History of Flight
On October 28, 2012, at about 1434 eastern daylight time, a Piper PA-32R-300, registration N4478F, struck a pole and trees shortly after departing from Gatlinburg-Pigeon Forge Airport (GKT) in Sevierville, Tennessee. The private pilot and one passenger were not injured, while three passengers received minor injuries. The portion of the airplane forward of the empennage was consumed by a postimpact fire. The flight was conducted under Title 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions were present at the airport, but instrument meteorological conditions prevailed in the area, and an instrument flight rules (IFR) flight plan had been filed for the flight to Space Coast Regional Airport (TIX) in Titusville, Florida.
The pilot filed the IFR flight plan at 1328 via the Direct User Access Terminal System (DUATS). The planned route included the Volunteer VORTAC, direct to DUBBS intersection, direct to NELLO intersection, direct to Craig VORTAC, Ormond VORTAC, and then direct to the destination, with a cruise altitude of 6,000 feet mean sea level (msl).
Air traffic control provided radar vectors. The pilot received a terrain warning on his GPS and queried the controller but received no reply. Subsequently, the GPS issued an obstacle warning, and the pilot saw a rooftop and trees through the clouds. He pitched up and banked to avoid the obstacles, but the underside of the airplane struck several trees, and the airplane came to rest inverted in a tree about 15 feet above ground level. A postimpact fire began, and the occupants exited the airplane.
Aircraft and Pilot Information
The seven-seat, low-wing, retractable-gear airplane was manufactured in 1976, powered by a Lycoming IO-540-K1GSD 300-horsepower engine and equipped with a Hartzell controllable-pitch propeller. It had a Garmin GNS430 GPS with an integrated terrain database. According to the pilot, the most recent annual inspection was completed on July 31, 2012, at an airframe total time of 3,051 hours, and the engine time since overhaul was 1,271 hours. Thermal damage precluded determination of current values. The pilot reported the gross weight at the time of the accident was 3,461 pounds.
The pilot, age 48, held a private pilot certificate with ratings for airplane single-engine land and instrument airplane, and a third-class medical issued June 23, 2011. He reported 502 total flight hours, with 242 hours in the accident airplane make and model. He estimated about 80 hours of instrument flight experience, but his logbook was consumed by the fire, so exact experience could not be determined.
Meteorological Information
Recorded data from the GKT automated weather observation station at 1420 showed wind from 330 degrees at 7 knots, visibility 3 miles, scattered clouds at 1,000 feet above ground level (agl), overcast at 1,700 feet agl, temperature 8°C, dew point 7°C, and barometric altimeter setting of 29.89 inches of mercury.
Air Traffic Control
According to voice and radar data from the FAA air traffic control facility in Knoxville, Tennessee (TYS), located about 22 nautical miles west of GKT, the pilot first contacted TYS at 1419. He requested and received his IFR clearance as filed and was assigned an initial altitude of 5,000 feet msl.
At 1428:01, the pilot reported he was number one for departure from runway 28 and was released for departure. The controller instructed him to contact the same controller when airborne. At 1430:28, the pilot reported climbing through 1,500 feet. About one minute later, he was asked to "ident" and received clearance to continue to 6,000 feet. At 1430:36, the first radar target indicated the airplane at 1,400 feet msl. At 1431:52, the controller offered vectors, and the pilot accepted. At 1432:02, the controller instructed the pilot to "fly heading two six zero climb and maintain six thousand." Radar data indicated a left turn toward the assigned heading.
The last transmission from the pilot occurred at 1434:05, stating, "and uh knoxville seven eight fox uh we getting a uh terrain advisory are we still in the clear." At that time, radar indicated the airplane at 2,400 feet msl. At 1435:19, the controller stated, "say uh traffic I mean not traffic uh a obstruction thirty four hundred feet fly heading uh two niner zero for now."
On November 5, 2012, an NTSB ATC Group reviewed radar and voice data and interviewed facility personnel. The controller acknowledged that he had not radar identified the accident airplane and had issued a vector without required radar identification. He also acknowledged not issuing a safety alert, even though the airplane was maneuvering below the FAA charted minimum vectoring altitude (MVA). The controller reported that just prior to the accident, he was obtaining flight strips. Other controllers noted that deviation from the approved departure procedure occurred on a "regular basis," and they would normally query the pilot to confirm terrain was in sight and give a suggested heading. Prior to the accident flight, another airplane had departed GKT and received the same turn below MVA without a safety alert.
Wreckage and Impact Information
Examination by an FAA inspector revealed that the airplane first impacted a pole and trees on a mountain at about 2,600 feet msl. The airplane was consumed by postimpact fire except for about 6 feet of the empennage. Control cable continuity was confirmed. Tree limbs exhibited marks consistent with being cut by the propeller during impact. One propeller blade had curling on its tip; the other showed slight bowing forward. The pilot reported no mechanical malfunctions or anomalies that would have precluded normal operation.
A topographical chart showed tightly-spaced contour lines around the flight track, indicating rapidly rising terrain. The accident location was near a contour line of 2,520 feet, with the highest contour at 2,600 feet.
Additional Information
FAA Publication JO7110-65U defines Minimum Vectoring Altitude (MVA) as the lowest MSL altitude at which an IFR aircraft will be vectored by a radar controller, except as authorized for radar approaches, departures, and missed approaches. Section 2-1-2 states that first priority is separating aircraft and issuing safety alerts. Section 2-1-29 requires providing safety alerts regarding terrain or obstructions. Section 5-6-3 allows vectors below minimum altitude if the flight path is 3 miles or more from the obstacle.
The obstacle departure procedure for runway 28, per the Terminal Procedures Publication, was to climb direct to VXV VORTAC to 5,000 feet before turning on course.
At the time of the accident, the radar room was staffed by two controllers: the accident controller and another controller who was also the controller in charge (CIC), responsible for oversight. A frontline manager was present but in an office performing administrative duties. Neither observed the controller's interaction with the accident airplane.
FAA Advisory Circular 61-134 Section 9 suggests that general aviation pilots flying IFR in IMC conditions should know the planned procedure well enough to recognize unsafe clearances, and have knowledge of minimum safe or sector altitude and the highest terrain in the area.
The NTSB had previously issued Safety Recommendation A-11-17 on March 21, 2011, recommending that the FAA prohibit controllers from providing supervisory oversight while performing operational duties. As of the report, the recommendation remained open with a status of "open – unacceptable response."