MIA03FA025
MIA03FA025

HISTORY OF FLIGHT

On December 6, 2002, about 1541 eastern standard time, a Raytheon 58 twin-engine airplane, N241JG, was destroyed when it departed controlled flight and impacted private homes in a residential area near Fort Myers, Florida. The airplane was registered to KC Services Inc., and operated by the pilot. Instrument meteorological conditions prevailed at the time and an instrument flight rules (IFR) flight plan was filed for the 14 CFR Part 91 personal cross-country flight. There were no injuries to anyone on the ground. The instrument-rated private pilot and one passenger were fatally injured. The flight departed from Centerville, Alabama, about 1220 (1120 central standard time).

The flight had originally departed from Rosecrans Memorial Airport (KSTJ), St. Joseph, Missouri, at 0903 (0803 central standard time), en route to Naples, Florida, with an intermediate fuel stop at the Centerville Airport (0A8), Centerville, Alabama. While in Centerville, the pilot contacted the Anniston Flight Service Station (FSS) and filed the IFR flight plan to Naples and obtained an abbreviated weather briefing for the flight. According to the filed flight plan, the pilot intended to fly at 200 knots at 7,000 feet. His planned route had him going from 0A8 to SZW (Seminole, Florida), CTY (Cross City, Florida), PIE (St. Petersburg, Florida), SRQ (Sarasota, Florida), and ending in APF (Naples, Florida). According to the pilot's family, the pilot did not want to fly direct because the airplane was not equipped for extended operations over water. According to the pilot's flight plan, he estimated the flight would last 2 hours and 30 minutes and he had 4 hours and 15 minutes of fuel on board. The pilot did not file an alternate destination. After departure from 0A8 the flight proceeded to Naples without incident.

Aircraft radar data was obtained from the Federal Aviation Administration's (FAA) terminal radar approach control located at Southwest Florida International Airport (RSW), Fort Meyers, Florida. The facility is equipped with an Airport Surveillance Radar-8 radar system, which supplies data to an Automated Radar Terminal System (ARTS) model IIE at RSW. Radar targets for the accident airplane were recorded by the ARTS from 1434 to 1540. Transcripts of the pilot's communications with air traffic controllers were also obtained. The pilot attempted four instrument approaches (one at Naples, and three at Fort Meyers Page Field) prior to the accident. A NTSB air traffic control specialist overlayed the aircraft's radar data onto the various approach plates to provide a bird's-eye view of the airplane's flight track in relation to the final approach courses. The following is a summary of the aforementioned radar data and communications.

Approach #1 (1440 to 1510)

At 1440:05, the pilot contacted the Southwest Florida International Air Traffic Control (ATC) departure facility and informed the controller that they were at 7,000 feet. The controller provided the altimeter setting (30.06 inches of mercury) and asked the pilot to report when he had ATIS (automatic terminal information services) Sierra for Naples. He also informed the pilot he could expect the VOR (very high omni-directional range navigation aid) Runway 23 approach with a circle to land on runway 32. At 1441:28, the pilot called back and informed the controller he had ATIS information Sierra and confirmed the approach information.

At 1444:52, the controller made a general radio announcement to all aircraft indicating ATIS information Tango was current at Naples. He then provided the updated weather, which at the time was reported as visibility two statute miles in light rain and mist with an overcast ceiling of 500 feet above ground level (agl). The wind was from 320 degrees at 7 knots and the altimeter setting was 30.04 inches of mercury. The controller informed all aircraft to expect the VOR runway 23 approach with a circle to land runway 32 at Naples.

At 1446:01, the controller cleared the airplane direct to Naples and to descend to 5,000 feet. At 1447:22, the controller provided the pilot with a vector of 190 degrees for the VOR 23 approach. At 1450:44, the controller instructed the pilot to switch to Fort Meyers control (Southwest Florida International ATC south radar position) on another frequency after providing him a vector of 180 degrees.

Once the pilot switched frequencies, that controller instructed the pilot to descend to 3,000 feet and to fly a heading of 130 degrees for sequencing. At 1456:58, the controller provided the pilot with a vector of 180 degrees and informed the pilot to "expect vectors across the final approach course for sequence" to which the pilot acknowledged. The controller then informed the pilot to expect vectors back toward the final approach in five miles, to which he responded, "I'll be waiting." At 1459:43, the controller gave the pilot a vector of 330 degrees and asked him to descend to 2,000 feet. At 1501:25, the controller provided the pilot a left vector to 270 degrees to join the VOR 23 approach. Thirty five seconds later, the controller asked the pilot to reduce his final approach speed and informed him he was 12 miles from the airport. He instructed the pilot to maintain 2,000 feet until he was established on final approach and cleared him for the VOR 23 approach circle to land runway 32. The pilot acknowledged and reported he was established. At 1502:16, the controller informed the pilot that two aircraft went missed on their approaches and one Piper Comanche just landed and a Westwind was ahead of his flight. One minute and 40 seconds later, the controller informed the pilot that the Westwind conducted a missed approach, and his radar services were terminated. He then instructed the pilot to switch frequencies to the Naples control tower, which he did.

Examination of the aircraft's radar data for that approach revealed the pilot flew through the final approach (radial 055 from the Cypress VOR) about eight miles from the VOR. The aircraft's track then paralleled the final course on the northwest side of the course starting about four miles out. The aircraft remained on that parallel track until it passed the VOR where the pilot initiated the missed approach. The radar data for that approach indicates that the aircraft descended to about 500 feet (the minimum descent altitude for the VOR 23 approach circle to land was 500 feet).

Approach #2 (1511 to 1527)

Upon conducting the missed approach at Naples, the pilot contacted the Southwest Florida International ATC departure facility and requested to divert to Page Field, Fort Meyers, Florida (located 26.5 nautical miles north of Naples). The controller then provided radar vectors to Page Field and cleared the pilot back up to 3,000 feet. At 1513:37, the controller provided Page Field's weather information, which was reporting the wind from 020 degrees at 13 knots, visibility 3 statute miles in light rain and mist, an overcast ceiling at 300 feet, and an altimeter setting of 30.06 inches of mercury. At 1515:05, the controller transferred the pilot to Fort Myers approach control.

At 1522:22, the approach controller informed the pilot he was five miles from Caloo (the locator outer marker and initial approach fix for the instrument landing system [ILS] runway 5). He was given a vector of 030 degrees and told to maintain 2,000 feet until established on the localizer and was cleared for the ILS runway 5 approach. The pilot acknowledged the clearance. At 1523:26, the pilot was instructed to contact the control tower.

The pilot then contacted Fort Meyer's control tower and was cleared to land. The controller asked the pilot whether he was established on the approach, to which the pilot responded "yeah, I'm not quite established yet. I'm comin up on Caloo, but I'm not actually on the glide slope yet. Looks like I should intercept it here in just about a minute." The controller then informed the pilot that most of the other airplanes had been breaking out of the cloud bases around 300 feet and they were reporting 3 statute miles visibility in light rain and mist.

At 1526:15, the controller called the pilot, and the pilot responded with, "yeah, I missed it. Uh, I'm going back up to two thousand and uh can you bring me back around?"

Review of the aircraft's radar data for that approach revealed the airplane tracked toward the ILS on an approximate 030 degree heading and intercepted the localizer (231-degree radial) about one mile outside (southwest of) Caloo. The airplane maintained that 030-degree track for about another mile before it turned back toward the localizer. The airplane's track then paralleled the final course for about one mile before it made a teardrop turn to the right before rolling out on a westerly heading (making a turn to reverse course). It was at this point that the controller called the pilot. This all took place within 2.5 miles of Caloo. During the course reversal, the airplane track was observed descending from 1,100 feet (lowest point during the parallel leg of the inbound portion), to a low of 200 feet (as the airplane's track made the right turn to the west).

At 1526:24, the tower controller began coordinating with the approach controller regarding N241JG's status. The tower controller informed the approach controller that the pilot initiated a turn outbound on his own and asked on what heading the approach controller wanted N241JG. At 1526:54, the tower controller instructed the pilot to fly a heading of 270 degrees, maintain 2,000 feet and contact the approach controller. The tower controller then informed the pilot that he needed to let someone know if he was going to initiate a missed approach.

Approach #3 (1528 to 1535)

At 1528:02, the approach controller asked the pilot for his intentions. The pilot responded by stating he would like to try the ILS for runway 5 again. The controller provided another vector toward the south and the localizer frequency, to which the pilot responded that he had it.

At 1530:09, the controller instructed the pilot to fly a heading of 080 degrees and maintain 2,000 feet until he was established on the localizer. He also informed the pilot that he was about three miles from Caloo. At 1531:01, the controller informed the pilot that he was "just about ready to be established sir." Nine seconds later the controller informed the pilot he was going left of course and asked if he was picking up the localizer, to which the pilot responded he was "through the localizer." The controller asked if he was not receiving the localizer or if the pilot was just getting on it right now. The pilot answered he had flown through the localizer. However, the radar data depicted the airplane's track flying southeast toward the localizer, but turning toward the northeast (parallel to the course). The airplane never crossed over the final course. The track diverted from the course further, but then paralleled the final course for a few miles. At 1531:33, the controller instructed the pilot to turn to a heading of "070 [degrees] and reintercept. Your over the marker now." The pilot responded by repeating the heading and stating "I'm on it now." The airplane's track displayed it turning toward the final course. However, before the airplane's track met that of the localizer, the airplane made a left teardrop shaped turn, reversing its course. The controller asked the pilot to inform him when he had the localizer "locked" but received no response, he then asked the pilot to confirm whether he was on the localizer. The pilot stated, "Sir, I'm having very big difficulties out here. I've gone through it again and I'm climbing back to 2,000." The lowest the airplane got on this attempt was 1,400 feet, which occurred while in the teardrop shaped turn.

The controller informed the pilot that the approach clearance was cancelled and instructed him to fly a heading of 310 degrees. He then informed the pilot to "just fly straight...ahead sir, fly straight ahead." The pilot asked if the controller wanted him on a 310-degree heading, to which the controller responded, "fly straight ahead. Just whatever heading you have now. Maintain 2,000 feet." The controller then informed the pilot to expect radar vectors the ILS runway 5 approach.

At 1533:24, the controller asked the pilot what his fuel status was, to which the pilot responded, "it's down in the yellow." The controller asked the pilot how much that was in time and the pilot responded "practically nil." The controller acknowledged and asked the pilot to turn to a heading of 300 degrees. He then asked the pilot to report his flight weather conditions, to which the pilot stated, "I'm above the clouds at the moment turning two one oh over to 300."

The controller informed the pilot that he could set him up for the NDB (non-directional beacon) approach, but the minimum descent altitude was higher. The pilot said no, and that he was trying to fly the approach, "with my automatic" and he was going to "have to fly it manual. I've got some kind of instrument problem."

Approach #4 (1535 to 1540)

At 1535:38, while the airplane was flying a southern track, the controller informed the pilot that he was going to turn him onto a base leg and would monitor his progress. He also informed the pilot that he was four miles from Caloo, gave the pilot a vector of 040 degrees, and cleared him for the ILS runway 5 approach. Following this communication, the approach controller contacted Fort Meyer's control tower and asked what the weather was at the airport. The tower controller informed the approach controller that the visibility was three statute miles and that most of the airplanes are breaking out of the cloud bases around 300 feet, which is what the tower was reporting the cloud bases.

At 1536:51, the controller informed the pilot that he was flying through the localizer again and suggested he turn right to a heading of 060 degrees to recapture the localizer. Nine seconds later, the controller instructed the pilot to descend and maintain 1,500 feet and informed him he was over the outer marker and he was going to initiate the pilot's descent early. At 1537:18, the pilot repeated the clearance.

At 1537:33, the controller instructed the pilot to fly a heading of 050 degrees and informed the pilot that he was going to convert the ILS approach to a surveillance approach to runway 5. He informed the pilot that the published missed approach point was one mile from the runway threshold and the minimum descent altitude was 500 feet. At 1538:01, the approach controller instructed the pilot to fly a heading of 070 degrees and descend and maintain 900 feet, and informed the pilot he was 3.5 miles from the runway and "very slightly left of course."

The controller provided additional vectors and altitudes bringing the airplane down to 500 feet along the final course at the missed approach point. The controller cleared the pilot to land if he could see the runway; however, he also provided missed approach instructions (climb straight ahead to 2,000 feet) in the event the pilot could not see the runway environment.

At 1539:20, the controller informed the pilot that he was less than a mile from the threshold at an indicated altitude of 300 feet. He instructed the pilot that if he did not see the runway, to go around.

The radar data depicted the airplane on course for the last three miles of the approach. The airplane's altitude descended to 300 feet near the runway threshold. The airplane's track over flew the runway as the altitude increased to 600 feet. As the airplane's track neared the end of the runway, the airplane began a left turn and another descent to 300 feet.

At 1539:52, the controller informed the pilot that he had radar contact with his aircraft and he was to maintain 1,500 feet if he could. At, 1540:12, the controller asked the pilot how he could hear him, to which the pilot responded, "I hear ya." The controller then instructed the pilot to climb and maintain 1,500 feet and fly a heading of 180 degrees. The radar data depicted the airplane track straighten along a southeastern heading with a climb to 1,200 feet. At 1540:33, the controller provided the pilot a heading of 230 degrees, but the radar data never depicted a turn in that direction. After the airplane peaked at 1,200 feet, it began a descent and turn toward the east. There were no additional communications from the pilot. The last seven radar returns were as follows:

1540:17: 1,200 feet
1540:21: 1,100 feet
1540:26: 1,100 feet
1540:31: 1,000 feet
1540:35: 1,000 feet
1540:40: 1,000 feet
1540:45: 700 feet

The last three radar returns depicted a track that was turning toward the south. Upon seeing the last radar returns, the controller called the Fort Meyers control tower and asked if they could see the airplane. At 1541:32, the controller requested that they begin a search and initiated an alert 3.

The airplane descended into a residential area and impacted a garage attached to a home before impact terrain. A witness to the accident site said he observed the airplane impact the garage roof and hit the ground as "pieces scattered." This witness indicated that the clouds were very low and almost a fog condition. Another witness heard an airplane departing the airport in instrument conditions with "low ceiling and no visibility". The airplane descended out of the clouds and he observed that it was a twin-engine airplane heading south at a low altitude, with the landing gear retracted, full power and a high rate of speed. The airplane was losing altitude and slowly banking to the right. The witness then ceased to hear the engines. He didn't see the airplane's final impact with the house.

Two other witnesses, both residences located near the accident site, heard the airplane fly overhead. One heard the "propeller noise change abruptly to a very high tone, which lasted approximately five seconds. This was followed immediately by a large increase in engine noise as if the pilot added power to the engine." This observer (an airline transport pilot) noted the ceilings were 300-400 feet and visibility was 1+ mile. The other witness (a former pilot and FAA inspector) heard "a very loud and unusual engine noise, which lasted for approximately 7 to 10 seconds before the noise abruptly stopped." He did not "detect an engine malfunction such as a backfire or propeller surge, but an instant, steady high rpm engine (or engines) sound."

PERSONNEL INFORMATION

The pilot held a private pilot certificate with single- and multi-engine land airplane ratings. He also had an instrument rating, which was issued in May of 1998. Review of the pilot's logbook revealed he accumulated a total of 910.5 hours of flight time, of which 211.8 hours were accumulated in multi-engine airplanes. All of the pilot's multi-engine experience was accumulated in the same make and model as the accident airplane. The pilot logged 70.5 hours of actual instrument time and 65.9 hours of simulated instrument time.

Between April 30, 2001 and May 30, 2001, the pilot completed a ground and flight instruction course at a Flight Safety International - Raytheon Learning Center for the Raytheon 58 airplane. During the course, the pilot obtained 16.0 hours of simulated flight training, 4.33 hours of actual airplane flight training, and 27.0 hours of ground training.

The pilot obtained a third-class medical certificate with no limitations on June 21, 2002.

AIRCRAFT INFORMATION

The 6-seat airplane (serial number TH-1987) was manufactured in 2001 with two Teledyne Continental Motors IO-550-C (31) engines and the following avionics and instrument equipment:

King 130A Encoding Altimeter
King 285A Autopilot Mode Annunciator
King 0525A Horizontal Situation Indicator (HSI) 30/400
King 0102A Directional Gyro
King 0076C Transponder
King 0225 Computer, 3-axis autopilot with yaw
GNS NAV/COMM/GPS 430 (number 2 radio position)
GNS NAV/COMM/GPS 530 (number 1 radio position)
Global Positioning System Annunciator Control Unit
BF Goodrich WX-5006 Stormscope Weather Mapping System
Honeywell RDR-2000VP Color Weather Radar, ART 2000 RADAR REC/XMITTER
Honeywell IN-182A Indicator and Mounting
Shadin ADC 200+ Fuel/Air Data Computer
ARTEX ELT, S/N 65086, Battery date November, 2002

Maintenance records (in the form of work orders, endorsements, and major repair and/or alteration forms) were provided to the NTSB. The whereabouts of the aircraft and engine logbooks are unknown; however, the following information was gleaned from the aforementioned records. A weight and balance report completed by Executive Beechcraft Inc. of Kansas City, Missouri (an FAA approved repair station), dated May 21, 2001, indicated that the King HSI and slaving mechanism was removed and replaced with a Sandel EHSI (electronic HSI) and a BF Goodrich attitude gyro. The pilot flew to Kansas City, Missouri, to pick up the new airplane on May 24, 2001.

On a work order invoice dated May 29, 2002, an altimeter disagreement discrepancy was noted. According to the work order the encoding altimeter was removed and replaced with a certified unit (up to 35,000 feet on March 11, 2002). On May 23, 2002, the airplane, engines and propellers received an airworthy endorsement following an annual inspection at Executive Beechcraft Inc. At the time of the annual inspection, the airframe, engines, and propellers accumulated a total time of 119.4 hours since new.

On August 16, 2002, and September 26, 2002, the airplane was Executive Beechcraft Inc.'s repair facility for the left alternator kicking offline. On the August 16th work order they replaced the left voltage regulator. On the September 26th work order they adjusted the voltage regulators and soldered the fuse holder connections at the alternator. The last maintenance performed on the airplane, according to the provided records, took place on October 24, 2002, at an airframe total time of 168.6 hours since new.

According to the work orders provided, there were no open discrepancies on the airframe, engines, or propellers. At the accident site, the Hobbs hour meter indicated 186.1 hours.

According to the line service person at Rosecrans Memorial Airport (KSTJ), the pilot ordered 15 US gallons of 100LL-per/main tank prior to departure. The line-service person told the NTSB investigator that "the pilot only wanted 30 gallons because he was worried about being overweight." The line-service person was asked to fill the main tanks only. The flight arrived at Centerville, Alabama, and the pilot fueled the airplane with 60.5 US gallons of 100LL from a self-service facility before departing for Naples.

The airplane was equipped with inboard left and right engine fuel cells, outboard left and right engine fuel cells and a box section fuel cell in each wing. The system provided a total capacity of 200 gallons, 194 of which are considered usable. The airplane was equipped with a Shadin ADC (airdata computer) 200, which is capable of providing fuel flow functions such as left and right fuel flow, fuel flow used, fuel remaining, fuel to destination, range, specific range, and endurance.

METEOROLOGICAL INFORMATION

At Fort Meyers at the time of the accident (1540), the weather observation facility reported the wind from 040 degrees at 11 knots, ceiling overcast at 300 feet, visibility 3 statute miles in mist, temperature 16 degrees F, dew point 16 degrees F, and the altimeter was 30.07 inches Hg.

As previously mentioned in this report, the pilot filed a flight plan and obtained an abbreviated weather briefing from the Anniston FSS. After the pilot filed his flight plan, the weather briefer asked if he had the current weather and advisories. The pilot indicated that he obtained weather information a couple of hours ago, and asked if anything had changed. He added that he hoped things had gotten better.

The briefer informed the pilot that there was an AIRMET (airmen's meteorological information) over Florida for icing conditions above 15,000 feet and that IFR conditions existed until 2100 UTC (1600 local) and that it looked as though it was going to be "foggy down that way." The pilot asked if they were depicting any rain and stated that they had been calling for rain around Naples in the afternoon. The briefer checked the weather radar and informed the pilot that there were scattered showers around the St. Petersburg area and south and that there were no Convective SIGMETS (significant meteorological information) yet. The briefer added that he looked like he was in "good shape" and that around the Tallahassee area and south they had cloud decks between 1,200 and 1,500 feet with patchy IFR conditions. He then provided the pilot with the then current Naples weather information, which at the time was reported as wind calm, 10 statute miles visibility, broken clouds at 1,600 and 2,300 feet, and overcast clouds at 3,200 feet. The briefer asked if the pilot needed additional information, to which the pilot responded in the negative.

AIDS TO NAVIGATION

The VOR approach to runway 23 at Naples is along a final approach course of 235 degrees to the Cypress VOR, which is located on the airport. The minimum descent altitude is 500 feet for both a straight in and a circling approach for both category A and B aircraft (categories are determined by the stall speed multiplied by a factor of 1.3). The circling approach required a visibility of one mile. The published missed approach procedures for the VOR 23 approach called for a climbing left turn to the Cypress VOR at 2,000 feet, where the pilot is to enter a holding pattern along the approach course.

The ILS approach to runway 5 at Fort Meyers follows the localizer along a final course of 051 degrees. The decision height for the ILS is 265 feet with a minimum visibility requirement of 1 mile. The localizer approach (without the glide slope) has a minimum descent altitude of 440 feet with the same visibility requirement as the ILS. The surveillance radar approach for runway 5 required a minimum visibility of 1.25 miles at a minimum descent altitude of 440 feet. The published missed approach procedures for the ILS 5 approach called for a climb straight ahead (along the approach course) to 1,000 feet. The pilot is to then continue the climb to 2,500 feet while conducting a left turn toward SERFS intersection (which is defined by the 354-degree radial from the Lee County VOR at a distance of 16.4 miles). The pilot is to then enter a holding pattern.

According to air traffic controllers, no anomalies were reported regarding either of the instrument landing systems on the day of the accident. On December 7, 2002 (the day after the accident), the FAA produced a flight inspection report (After Accident Continuation Sheet; FAA Form 8240-14), following a test flight of the ILS runway 5 approach. According to the report, both the facility operation (localizer, glide slope, and markers) and minimum safe altitude warning systems were found to be satisfactory.

WRECKAGE AND IMPACT INFORMATION

The airplane impacted a garage attached to a house at 26 degrees 33.36 minutes north and 081 degrees 49.49 minutes west at an elevation of 17 feet msl. A secondary impact point was noted on the ground adjacent to the impacted garage. The secondary impact point was located at 26 degrees 33.37 minutes north and 081 degrees 49.49 minutes west. The debris field extended from the garage to about 350 feet along a 220-degree course.

A portion of the right wing containing the right auxiliary fuel tank separated and was found, along with the right aileron bell crank, in the garage near the initial impact point. Six feet of right wing, less the aileron and wingtip was located in a street. The right engine separated from the engine mounts and traveled about 75 feet across the street before puncturing through an exterior wall of a house about 10 feet above the ground. The engine continued through the roof of the house and eventually came to rest in the attic. The right propeller separated from the right engine forward of the propeller flange. The propeller hub and two of its three blades traveled through the exterior wall of the house and one interior wall knocking over a wall unit and television before coming to rest in the living room (the root of the separated blade remained with the hub; however, it was fractured just outboard of its attach point).

The left engine separated from its mounts and was located in the street with its propeller separated from the crankshaft (aft of the propeller flange). The left wing auxiliary fuel tank was also located in the debris path.

The aft end of the fuselage and empennage were intact, but separated from the remaining forward fuselage. The vertical stabilizer remained attached to the empennage and the rudder remained attached to the vertical stabilizer. The horizontal stabilizer remained attached to the empennage and the inboard portions of the right and left elevators remained attached to the horizontal stabilizer. The elevator and rudder control cables were separated at the fuselage separation point, but manual manipulation of the cables had a corresponding movement of the elevator and rudder. The left and right elevator trim actuators measured 1.07 inches, which according to Raytheon investigators, equated to a 5 degrees tab up position. The rudder trim actuator measured 4 inches, which equated to 2.5 degrees tab left.

Due to the extent of wing damage, aileron control continuity could not be determined. All flight control counterweights were accounted for and all wing attach bolts were found intact and secured to the center section and both front and rear spars.

The flap actuator was measured at 1.75 inches, which equated to a retracted position.

The instrument panel was separated from the fuselage and was destroyed. The sustained damage precluded functional testing of any of the navigational instruments. A number of the flight and engine instruments were found throughout the debris field. The following instruments were identified with the following indications:

- Fuel flow indicator - separated from instrument panel; indicating 20 gallons/hour
- Fuel flow indicator - separated from instrument panel; indicating 0 gallons/hour
- Oil temperature/Oil pressure - separated from instrument panel; indicators missing
- Attitude indicator - separated from instrument panel; indicating an inverted position
- Exhaust gas temperature/cylinder head temperature - separated from instrument panel; both needles indicating zero (on opposite sides of gauge)
- Encoding altimeter - separated from instrument panel; 30.02 inches of mercury
- Airspeed indicator - separated from instrument panel; needle indicated 250 knots
- Vertical speed indicator - separated from instrument panel; 850-foot/minute descent
- Vacuum gauge - in place in instrument panel; needle pointed to 5.5
- Fuel quantity gauge - separated from instrument panel; needle between 1/4 and 1/2
- Fuel quantity gauge - separated from instrument panel; needle pointing to E
- Engine RPM - separated from instrument panel; needle indicating less than zero
- Engine RPM - separated from instrument panel; needle indicating 2,300 RPM

The landing gear control lever was found in the retracted position, with the handle broken off. The landing gear actuator was separated from the aircraft. All three landing gear were separated from the fuselage and wings. Both main landing gear separated from the gear retract mechanism at the lower end of the shock assembly. The nose gear was separated from the airframe at the nose gear strut.

The two front seats (pilot and copilot) and two aft-facing center seats were separated from the airframe. The two aft forward-facing seats were attached to the aft fuselage/empennage section.

The left engine sustained impact damage to the cylinder vanes, and the #6 rocker arm cover was destroyed and the valve section was destroyed. The accessory gearbox and magnetos were separated and the magnetos were found destroyed. The top spark plugs were removed and no anomalies were noted. The vacuum pump was separated and found destroyed.

The right engine's magnetos were separated. The top spark plugs were removed and no anomalies were noted. The vacuum pump was separated from the engine. Investigators opened the vacuum pump and found the pump rotor and vanes intact. The #5 cylinder was separated between the head and barrel.

The left propeller had two blades that were separated from the hub, each displaying s-bending and gouges. One blade remained attached to the hub, though loosely with its outboard 15 inches separated.

The right propeller had all three blade roots attached to the hub, though loosely. As previously mentioned, one blade was separated from the root and located in the debris field. The fractured blade and the other two blades were twisted toward a low blade angle and the outboard tips were ground down and gouged.

According to the Raytheon investigator who responded to the accident site, the fuel selector valve for the right engine fuel system was in the OFF position, while the left fuel selector valve was in the ON position.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was performed on the pilot at the District 21 Medical Examiner's Office located in Fort Meyers, Florida. The pilot died as a result of blunt force trauma. Toxicological tests conducted by the medical examiner were positive for ethanol from a liver specimen; however, tested vitreous fluids were negative for ethanol, which according to the medical examiner was consistent with postmortem alcohol production.

Toxicological tests were conducted at the FAA's Civil Aeromedical Institute in Oklahoma City, Oklahoma. The toxicological tests were negative for volatiles. They were positive for an unquantified amount of amlodipine detected in the kidney and liver samples.

TESTS AND RESEARCH

The two TCM engine fuel control units were shipped to the manufacturer's facility for further examination. On February 26, 2003, an FAA inspector, along with investigators from TCM and Raytheon, examined the units. The left throttle body and fuel metering unit (serial number A00KA060) had two holes punctured in the throttle body. The mixture control arm remained attached, but was bent, and the fuel inlet and outlet fittings were fractured. The fuel inlet filter was clean and free from contaminates. The sustained impact damage precluded functional testing of the unit and instead, it was disassembled and examined. No pre-impact anomalies were noted with the internal components.

The right fuel metering unit and throttle body (serial number A001A304) sustained impact damage but was in a condition where it could be placed on a test bench and flow tested. Prior to testing, the fuel inlet filter was removed and examined. No debris or contaminates were noted. The observed fuel flow (measured in pounds per hour) was noted for various throttle angles during the testing. In all but the high-end throttle angle the fuel flows exceeded those called for in the target fuel flows.

ADDITIONAL INFORMATION

The wreckage was released to the owner's representative on May 20, 2003.


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