Aviation Accident Summaries

Aviation Accident Summary ANC06FA018

Ketchikan, AK, USA

Aircraft #1

N104XX

Aero Vodochody L-39MS

Analysis

The airline transport certificated pilot was on a Title 14, CFR Part 91 ferry flight in a military jet surplus warbird when the airplane collided with water and a residential area during an instrument approach to land. During the circle-to-land contact approach, the pilot was advised by an FAA flight service station specialist at the island airport that the weather did not look favorable for a contact approach due to low clouds and visibility. A pilot-rated witness on the shore across from the island reported seeing the airplane descend from the clouds and strike the ocean three times before it climbed out of sight. The witness described the visibility as about 3/4 mile in blowing snow. The airplane continued to fly for approximately 2.3 miles, until other witnesses near a town on the shore heard the engine stop, and saw the jet and a parachute at a low altitude. The airplane collided with the ground in a large lot, and continued into an occupied trailer home and parked vehicles. A postcrash fire ensued. Inspection of the airplane disclosed no preimpact mechanical problems with the airplane. The loss of engine power was consistent with the water impact which damaged the inlet fan and compressor stator. The circle-to-land minimum descent altitude for aircraft with a 120 knot approach speed is 2,500 feet msl, and requires 3 miles visibility. Prior to impact, the pilot attempted to eject from the airplane at a low altitude. The ejection was unsuccessful, and the pilot struck a tree while still in the ejection seat. Inspection of the ejection apparatus disclosed no evidence of any preimpact malfunction.

Factual Information

HISTORY OF FLIGHT On January 25, 2006, about 1250 Alaska Standard time, an Aero Vodochody L-39MS airplane, N104XX, a surplus military warbird built in the Czech Republic, was destroyed by impact and postimpact fire when it collided with the ground and an occupied trailer home during an instrument approach/circle to land at the Ketchikan International Airport, Ketchikan, Alaska. The experimental airplane was being operated as an instrument flight rules (IFR) cross-country ferry flight under Title 14, CFR Part 91, when the accident occurred. The airplane was operated by Air USA Inc., Quincy, Illinois. The airline transport certificated pilot, the sole occupant, received fatal injuries, and five persons on the ground received minor injuries. The flight departed in VFR conditions about 1141 from the Sitka Rocky Gutierrez Airport, Sitka, Alaska. While en route, the pilot obtained an IFR flight plan to Ketchikan. Instrument meteorological conditions prevailed in the area of the accident. According to Federal Aviation Administration (FAA) personnel, the airplane was issued a special ferry permit by an inspector with the Van Nuys Flight Standards District Office (FSDO), Van Nuys, California, on January 23, 2006, with options to fly under visual flight rules (VFR) or instrument flight rules (IFR), day or night, from Anchorage, Alaska, to Seattle, Washington. A ferry permit was required because the accident airplane's most recent experimental airworthiness certificate had expired. The ferry permit application was signed by an FAA certificated mechanic who was hired by the operator, certifying that the airplane was safe for ferry flight. According to the operator, the accident airplane departed Palmer, Alaska, on January 23, about 1500, with another L-39MS airplane (N106XX), with an intended destination of Ketchikan. Due to adverse weather conditions in Ketchikan, the two airplanes diverted to Sitka, and remained there throughout the day of January 24. Because of a personal time commitment, the pilot of N106XX departed for his residence, leaving the airplane parked at Sitka. On January 25, at 0710, the accident airplane pilot contacted the Sitka Flight Service Station (FSS) via telephone, stating he had tried to leave Sitka the previous day, and indicated he was trying to get to Bellingham, Washington. The FSS specialist provided weather conditions at Sitka and Bellingham, which were VFR at both locations. The pilot requested the winds aloft forecast for 24,000 and 27,000 feet, and after a discussion about where he would encounter the most adverse headwinds, the FSS specialist examined U.S. and Canadian weather charts and reported winds from 190 degrees at 84 knots at 24,000 feet, and from 190 degrees at 90 knots at 30,000 feet. The specialist also noted that there were AIRMETS for occasional moderate rime icing for the coastal waters of Alaska. The FSS specialist stated that the current weather for Ketchikan was: "...wind, 140 [degrees] at 13 [knots], gusts 23 [knots]; visibility, 4 [statute miles] light rain and mist; ceiling, 1,200 [feet] broken, 1,700 [feet] overcast; temperature, 7 [degrees C], dew point 6 [degrees C]; altimeter, 29.23 [inHg]. What they've got there is basically the south end of a cold front from a low that's off to the east of us towards British Columbia and the Yukon, then, and so they're forecast to get a little bit of wind and snow today, diminishing basically towards the afternoon." The pilot commented: "O.K. so there, they'll be right above ah my mins to go in there..." The pilot commented again about the forecast weather conditions at Ketchikan, stating: "...so just, man, I wish Ketchikan's weather was gonna be better, it's not any, not any better a thousand and three...just right at mins, hum." The FSS specialist stated: "and again, that wind that's outa the southeast at 13, gust up ta 23, that's a fair amount of wind for Ketchikan." The pilot replied: "yeah, that's a s### load of wind." The specialist jokingly inquired how the pilot liked Sitka, to which the pilot replied: "yeah, no kiddin, I just can't make Bellingham with those winds, I mean it's, I just can't do it." The briefing was concluded at 0721. At 0855, the pilot again telephoned the Sitka FSS and inquired about the weather conditions in Ketchikan. The FSS specialist reported: "...wind, 340 [degrees] at 8 [knots]; visibility, 10 [statute miles] light rain and mist; ceiling 2,300 [feet] overcast; temperature 3 [degrees C], dew point temperature 1 [degree C]; altimeter, 29.29 [inHg]. ...I just got a pilot report from Ketchikan as well...from the top of the hour, a deHavilland Beaver, 6 miles west of Ketchikan reported 700 [feet] scattered; flight visibility 10 [miles], wind outa the west at 20 [knots], with higher cloud layers which were probably above 12,000 feet." The distance from Sitka to Ketchikan is about 160 nautical miles. The operator reported that the normal range for planning purposes in the L-39 was about 750 nautical miles. The pilot confirmed that the Ketchikan airport was utilizing runway 29 because of the wind direction and then stated: "and again, you said that METAR, that was 3,500 [feet] over [cast], that's what they were callin it." The FSS specialist initially agreed, stating: "3,200 overcast, yeah," but corrected himself, stating: "and that ceiling at 2,400 [feet] broken, this was, actually this is a new observation from 2 minutes ago, they just put another observation, ah, visibility, 10 [miles] light rain; 900 [feet] scattered, ceiling 2,400 [feet] broken, 3,200 [feet] overcast. ...ah I am showing AIRMETS for mountain obscuration and IFR conditions for southern, southeast Alaska, and I have an AIRMET for occasional moderate rime icing from 1,500 [feet] up ta 12,000 [feet]." The pilot thanked the specialist and concluded the call at 0859. At 1140, the pilot contacted the Sitka FSS via radio and reported he was beginning to taxi, and at 1148, the pilot stated: "Sitka traffic, N104XX is departing VFR to the southeast, left turn out Sitka." While en route to Ketchikan, the pilot contacted the Anchorage Air Route Traffic Control Center (ARTCC) at 1210. He reported that he was 90 miles northwest of Ketchikan at 17,500 feet, and requested the ILS approach to runway 11 at Ketchikan with a circle to land on runway 29. The controller verified the airplane was equipped with a GPS receiver (global positioning system), and cleared the airplane to the Ketchikan Airport, via DOOZI intersection, at 17,000 feet. DOOZI intersection is 40 nautical miles from the Annette Island VOR, on the 303 degree radial. At 1217, the ARTCC controller verified that the pilot had the current weather information from Ketchikan, and cleared the airplane at the pilot's discretion to descend and maintain 7,000 feet. At 1223, the ARTCC controller contacted the pilot and requested he slow down if he could, and told the pilot that he may have to hold at the DOOZI intersection for arrival aircraft ahead of him into Ketchikan. One minute later, the ARTCC controller amended the previous clearance, advising the pilot to maintain 8,000 feet and cleared him to hold at the 17 mile fix on the Ketchikan localizer, and to expect further clearance at 1240. The pilot responded by stating: "Roger that sir, is there any way you could hold us at DOOZI, my DME (distance measuring equipment) is intermittent for the leg." The controller then cleared the airplane to hold at DOOZI, and to maintain 8,000 feet. At 1228, the pilot inquired whether the controller would prefer a left or right turn in holding, and the controller approved either direction. One minute later, the pilot contacted ARTCC and stated: "And ah center from 104XX, just be advised we are picking up some ah ice out here, and if you can give us a descent that would be great." The controller responded by stating: "N104XX ah roger, after you get back established in hold, make right hand turns and descend and maintain 7,000 [feet], that is as low as I can go for you there." The controller inquired if the pilot had the outside air temperature, to which the answer from the pilot was negative. At 1233:15, the ARTCC controller advised the pilot: "N104XX, the ah jet landed at Ketchikan, I've got one departing that's ah depart just as soon as the other aircraft leaves the runway, and he should be clear in just about three or four minutes, and then you can expect an approach clearance after that." The controller asked if the pilot was still in the icing conditions, to which the pilot replied affirmative. At 1233:38, the controller told the pilot: "I show you back over DOOZI now, descend and maintain 7,000 [feet]." The pilot acknowledged the clearance. At 1236:59, at 1237:21, and again at 1238:09, the ARTCC controller stated: "N104XX radar contact lost, say altitude." At 1238:14, the pilot responded, "7,000 [feet]." The controller then stated: "104XX maintain 7,000 [feet] until established on a published segment of the approach, cleared ILS DME-1, runway 11 approach to the Ketchikan Airport." The pilot acknowledged the clearance, and at 1239:22, the ARTCC control advised the pilot to contact Ketchikan Radio. A review of radio traffic at Ketchikan revealed that at 1238, a de Havilland Beaver (DHC-2), N60G, provided a pilot report of the weather conditions in the Ketchikan area to the Ketchikan Flight Service Station, stating: "yeah, it's not very nice out here, um (unintelligible) scud, your probably 500 feet, maybe 2 miles at best, mixed rain and snow, ah, what's wind about ah oh 20, 25 [knots], I guess." At 1239:42, the accident pilot contacted the Ketchikan FSS via radio and stated: "Ketchikan radio, 104XX is with you, ah we're at 7,000 [feet] for ah the intercept, ILS [instrument landing system], circle to land [runway] 29." The Ketchikan FSS specialist replied, "roger, report 10 [miles] out for, ah or the final approach fix 11 [mile] DME for ah traffic please, altimeter 29.32 [inHg]." At 1244:01, the pilot stated: "and 104XX's 11 [DME]." The Ketchikan FSS specialist replied: "Albatross 4XX Ketchikan Radio roger, channel traffic, only one Beaver is inbound the harbor from the west, over the water. I have a Brasilia [airplane] holding at the top of ah Alpha [taxiway] for your arrival. No other traffic. Wind, 300 [degrees] at 16 [knots] gust 21 [knots], altimeter 29.32 [inHg], and I have to tell ya, it just, it does not look real favorable for a contact approach at this point, there is a ah 4 to 5 hundred foot layer east of the field for circling for [runway] 29, and ah I'll just, I will turn the lights up ta high for ya." The pilot replied: "O.K. thanks, we'll make the call when we get (unintelligible)." At 1247:29, the pilot reported: "(unintelligible) contact with the ground, looking." At 1248:13, an unknown voice was heard on the Ketchikan FSS radio frequency, stating: "looks like he's abeam the Narrows, over the channel there Paul." At 1248:17, the pilot stated, "and I got the field in sight, I'm gonna try an cut the circle." At 1248:49, the Ketchikan FSS specialist stated: "Albatross 4XX, I recommend an immediate climb and missed approach at this point, Ketchikan altimeter 29.34 [inHg]." In a supplement to his original personnel statement about the accident events, the Ketchikan FSS specialist indicated that he issued the recommendation for an immediate climb and missed approach because of the radio report of the accident airplane's position from a turbine de Havilland DHC-3 as, "over the water, by the narrows." According to the FSS specialist, that position report placed the accident airplane approximately 1 nautical mile northwest of the airport, which indicated to him that the airplane, "was off-course, and in potential danger." At 1249:29 and again at 1249:59, the Ketchikan FSS specialist stated: "Albatross 4XX Ketchikan Radio, say your position." There was no response from the pilot. A pilot-rated witness who was moving an airplane on a ramp at Peninsula Point, which is about 2.3 miles west the crash site, said he saw the airplane descend from the clouds, from about 200 feet above the waters of the Tongass Narrows, near Peninsula Point. The witness indicated that the visibility was about 3/4 mile in wet blowing snow, and the wind at the time was from the northwest, about 30 knots. The witness indicated he could see the outline of the Alaska Marine Highway vessel "Columbia" as it was southeast bound toward the Ketchikan ferry terminal. The witness said the accident airplane, with the landing gear down, descended on about a 20 to 25 degree angle at a high rate of descent to the surface of the water, about 200 yards from the shore. The airplane struck the surface twice, each time gaining about 10 feet before skipping on the surface for a third time. The first two water impacts produced an extensive spray of water that obscured his view of the airplane. The airplane then gained altitude and climbed out of his sight. The water impact location was about 1.2 miles from the threshold of runway 11, and about .4 mile left of the runway 11 centerline. Several witnesses aboard the vessel "Columbia" were interviewed by an FAA inspector from the Juneau Flight Standards District Office. They reported seeing a large splash in the water between 3/4 to 1 mile in front of the vessel. They thought the splash was a whale, but due to the limited visibility of 1/2 to 3/4 mile, none reported seeing or hearing an airplane. When questioned about any visible evidence of an airplane impact, none reported seeing any debris or any type of oily sheen on the water. Several witnesses reported seeing the airplane over Tongass Boulevard, (the main road of the City of Ketchikan, which runs along the coastline). One witness who was exiting a store near the crash site, reported hearing a jet engine sound that she described as sputtering and "one that did not sound right." She then heard a loud "bang" and looked up. Over the top of an adjacent building, she said she saw an airplane canopy, and in front of the canopy, observed a small parachute about 10 feet above the building that "was not full." She did not see the pilot seat, but she could see the crash scene at the trailer park. She said the visibility was low, and it was snowing hard. A witness who was working at his residence directly above the crash site, reported that he heard jet engine sounds that abruptly stopped. After several seconds, he saw black smoke from the crash site. He said that is was snowing, the ceiling was about 150 to 200 feet, but he could see the outline of Gravina Island across the Tongass Narrows, which is about .4 mile. Another witness driving on Tongass Boulevard, reported seeing the airplane descending from about 300 feet, out of the base of clouds, into snowing conditions. The wings were level, and the nose of the airplane was upward. He diverted his attention for a moment, and then saw the airplane nose down, about 45 degrees. He saw a small, white parachute, about 6 feet in diameter, that appeared to be opening and closing. The parachute appeared to be traveling the same speed, and along the "same line" as the airplane. He indicated that it appeared that the parachute may have been attached to some part of the airplane, but he could not be certain. The unoccupied airplane collided with the ground in a large open lot on an easterly heading, struck the western bank of Carlanna Creek, and bounced/flew over the creek into a small trailer park area. The airplane struck a trailer home on the east side of the creek that was occupied by two persons. It then crashed into several unoccupied automobiles, and into an open lot area. Portions of airplane wreckage were located in Carlanna Creek, and within the interior of the trailer. The airplane fuselage, minus it wings and horizontal stabilizer, came to rest pointing upward, pinned against a hillside and an empty, metal dumpster/bin. Ketchikan Fire Department personnel responded to the scene and evacuated residents, and began fighting the trailer fire and the burning airplane fuselage. INJURIES TO PERSONS The pilot received fatal injuries. Five persons on the ground received minor injur

Probable Cause and Findings

The pilot's failure to follow published instrument landing procedures and his descent below approach minimums during an IFR circle to land approach, which resulted in the airplane striking the ocean and a loss of engine power. Factors contributing to the accident were low clouds and snow.

 

Source: NTSB Aviation Accident Database

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