Gatlinburg-Pigeon Forge Airport
Aircraft Accident/Incident Report

Sevierville, Tennessee 37862
Sunday, October 28, 2012 14:34 EDT

NTSB Narrative Summary Released at Completion of Accident

Before departure, the pilot had contacted the air traffic control (ATC) facility and received his instrument flight rules (IFR) clearance, which entailed flying direct to a navigational facility about 22 miles west of the departure airport. Shortly after departure, the pilot contacted ATC, and was given radar vectors toward that navigational facility and toward rising terrain. Because the airplane was in instrument conditions, the pilot was unable to see the surrounding terrain. When the airplane’s global position system's terrain feature alerted the pilot of a possible terrain issue, the pilot queried the air traffic controller. However, before the controller responded, the airplane impacted a pole and trees; a postimpact fire ensued and consumed the airplane. The Federal Aviation Administration (FAA) defines minimum vectoring altitude (MVA) as the lowest altitude at which an IFR aircraft will be vectored by a radar controller to ensure obstacle clearance. The FAA further states that air traffic controllers are to give first priority to separating aircraft, issuing safety alerts, and providing safety alerts regarding terrain or obstructions. Despite FAA requirements, a review of accident-related ATC radar and voice data revealed that ATC personnel issued a radar vector without first identifying the accident airplane on radar, provided radar vectors when the airplane was below the MVA, and did not provide safety alerts to the accident airplane or another airplane that had departed just before the accident flight. Interviews with the accident ATC personnel indicated that a facility-wide culture of providing vectors to aircraft below minimum altitudes existed, air traffic controllers supervised other controllers while performing operational duties, and the facility was non-compliant with safety alert requirements. The accident air traffic controller failed to adhere to the required procedures for vectoring and providing appropriate safety alerts, which negated the safety margins afforded by those procedures. This culture of disregard for standard operating procedures among the controller workforce at the ATC facility was indicative of a continuous failure of management at the facility.

NTSB Probable Cause Narrative

The air traffic controller’s failure to comply with the required vectoring and safety alert procedures, which resulted in the airplane’s flight into rising terrain. Contributing to the accident was the Federal Aviation Administration’s continued practice of using air traffic controllers who were performing required radar operational duties to supervise other controllers and the air traffic control facility’s culture of non-compliance with required procedures.

Event Information

Type of Event Accident
Event Date 10/28/2012
Event Day of the Week Sunday
Time of Event 1434
Event Time Zone Eastern Daylight Time
Event City Sevierville
Event State TENNESSEE
Event Country --
Zipcode of the event site 37862
Event Date Year 2012
Event Date Month 10
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 354833N
Event Location Longitude 0833908W
Event Location Airport Gatlinburg-Pigeon Forge
Event Location Nearest Airport ID GKT
Indicates whether the acc/inc occurred off or on an airport Off Airport/Airstrip
Distance from airport in statute miles 7
Degrees magnetic from airport --
Airport Elevation 1014
Weather Briefing Completeness --
Investigator's weather source Weather Observation Facility
Time of the weather observation 1456 Eastern Daylight Time
Direction of event from weather observation facility (degrees) 85
Weather Observation Facility ID GKT
Elevation of weather observation facility 1013
Distance of event from weather observation facility (units?) 6
Time Zone of the weather observation EDT
Lighting Conditions Day
Lowest Ceiling Height 4000
Lowest Non-Ceiling Height 1400
Sky/Lowest/Cloud Conditions Few
Sky Condition for Lowest Ceiling Broken
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) 10
Air Temperature at event time (in degrees celsius) 9
Dew Point at event time (in degress fahrenheit) 6
Wind Direction (degrees magnetic) --
Variable Wind Indicator Variable
Wind Speed (knots) 5
Wind Velocity Indicator --
Wind Gust Indicator Not Gusting
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) 29.9
Density Altitude (feet) --
Intensity of Precipitation --
METAR weather report --
Event Highest Injury Minor
On Ground, Fatal Injuries --
On Ground, Minor Injuries --
On Ground, Serious Injuries --
Injury Total Fatal --
Injury Total Minor 3
Injury Total None 2
Injury Total Serious --
Injury Total All 3
Investigating Agency NTSB
NTSB Docket Number (internal use) 31665
NTSB Notification Source FAA Southern C-ROC
NTSB Notification Date --
NTSB Notification Time --
Fiche Number and/or location -used to find docket information --
Date of most recent change to record Jun 26 2013 10:51AM
User who most recently changed record kenj
Basic weather conditions Instrument Meteorological Cond
FAA District Office --

Aircraft Involved

Aircraft #1

Aircraft Registration Number N4478F
NTSB Number ERA13LA042
Missing Aircraft Indicator --
Federal Aviation Reg. Part Part 91: General Aviation
Type of Flight Plan filed IFR
Flight plan Was Activated? Yes
Damage Substantial
Aircraft Fire Ground
Aircraft Explosion None
Aircraft Manufacturer's Full Name PIPER
Aircraft Model PA-32R-300
Aircraft Series Identifier --
Aircraft Serial Number 32R-7680450
Certified Max Gross Weight 3600
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 7
Number of Engines 1
Fixed gear or retractable gear Retractable
Aircraft, Type of Last Inspection Annual
Date of Last Inspection Jul 31 2012 12:00AM
Airframe hours since last inspection --
Airframe Hours 3051
ELT Installed Yes
ELT Activated Yes
ELT Aided Location of Event Site No
ELT Type C91-A
Aircraft Owner Name SPACE COAST AVIATION SALES LLC
Aircraft Owner Street Address --
Aircraft Owner City WILMINGTON
Aircraft Owner State DE
Aircraft Owner Country USA
Aircraft Owner Zipcode 19810-4902
Operator is an individual? Yes
Operator Name Kevin Saltsman
Operator Same as Owner? No
Operator Is Doing Business As --
Operator Address Same as Owner? No
Operator Street Address --
Operator City Rockway
Operator State FL
Operator Country USA
Operator Zip code --
Operator Code --
Owner has at least one certificate None
Other Operator of large aircraft? No
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 Yes
Departure Airport Code GKT
Departure City Sevierville
Departure State TN
Departure Country USA
Departure Time 1430
Departure Time Zone EDT
Destination Same as Local Flt --
Destination Airport Code TIX
Destination City Titusville
Destination State FL
Destination Country USA
Specific Phase of Flight --
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record Jun 26 2013 10:51AM
User who most recently changed record kenj
Since inspection or accident Last Inspection
Event Location Runway Number and Location 28
Runway Length 5506
Runway Width 75
Sight Seeing flight No
Air Medical Flight No
Medical Flight --