NTSB Factual Report

HISTORY OF FLIGHT

On October 24, 2000, at 2010 eastern daylight time (edt), a Piper PA-28R-200, N15900, owned and piloted by a private pilot, was destroyed during an in-flight collision with trees and subsequent collision with terrain while executing the Instrument Landing System (ILS) runway 9 approach to the Otsego County Airport (GLR), Gaylord, Michigan. Instrument meteorological conditions prevailed at the time of the accident. The business flight was operating under the provisions of 14 CFR Part 91 on an instrument flight plan. The pilot and his single passenger were fatally injured. The flight departed the Gerald R. Ford International Airport, Grand Rapids, Michigan, at 1856.

According to a Federal Aviation Administration (FAA) Air Traffic Control (ATC) accident report, the accident airplane was issued vectors to intercept the final approach course for the ILS runway 9 approach to GLR. The accident airplane was cleared for the ILS runway 9 approach and the pilot was instructed to cancel his flight plan through another airplane, a Piper Navajo (N59815), which was holding at the Gaylord VHF omni-directional range/distance measuring equipment (GLR VOR/DME). The GLR VOR/DME is located within the airport's perimeter and provides navigation assistance for visual and instrument flight operations.

Aircraft radar track data for the period before and after the reported accident time was obtained from the FAA. The aircraft radar track data was plotted using commercial software. The plot is appended to this factual report along with a copy of the source data.

According to the supplied radar track data, the accident airplane's first radar return was a reinforced discrete beacon code 12.235 nautical miles (nm) southwest of GLR at 2001:29 (hhmm:ss). The radar track data indicated the airplane continued heading north until 2005:05 when a right turn was initiated. The last radar return was recorded 7.631 nm west of GLR. The wreckage was located approximately 3 nm west-northwest of GLR.

PERSONNEL INFORMATION

The pilot held a private pilot certificate with ratings for airplane single engine land and instrument airplane operations. The pilot's last medical examination was conducted on June 16, 1999, and he was issued a third-class medical certificate with the limitation, "Must wear corrective lenses."

According to the pilot's flight logbook, the pilot had a total flight time of 918.2 hours, all of which were in single engine land airplanes. The pilot's last biennial flight review, as required by Federal Aviation Regulation (FAR) 61.56, was completed on August 18, 1998.

The pilot had logged a total of 60.9 hours in actual instrument meteorological conditions (IMC) and 69.3 hours as simulated IMC. The pilot's last recorded instrument proficiency check (IPC) was completed on April 17, 1998. The pilot's last recorded holding procedure was completed on August 18, 1998. During the 6 month period following the last IPC the pilot logged 8 approaches and 1 holding pattern. Between August 18, 1998, and February 18, 1999, the pilot logged 6 approaches and 1 holding pattern. Between February 18, 1999, and August 18, 1999, the pilot logged 4 approaches and no holding patterns. The pilot did not record an IPC subsequent to August 18, 1999. During the 6 month period prior to the accident, the pilot logged 9 instrument approaches and no holding procedures.

The pilot logged 57.0 hours in the last 90 days, all of which were in the accident airplane. During the last 90 days the pilot recorded 7.6 hours in actual IMC and 6 instrument approaches.

The pilot logged 41.9 hours in the last 60 days, during which time he recorded 4.4 hours in actual IMC and 3 instrument approaches.

The pilot logged 17.3 hours in the last 30 days, during which time he did not record any instrument time or instrument approaches.

There were no flight logbook entries within 24 hours of the accident.

AIRCRAFT INFORMATION

The airplane was a Piper PA-28R-200, serial number 28R-7335103. The Piper PA-28R-200 is a low-wing monoplane of all metal construction and is equipped with a constant-speed propeller, wing flaps, and retractable landing gear. The PA-28R-200 can accommodate a pilot and up to three passengers.

The airplane was issued a Standard Airworthiness Certificate on December 27, 1972, and was certified for normal category operations. The airframe had accumulated a total flight time of 5,358.40 hours. The last annual inspection was performed on April 1, 2000, and the airplane had accumulated 117.66 hours since the inspection.

According to the maintenance logbooks, the last transponder test, as required by FAR 91.413, was completed on September 18, 1998.

According to the maintenance logbooks, the last altimeter system test, as required by FAR 91.411, was completed on January 19, 1995.

The last recorded VOR equipment check, as required by FAR 91.171, was completed on August 9, 1994.

The engine was a 200 horsepower Textron Lycoming IO-360-C1C, serial number L-6235-51A. The engine had accumulated 1,584.90 hours since the last major overhaul, which was completed on April 9, 1985. The last inspection of the engine was on April 1, 2000, and the engine had accumulated 117.66 hours since the inspection.

The propeller was a two-bladed Hartzell HC-C2YR-1BF, serial number CH11457.

METEOROLOGICAL INFORMATION

An Automated Surface Observing System (ASOS), located at the Otsego County Airport, Gaylord, Michigan, recorded the weather as follows:

Observation Time: 2001 edt

Wind: 330 degrees magnetic at 4 knots

Visibility: 1/2 statute mile with fog

Sky Condition: Overcast layer at 200 feet above ground level (agl)

Temperature: 11 degrees Celsius

Dew Point: 11 degrees Celsius

Pressure: 30.35 inches-of-mercury

Observation Time: 2010 edt

Wind: Variable direction at 3 knots

Visibility: 1/4 statute mile with fog

Sky Condition: Vertical visibility 100 feet agl

Temperature: 11 degrees Celsius

Dew Point: 11 degrees Celsius

Pressure: 30.35 inches-of-mercury

At 1841 edt a pilot representing the accident airplane contacted the Lansing Automated Flight Service Station (AFSS) and requested a weather briefing. The AFSS briefer issued a standard weather briefing and at the completion of the weather briefing the pilot filed an IFR flight plan. According to a memorandum provided by the FAA, "All services provided by Lansing AFSS were normal and there were no pertinent transmissions."

AIDS TO NAVIGATION

On October 25, 2000, the ILS runway 9 approach to GLR was flight tested by the Battle Creek Flight Inspection Field Office. According to the Flight Inspection Report, the ILS runway 9 approach was fully operational and tested satisfactory. The Flight Inspection Report is appended to this factual report.

COMMUNICATIONS

The voice transmissions between the accident aircraft (N15900), Minneapolis Air Route Traffic Control Center (ZMP-ARTCC), and the holding airplane (N59815) were transcribed in part as follows:

1951:22 (hhmm:ss)

ZMP-ARTCC: november one five niner zero zero descend maintain three thousand five hundred

1951:25

N15900: out of six three point five nine zero zero

1951

1952

1953

1954

1955

1956

1957

1957:01

ZMP-ARTCC: november one five niner zero zero turn further ten degree left

1957:06

N15900: ten degrees left nine zero zero

1957:40

ZMP-ARTCC: november one five niner zero zero maintain three thousand two hundred please

1957:46

N15900: three point two nine zero zero

1957:49

ZMP-ARTCC: and what is your new heading going to be once your turn further left

1957:52

N15900: fifteen degrees nine zero zero

1957:52

ZMP-ARTCC: okay make the heading of zero zero five please for nine zero zero

1957:51

N15900: zero zero five nine zero zero

1958

1959

2000

2001

2002

2003

2004

2004:38

ZMP-ARTCC: november one five niner niner zero zero you're three from bangu right heading zero six zero maintain three thousand two hundred until established on localizer cleared i l s nine approach to gaylord airport

2004:48

N15900: okay zero three zero ah cleared on the i l s zero niner Gaylord three thousand until established nine zero zero

2004:54

ZMP-ARTCC: november nine zero zero fly heading zero six zero and ah cleared for approach

2004:59

N15900: zero six zero niner zero zero

2005

2005:37

ZMP-ARTCC: november one five niner zero zero change to advisory frequency is approved and try and cancel through a five niner eight one five he's right on top of you ah outbound in the holding

2005:53

ZMP-ARTCC: november niner zero zero change to advisory frequency approved relay your down time through a ah five niner eight one five if I don't hear ya he's above waiting to get in

2006:00

N15900: yeah we got him in sight we'll stay with you for a bit nine zero zero

2007

2008

2009

2010

2011

2012

2012:06

ZMP-ARTCC: november eight one five did you hear from nine zero zero yet he should be ah should be touching down any second

2012:11

N59815: negative i haven't heard anything from him

2013

2014

2014:41

ZMP-ARTCC: november eight one five wanta go over to unicom real quick and see if one five niner zero zero is on the ground he should be down by now

2014:46

N59815: alright stand by one

2015

2016

2016:33

ZMP-ARTCC: november eight one five did you hear from him at all

2016:44

N59815: eight one five negative ah unicom hadn't from him either

2016:47

ZMP-ARTCC: okay he should have been down a couple of minutes ago expect further clearance at zero zero two five [2025 edt] now for november five niner eight one five

2016:54

N59815: zero zero two five eight one five

2017

2018

2018:18

ZMP-ARTCC: november eight one five unicom hadn't heard from him at all if you would go back over to frequency ah over to Unicom there and see if they can ah scare him up otherwise we'll have our guys um call and see if we can find him here and expect further clearance at ah zero zero four zero [2040 edt] now

2018:34

N59815: okay further clearance zero zero four zero and we'll call unicom again

2018:37

ZMP-ARTCC: okay thanks

2019

2019:41

N59815: minneapolis center navajo five niner eight one five

2019:43

ZMP-ARTCC: november eight one five go ahead

2019:45

N59815: yeah unicom still hadn't heard anything from this guy ah they said they said they had one guy that ah thought they ah might of heard him call but ah they can't confirm whether he's on the ground nobody's seen him

2019:56

ZMP-ARTCC: okay ah very good we have our people calling up there right now as well but ah he should a he he understood that he was supposed to relay through you so ah i'm starting to get a little concerned about where he is so well keep calling in if you hear anything in the interim let me know

2020:09

N59815: ya we'll do we may not be able to get in here anyway so we'll let you know what the plan is

The entire ATC transcript is appended to this factual report.

A review of the certified rerecording of the voice transmissions shows that ZMP-ARTCC did not issue the current weather conditions to the pilot or verify that the pilot had the current weather conditions prior to issuing the clearance for the ILS runway 9 approach.

WRECKAGE AND IMPACT INFORMATION

The wreckage was located in a heavily wooded planned forest of pine-trees near the city of Gaylord, Michigan. A global positioning system (GPS) receiver recorded the position of the main wreckage as 45-degrees 01-minutes 31.02-seconds north latitude, 84-degrees 46-minutes 17.58-seconds west longitude. The initial impact was at 45-degrees 01-minutes 29.52-seconds north latitude, 84-degrees 46-minutes 20.82-seconds west longitude. The wreckage was located 0.66 nautical miles (nm) left of the ILS runway 9 course centerline and 2.44 nm from the runway threshold. All major airframe components were located along a debris field that was approximately 280 feet in length and orientated on a 070 degree magnetic heading. Along the debris field there were multiple portions of severed tree material.

The fuselage was resting against a tree and was canted approximately 35 degrees to the left. The main cabin and instrument panel was destroyed. The nose landing gear was in an extended position. Both main landing gear were separated from their respective wings and were located along the wreckage debris field.

Both wings were separated from the fuselage and found along the wreckage debris field. The upper skins of both wings had semicircular crush marks that were oriented along the wing's chordline. The semicircular crush marks were the same average diameter as trees near the location of the accident. Aileron control continuity could not be established due to damage. All aileron control cable breaks were consistent with tension overload.

The vertical stabilizer remained attached to the fuselage and the rudder remained partially attached to the vertical stabilizer. The right side of the horizontal stabilator remained attached to the fuselage. The left side of the horizontal stabilator was separated from the fuselage at the root. The leading edge of the entire horizontal stabilator had semicircular crush marks that were perpendicular to the leading edge. Horizontal stabilator and rudder control cable continuity was established from the control surfaces to the main cabin.

The engine remained partially attached to the airframe and was bent approximately 45 degrees to the left. Engine crankshaft and valve train continuity was established by rotating the crankshaft through the accessory gear section. There was thumb compression on all cylinders. There was fuel in the fuel flow divider and the fuel line leading to the fuel flow divider. The left magneto produced spark on all leads when the engine crankshaft was rotated. The right magneto produced spark on all leads when rotated by hand. The vacuum pump was removed and disassembled. The vacuum pump drive and vanes were intact.

The propeller was separated from the engine. The propeller blades had chordwise scratching, leading edge damage, and S-shape bending.

No anomalies were found with the airframe, flight controls, propeller, and engine that could be associated with a pre-impact condition.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was performed on the pilot at the Nelson Funeral Home, Gaylord, Michigan, on October 25, 2000.

A Forensic Toxicology Fatal Accident Report was prepared by the FAA Civil Aeromedical Institute, Oklahoma City, Oklahoma.

The toxicology results for the pilot were:

* No Ethanol detected in Urine

* No Drugs detected in Urine

TESTS AND RESEARCH

The avionics from the accident airplane were removed and bench tested. The VOR/Localizer/Glideslope Indicator was operational. The localizer function was within calibration specifications. The glide slope function indicated one-dot high with a centered signal input. The VOR/Localizer Indicator was operational. The localizer function was within calibration specifications. The VOR function had a 6 degree error. Both Nav/Com receivers were operational. The marker beacon receiver was operational and was within specifications. The automatic direction finder was operational. The DME system was operational.

ADDITIONAL DATA/INFORMATION

According to 14 CFR Part 61.56, "Flight Review":

(c) Except as provided in paragraphs (d), (e), and (g) of this section, no person may act as pilot in command of an aircraft unless, since the beginning of the 24th calendar month before the month in which that pilot acts as pilot in command, that person has -

(1) Accomplished a flight review given in an aircraft for which that pilot is rated by an authorized instructor; and

(2) A logbook endorsed from an authorized instructor who gave the review certifying that the person has satisfactorily completed the review.

According to 14 CFR Part 61.57, "Recent Flight Experience - Pilot-In-Command":

(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 t

NTSB Probable Cause

The pilot not maintaining proper glideslope and localizer alignment during the precision instrument approach, the pilot continuing flight below the decision height, the pilot not performing a missed approach, and the pilot not maintaining altitude/clearance from the trees and terrain. Contributing factors to the accident were the air traffic controller not issuing the current weather conditions to the pilot prior to the approach clearance, the weather conditions being below the instrument approach landing minimums, the pilot's lack of recent experience in instrument flight rules (IFR) operations and the pilot disregarding federal regulations regarding instrument currency.