NTSB CAROL · Event
Event MIA04FA029
Aircraft involved
Probable cause & findings
The pilot's descent below decision height while performing an ILS approach with low ceilings and fog, resulting in an in-flight collision with trees and the ground. A factor associated with the accident was the pilot's decision to attempt the instrument approach with weather below the prescribed minimums.
Factual narrative
HISTORY OF FLIGHT
On November 27, 2003, about 0752 eastern standard time, a Swearingen SA-26-AT, N698X, registered to a private owner, operating as a 14 CFR Part 91 personal flight, collided with trees while on approach to the Craig Airport (CRG), Jacksonville, Florida. Instrument meteorological conditions (IMC) prevailed and an instrument flight rules (IFR) flight plan was filed. The airplane was destroyed. The commercial-rated pilot (Father) was fatally injured. Four passengers reported minor injuries. The flight had departed from Beaumont, Texas, at 0400 on November 27, 2003. The passengers stated their father was aware of the fog at their destination airport. Two of the four passengers were asleep during the approach and awoke when the airplane collided with the trees. The passengers stated their father did not say anything, alerting them to any impending danger. One passenger stated she looked outside and the airplane was in the clouds and it appeared to be real foggy. A short time later the passenger heard the airplane hitting something. She looked outside and saw trees. The airplane flipped about one and a half times, and skidded before it came to a complete stop. All four passengers exited the airplane through a window. Several witnesses interviewed by the Jacksonville Sheriff's Office who live in the vicinity of the crash site reported hearing an airplane fly over their location at a very low altitude. None of the witnesses could see the airplane due to foggy conditions. One witness reported the fog being "approximately one foot off of the ground and it was very thick." Two of the witnesses reported hearing the airplane as it collided with the trees. Review of air traffic control (ATC) transcripts, tape recordings, and an NTSB Radar Study revealed the airplane was approximately 20 miles west of Panama City, Florida, at Flight Level (FL) 210 at 0644:16. The pilot asked Jacksonville Center if Craig Airport was still fogged in. The controller informed the pilot the visibility was one-quarter of a mile, with a vertical visibility of 100 feet. The controller offered to call Craig Tower for the current Runway Visual Range (RVR), but the pilot declined the offer, and advised the controller that he would slow the airplane down and wait for the fog to lift. The airplane was about 30 miles east of Tallahassee, Florida, at 0717:06, when the pilot advised Jacksonville Center the airplane was "slowed back". The controller informed the pilot that it would be "a good hour and a half" before the fog at CRG would burn off. The controller informed the pilot the Saint Augustine, Florida (SGJ), weather observation was, winds calm, visibility 2 miles, clear skies, temperature 61-degrees Fahrenheit, dew point temperature 59-degrees Fahrenheit and altimeter 30.13. At 0724:30, Jacksonville Center cleared the pilot to descend at pilot's discretion to 16,000 feet. The pilot acknowledged the clearance, and the radar indicated the airplane started to descend at 0727:11. The first anomalous modes C altitude return (inaccurate mode C altitude values indicating altitudes impossible for the airplane to fly) was received by ATC radar, and sporadic anomalous returns continued throughout the remainder of the flight. The pilot established initial radio contact with Jacksonville Approach Control at 0731:22. The east sector controller issued the pilot a heading and clearance down to 10,000 feet. The controller informed the pilot, "last weather we have at Craig, shows wind calm, visibility one quarter mile in fog, indefinite ceiling one hundred obscured, and altimeter three zero one three, expect instrument landing system (ILS) to runway 32." The pilot acknowledged the clearance and informed the controller he had Automatic Terminal Information Service (ATIS) Sierra. The pilot further stated, "Saint Augustine sounds pretty good, so we'll take a look when we get over at Craig, hopefully some of that will burn off." The controller informed the pilot the fog would not burn off for at least an hour. The pilot asked the controller if anyone else had completed the approach to Craig and the controller stated no. The pilot replied, "I'm the first fool on turkey day, huh?" The pilot informed Jacksonville Approach Control at 0737:23 that he could see the buildings of downtown Jacksonville. The controller informed the pilot he had just driven into work past CRG and the fog was very thick, but 3 miles north of the airport on a bridge the view was clear. The controller cleared the pilot to descend to 3,000 feet and issued vectors toward the ILS final approach course. The pilot acknowledged the clearance and informed the controller that he would like to get "a little closer and take a look," then added, "Saint Augustine is evidently pretty good." The pilot acknowledged the instructions and the radar returns were consistent with the instructions. The mode C altitude returns stopped, started again at 0746:11, indicating 3,000 feet consistent with ATC instructions. The controller informed the pilot at 0749:11, "five miles from final approach fix, turn left heading three five zero maintain two thousand feet until established on the localizer, cleared for the ILS 32 approach." The pilot acknowledged the clearance and the controllers' radar returns were consistent with the clearance. When the airplane was 9 miles southeast of the airport at 2,000 feet within one quarter of a mile of the ILS centerline, the controller instructed the pilot to contact CRG tower. The pilot contacted the tower and was instructed to report passing the final approach fix. Jacksonville Approach Control advised CRG tower at 0751:06, that Jacksonville International Airport was reporting an RVR of "more than six thousand feet and airplanes are making it in." In addition, Jacksonville Approach Control advised the tower controller what headings to issue to the pilot, if the pilot wanted to divert. CRG tower contacted the pilot and relayed the information from Jacksonville Approach Control. The pilot was asked what his intentions were in the event of a missed approach. The pilot replied "I got my brother bringing my Mom there into your airfield, so I don't know, what do you think is best, what's closest?" The CRG controller replied Jacksonville was closer than St. Augustine. The pilot informed the controller at 0752:03, that he would go to Jacksonville in the event of a missed approach. The controller cleared the pilot to land and there was no other radio communications between the pilot and CRG tower. The airplane passed over ADERR intersection, the final approach fix for the ILS Runway 32 approach. The radar returns indicated the airplane was within one-tenth of a mile of the ILS centerline, and anomalous altitude values between 23,000 and 37,000 feet were received. At 0751:39, the airplane was one-half mile southeast of the final approach fix and the mode C indicated 1,700 feet. The published procedure indicates 1,900 feet is the minimum altitude to cross ADERR. The next seven mode C returns were anomalous. At 0752:16, the airplane was approximately 4.4 miles from the runway, and a mode C of 1,700 was received. The next six mode C returns were consistent with the published procedure. At 0752:58, the airplane was approximately 2.8 miles from the runway threshold and a mode C return was received indicating 33,000 feet. The next two returns did not have any mode C values. At 0753:12, a return was received indicating 400 feet. At 0753:16 a return with no mode C was received. The last mode C return was received at 0753:21, and the airplane was at 200 feet. The last two mode C returns were not considered anomalous. The mode C returns were consistent with the performance characteristics of the airplane, and the altitudes were below the glide path of ILS runway 32.
PERSONNEL INFORMATION
Review of information on file with the FAA Airman's Certification Division, Oklahoma City, Oklahoma, revealed the pilot was issued a private pilot certificate on October 13, 1993, with ratings for airplane single engine land and sea, airplane multiengine land and sea, and instrument airplane. The pilot held a second class medical issued on November 1, 2001, with the restriction, " must wear lenses for distant vision and possess glasses for near vision." The pilot's logbook was not located and his total time, make and model, and instrument flight time could not be determined. The pilot's last flight review was not be determined. The pilot indicated on his application for his second-class medical certificate that he had accumulated 4,500 total flight hours.
AIRCRAFT INFORMATION
The last A and B inspections was completed on May 3, 2003, and the hour meter at the time of the inspection was 0229.7. The airplane airframe total time at the time of the inspection was 8,229.9 hours. The pitot static system check was completed on November 21, 2001. The last entry in the airframe maintenance manual was on November 18, 2003, at 263.0 hours when the right outboard flap and aileron were replaced. The total time flown since the A and B inspection on November 18, 2003, was 33.3 hours, and the total airframe hours were 8,263.2 hours.
METEOROLOGICAL INFORMATION
Prior to pilot departing Beaumont, Texas, the observations from Jacksonville International Airport, and Craig Municipal Airport indicated the visibility was one-quarter of a mile in fog, with overcast ceilings between 100 to 200 feet. As the aircraft transversed the Florida panhandle, St. Augustine, Florida, reported visual flight rules conditions with wind from 300-degrees at 4 knots, visibility 5 miles, scattered clouds at 5,500 feet, temperature 51-degrees Fahrenheit dew point temperature 59-degrees Fahrenheit, and altimeter 30.12. "The Craig information Sierra, one one five zero zulu, wind calm, visibility one quarter of a mile in fog, indefinite ceiling, vertical visibility one hundred, temperature one six, dew point one five, altimeter three zero one three, expect an ILS approach, runway three two in use, advise on initial contact you have sierra." The 0753 surface weather observation for Craig Municipal Airport, Jacksonville, Florida, was wind calm, visibility less than one-quarter statute mile, fog, vertical visibility one hundred feet, temperature 61-degrees Fahrenheit, dew point temperature 61-degrees Fahrenheit, and altimeter 30.14. The 0816 special surface weather observation for Craig Municipal Airport, Jacksonville, Florida, was wind calm, visibility less than one-quarter statute mile, fog, vertical visibility one hundred feet, temperature 66-degrees Fahrenheit, dew point temperature 66-degrees Fahrenheit, and altimeter 30.04. The 0755 surface weather observation for St. Augustine Airport, St. Augustine, Florida, was wind calm, visibility 5 miles, few clouds at 5,500 feet, temperature 59-degrees Fahrenheit, dew point temperature 57-degrees Fahrenheit, and altimeter 30.14. The 0756 surface weather observation for Jacksonville International Airport, Jacksonville, Florida, was wind calm, visibility 1 mile, mist, scattered clouds at 100 feet, scattered clouds at 20,000 feet, temperature 59-degrees Fahrenheit, dew point temperature 57-degrees Fahrenheit, and altimeter 30.13. The remarks from the automated weather observation indicated tower visibility was 4 miles and the RVR was not available. Airmet SIERRA was issued at 0345 eastern standard time called for IFR conditions extending over portions of North Carolina, South Carolina, Georgia, and Florida, which extended over the accident site. The advisory warned of occasional ceilings below 1,000 feet and or visibility below 3 miles in mist. The conditions were expected to continue until 1000 to 1200. AIRPORT INFORMATION: Review of the ILS Runway 32 approach plate for Jacksonville/Craig Municipal Airport revealed the minimums for the approach were decision height 241 feet and one-half mile visibility. The minimum crossing altitude and glide slope intercept altitude at ADERR intersection is 1,900 feet. The Jacksonville International Airport, Jacksonville, Florida, is located 15 statue miles northwest of Craig Municipal Airport. Review of the ILS Runway 7, 13, and runway 25, revealed the decision height for runway 7 was 230 feet and one-half mile visibility. The decision height for runways 13 and 25 was 227 feet, and one-half mile visibility. The St. Augustine Airport, St. Augustine, Florida, is located 25 miles from Craig Municipal Airport. Review of the ILS Runway 31 approach revealed the decision height 258 feet and three-quarters of a mile visibility. Investigators obtained the FAA files on the ILS 32 equipment at Craig Airport. The ILS was originally commissioned in March of 1989. After an accident in December of 1992, a post-accident flight check included the remark "a glide slope course reversal was observed during the inspection at .93 nm from runway threshold. FDC NOTAM 2/7736 issued 12/29/92." This NOTAM stated "auto coupled approaches NA." On May 29, 1994, the approach was published with the notation "glide slope unusable for coupled approaches below 475 feet msl." and the NOTAM was removed. The notation appeared on the published chart in effect on the day of the accident. A post accident flight was conducted on November 28, 2003, and was satisfactory except for some light bulb outages. The ILS and Medium Intensity Approach Lighting System (MALSR ) were shut down for flight check and verification purposes. As a result, 2 of the 5 Runway Alignment Indicator Lights (RAIL) portion of the MALSR were found to be burned out and were replaced. No anomalies with the ILS were found. A review of the calendar year 2003 discrepancy reports reveals no abnormalities with the ILS equipment relevant to the accident. At the time of the accident, Gainesville, Florida Automated Flight Service Station (GNV AFSS) was holding an FAA Notice to Airmen - Local (NOTAM-L) advising that the runway 32 Precision Approach Path Indicator (PAPI) lights were out of service. The NOTAM had been issued on November 3, 2003, at 0715 effective until 0929. The airport authority had advised CRG FCT of the outage on November 3. Approximately three hours later, the FAA Area Operations Communications Center (AOCC) telephoned the tower and advised the PAPI's had returned to service. However, the AOCC did not advise GNV AFSS.
WRECKAGE AND IMPACT INFORMATION
The airplane wreckage was located in a wooded area 1.8 miles from Craig Municipal Airport and about 531 feet east of the 1800 block of Kernan Boulevard South (south of the intersection of Kernan Boulevard and Atlantic Boulevard) and about 189 feet south of the rear parking lot of 12200 Atlantic Boulevard, Jacksonville, Florida. Examination of the crash site revealed the airplane collided with trees while descending, and separated sections of the left and right wing. The airplane rolled right and collided with the ground in a nose down attitude. Tree branches with diagonal cuts were located along the crash debris line. The radome, radar, nose section, and forward baggage compartment door of the airplane were destroyed. The nose landing gear was extended and separated. The cockpit windshield and both side windows were destroyed. The cockpit was compressed aft into the passenger area aft of the left and right forward passenger seats. The cockpit roof was destroyed and cabin roof was crushed inward to the center of the center wing assembly. The left and right forward crew seats, instrument panel, center console, and both side panels were destroyed. The pilots encoding altimeter was located and taken to an authorized repair facility for further examination. The examination of the encoding altimeter revealed the altimeter had had a positive correlation for emitting an anomalous/erroneous signal. The right airspeed indicator, pilot's vertical speed indicator and electric turn and bank indicator were destroyed. The pilot's airspeed indicator, HSI, and right side attitude indicator were documented and not disassembled. The landing gear handle was in the down position. The landing gear actuator pistons were examined and indicated the landing gear was in the down and locked position. The center wing assembly remained attached and the left and right landing gear were extended. All separated flight controls were located along the crash debris line or attached to their respective location and were damaged. Flight control continuity was confirmed from the remaining cockpit area aft to all flight control cables and aileron push pull tubes separations, aft to the flight controls surfaces. The aft cabin area was damaged. The left and right cabin windows were broken. The cabin door remained attached and was in the locked position. The left, right, and bottom side of the fuselage was damaged. The right wing remained attached to the center wing section at the fuselage. The right wing separated outboard of the inboard hinge of the right aileron. The aft spar separated outboard of the right engine outboard nacelle and flap junction. The wing was accelerated forward 45-degrees. The right flap was torn 6-inches outboard of its inboard hinge point, and separated from its outboard hinge point. The right aileron was damaged and remained attached to its hinge points. The right aileron trim remained attached to the right aileron. The right wet wing fuel tank was not ruptured. The right wing fuel lines and fittings were compromised. The right wing leading edge center section was damaged and the right engine separated. The right engine was located in front of the right wing. The upper and lower engine cowlings were damaged and remained attached. The right propeller spinner was destroyed. The right propeller assembly remained attached to the propeller crankshaft flange and all three-propeller blades remained in their clamps. The right propeller assembly was removed from the engine assembly and forwarded to the manufacture for examination in the presence of the FAA. The right engine was forwarded to the engine manufacturer for examination in the presence of the FAA. The dorsal fairing was damaged. The vertical stabilizer, rudder assembly, and left horizontal stabilizer separated from the empennage and were damaged. The right horizontal stabilizer remained attached. A downward diagonal bend was present extending from the leading edge of the right horizontal stabilizer aft to the right elevator outboard hinge. The right elevator was damaged and remained attached to the right horizontal stabilizer. The elevator trim tab remained attached to the right elevator. The left horizontal stabilizer was bent upward at midspan. The inboard 1-foot of the left elevator and elevator trim tab remained attached to the left elevator. The remaining left elevator and elevator trim tab was separated and damaged. The left wing remained attached to the center wing section at the fuselage. The left inboard center wing section was damaged extending outboard of the left engine nacelle. The left wing separated outboard of the left engine nacelle and was intact except for the leading edge of the left wing outboard of the left wing aileron attachment point. The remaining leading edge was separated outboard to the left wing tip. The inboard section of the flap was separated at midspan. The outboard section of the flap remained attached to its hinge points. The left wet wing fuel tank was ruptured and the fuel lines and fittings were compromised. The left engine separated. The upper and lower engine cowlings were damaged and remained attached. The left propeller spinner was destroyed. The left propeller assembly remained attached to the propeller crankshaft flange and all three-propeller blades remained in their clamps. The left propeller assembly was removed from the engine assembly and forwarded to the manufacture for examination in the presence of the FAA. The left engine was forwarded to the engine manufacturer for examination in the presence of the FAA. The left and right engines were transported to Honeywell Product Integrity Investigation Laboratory in Phoenix, Arizona. Both engines were disassembled on January 13, 2004, through January 14, 2004, in the presence of the FAA. Honeywell concluded, "The teardown and examination of the left and right engine disclosed that the type and degree of damage was indicative of engine rotation and operation at the time of impact. No preexisting condition was found with normal operation of both engines." The left and right propeller assemblies were transported to Hartzell propeller Inc., in Piqua, Ohio, and examined in the presence of the FAA. Hartzell Propellers concluded, "Both propellers were rotating at the time of impact. The blade damage to both propellers suggests low power at the time of impact. There were no discrepancies noted that would preclude normal operation. All damage was consistent with impact damage."
MEDICAL AND PATHOLOGICAL INFORMATION
The Office of the Medical Examiner, Jacksonville, Florida, conducted a postmortem examination of the pilot, on November 28, 2003. The cause of death was "multiple injuries." The Forensic Toxicology Research Section, Federal Aviation Administration, Oklahoma City, Oklahoma performed postmortem toxicology of specimens from the pilot. No carbon monoxide or cyanide was detected in the blood. No ethanol was detected in the urine. The samples were negative for basic, acidic, and neutral drugs.
TEST AND RESEARCH
Sporadic anomalous mode C transponder altitude values were received throughout the descent of N698X. The actual anomalous values were obtained through post-accident data examination, in real-time the processing and display equipment used by controllers would blank the values that were out of tolerance. The mode C values that were displayed appeared to be nominal and in conformance with pilot reports and ATC instructions, and no action was required by the controllers. The anomalies were confirmed to be originating from the mode C signals transmitted by the aircraft, not the radar sites or processing equipment, by comparing returns from independent radar sites and processors at Jacksonville Center, Jacksonville Approach, and the Radar Evaluation Squadron. The sporadic nature of the anomalous returns from N698X did not provide the MSAW program sufficient data to generate a low altitude alert prior to the accident.
ADDITIONAL INFORMATION
The aircraft wreckage, transponder, two altimeters, and two propellers were released to Sample International Aviation Inc., on March 12, 2004. The aircraft logbooks were released to Sample International Aviation Inc., on January 7, 2004. The two airplane engines were released to Command Aircraft Parts and Recovery on March 29, 2005. The pilot was on an instrument flight from Beaumont, Texas, to Craig Airport, Jacksonville, Florida. According to the pilot's children who were passengers on the airplane, the pilot knew the destination airport was forecast to have fog upon their arrival. Air traffic controllers informed the pilot east of Tallahassee, Florida, the fog at his destination airport would not lift for at least an hour and a half. The pilot was informed the weather at Saint Augustine, Florida, was clear skies with two miles visibility. The pilot informed the controller that he would slow the airplane and continue to Craig. The pilot was subsequently cleared to descend and provided vectors for the ILS Runway 32 approach at Craig. The pilot informed the controller that he had the current automatic terminal information service (ATIS) information. The ATIS for Craig reported an indefinite ceiling with a vertical visibility of 100 feet, and one-quarter of a mile visibility. The weather minimums for the ILS runway 32 approach is a decision height of 241 feet, and one-half mile visibility. The controller informed the pilot to contact Craig Tower. The pilot contacted Craig Tower, and was instructed to report passing the final approach fix. The controller informed the pilot that Jacksonville International Airport had a runway visual range of more than 6,000 feet, and that airplanes were making it in. The controller asked the pilot what his intentions were in the event he made a missed approach. The pilot replied, "I got my brother bringing my mom there into your airfield, so I do not know, what do you think is best, what's closest." The controller replied Jacksonville was closer than Saint Augustine. The pilot informed the controller that he would go to Jacksonville in the event of a missed approach. The pilot was cleared to land, and there was no further radio contact between the pilot and Craig Tower. The airplane was located a short time later in a wooded area, 1.8 miles from the airport. Postaccident examination of the airplane revealed no preimpact mechanical anomalies. Source: NTSB Aviation Accident Database (Pre-2008 Archive) Retrieved: 2026-02-12
Verbatim from NTSB's published report. Source file
NTSB_2003_MIA04FA029.txt.
Findings + structured fields enriched from FAA avall.mdb.
Full investigation docket on
data.ntsb.gov ↗.
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