Centennial Airport
Aircraft Accident/Incident Report

Parker, Colorado 80134
Thursday, August 4, 2005 2:06 MDT

NTSB Narrative Summary Released at Completion of Accident

The commercial pilot was executing a precision instrument approach at night in instrument meteorological conditions when the airplane collided with terrain about four miles short of the runway. A review of air traffic control communications and radar data revealed the pilot was vectored onto the final approach course but never got established on the glide slope. Instead, he made a controlled descent below the glide slope as he proceeded toward the airport. When the airplane was five miles from the airport, a tower controller received an aural low altitude alert generated by the Minimum Safe Altitude Warning (MSAW) system. The tower controller immediately notified the pilot of his low altitude, but the airplane collided with terrain within seconds. Examination of the instrument approach system and onboard flight navigation equipment revealed no pre-mishap anomalies. A review of the MSAW adaptation parameters revealed that the tower controller would only have received an aural alarm for aircraft operating within 5 nm of the airport. However, the frequency change from the approach controller to the tower controller occurred when the airplane was about 10.7 miles from the airport, leaving a 5.7 mile segment where both controllers could receive visual alerts, but only the approach controller received an aural alarm. A tower controller does not utilize a radar display as a primary resource for managing air traffic. In 2004, the FAA changed a policy, which eliminated an approach controller's responsibility to inform a tower controller of a low altitude alert if the tower had MSAW capability. The approach controller thought the MSAW alarm parameter was set 10 miles from the airport, and not the 5 miles that existed at the time of the accident. Subsequent investigation revealed, that The FAA had improperly informed controllers to ensure they understood the alarm parameters for control towers in their area of responsibility. This led the approach controller to conclude that the airplane was no longer her responsibility once she handed it over to the tower controller. Plus, the tone of the approach controller's aural MSAW alarm was not sufficient in properly alerting her of the low altitude alert.

NTSB Probable Cause Narrative

The pilot’s failure to fly a stabilized instrument approach at night which resulted in controlled flight into terrain. Contributing factors were; the dark night, low clouds, the inadequate design and function of the airport facility’s Minimum Safe Altitude Warning System (MSAW), and the FAA’s inadequate procedure for updating information to ATC controllers.

Event Information

Type of Event Accident
Event Date 8/4/2005
Event Day of the Week Thursday
Time of Event 206
Event Time Zone Mountain Daylight Time
Event City Parker
Event State COLORADO
Event Country --
Zipcode of the event site 80134
Event Date Year 2005
Event Date Month 8
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 392933N
Event Location Longitude 1045048W
Event Location Airport Centennial Airport
Event Location Nearest Airport ID APA
Indicates whether the acc/inc occurred off or on an airport Off Airport/Airstrip
Distance from airport in statute miles 4
Degrees magnetic from airport --
Airport Elevation 180
Weather Briefing Completeness --
Investigator's weather source Weather Observation Facility
Time of the weather observation 205 Mountain Daylight Time
Direction of event from weather observation facility (degrees) 350
Weather Observation Facility ID APA
Elevation of weather observation facility 5883
Distance of event from weather observation facility (units?) 4
Time Zone of the weather observation MDT
Lighting Conditions Night
Lowest Ceiling Height 1000
Lowest Non-Ceiling Height --
Sky/Lowest/Cloud Conditions Unknown
Sky Condition for Lowest Ceiling Broken
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) 2.5
Air Temperature at event time (in degrees celsius) 15
Dew Point at event time (in degress fahrenheit) 14
Wind Direction (degrees magnetic) 10
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) 30.38
Density Altitude (feet) --
Intensity of Precipitation --
METAR weather report --
Event Highest Injury Fatal
On Ground, Fatal Injuries --
On Ground, Minor Injuries --
On Ground, Serious Injuries --
Injury Total Fatal 1
Injury Total Minor --
Injury Total None --
Injury Total Serious --
Injury Total All 1
Investigating Agency NTSB
NTSB Docket Number (internal use) 20928
NTSB Notification Source FAA Comm.Ctr.
NTSB Notification Date Aug 4 2005 12:00AM
NTSB Notification Time --
Fiche Number and/or location -used to find docket information DMS
Date of most recent change to record Dec 28 2006 9:08AM
User who most recently changed record NTSB\johb
Basic weather conditions Instrument Meteorological Cond
FAA District Office FAA AAI-100

Aircraft Involved

Aircraft #1

Aircraft Registration Number N454MA
NTSB Number DFW05FA202
Missing Aircraft Indicator --
Federal Aviation Reg. Part Part 135: Air Taxi & Commuter
Type of Flight Plan filed IFR
Flight plan Was Activated? Yes
Damage Destroyed
Aircraft Fire None
Aircraft Explosion None
Aircraft Manufacturer's Full Name Mitsubishi
Aircraft Model MU-2B-60
Aircraft Series Identifier --
Aircraft Serial Number 1535SA
Certified Max Gross Weight 11575
Aircraft Category Airplane
Aircraft Registration Class --
Aircraft is a homebuilt? No
Flight Crew Seats --
Cabin Crew Seats --
Passenger Seats --
Total number of seats on the aircraft 2
Number of Engines 2
Fixed gear or retractable gear Retractable
Aircraft, Type of Last Inspection 100 Hour
Date of Last Inspection Jul 1 2005 12:00AM
Airframe hours since last inspection --
Airframe Hours 12575
ELT Installed Yes
ELT Activated No
ELT Aided Location of Event Site No
ELT Type --
Aircraft Owner Name Flight Line, Inc.
Aircraft Owner Street Address --
Aircraft Owner City Watkins
Aircraft Owner State CO
Aircraft Owner Country USA
Aircraft Owner Zipcode 80137
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 VOXA
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 Non-scheduled
Indicates Domestic or International Flight Domestic
Operator carrying Pax/Cargo/Mail Cargo
Type of Flying (Per_Bus / Primary) --
Second Pilot on Board No
Departure Point Same as Event No
Departure Airport Code SLC
Departure City Salt Lake City
Departure State UT
Departure Country USA
Departure Time 40
Departure Time Zone CDT
Destination Same as Local Flt --
Destination Airport Code APA
Destination City Denver
Destination State CO
Destination Country USA
Specific Phase of Flight Approach - final approach fix (FAF)/outer marker to threshold (IFR)
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record Aug 29 2006 4:27PM
User who most recently changed record CASH
Since inspection or accident Last Inspection
Event Location Runway Number and Location NA
Runway Length --
Runway Width --
Sight Seeing flight No
Air Medical Flight No
Medical Flight --