of a second-class aviation medical certificate issued on December 28, 1998.

According to the pilot's logbook, he had accumulated the following flight times as of the last entry dated November 19, 2000:

Total Time 499.8 Pilot in Command 440.6 Single-Engine Land 499.8 Night 68.2 Actual Instrument 40.3 Simulated Instrument 71.3

The logbook indicates that the pilot accumulated 1.3 hours simulated instrument flight time and 0.9 hours of actual instrument flight time within the 6 months preceding the accident. The logbook entry dated November 11, 2000 indicates that the pilot accumulated 1.0 hours simulated instrument flight time with a safety pilot, 1.4 hours total flight time, 3 landings, and 6 instrument approaches. No logbook entry was found to indicate that the holding procedures requirements listed in FAR 61.57 (c) were performed. The flight dated November 11, 2000 was performed in the accident airplane.

FAR 61.57 (c) states: 61.57 (c) Instrument experience. Except as provided in paragraph (e) of this section, no person may act as pilot in command under IFR or in weather conditions less than the minimums prescribed for VFR, unless within the preceding 6 calendar months, that person has: (1) For the purpose of obtaining instrument experience in an aircraft (other than a glider), performed and logged under actual or simulated instrument conditions, either in flight in the appropriate category of aircraft for the instrument privileges sought or in a flight simulator or flight training device that is representative of the aircraft category for the instrument privileges sought - (i) At least six instrument approaches; (ii) Holding procedures; and (iii) Intercepting and tracking courses through the use of navigation systems.

A written endorsement within the pilot logbook indicates that the pilot completed the flight review requirements of FAR 61.56 on October 09, 1999.

A review of FAA records shows that the pilot received two disapprovals prior to the issuance of his private pilot certificate on August 03, 1995. The records also show that the pilot received 3 disapprovals prior to the issuance of his instrument rating on June 16, 1997.

The first disapproval notice for the instrument rating, dated March 06, 1997, indicated the following items for reexamination:

Preflight preparation - Cross-country flight planning

The second disapproval notice for the instrument rating, dated April 04, 1997, indicated the following items for reexamination:

Flight by reference to instruments - Steep turns Flight by reference to instruments - Recovery from unusual flight attitudes Instrument approach procedures - Precision ILS instrument approach Instrument approach procedures - Missed approach

The third disapproval notice for the instrument rating, dated May 13, 1997, indicated the following items for reexamination:

Flight by reference to instruments - Change of airspeed Flight by reference to instruments - Constant airspeed climbs and descents Flight by reference to instruments - Rate climbs and descents Flight by reference to instruments - Steep turns Instrument approach procedures - Precision ILS instrument approach Instrument approach procedures - Missed approach

AIRCRAFT INFORMATION

The airplane was a Piper PA-28R-180, serial number 28R-30400. A Lycoming IO-360-B1E engine that produced 180 horsepower powered it. The aircraft logbooks indicate that the last annual inspection was performed on January 22, 2000. At the time of the accident, the airframe had accumulated 8,363.9 hours time in service. The engine had accumulated 328.5 hours time in service since it's last major overhaul on December 18, 1996. The airframe logbook indicates that the most recent altimeter, static and transponder inspection, as required by FAR 91.411, was performed on September 05, 1998.

FAR 91.411 states: 91.411 Altimeter system and altitude reporting equipment tests and inspections. (a) No person may operate an airplane, or helicopter, in controlled airspace under IFR unless - (1) Within the preceding 24 calendar months, each static pressure system, each altimeter instrument, and each automatic pressure altitude reporting system has been tested and inspected and found to comply with appendix E of part 43 of this chapter

METEOROLOGICAL INFORMATION

The weather reporting station located at DNV recorded the following:

Time 2245 UTC (1645 cst) Wind direction 240 degrees magnetic Wind speed 8 knots Visibility 5 statute miles Ceiling 500 feet, overcast Temperature 29 degree Fahrenheit Dewpoint 29 degree Fahrenheit Altimeter setting 29.98 inches of mercury

COMMUNICATIONS

The aircraft was in communication with the Champaign, Illinois, Air Traffic Control Tower, East Radar position (ER). The following excerpts are from transcripts of the recorded conversations between ER and N4541J. All times listed below are UTC. The full transcripts are appended to this report.

2223:59 N4541J five four juliet with you at four

2224:01 ER november four one juliet champaign approach altimeter two niner niner five

2224:05 N4541J altimeter two niner niner five

2234:57 ER november four one juliet fly heading three six zer zero vector i l s two one approach

2235:05 N4541J three six zero

2235:08 ER november four one juliet affirmative three six zero for the heading

2235:11 N4541J roger three six zero for four one juliet

2235:41 ER november four one juliet descend and maintain three thousand

2235:45 N4541J roger four one juliet descend and maintain three thousand

2236:09 ER arrow four five four one juliet advise you have danville weather

2236:16 N4541J four one juliet has the danville weather

2236:21 ER november four one juliet thank you

2236:51 ER November four one juliet turn right heading zero correction turn right heading one zero zero

2236:57 N4541J repeat one zero zero four one juliet

2238:21 ER arrow four one juliet eight miles form julip turn right heading one eight zero maintain three thousand till established on the localizer cleared i l s runway two (unintelligible) two one approach

2238:36 ER arrow four one juliet eight miles form julip fly heading one eight zero maintain three thousand till established on the localizer cleared i l s runway two --- runway two one approach

2238:54 ER arrow four one juliet champaign approach

2239:35 ER arrow four one juliet if you hear this transmission ident

2240:10 ER arrow four one juliet report cancelling your i f r on the ground through one two one point seven change to advisory approved if you understand this transmission ident

2241:24 ER arrow four one juliet if you show your self established on the approach ident

2241:38 ER arrow four one juliet change to advisory approved report canceling i f r on the ground via one two one point seven

2242:54 ER arrow four one juliet change to advisory approved report canceling i f r on the ground via one two one point seven reply with an ident

No further transmissions were received from N4541J

WRECKAGE AND IMPACT INFORMATION

The wreckage location was obtained using a Global Positioning System (GPS) receiver and was found to be 40-degrees, 17-minutes, 2.9-seconds north latitude, 87-degrees, 31-minutes, 54.5-seconds west longitude.

A postaccident examination of the aircraft was conducted on November 28, 2000. The aircraft impacted in a level farm field. The wings and tail surfaces remained attached to the wreckage. The fuselage was oriented on a 265-degree magnetic heading. The leading edge of both wings exhibited leading edge crushing at an angle approximately 45 degrees relative to the longitudinal axis of the airplane. Both fuel tanks were ruptured. The flight control system was examined and was found to exhibit continuity from the control surfaces to the cockpit. The control surfaces remained attached to their respective surface and all hinges were intact. The landing gear was found to be in the extended position. The flap position was not able to be determined due to the amount of damage in the cabin area. The fuselage from the aft end of the cabin area forward was crushed and the cabin roof was separated from the fuselage.

The aircraft engine was removed from the airframe and examined at the accident scene. The engine is a Lycoming IO-360-B1E serial number L-4579-51A. The engine was rotated and exhibited crankshaft, valve train and accessory drive gear continuity. "Thumb" compression was established for all cylinders. Both magneto's were separated from the engine due to impact forces. Both magneto's produced spark on all leads when rotated by hand. The upper set of spark plugs was removed and no anomalies were noted. The mechanical fuel pump was broken loose from its mount and the plunger arm. The engine driven vacuum pump was found broken loose from its mount. The vacuum pump was a Sigma Tek, part number 1U128B, serial number T 28262E. The vacuum pump was disassembled and the rotor and vanes were found intact. The fuel injection servo was broken loose from its mount. The throttle and mixture linkages on the fuel servo were bent and smashed. The inlet screen was removed from the fuel injection fuel servo and was found to be clean. The fuel injection flow divider was disassembled and no anomalies were noted. A fluid consistent with aviation gasoline was found in the fuel selector valve, mechanical driven fuel pump, fuel injection servo, fuel injection flow divider and fuel lines.

No anomalies were found with respect to the airframe or engine that could be associated with a preexisting condition.

MEDICAL AND PATHOLOGICAL INFORMATION

Autopsies were performed, on the two front seat occupants, in Bloomington, Illinois on November 28, 2000, on behalf of the Vermillion County Coroner.

The FAA prepared a Final Forensic Toxicology Fatal Accident Report on the pilot. The results were negative for all tests performed.

TESTS AND RESEARCH

Radar data for the accident flight was obtained and examined. The radar data along with the voice transcripts show that the aircraft was given a right turn to a 180-degree heading to intercept the ILS 21 approach to DNV. The data further shows that the aircraft turned left prior to intercepting the localizer course. The aircraft proceeded through the localizer course before commencing a right turn to intercept the 209-degree approach bearing. The data indicates that when the aircraft was about 9.6 nautical miles from the localizer antenna, it was about 0.7 miles left of the localizer course.

The aircraft altitude returns from the radar data were plotted against a standard 3-degree glide slope. The plot indicates that the aircraft remained below the 3-degree glide slope path during the approach. The last radar return shows that the aircraft was about 400-feet below the standard 3-degree glide slope. The aircraft wreckage was located about 0.3 nautical miles and 196 degrees from the ILS outer marker antenna. A full report of the examination of the radar data is appended to this report.

ADDITIONAL INFORMATION

The wreckage was released to an insurance company representative on January 18, 2001.

The FAA Flight Standards District Office, Springfield, Illinois, Textron Lycoming, and The New Piper Aircraft were parties to the investigation.

NTSB Probable Cause

The pilot's failure to maintain altitude/clearance during the instrument approach. Factors were the low ceilings, the pilot's failure to maintain proper alignment and glidepath during the approach, his lack of recent instrument experience, and his failure to perform the missed approach.