Aviation Accident Summaries

Aviation Accident Summary MIA94FA175

Aircraft #1

N3610W

PIPER PA-32-260

Analysis

WHILE OVER WATER ABOUT 14 MILES NORTH OF THE DESTINATION, A LOSS OF ENGINE POWER OCCURRED. EMERGENCY PROCEDURES FAILED TO RESTORE ENGINE POWER. BEFORE DITCHING, THE PILOT ADVISED ATC OF HIS POSITION, AND RADAR RETURN AT 100 FEET WAS MARKED ON THE CONTROLLER'S RADAR SCOPE. THE AIRPLANE WAS DITCHED AT SEA, AND THE 4 OCCUPANTS EGRESSED FROM THE SINKING PLANE. THE PILOT REPORTED THAT 3 LIFE PRESERVERS WERE ABOARD THE PLANE, BUT THEY WERE NOT RECOVERED BEFORE THE PLANE SANK (HE HAD NOT BRIEFED THE PASSENGERS ABOUT THE LIFE PRESERVERS BEFORE FLIGHT). ABOUT 3 MINUTES AFTER DITCHING, A COAST GUARD AIRPLANE (WHICH WAS ON A TRAINING MISSION IN THE VICINITY, BUT WAS NOT DROP EQUIPPED) FLEW OVER AND FOUND THE 4 SURVIVORS. A RESCUE BOAT AND HELICOPTER WERE DISPATCHED TO THE AREA, BUT ONE OF THE SURVIVORS DROWNED BEFORE HELP ARRIVED. THE DITCHED AIRPLANE WAS NOT RECOVERED.

Factual Information

HISTORY OF FLIGHT On July 8, 1994, about 1016 eastern daylight time, a Piper PA-32-260, N3610W, registered to Michael S. Turner, was ditched in the Gulf of Mexico about 14 statute miles north-northwest of the Key West International Airport, Key West, Florida, while on a 14 CFR Part 91 personal flight. Visual meteorological conditions prevailed at the time and an IFR flight plan was filed. The airplane has not been recovered and is presumed to be destroyed. The commercial-rated pilot and two passengers sustained serious injuries. One passenger was fatally injured. The flight originated from the Pine Shadows Airpark, Fort Myers, Florida, about 0915. The pilot stated that after departure he obtained his IFR clearance and climbed to 5,000 feet mean sea level (msl) but he elected to descend to 2,000 feet and canceled his IFR clearance when the flight was north of Marco Island. Flight following was obtained with ATC and he elected to descend to 1,500 feet continuing to Key West. At 1003.36, the pilot contacted the Navy Key West Approach Controller and advised the controller of the distance away which according to the certified recording, was unreadable. The controller advised the pilot that runway 9 was the active, to which the pilot acknowledged. The controller then advised the pilot to descend at his discretion and to report when the field is in sight. Additionally, at 1010.18, the crew of a Coast Guard Falcon 20 "charlie" model (2141) airplane contacted the same controller and advised that the flight was 27 miles east, training, transitioning west. At 1014.40, the pilot of N3610W advised the controller that the Key West Airport was in sight to which the controller advised the pilot to contact the Key West ATC tower. At 1015.12, the pilot advised the Key West Approach controller "I've got a rough running engine here." The pilot later stated that the flight was 11.7 nautical miles on the 360- degree radial from the Key West Vortac going down. Attempts to restore the engine power were unsuccessful. The controller marked his scope of the last radar return which was when the airplane was at 100 feet and on the 005-degree radial and 10.6 nautical miles from the Key West Vortac. The crew of the Coast Guard Falcon hearing the transmissions about the imminent ditching, advised the controller that they would proceed to that location and the controller provided the crew with a heading to fly. At 1019.49, the crew of the Falcon advised the controller that two of the occupants are in sight. At about 1022, the Key West Naval Air Station Search and Rescue (SAR) crew on duty was called. At about 1022.45 the controller asked the Falcon crew if there were any boats in the area to which the crew responded negative. At about 1025.17, the Falcon crew advised the controller that four people were in the water, three were assisting the fourth, there was no flotation equipment and no obvious injuries. At about 1028.09, the Falcon crew advised the Key West Approach controller that there was a boat about 10 miles away. The approach controller advised the crew that the SAR helicopter should be airborne momentarily. At 1029.05, the controller asked the Falcon crew if they could drop flotation equipment to the people to which the crew responded "negative, were not drop capable." At about 1030, the approval was granted to launch the Navy SAR helicopter. At about 1034.25, the controller asked the Falcon crew if the survivors were still afloat to which the crew stated they were trying to relocate them after they went to look for a boat. The controller then provided the Falcon crew with a suggested heading to fly direct to the last known position of the ditched airplane. At about 1040.35, the crew of the Falcon advised the approach controller that they would reenter the search. At about 1046.50, the crew of the Navy SAR helicopter made initial contact with the approach controller and at 1048.50, the Navy SAR helicopter crew contacted the Falcon crew. At 1054, a Florida Marine Patrol (FMP) boat located at the FMP Summerland Key facility was dispatched to assist in the search and rescue for the downed occupants. At about 1054.50, the crew of the Falcon advised the crew of the Navy helicopter that the people were in sight. The Navy crew arrived at the reported location and reported that the sightings were birds in the water. At about 1104, a Coast Guard boat was also on scene involved in the search and rescue. At about 1135.35, the Falcon crew reported sighting of the occupants which was verified by the Navy SAR crew at about 1135.59. At about 1136, the FMP boat arrived on scene and about 1141, a rescue swimmer from the Navy SAR helicopter was dropped into the water providing three uninflated flotation devices to the survivors. The pilot of the ditched airplane directed the swimmer to the deceased passenger who was away from the three who were clinging to the nose landing gear of the airplane. The FMP boat driver pulled the three survivors into his boat and the deceased passenger was hoisted into the helicopter. The pilot and one of the passengers were then placed back into the water and both were hoisted into the helicopter. The remaining survivor was placed in a litter in the FMP boat and hoisted into the helicopter. At about 1215, the U.S. Navy helicopter departed the scene and arrived at the hospital about 1222. The occupants were located according to the Coast Guard about North 24.44.6 Latitude, West 081.49.3 Longitude. The last known radar return was about North 24.45.5 Latitude, West 081.46.9 Longitude. The pilot stated that three life preservers were located in a bag of his which was located one of the rear seats of the airplane and that there was no life raft. The deceased's wife stated that her husband was alive up until 15 minutes before the rescue. PERSONNEL INFORMATION Information pertaining to the pilot is contained in the NTSB Factual Report-Aviation. AIRCRAFT INFORMATION Information pertaining to the airplane is contained in the NTSB Factual Report-Aviation. Review of the engine logbook revealed that the engine was last overhauled on October 16, 1981, at a tachometer reading of 1463.93 hours. On May 23, 1994, the last entry in the engine logbook, the tachometer was recorded as 2708.94 hours. METEOROLOGICAL INFORMATION Information pertaining to the weather is contained in the NTSB Factual Report-Aviation. COMMUNICATIONS Before the ditching, two-way radio communications were established with the Key West Approach Control facility. At about 1015.23, the accident pilot advised the approach controller of his position (distance and direction) from the Key West Vortac and that the airplane was going down. The approach controller marked his screen of the last radar return when the airplane was at about 100 feet and on the 005 degree radial and 10.6 nautical miles from the Key West Vortac. Several times during the search and rescue mission, the approach controller gave suggested headings to fly to the crew of the Falcon to locate the last known position of the ditched airplane. WRECKAGE AND IMPACT The airplane was not recovered. MEDICAL AND PATHOLOGICAL A postmortem examination of the deceased passenger was conducted by R.J. Nelms Jr., M.D., Medical Examiner District Sixteen, Monroe County, Florida. The cause of death was listed as salt water drowning related to airplane crash. The following anatomical diagnoses were discovered; 1) pulmonary edema 2) sigmoid diverticulosis and chronic diverticulitis with adhesions 3) chemical burns on chest, abdomen, and back 4) chronic bronchitis, mild, and 5) chronic duodenitis, mild. A toxicological analysis was performed by the Wuesthoff Memorial Hospital. The results were positive in the urine for nortriptyline, nortriptyline metabolite, acetaminophen, quinine/quinidine, and caffeine. Tricyclic antidepressants was positive in the quantity of .12 UG/ML. Acetaminophen by FPIA is 19.69 UG/ML. Quinidine by enzamatic analysis is less than assay range (.5-8.0 UG/ML.) The results were negative for tested drugs in the urine. The results were positive in the blood for caffeine, acetaminophen (2.05 UG/ML), tricyclic antidepressants (notriptyline) .03 UG/ML. The results were negative for carbon monoxide, volatiles, and tested drugs. The FAA Toxicology and Accident Research Laboratory also performed a toxicological analysis from specimens received. The results were negative for carbon monoxide and cyanide. SURVIVAL ASPECTS According to the pilot, all occupants were conscious after the ditching with no obvious injuries to any of them. The deceased passenger had been talking and was coherent while in the water. The pilot also stated that three life preservers were located in his pilot bag which was on one of the rear seats of the airplane. The life preservers were not recovered before the airplane sank. According to the surviving passengers, the pilot briefed them before departure about the use of seatbelts but did not mention that there were life preservers on board the airplane. After the ditching when the occupants were in the water, the pilot mentioned to one of the passengers that life preservers were in the airplane. The crew of the Coast Guard Falcon reported that the sea state was 3-5 foot swells with 8 miles of visibility. Prolonged submersion in the fuel contaminated water resulted in chemical burns to the survivors. The crew of the Falcon reported problems with their RNAV equipment during the Search and Rescue mission.

Probable Cause and Findings

LOSS OF ENGINE POWER DUE TO AN UNDETERMINED REASON. A FACTOR RELATED TO THE ACCIDENT WAS: INADEQUATE PASSENGER BRIEFING BY THE PILOT.

 

Source: NTSB Aviation Accident Database

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