CEN15FA087

The pilot’s decision to continue flight below the minimum descent altitude without visually acquiring the runway and his delayed and improperly executed missed approach procedure in instrument meteorological conditions.

The private pilot was conducting a business flight. He had obtained weather briefings on the day before and the day of the flight, which indicated marginal visual flight rules conditions. However, upon arrival in the vicinity of the airport, instrument meteorological conditions prevailed with visibility at or below the approach's visibility minimums. However, the pilot contacted the controller, obtained the weather information, and chose to continue the approach. Radar data showed that the airplane's final approach course was unstabilized. The last data point along the final approach course was about 0.5 mile southwest of the missed approach point, which was near the runway 4 approach end at an altitude of 1,100 ft. The missed approach procedure was to climb to 2,500 ft, make a climbing left turn to 4,000 feet, proceed direct to the outer marker, and hold. The lack of radar data points below 1,100 feet between the approach and departure ends of runway 4 may indicate that the airplane was below 1,100 ft over the runway area, which may indicate that the pilot attempted to visually acquire the runway environment with visibilities that did not allow for adequate visual reference to land. Likely unable to see the runway, the pilot notified air traffic control that he was executing a missed approach. The airplane impacted a wooded area about 0.39 mile north/northwest of the runway 4 departure end. The wreckage path length and slope through the trees was consistent with a shallow angle of impact at relative high speed. It is likely that the pilot continued flight below the minimum descent altitude without visually acquiring the runway and did not execute the missed approach procedures in a timely manner. Examination of the wreckage did not reveal any anomalies that would have precluded normal operation of the airplane. The filed alternate airport for the flight showed weather about the time of the accident that was above weather minimums for a precision approach that was available at the alternate airport.

Destination Airport (PHN) PHN was a non-towered airport served by runway 4/22 (5,104 feet by 100 feet, asphalt/grooved ) and runway 10/22 (4,000 feet by 75 feet, asphalt). The airport elevation was 650 feet. The ILS 4 approach chart follows: Figure 1: The ILS 4 approach chart shows straight-in approach minimums with a decision height of 847 feet and a ½ mile visibility. The locator outer marker, PHURN, was 4.6 miles from the approach end of runway 4 which had a touchdown zone elevation of 647 feet. The missed approach procedure upon reaching the missed approach point/decision height was climb to 2,500 feet then climbing left turn to 4,000 feet direct PHURN and hold, continue climb-in-hold to 4,000 feet. Alternate Airport (HYX) HYX was a non-towered airport served by runway 9/27 (5,002 feet x 100 feet, asphalt) and 5/23 (2,952 feet by 60 feet, asphalt). The airport had an elevation of 601 feet. HYX was equipped with the following approaches: ILS OR LOC/DME RWY 27, RNAV (GPS) RWY 09 and RNAV (GPS) RWY 27, and VOR/DME-A. Both engines were shipped to Continental Motors, Mobile, Alabama for disassembly examination under the supervision of a FAA Inspector. The examination revealed no mechanical abnormalities that would lead to an inflight/operational failure. Radar data derived from the Mount Clemens military airport surveillance radar located at the Selfridge Air National Guard Base, Mount Clemens, Michigan was plotted along the final approach course for runway 4, which is depicted in the following figures. Figure 1: The radar flight track of N38884 is indicated by red dots. Direction of flight is indicated by black arrows. Final approach course of the ILS RWY 4 approach to PHN is indicated by a red arrow. Figure 2: A closer view of the radar flight track for N38884 showing the last recorded radar altitude of the airplane which was 1,100 feet and about 0.7 miles from the approach end of runway 4. The next recorded radar altitude for the airplane was northwest of the departure end of runway 4 near the accident site. An autopsy of the pilot was conducted by the St. Clair County, Michigan Office of the Medical Examiner. The medical examiner's report listed the cause of death as multiple blunt traumatic injuries and the manner of death as accident. The FAA Final Forensic Toxicology Fatal Accident Report for the pilot reported: oxymetazoline detected in urine; oxymetazoline not detected in blood (heart); cyanide - not performed; carbon monoxide - no carbon monoxide detected in blood (heart); volatiles – no ethanol detected in vitreous. According to the FAA website, Aerospace Medical Research, oxymetazoline is a decongestant used in the treatment of nasal congestion. The main wreckage was located about 0.39 miles on a heading of about 336 degrees from the departure end of runway 4, behind a house and in a wooded area with trees with an estimate height of 40-50 feet. The wreckage path to the main wreckage was about 275 feet in length and with a heading of about 032 degrees through the trees. The wreckage path contained broken trees, which were fallen in the direction of the wreckage path, and pieces of the airplane wings. The main wreckage included the fuselage and the attached empennage with its horizontal and vertical stabilizers and their respective control surfaces. The main wreckage, airframe, and engines did not display evidence of soot or fire damage. Control cable continuity was verified from the vertical and horizontal stabilizer control surfaces to the cockpit. The right wing was fragmented and the flap and aileron were found along the debris line. A portion of the right aileron control cable remained with the fuselage but the rest of the cable was not noted. The outboard section of the left wing was separated and found along the debris path with the aileron. Both the aileron control and aileron balance cable had been pulled from the fuselage during the impact sequence. Sections of the cable were found along the debris trail. All separations of the control cables were consistent with overload. Most of the left wing flap remained with the inboard section of the wing. The wing flap, wing flap torque tube, and the cockpit wing flap control handle were all positioned consistent with a 25-degree flap setting. The right landing gear was separated and the gear actuator was in the retracted position. The instrument panel containing the flight/navigation instruments sustained impact damaged and was separated from the rest of the instrument panel. The altimeter gauge had an altimeter setting of about 29.42 inches Hg. The horizontal situation navigation course arrow was bent toward the left indicating about 030 degrees. The tail of the arrow was about 230 degrees. The orange triangular heading select bug was about 070 degrees. Both engines were found near the main wreckage with the propellers separated at their propeller hubs, which displayed separation features consistent with overload. Area Forecast The Area Forecast issued at 0545, valid at the accident time, forecasted an overcast ceiling at 2,000 feet msl with tops to flight level 310, visibility of 3 miles, light rain, and mist. The outlook was for IFR ceilings with rain, mist, wind. Terminal Aerodrome Forecasts (TAFs) CYZR was the closest non-official site to the accident site with a TAF. The TAF valid at the time of the accident was issued at 1218 and was valid for a 8-hour period beginning at 1200. The CYZR forecast from 1218 expected a variable wind at 3 knots, a quarter mile visibility, fog, and a vertical visibility of 200 feet agl. Temporary conditions between 1200 and 1900 of 2 and a half miles visibility, light rain, mist and an overcast ceiling at 600 feet agl were forecast. Coleman A. Young Municipal Airport (DET) was the closest site with a NWS TAF located 37 miles southwest of the accident site. The TAF valid at the time of the accident was issued at 1232 and was valid for a 24-hour period beginning at 1300. The 1232 forecast expected a wind from 030° at 5 knots, a quarter mile visibility, drizzle, fog, and a vertical visibility of 200 feet agl around the time of the accident. The closest TAF forecast for the accident site from CYZR and the official NWS TAF from DET forecasted LIFR ceilings and visibilities for the accident site at the accident time before the takeoff time of 1025. Destination Airport Weather (PHN) PHN weather at 1217 was reported as wind from 060° at 4 knots, ½ sm visibility, fog, an overcast ceiling at 200 above ground level (agl), temperature of 6° Celsius (C), dew point temperature of 6° C, and an altimeter setting of 29.45 inches Hg. Remarks: automated station with precipitation discriminator. PHN weather at 1237 was reported as wind calm, ½ sm visibility, fog, an overcast ceiling at 200 agl, temperature of 6° C, dew point temperature of 6° C, and an altimeter setting of 29.44 inches Hg. PHN weather at 1257 was reported as wind calm, ¼ sm visibility, fog, an overcast ceiling at 200 agl, temperature of 6° C, dew point temperature of 6° C, and an altimeter setting of 29.41 inches Hg. Remarks: automated station with precipitation discriminator. PHN weather at 1317 was reported as wind calm, ¼ sm visibility, fog, an overcast ceiling at 200 agl, temperature of 6° C, dew point temperature of 6° C, and an altimeter setting of 29.40 inches of mercury. Remarks: automated station with precipitation discriminator. Alternate Airport Weather (HYX) HYX weather at 1215 was reported as wind from 020° at 11 knots, 3 sm visibility, an overcast ceiling at 500 agl, temperature of 3° C, dew point temperature of 3° C, and an altimeter setting of 29.48 inches Hg. Remarks: automated station with precipitation discriminator. HYX weather at 1235 was reported as wind from 030° at 11 knots with gusts to 16 knots, 5 sm visibility, light rain, an overcast ceiling at 300 ag