PORTAGE CREEK, AK, USA
N8297X
PIPER PA-32-301
ACCORDING TO A WITNESS, THE AIRPLANE WAS HEAVILY LOADED WITH PASSENGERS & BAGGAGE. THE PILOT ELECTED TO TAKE OFF EAST ON A 1920' SOFT WET RUNWAY WITH A 2-DEGREE UPSLOPE, WHICH ENDED AT A STEEP DROP-OFF. ABOUT 20 MILES EAST AT DILLINGHAM, THE 1147 ADT WIND WAS FROM 060 DEGREES AT 5 KNOTS. THE WITNESS SAID THAT THE WIND WAS FROM THE EAST WITH GUSTS TO 20 KNOTS & THAT THE AIRPLANE ACCELERATED SLOWLY DURING THE TAKEOFF ROLL. TIRE MARKS (MATCHING THE AIRPLANE) SHOWED THAT IT LIFTED OFF 261' BEFORE THE END OF THE RUNWAY. AFTER LIFT-OFF, THE AIRPLANE SETTLED IN A DESCENDING LEFT TURN & CRASHED. NO PREIMPACT MECHANICAL FAILURE WAS EVIDENT. THE AIRPLANE'S WEIGHT & BALANCE WAS ESTIMATED TO BE 4011 POUNDS WITH A CENTER-OF-GRAVITY (CG) OF 97.8 INCHES. ITS MAXIMUM CERTIFICATED GROSS WEIGHT WAS 3600 POUNDS WITH A CG RANGE OF 90 TO 95 INCHES.
HISTORY OF FLIGHT On July 11, 1994, at 1240 Alaska daylight time, a wheel equipped Piper PA-32 Saratoga, N8297X, registered to and operated by Peninsula Airways, Inc., of Anchorage, Alaska, crashed after takeoff from Portage Creek, Alaska, which is located approximately 20 miles west of Dillingham, Alaska. The air taxi flight, operating under 14 CFR Part 135, was departing Portage Creek on a company visual rules flight plan and the destination was Dillingham. Visual meteorological conditions prevailed. The pilot and one passenger were seriously injured and 3 passengers received fatal injuries. The airplane was substantially damaged. WITNESSES According to John Alto, the fishing guide for the passengers, the weather at Portage Creek had been rainy, heavy at times, for the previous 4 to 5 days. He stated there was a slight easterly wind when the airplane arrived. Another witness, Chris Carr, stated the wind was from the west. Mr. Alto stated the following: "The airplane arrived at 12:10 p.m., circling around and then landing on the North-South runway with the plane heading south. Chris Carr of Portage Creek arrived at this time with a cooler bound for Dillingham to see if there was room to fit it on. Luggage from our party was as follows: 3 fish boxes weighing 65-70 pounds apiece, 2 coolers containing fish, also weighing 65-70 pounds apiece, 4 duffel bags containing laundry weighing 25-35 pounds apiece. Then there were the belongings of Ray and Kent which was 3 or 4 duffel bags weighing 30-50 pounds apiece. The cooler that Chris Carr placed on the plane weighed in excess of 100 pounds. After re-arranging the gear loaded into the rear of the plane a couple of different times to make it all fit the cargo door was closed. While the pilot was loading the rear of the plane, he had me place two fish boxes in the nose compartment, and when he discovered that all of the gear would not fit he placed 1 duffel bag and a small carry on in the nose with the fish boxes, it was an extremely tight fit, as it took two people pushing on one of the fish boxes to get it in." Mr. Alto stated that the passengers were loaded and the pilot instructed the passengers where to sit. In his witness statement he commented, "I have never seen a plane packed so tightly with people and gear-I remember commenting just before they closed the door they looked packed like cord wood." Mr. Alto stated he saw the airplane taxi out onto the east- west runway. He stated he has seldom seen any airplanes use that runway. He heard the engine "rev up" and watched the airplane attempt to take off. The acceleration was very slow. The wheels of the airplane were still on the ground when the tail of the airplane disappeared from his sight. He did not see the airplane emerge and seconds later he heard a loud "whoom!" INJURIES TO PERSON The pilot and one passenger were seriously injured and three passengers received fatal injuries. DAMAGE TO AIRCRAFT The airplane was substantially damaged in the accident. The main fuselage of the airplane was resting upright. The engine, with the instrument panel attached to the firewall, was torn away from the main fuselage and was resting to the left side of the airplane. The left wing was torn away from the fuselage and located behind the airplane in the wreckage path. The right wing remained partially attached with the leading edge pointed downward at approximately a 45 degree angle. The vertical fin, rudder, and horizontal stabilizer were unremarkable. Both main landing gear remained attached to their respective wing attach points. The nose gear was sheared off. PERSONNEL INFORMATION The 28 year old pilot is the holder of an Airline Transport Pilot certificate, number 525395086, with an airplane multi engine land rating. He holds commercial privileges for airplane single engine land. He has a flight instructor certificate for airplane single and multi engine and instrument airplane ratings and a advanced and instrument ground instructor ratings. According to the Federal Aviation Administration the pilot was issued a first class medical certificate dated September 28, 1993 which required that he wear corrective lenses. According to the information provided by the company on the NTSB form 6120.1/2, the pilot had a total time of 5700 hours with 780 hours in the PA-32. According to the Director of Operations, the pilot had been flying as a first officer on the Metro airplane in scheduled service. The company policy is to send pilots, who are going to be upgraded to captain, to the "bush" to fly single pilot 14 CFR Part 135 air taxi work in single engine airplanes. The pilot was being considered for upgrade to captain on the Metro and had been in the "bush" flying the same airplane for approximately 6 months. METEOROLOGICAL INFORMATION The nearest weather observation facility is Dillingham, Alaska, located approximately 20 miles east of Portage Creek. The Dillingham record observation taken at 1147 Alaska daylight time, showed the ceiling to be estimated at 500 feet, visibility 2 1/2 miles with light rain and fog, temperature 53 degrees Fahrenheit, dewpoint 52 degrees Fahrenheit, the winds from 060 degrees at 5 knots, and the altimeter was 30.10 inches of mercury. AERODROME INFORMATION Portage Creek Airport is located approximately 20 miles West of Dillingham, Alaska. The airport identifier is AK14. The airport has two runways which align with 18-36 and 09-27. The longest runway is listed as 1900 feet and the surface is composed of gravel. The airport remarks section states that the airport is unattended and that runway conditions are not monitored, "...recommend visual inspection prior to use. RWY edges marked by orange cones with white reflectors. RWY thlds marked by orange cones with green reflectors." Examination of the airport showed that the runway surface was composed of river gravel, about 1/4 to 1/2 inch in size, and dirt. Walking on the surface caused the gravel to shift and roll from under the feet. Runway 09, the runway from which the take off was attempted, was found to be approximately 60 feet wide and 1920 feet long. The runway was found to have an upslope of 2 degrees. The departure end of runway 09 ended with the terrain dropping away at a 30 degree angle to an elevation approximately 100 feet below the end of the runway. The departure end of the runway was located 191 feet from the edge of the drop off and was clearly marked with green banded orange cones. The runway surface at the departure end of runway 09 was marked by deep tire grooves that were made by the rescue airplanes. According to Larry Tibets of Penair, and Chris Carr of Penair, the airplanes that parked at the departure end of the runway during the rescue, sank into the gravel and had to be pushed out by hand. The tracks on the runway were examined and a set of tire tracks were located that matched the take off description provided by the witnesses. The tire tracks start at the intersection of the two runways and continue to a point 261 feet short of the marked runway threshold. WRECKAGE AND IMPACT INFORMATION The airplane was located 1/4 mile off the departure end of runway 09 on a magnetic bearing of 060 degrees. The descent angle from the drop off after the end of the runway was 8 degrees. The main airplane wreckage was resting on a 032 degree heading. The terrain in the area was covered with muskeg, tundra and pools of water. The terrain under the muskeg and tundra was hard gravel. This was determined by examining the impact crater. The crater was approximately 3 feet deep. The crater was located 20 feet behind the airplane and was aligned with the wreckage path of 032 degrees. All the flight control surfaces of the airplane were located at the accident site and flight control continuity was established up to the cable separations associated with the left wing. Examination of the cockpit showed that the throttle, propeller control, and mixture, were in the full rich position, however, the engine, firewall, and instrument panel had separated for the airplane. The magneto switch was on the both position. The fuel valve was turned off by rescue personnel. The fuel pump switch was in the on position. The flap handle was set in the first extended flaps position. The elevator trim wheel was trimmed with the nose up indicator full up, however, the indicator did not function when the trim wheel was turned at the accident site. The altimeter read 360 feet with an altimeter setting of 30.05 set in the Kollsman window. The ADF was set to 330 degrees and the directional gyro showed 305 degrees. The engine tachometer showed 0 RPM and a total time of 1342.76 hours. The anti-collision and landing light switches were found in the on position. The parking brake handle was found in the on position but the system was not pressurized. The brake hydraulic system was compromised by the impact. The brake handle was actuated and the brake cylinders squirted hydraulic fluid. External examination of the engine showed no damage to the outer engine area that could be attributed to the internal rotating components. The propeller had separated from the engine and portions were located beneath the fuselage. The propeller blade leading edges were missing large pieces and there was chordwise scoring on both the front and rear of the blades. One blade was missing a large portion of the blade tip. Most of the cargo and personnel belongings had been removed by rescue workers and could not be accounted for at the accident site. The Alaska State Troopers removed some baggage, weighed it and then released the baggage to fish camp personnel. MEDICAL AND PATHOLOGICAL INFORMATION The toxicological examination of the pilot was conducted by the Kanakanak hospital and the doctor verbally confirmed that the toxicological test were negative except for those drugs that they used for treatment. TEST AND RESEARCH The engine was removed for examination at Sea Air Inc., in Anchorage, Alaska. The teardown showed that the engine was a Lycoming IO-540-K1G5, serial number L-15784-48A, capable of producing 300 horsepower at 2700 RPM. External examination showed that the mixture lever at the controller was full rich, the propeller governor was in the high RPM position, and the throttle lever was in the full throttle position. The engine was rotated and all the valves and rocker arms moved. The magneto timing was checked and the right magneto was found to be at 23 degrees before top dead center (BTDC) and the left magneto was at 22 degrees BTDC. During the engine rotation both magneto drives rotated. Normal timing for this engine is 20 degrees BTDC. Fuel was found in the fuel line between the fuel pump and fuel controller and in the fuel injector distributor (spider). The fuel pump was operated and functioned normally. Upon disassembly of the fuel pump, a trace of water was found in the diaphragm area. The fuel controller was then "split" and the "air" side of the controller was found to be dry. A drop of water was found in the spider. The injectors were bench tested and found to function normally. The results were 4.5 inches of pressure and the flow was 176 pounds per hour. The magneto's were bench checked and the right magneto checked normally. The left magneto sparked but could be tested no further due to a broken gear tooth. The fuel screens and oil filter were examined and found to be clean except for one small fleck of aluminum found in the oil filter. A compression check was accomplished cold and cylinders number 1,3,5, and 6 were at least 60 pounds of 80 pounds, cylinder number 2 was 50 pounds of 80 pounds, and cylinder number 4 was 15 pounds of 80 pounds. The number 4 cylinder was removed and the piston was in place and appeared normal. Fuel was poured into the intake and exhaust ports to determine if the valves leaked. The exhaust valve had a small leak and the intake valve had a large leak. The piston was removed and the ring gap checked at .042 inches. The maximum allowable gap is .045 inches. The ring gaps were staggered as recommended by the engine manufacturer. No cracks or holes were visible on the cylinder or cylinder head. The camshaft was removed and examined and the lobes were not worn nor did they exhibit any "flat" spots. ADDITIONAL INFORMATION According to the information obtained during an interview and from an unsigned statement provided by Mr. John Alto, a weight and balance calculation was accomplished using the lesser of his estimated weights. The Alaska State Troopers (AST) also weighed some of the cargo and those were used in the calculations. Weight Arm Moment Airplane empty 2169 82.4 178725.6 Pilot 157 85.5 13423.5 Front seat passenger 295 85.5 25222.5 Three center forward facing passengers with weights of 200,220,130 550 118.1 64955 Nose compartment, 2 fish boxes at 60 (AST actual weight) lbs each and one duffel bag estimated at 25 lbs 145 42.0 6090 Aft baggage, 1 fish box (AST actual weight) 60 178.7 10722 2 coolers estimated 65 lbs. each 130 178.7 23237 1 cooler estimated 100 lbs 100 178.7 17870 3 duffels estimated 25 lbs each 75 178.7 13402.5 3 duffels estimated 30 lbs each 90 178.7 16083 Fuel 40 gals at 6 lbs per gallon 240 94.0 22560 (according to flt plan, pilot filed with 2.5 hrs of fuel on board) __________________________________ TOTAL 4011 392291.1 Center of Gravity = 97.8 According to the NTSB Form 6120.1/2, signed by Dick Harding, Director of Operations for Penair, the airplane had only 18 gallons of fuel on board at the last takeoff. However, the flight plan, which the pilot filed, showed that he had 2.5 hours of fuel on board. The Airplane Information Manual shows that at 75% power the engine consumes approximately 16 gallons per hour. Based on the flight plan information, the pilot would have had at least 40 gallons of fuel on board the airplane. The weight and balance calculation above is based upon the flight plan fuel load. The calculation below alters only the fuel load based upon the NTSB form 6120.1/2. Fuel 18 gals at 6 lbs per gallon (information based on NTSB 6120.1/2) 108 94.0 10152 ___________________________________ TOTAL 3879 379883.1 Center of Gravity = 97.93 The fuel system was compromised and the actual quantity of fuel on the airplane could not be determined. According to the PA-32-301 Information manual, the maximum gross weight of the airplane is 3600 pounds and the center of gravity limits are 90 to 95 inches at the 3600 pound gross weight limit. The PA-32-301 airplane manual shows that for a maximum effort takeoff, with flaps set at 25 degrees, on a paved, dry, level runway, temperature of 10 degrees centigrade, sea level pressure, gross weight of 3600 pounds, and no wind, the takeoff ground roll of a two blade propeller is approximately 1100 feet. According to the Director of Operations for Penair, each airplane is equipped with a portable "fish" scale so the pilots can weigh the baggage/cargo. A portable "fish" scale was located in the airplane during the on site examination. During an interview with Chris Carr, part-time station agent for Penair at Portage Creek, he could not recall if the pilot used the scale.
THE PILOT'S INADEQUATE PREFLIGHT PLANNING AND PREPARATION, AND HIS FAILURE TO ENSURE THAT THE AIRPLANE WAS WITHIN ITS GROSS WEIGHT AND CENTER-OF-GRAVITY LIMITS, WHICH RESULTED IN AN INABILITY TO OBTAIN SUFFICIENT AIRSPEED FOR SUSTAINED FLIGHT AND A RESULTANT STALL/MUSH. A FACTOR RELATED TO THE ACCIDENT WAS: THE SOFT/WET/UPHILL RUNWAY CONDITION.
Source: NTSB Aviation Accident Database
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