San Antonio Intl Airport
Aircraft Accident/Incident Report

San Antonio, Texas 78123
Sunday, November 14, 2004 17:18 CST

NTSB Narrative Summary Released at Completion of Accident

The twin-engine airplane collided with a residential structure and terrain following a loss of control after the pilot experienced difficulties maintaining course during an Instrument Landing System (ILS) approach while on instrument meteorological conditions. The impact occurred approximately 3.7 miles short of the approach end of the runway. Radar data depicted that after the 8,700-hour commercial pilot was vectored to the ILS Runway 3 approach, the airplane remained left throughout the approach before turning right of the localizer approximately 2 miles before the final approach fix (FAF). Radar then showed the aircraft turn to the left of course line. When the aircraft was abeam the FAF, it was approximately 1 mile left of the course line. As the aircraft closed to approximately 1.5 miles from the runway threshold, the aircraft had veered about 1.3 miles left of the course line (at which time air traffic control instructed the pilot to turn left to a heading of 270 degrees). The aircraft continued to turn left through the assigned heading and appeared to be heading back to the ILS course line. According to the radar, another aircraft was inbound on the ILS course line and Air Traffic Control Tower (ATCT) instructed the pilot to turn left immediately. Thereafter, the aircraft went below radar coverage. A witness, located approximately 1.25 miles northwest of the accident site, reported that he heard a very loud noise, and then observed an airplane flying toward a building, approximately 60 feet in height. The airplane was observed to have pitched-up approximately 45 - 90 degrees just before the building and disappeared into the clouds. A second witness located approximately 1 mile northwest of the accident site reported that he heard a low flying aircraft, and then observed a white twin-engine airplane banking left out of the clouds. The airplane leveled out, and flew into the clouds again a few seconds later. The witness stated that the airplane was at an altitude of 100-200 feet above the ground. A third witness located adjacent to the accident site reported that they heard the sound of a low flying airplane in the distance. As the sound became louder and louder, they looked up and observed the airplane in a near vertical attitude as it impacted trees and the side of an apartment complex. Examination of the airplane did not reveal any pre-impact mechanical anomalies. A weather observation taken approximately 15 minutes after the accident included a visibility 4 statue miles, light drizzle and mist, and an overcast ceiling at 400 feet.

NTSB Probable Cause Narrative

The pilot's failure to maintain control during an ILS approach. Contributing factors were the prevailing instrument meteorological conditions( clouds, low ceiling and drizzle/mist), and the pilot's spatial disorientation.

Event Information

Type of Event Accident
Event Date 11/14/2004
Event Day of the Week Sunday
Time of Event 1718
Event Time Zone Central Standard Time
Event City San Antonio
Event State TEXAS
Event Country --
Zipcode of the event site 78123
Event Date Year 2004
Event Date Month 11
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 293201N
Event Location Longitude 0982811W
Event Location Airport SAN ANTONIO INTL
Event Location Nearest Airport ID SAT
Indicates whether the acc/inc occurred off or on an airport Off Airport/Airstrip
Distance from airport in statute miles 3.7
Degrees magnetic from airport 200
Airport Elevation 809
Weather Briefing Completeness Unknown
Investigator's weather source Weather Observation Facility
Time of the weather observation 1732 Central Standard Time
Direction of event from weather observation facility (degrees) 200
Weather Observation Facility ID SAT
Elevation of weather observation facility 809
Distance of event from weather observation facility (units?) 3
Time Zone of the weather observation CST
Lighting Conditions Dusk
Lowest Ceiling Height 400
Lowest Non-Ceiling Height 400
Sky/Lowest/Cloud Conditions Thin Overcast
Sky Condition for Lowest Ceiling Overcast
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) 4
Air Temperature at event time (in degrees celsius) 12
Dew Point at event time (in degress fahrenheit) 11
Wind Direction (degrees magnetic) 50
Variable Wind Indicator Wind direction could be determined
Wind Speed (knots) 9
Wind Velocity Indicator --
Wind Gust Indicator Not Gusting
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) 30.28
Density Altitude (feet) --
Intensity of Precipitation Light
METAR weather report --
Event Highest Injury Fatal
On Ground, Fatal Injuries --
On Ground, Minor Injuries --
On Ground, Serious Injuries --
Injury Total Fatal 5
Injury Total Minor --
Injury Total None --
Injury Total Serious --
Injury Total All 5
Investigating Agency NTSB
NTSB Docket Number (internal use) 17939
NTSB Notification Source FAA Operations Center
NTSB Notification Date Nov 14 2004 12:00AM
NTSB Notification Time 1800
Fiche Number and/or location -used to find docket information DMS
Date of most recent change to record Jul 7 2005 10:33AM
User who most recently changed record NTSB\JOHB
Basic weather conditions Instrument Meteorological Cond
FAA District Office San Antonio, Texas

Aircraft Involved

Aircraft #1

Aircraft Registration Number N40731
NTSB Number DFW05FA020
Missing Aircraft Indicator --
Federal Aviation Reg. Part Part 91: General Aviation
Type of Flight Plan filed IFR
Flight plan Was Activated? Yes
Damage Destroyed
Aircraft Fire Ground
Aircraft Explosion None
Aircraft Manufacturer's Full Name Piper
Aircraft Model PA-31-350
Aircraft Series Identifier --
Aircraft Serial Number 31-8152003
Certified Max Gross Weight 7000
Aircraft Category Airplane
Aircraft Registration Class U.S. Registered/U.S. Soil
Aircraft is a homebuilt? No
Flight Crew Seats --
Cabin Crew Seats --
Passenger Seats --
Total number of seats on the aircraft 7
Number of Engines 2
Fixed gear or retractable gear Retractable
Aircraft, Type of Last Inspection Annual
Date of Last Inspection Jul 31 2004 12:00AM
Airframe hours since last inspection --
Airframe Hours 2248.7
ELT Installed Yes
ELT Activated No
ELT Aided Location of Event Site No
ELT Type --
Aircraft Owner Name Dash Air Charter Inc.
Aircraft Owner Street Address PO Box 13430
Aircraft Owner City San Antonio
Aircraft Owner State TX
Aircraft Owner Country USA
Aircraft Owner Zipcode 78213
Operator is an individual? No
Operator Name --
Operator Same as Owner? Yes
Operator Is Doing Business As --
Operator Address Same as Owner? Yes
Operator Street Address --
Operator City --
Operator State --
Operator Country --
Operator Zip code --
Operator Code --
Owner has at least one certificate None
Other Operator of large aircraft? --
Certified for Part 133 or 137 Operation --
Operator Certificate Number --
Indicates whether an air carrier operation was scheduled or not --
Indicates Domestic or International Flight --
Operator carrying Pax/Cargo/Mail --
Type of Flying (Per_Bus / Primary) Personal
Second Pilot on Board No
Departure Point Same as Event No
Departure Airport Code DDC
Departure City Dodge City
Departure State KS
Departure Country USA
Departure Time 1345
Departure Time Zone CST
Destination Same as Local Flt crash at destination city
Destination Airport Code SAT
Destination City San Antonio
Destination State TX
Destination Country USA
Specific Phase of Flight Approach - final approach fix (FAF)/outer marker to threshold (IFR)
Report sent to ICAO? No
Evacuation occurred No
Date of most recent change to record May 9 2005 7:17PM
User who most recently changed record CASH
Since inspection or accident Last Inspection
Event Location Runway Number and Location 3
Runway Length 7505
Runway Width 150
Sight Seeing flight No
Air Medical Flight No
Medical Flight --