Piper PA-23-250 accident near Burlington, Vermont, November 22, 2005

The NTSB's narrative final · quoted from the NTSB record

While flying the ILS approach to the destination airport, the airplane remained aligned (laterally) with the inbound approach course; however, it remained above the glideslope, and then descended through it, approximately 7 miles from the runway. The airplane continued a gradual descent until it impacted wooded terrain approximately 3 miles from the approach end of the runway. Examination of the airplane revealed no mechanical deficiencies. The airport was equipped with a Minimum Safe Altitude Warning System (MSAW) designed to alert controllers when an aircraft is in danger of colliding with terrain or obstructions. Examination of system documentation and the radar replay revealed a low-altitude alert was displayed on the radar screen, and an alert message was sent to activate the MSAW alarms. Although the approach controller had transferred control of the airplane to the local controller, he continued to monitor the airplane on the approach. When he noticed the airplane descend below the glidepath, he notified the local controller, whose radar display also indicated a low altitude alert; however, the local controller's first instruction to the pilot to "climb," was 5 seconds after the last target was observed on radar. The pilot reported 470 total hours of flight experience, and 92 hours of total (actual) instrument flight time. During the preceding 6 months, the pilot accumulated 2 hours of instrument flight time.

The complete narrative as the NTSB published it. The NTSB's docket holds the report as a PDF and any photographs, statements and other documents from the investigation.