ATC contributes to fatal Arkansas accident

These July 2004 Accident Reports are provided by the National Transportation Safety Board. Published as an educational tool, they are intended to help pilots learn from the misfortunes of others.

Aircraft: Piper Cherokee Six.

Location: Hot Springs, Ark.

Injuries: 1 Fatal.

Aircraft damage: Destroyed.

What reportedly happened: The 1,765-hour instrument rated private pilot was attempting to execute the ILS RWY 5 approach. Air traffic control was providing vectors for the pilot to intercept the localizer course. The controller instructed the pilot to fly a heading 020° and intercept the localizer. The pilot was instructed to maintain 3,000 feet until established on the approach. The pilot acknowledged the clearance and began a right turn towards the airport. Over the next two minutes, the airplane tracked the assigned heading but still remained south of the final approach course. A few minutes later, the airplane was just southeast of the FAF at an altitude of 3,000 feet msl. The published altitude for that leg of the approach is 2,300 feet msl. The pilot still had not reported being established on the localizer. The approach controller then conducted a position relief briefing with a controller coming on duty. The briefing included a discussion of the approach in progress. The first controller told the relief controller that the pilot would probably have to execute the missed approach as the controller had turned him too late to intercept the final approach course and descend to the published altitude. The pilot then reported he was established on the final approach course. The airplane was now 2.5 miles past the FAF and three miles from the runway and still 700 feet above the published altitude. The relief controller responded, “Roger change to advisory approved report your arrival time this frequency.” The pilot acknowledged the transmission. The relief controller then transmitted, “Well just make sure you got this approach you are cleared for the ILS runway five approach and change to advisory approved report your arrival time this frequency.” The pilot responded that he was cleared for the ILS runway five approach and indicated he would contact the controller again after landing. There were no further transmissions from the pilot and no further attempts on the part of ATC to contact the pilot. According to radar data, the pilot then made a left turn. The plane collided with mountainous terrain approximately five miles northeast of the airport. Examination of the airplane and engine revealed no mechanical deficiencies.

Investigators determined that both controllers acknowledged the pilot’s abnormal approach and failed to provide known information that may have assisted the pilot in determining whether to continue with the approach or take alternate action as required per FAA Order 7110.65, Air Traffic Control paragraph 5-9-2, Final Approach Course Interception.

Probable cause: The pilot’s failure to fly the published instrument approach, which resulted in a collision with mountainous terrain. Factors were the air traffic controllers’ failure to provide known information that may have assisted the pilot in determining whether to continue with the approach or take alternate action.

Aircraft: Cessna T210.

Location: Cheyenne, Wyo.

Injuries: 1 Minor.

Aircraft damage: Substantial.

What reportedly happened: The pilot was cleared to land on runway 30. While on final approach, the engine lost power. The pilot couldn’t restore power and the aircraft came down in a field a mile and a half short of the runway. The airplane struck a fiber optics cable, a fence, and an irrigation ditch before coming to a stop.

The post-accident examination revealed that the bolt and nut that attach the throttle control cable to the fuel induction was missing. Examination of the aircraft maintenance records revealed that on April 1, 2004, the engine was removed from the airframe and inspected for metal contamination. Engine removal would necessitate detaching the throttle control cable from the fuel induction.

Probable cause: The detachment of the nut and bolt that attaches the throttle control cable to the fuel induction due to improper maintenance.

Aircraft: Beech Travel Air.

Location: Atlantic City, N.J.

Injuries: 2 Fatal.

Aircraft damage: Destroyed

What reportedly happened: A witness stated that she heard the accident pilot make a “normal inbound to land” transmission over the radio. However, when the airplane turned from base onto the final approach for the runway, the pilot transmitted, “Travel Air has a problem, we are going to climb out.” The witness then observed the landing gear on the airplane retract, and the nose pitch up. The airplane subsequently entered into a spin to the left, turning two times, before descending into the water off the approach end of the runway.

Examination of the wreckage revealed that the right engine fuel selector was observed in the “main” tank position, and the left engine fuel selector was in the “off” position. Investigators determined the left engine had lost power. No other mechanical abnormalities were noted with the airframe or engines.

Probable cause: The pilot’s failure to maintain control while performing a go-around after experiencing a loss of power to the left engine for undetermined reasons.

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