Aviation Accident Summaries

Aviation Accident Summary SEA06FA055

Goldendale, WA, USA

Aircraft #1

N888SR

Cessna 182P

Analysis

Prior to departing on the first leg of the night cross-country cargo flight, the pilot obtained a weather briefing which included an AIRMET that indicated mountains could be obscured by clouds, and that precipitation, mist and fog might be encountered over the route of flight. The pilot filed a VFR flight plan with a cruise altitude of 6,500 feet, departing at 1950 Pacific standard time. As the flight progressed, radar data indicated the following: at 2036:09 the airplane was 20 nm north of the accident site proceeding south at an altitude of 6,400 feet; at 2046:17 the airplane was 1.16 nm from the accident site and continued to proceed south at an altitude of 6,300 feet; from 2046:17 to 2046:53, when the last encoded altitude was received, the airplane had descended from 6,300 feet to 5,500 feet on a southerly heading; radar contact was lost at 2048. The airplane impacted trees in mountainous terrain at an elevation of 5,099 feet. Search and rescue personnel who reached the accident site 5 hours after the accident, reported hard blowing snow, winds from the west at 30 miles per hours, and from 3 to 4 feet of fresh snow covering the area. One search and rescue volunteer, who resides 12 miles south of the accident site, at an elevation of 1,678 feet, revealed that between 2100 and 2200 on the evening of the accident, there was a light rain falling and that the temperature was 34 degrees F. A post-accident examination of the airplane revealed no evidence of any mechanical anomalies which would have prevented normal operation.

Factual Information

HISTORY OF FLIGHT On February 22, 2006, approximately 2050 Pacific standard time, a Cessna 182P, N888SR, was destroyed when it collided with terrain while maneuvering near Goldendale, Washington. The instrument rated commercial pilot and pilot-rated passenger received fatal injuries. The aircraft was being operated by Wings of Wenatchee, Inc., Wenatchee, Washington, as a non-scheduled domestic cross-country cargo flight under 14 CFR Part 135. Night visual flight rule (VFR) conditions prevailed at the time of takeoff, and a visual flight rules (VFR) flight plan was filed from the Pangborn Memorial Airport (EAT), Wenatchee, Washington, to the Portland International Airport (PDX), Portland, Oregon. The flight departed EAT approximately 1950. In a statement provided by the operator to the NTSB investigator-in-charge (IIC), the flight was scheduled to transport cancelled bank documents for another cargo operator. The operator stated that the accident pilot had conducted the same flight the previous night, which had been the pilot's first Part 135 flight. The operator revealed that he had asked the pilot if he had checked the weather, to which the pilot replied that it was much better than the night before, and that he didn't think there would be any weather problems. The operator stated, "I did not personally check the weather for the flight. I confirmed that he had filed a VFR flight plan and reminded him to get flight following." At 1844, the pilot contacted the Dyncorp Direct User Access Terminal Service (DUATS) for a weather briefing over the route of flight, and at 1906 he filed a DUATS VFR flight plan from EAT to PDX via the Ellensburg (ELN), Yakima (YKM), and Klickitat (LTJ) very high frequency omnidirectional range (VOR) navigational facilities, all located in the state of Washington. The pilot listed a flight plan altitude of 7,500 feet, an estimated time en route of 2 hours, and fuel on board as 6 hours. At 2012, the pilot reported that he was 5 nautical miles east of the ELN VOR navigational facility at 6,500 feet. Air traffic control then gave the pilot the current altimeter setting and instructed him to contact Chinook approach control. At 2035, air traffic control switched the flight back from Chinook approach control to the original controller. The flight was observed to be continuing southbound, and subsequently the pilot was advised by air traffic control of turbulent conditions at 8,000 feet along his route of flight. The pilot was instructed to contact Seattle Center on 119.65, which the pilot acknowledged. There was no further contact with Seattle Center and radar contact was lost with the flight at 2048. According to the National Track Analysis Program (NTAP) data, at 2036:09 the accident airplane was proceeding on a southerly heading approximately 14 nautical miles (nm) south of the Yakima Air Terminal/McAllister Field (YKM), and about 20 nm from the accident site at an altitude of 6,400 feet msl. At 2046:17, still progressing on a southerly heading, the airplane was located 32.5 nm south of YKM on a magnetic heading of 182 degrees at an altitude of 6,300 feet msl. From 2046:17 to 2046:53, data revealed that the airplane descended from 6,300 feet msl to 5,500 feet msl on a magnetic heading of approximately 175 degrees; this computes to a rate of descent of approximately 1,333 feet per minute. The aircraft track from the last radar hit with altitude encoding information at 2046:53 to the accident site was on a magnetic heading of about 124 degrees, covering a distance of about 1,137 feet. (Refer to the NTAP data, which is appended to the factual report.) At 2127, the Seattle Air Route Traffic Control Center issued an Alert Notice (ALNOT) after radio and radar contact with the accident aircraft had been lost at 2048. A subsequent emergency locator transmission (ELT) was emitted, however, due to adverse weather conditions search and rescue personnel were not able to access the accident site until the following morning. At 1119 on February 23rd, personnel from the Klickitat County Search and Rescue division were able to access the accident site. Using a handheld Global Positioning System (GPS), the airplane was located in mountainous terrain on the Yakima Indian Reservation, about 12 nm north of Goldendale, Washington at coordinates 46 degrees 2.422 minutes north latitude and 120 degrees 47.780 minutes west longitude, at an elevation of 5,099 feet msl. The wreckage was approximately 1.25 nautical miles northeast of Castle Rock mountain, elevation 5,009 feet mean sea level (msl), 1.96 nm north-northwest of Simcoe Mountain, elevation 5,440 feet msl, and 3.3 nm north-northeast of Indian Rock peak, elevation 5,821 feet msl. Due to the remote location of the wreckage site and elevated snow depths, recovery and initial on-site examination of the wreckage was postponed until June 13, 2006. PERSONNEL INFORMATION The pilot in command held a commercial pilot certificate with airplane single-engine land and instrument airplane ratings. He also held a flight instructor certificate for single-engine airplanes, which was valid until December 31, 2006. The pilot's most recent second-class medical certificate was issued on April 1, 2005, and contained no limitations. According to the pilot's personal logbook records, his total aeronautical experience consisted of 699 hours, of which 36 hours were accrued in the accident airplane make and model. In the preceding 90 and 30 days prior to the accident, the company listed the pilot's flight time as 51 and 30 hours, respectively. According to the operator's Director of Operations (D.O.), who is also the owner of the company, the pilot approached the owner in the fall of 2004 to receive assistance in obtaining his flight instructor certificate, which was successfully accomplished in December of 2004. The owner then hired the pilot as a part-time flight instructor in January, 2005, and in September of 2005 the operator started the pilot in a VFR Part 135 pilot training program. The pilot successfully completed the program on February 16, 2006. A review of the pilot's records by the IIC revealed that the pilot had made fifteen flights over the accident route between December 22, 2004 and February 21, 2006; five of the flights were in the accident airplane, which totaled 8.7 hours of flight time. Six of the flights were for dual instructional purposes, in both single and multiengine airplanes. Five were Part 135 cargo flights with the accident pilot accompanying the pilot in command as a non-flying pilot; the accident pilot would log pilot in command time on the return segment, which was consistent with Part 91 when no cargo is being carried for revenue purposes. In a written report and in a personal interview with the IIC, a certificated private pilot, who worked as a line serviceman for the operator, reported that he accompanied the accident pilot on an on-demand Part 135 cargo flight over the same route on February 21, 2006; this was the accident pilot's first Part 135 revenue flight. The pilot stated that the accident pilot flew the first leg of the flight to PDX, during which a cloud bank was encountered past YKM. The pilot reported, "I advised [the accident pilot] that he might want to climb to get over it. [The accident pilot] took notice of the clouds that were hard to make out due to it being a dark night with no moon and initiated a climb." The pilot stated that the accident pilot climbed from 6,500 feet msl to 7,500 feet msl and proceeded to PDX uneventfully. The pilot-rated passenger on the accident flight was employed by the operator as a line serviceman, having obtained his private pilot certificate with the operator during March of 2005. A review of the pilot's logbook revealed that his total time was 132.4 hours. The pilot had received an FAA second-class medical certificate during December of 2004. It was not determined what the pilot's total time was at the time of the accident. According to the D.O. the pilot was in the process of obtaining his commercial pilot and instrument airplane ratings, while concurrently working as a line serviceman. AIRCRAFT INFORMATION The aircraft, N888SR, serial number 18261455, was manufactured in 1973. It was equipped with a Continental O-470-R engine, serial number 462119-H, rated at 230 horsepower, and a McCauley 2-blade, all metal, constant-speed propeller. According to maintenance records, the airframe and engine received their most recent inspection in accordance with an Approved Aircraft Inspection Program (AAIP) on February 15, 2006, at a tachometer reading of 8,977.0 hours. At this time, the engine had accrued 1,207.9 hours since major overhaul, with a total time of 3,197.8 hours. METEOROLOGICAL INFORMATION A synopsis of the area forecast included in the pilot's weather briefing indicated a broad eastern Pacific ridge of weather would produce a northwesterly flow of air over much of the western United States. The data also revealed that a low pressure system developing in southwestern Canada along the frontal boundary would pull a cold front into northwest Washington. The northwest United States would see deepening moisture and scattered precipitation. The following AIRMETs were issued by the National Aviation Weather Advisory Unit in Kansas City, Missouri on February 22, 2006 at 1245 and were valid until February 22, 2006 at 1900: AIRMET Sierra Update 3 for IFR and Mountain Obscuration reported mountains occasionally obscured by clouds, precipitation, mist, and fog. Conditions continuing beyond 1900 through 0100 on February 23, 2006. The area encompassed by this AIRMET included the accident site. AIRMET Tango Update 3 for Turbulence reported occasional moderate turbulence below flight level 180 due to strong low and mid level winds. Conditions continuing beyond 1900 through 0100 on February 23, 2006. The area encompassed by this AIRMET included the accident site. AIRMET Zulu Update 3 for ICE reported occasional moderate rime or mixed icing in cloud and in precipitation between 2,000 and 14,000 feet. Conditions continuing beyond 1900 through 0100 on February 23, 2006. The area encompassed by this AIRMET included the accident site. (Refer to the attached meteorological information, which is appended to the factual report.) The closest official weather observation station is located at the Columbia Gorge Regional/The Dalles Municipal Airport (DLS), The Dalles, Oregon, which is approximately 22 nautical miles southwest of the accident site. The 2053 observation reported wind 340 degrees at 5 knots, visibility 10 statute miles, overcast clouds at 4,900 feet, temperature 7 degrees C, dew point 4 degrees C, and an altimeter setting of 30.24 inches of Mercury, with rain ending at 8 minutes after the hour. At 2056, the weather reporting facility located at the Yakima Air Terminal/McAllister Field, Yakima, Washington, located approximately 35 nautical miles north-northeast of the accident site, reported wind variable at 5 knots, visibility 10 statute miles, sky clear, temperature 7 degrees C, dew point -2 degrees C, and an altimeter setting of 30.10 inches of Mercury. At 2000, a pilot report (PIREP) was recorded over the Klickitat VOR (LTJ), which is located about 7 nm north of DLS. The pilot reported that at 8,000 feet msl he was experiencing light mixed icing conditions, and that the temperature was minus 2 degrees C. At 2100, the NEXRAD National Mosaic Reflectivity Image generated for the area surrounding the accident site indicated a maximum reflectivity of 15 dBZ, which is considered indicative of light precipitation in the area. GOES-10 (Geostationary Operational Environmental Satellite-10) data for 2030 revealed a northwest-southeast band of clouds over the route of flight. A Goldendale, Washington witness, who is a volunteer with the local Search and Rescue unit reported that between 2100 and 2200 on the evening of the accident, there was a light rain falling and that the temperature was 34 degrees F; the elevation of Goldendale is 1,678 feet msl. The witness further reported that approximately 0200 on February 23rd while responding to the accident site, he could only get to within about one mile of the wreckage due to the inclement weather. The witness described the weather as a hard blowing snow with a westerly wind estimated at 30 miles per hour, and that approximately 2 to 3 feet of new snow had accumulated in the area. WRECKAGE AND IMPACT INFORMATION On June 13, 2006, a NTSB Senior Air Safety Investigator, accompanied by a representatives from Cessna Aircraft Company and Continental Teledyne Motors, traveled to the accident site. Numerous impact signatures to various trees in close proximity to the main wreckage revealed that the airplane had impacted the trees in a wings and nose-level attitude on a magnetic heading of 185 degrees. The airplane's wings had been separated from its wing roots, with the right wing coming to rest in the middle of the 300-foot debris path. The inboard portion of the left wing was located near the main wreckage, which came to rest at the end of the debris path, while the outboard portion of the left wing was scattered throughout the debris path. Additionally, a part of the left wing's structure, specifically the leading edge to the top surface, was found in a tree at the beginning of the debris path. All of the aircraft's flight control surfaces were accounted for and exhibited damage consistent with being attached in their appropriate locations at the time of the accident. Each control surface and control input cable attachment was observed for all the primary and secondary flight control surface-to-cable attachments. Some attachments, as well as some cables, exhibited overload type separations with frayed and fragmented type features at their respective ends. The engine crankshaft was rotated and continuity was confirmed to the accessory section. Thumb compression was obtained on all cylinders and both magnetos sparked at all leads. The mixture, propeller, and throttle controls were each positioned in the full forward range. The flap actuator jackscrew extension measurement equated to a 0-degree flap setting. The elevator trim tab was separated from the elevator, with the tap actuator measurement approximately 25-degree tab up. Both fuel tanks were breached with no fuel present. The fuel selector handle was in the BOTH position. MEDICAL AND PATHOLOGICAL INFORMATION On February 23, 2006, the Clark County Medical Examiner's Office, Vancouver, Washington, performed an autopsy on the pilot. The cause of death was listed as "hypothermia and multiple blunt force injuries". The FAA's Civil Aeronautical Institute (CAMI) in Oklahoma City, Oklahoma, performed toxicology tests on the pilot. According to CAMI's report (200600047001), the pilot's blood was tested for carbon monoxide and cyanide, with negative results, and no drugs were detected in the urine. His vitreous was tested for volatiles (ethanol), with negative results. The FAA's clinical report revealed the following: 50 (mg/dl) Glucose detected in Urine 259 (mg/dl) Glucose detected in Vitreous 4.7 (%) Hemoglobin A1C detected in Blood The clinical report notes that elevated glucose levels can be caused by emergency medical treatment, strenuous exercise, strong emotions, shock and burns. ADDITIONAL INFORMATION Company Information The Operations Specifications issued to the company by the FAA states that only the Director of Operations, or in his absence, his delegates, the Chief Pilot and the Assistant General Manager, may authorize the initiation of a flight. The pilot in command (PIC) must obtain the express permission of the above prior to the initial departure of a flight under FAR 135. The PIC is responsible for the conduct of the flight. The aforementioned company management or the PIC may terminate the flight. An FAA flight plan will be filed, and used whenever possible for all flights under FAA 135. When an FAA flight plan cannot be filed, the flight following procedures outlined in the company's accepted operations manual will be followed. According to the Aero

Probable Cause and Findings

The pilot's failure to maintain terrain clearance during descent. Factors contributing to the accident were the high mountains, mountain obscuration, the dark night condition, and the pilot's improper in-flight planning/decision making.

 

Source: NTSB Aviation Accident Database

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