Incident Overview
An emergency medical service (EMS) aircraft conducting an ILS approach to runway 03 departed from the localizer course about 1 mile from the runway at approximately 500 feet above ground level in fog. The aircraft then struck a pole, flew into a building, and burned. No distress call was made by the pilot. The paramedic was the only survivor.
Flight Sequence
During the approach, the aircraft remained well above the glide slope until close to the middle marker. Airspeed decreased from 153 to 100 knots, while vertical speed increased from 711 feet per minute to about 1,250 feet per minute descent. Approximately 1 mile from the runway and 500 feet agl in fog, the aircraft abruptly turned left of the localizer course and gradually descended. No preimpact mechanical problems were found with the aircraft or engines, and no ILS anomalies were identified. The flight nurse was using a cellular phone, but no evidence of interference with the aircraft's navigational system was found.
Pilot Background
The pilot, a recent ex-military helicopter pilot, had logged approximately 3,500 total flight hours and about 150 hours in multiengine airplanes. However, evidence indicated he lacked experience with actual instrument approaches in fixed-wing aircraft, and he had difficulty with instrument flying during recent training and FAA check flights. Before the flight, he expressed anxiety about possible low visibility for landing and the timely transport of a dying patient.
Weather and Conditions
Low ceiling, fog, and dark night conditions prevailed. Visibility and ceiling at the destination were less than forecast at the time of the pilot's preflight weather briefing. The pilot had received an abbreviated weather briefing for the flight.
Probable Cause
Failure of the pilot to follow proper IFR procedures, by failing to maintain proper alignment with the localizer course during the ILS approach and/or by failing to follow the proper missed approach procedure. Factors relating to the accident were: darkness; adverse weather conditions; and pressure on the pilot to complete the EMS flight, due to the circumstances and conditions that prevailed.