Port Heiden, AK, USA
N8361Q
Piper PA-32-301
The commercial pilot departed on a Title 14, CFR Part 135, scheduled passenger flight, returning from a remote coastal village during dark night conditions. The pilot's intended flight route was over remote and unpopulated terrain, with no ground based light sources to provide visual cues. The flight was originally scheduled to depart during daylight hours, but poor weather conditions contributed to its late departure. When the flight did not arrive at its destination, an aerial search was initiated. The airplane's fragmented wreckage was along the pilot's intended route, about 15 miles northeast of the departure airport. The airplane had collided with flat, featureless, snow-covered, terrain. The debris trail measured about 575 feet long. Responding aviation rescue crews reported that due to dark night conditions, along with absence of ground based light sources and the lack of visual cues in the area of the accident site, the use of night vision goggles (NVG) was required to discern topographical features. All of the airplane's major components were located at the main wreckage site, and no preaccident anomalies were noted with the accident airplane. A postaccident review of the pilot's personal flight logbook revealed that the pilot had logged about 322 hours of flight time at night, and all but 32.6 flight hours had been accrued while acting as second-in-command.
HISTORY OF FLIGHT On December 14, 2006, about 1810 Alaska standard time, a Piper PA-32-301 airplane, N8361Q, was destroyed when it collided with remote, snow-covered terrain, about 15 miles northeast of Port Heiden, Alaska. The airplane was operated by Peninsula Airways, Inc., Anchorage, Alaska. The flight was being conducted under Title 14, CFR Part 135, as scheduled commuter Flight 842, when the accident occurred. The certificated commercial pilot, and the one passenger, received fatal injuries. Company flight following procedures were in effect. The flight originated at the Port Heiden Airport, Port Heiden, about 1800, and was en route to King Salmon, Alaska. Witnesses reported that the accident airplane departed the Port Heiden Airport to the northeast in dark night conditions. The accident pilot contacted company dispatch personnel at 1805, and reported that he was en route to King Salmon, with an estimated time en route of 1 hour. No further radio communications were received from the accident airplane. When the flight failed to arrive at King Salmon by 1900, company dispatch personnel began a phone search of locations along the pilot's anticipated route, but were unable to locate the airplane. A company aerial search was initiated from King Salmon about 1930. The flight was officially reported overdue to the Federal Aviation Administration (FAA) at 1937. An emergency locator transmitter (ELT) signal was subsequently detected in a remote area about 15 miles northeast of Port Heiden, along the flight's route. Search and rescue personnel from Port Heiden initiated a ground search, but were unable to reach the accident site due to adverse terrain. About 2200, U.S. Coast Guard search and rescue personnel in a HH-60 rescue helicopter assigned to Air Station Kodiak, located the airplane's wreckage in an area of flat, snow-covered terrain. The flight crew of the rescue helicopter reported that due to dark night conditions and the lack of ground based light sources around the area of the accident site, the use of night vision goggles (NVG) was required to discern topographical features. According to Peninsula Airways dispatch personnel, Flight 842 was scheduled to depart Port Heiden at 1425, with a scheduled arrival time in King Salmon of 1535. However, on the day of the accident, poor weather conditions around Port Heiden contributed to the flight's late departure time, during dark night conditions. CREW INFORMATION The pilot held a commercial pilot certificate with airplane single-engine land, multi-engine land, and instrument airplane ratings. He also held a flight instructor certificate with airplane single-engine land and instrument airplane ratings. The most recent first-class medical certificate was issued to the pilot on November 28, 2006, and contained a limitation that he must wear corrective lenses for near vision. A review of the airmen Federal Aviation Administration (FAA) records on file in the Airman and Medical Records Center located in Oklahoma City revealed that on the pilot's application for medical certificate, dated November 28, 2006, he indicated that his total aeronautical experience consisted of about 2,900 hours, of which 600 were accrued in the previous 6 months. According to information contained in the Pilot/Operator Aircraft Accident Report (NTSB Form 6120.1/2) submitted by the operator, the pilot's total aeronautical experience consisted of about 2,841 hours, of which 77 were accrued in the accident airplane make and model. The operator reported that at the time of the accident the pilot's total pilot-in-command flight time was 311 hours, but did not note the pilot's total flight time while acting as the pilot-in-command, at night. A review of the pilot's personal flight logbook, provided to the NTSB IIC by family members, revealed that as of the pilot's last entry on December 7, 2006, the pilot had logged about 322 hours of flight time at night, and all but 32.6 flight hours had been accrued while acting as second-in-command of Cessna 208 and Saab 340 airplanes. The operator reported that the company hired the pilot on July 16, 2003, and at that time, his total flight experience was 262.8 hours, with 16.9 hours in multiengine airplanes, and 246.9 hours in single-engine airplanes. He completed his initial company training, including Cessna 208 ground and flight training, on November 30, 2003. The pilot was assigned between two of the company's satellite bases, King Salmon and Dillingham, Alaska, as a second-in-command pilot of Cessna 208 airplanes. Company records show that the pilot completed a company check ride in a Saab 340 simulator on November 3, 2004, and began accruing initial operating experience (IOE) in Saab 340 airplanes on November 16, 2004. He successfully completed his IOE in Saab 340 airplanes on November 18, and was assigned as a first officer operating from the company's Anchorage base. Company records indicate that the pilot received transition ground training on Piper PA-32-301 airplanes on August 8, and again on August 29, 2006. The pilot received flight training in a Piper PA-32-301 airplane on August 29, 2006, and accumulated 2.6 hours of dual instruction during that flight. On August 30, 2006, he successfully completed his initial part 135 check ride in accordance with FAR 135.293 and 135.299. He was assigned to the company's satellite base in King Salmon as a pilot-in-command of Piper PA-32-301 airplanes. He began accruing IOE in Piper PA-32-301 airplanes on September 25, and completed IOE on September 26. Company check airmen conducted all of the pilot's ground and flight training, check rides, and line checks. On October 5, after accruing 5.9 hours of IOE in Piper PA-32-301 airplanes, the pilot logged his first flight as a commercial pilot while flying without a co-pilot, or a company check airman. The accident pilot lived in Anchorage and commuted to the operator's King Salmon base when he was assigned to fly at that base. When not assigned to flying duties at the King Salmon base, he continued to serve as a first officer on the Saab 340 airplanes that originate out of the operator's Anchorage base. On December 12, two days before the accident, the pilot was assigned to a Saab 340. On December 13, the day before the accident, the pilot was assigned to the King Salmon base, and flew the accident airplane 4.9 hours. AIRCRAFT INFORMATION At the time of the accident, the airplane had accrued about 21,401 flight hours. The airplane was maintained on an FAA-approved aircraft inspection program (AAIP). The AAIP has four inspection cycles that are scheduled every 100 hours. Each inspection cycle may be completed within 10 hours before, to 10 hours after, the anticipated 100-hour cycle. The completion of all four cycles, within a 1-year period, qualifies as an annual inspection. Examination of the maintenance records revealed that the most recent inspection cycle was number four, accomplished on December 1, 2006, about 39 hours before the accident. The engine had accrued a total time of about 10,172 hours. The maintenance records note that a major factory overhaul was accomplished on October 21, 2004, about 1,196 hours before the accident. The airplane was equipped for basic instrument flight, which, among others, included an attitude indicator, a heading indicator, a rate of turn indicator, and a vertical speed indicator. The airplane was not autopilot equipped. METEOROLOGICAL INFORMATION The closest weather observation facility is Port Heiden. At 1816, the Port Heiden Aviation Routine Weather Report (METAR) was reporting, in part: Wind, 290 degrees (true) at 16 knots with peak gusts to 24 knots; Visibility, 4 statute miles; Clouds, 600 feet few, 4,000 feet broken, 5,500 feet overcast; temperature, 25 degrees F; dew point, 16 degrees F; altimeter, 29.90 inHg. Witnesses in Port Heiden reported that weather conditions consisted of transient snow squalls throughout the day, with associated reduced visibility and low clouds. Witnesses reported that dark night conditions prevailed when the pilot departed Port Heiden. COMMUNICATIONS According to dispatch documents provided to the NTSB by the operator, the accident pilot contacted Peninsula Airways King Salmon dispatch personnel at 1805, via the company's privately owned and operated remote communications system. During the brief conversation between the pilot and the dispatcher, the pilot reported that he had departed from Port Heiden, en route to King Salmon, with one passenger on board, with an estimated time en route of 1 hour. No further radio communications were received from the accident airplane. WRECKAGE AND IMPACT INFORMATION On December 18, 2006, the National Transportation Safety Board investigator-in-charge, along with a representative from Peninsula Airways, and an FAA airworthiness inspector from the Anchorage Flight Standards District Office (FSDO), traveled to the accident site via helicopter and examined the wreckage. The airplane was in an area of relatively flat, featureless, and snow-covered terrain. The wreckage was covered by roughly a half-inch of new snow. Fragmented portions of the airplane wreckage were widely scattered along the wreckage path. The debris trail, oriented principally on a magnetic heading of 130 degrees, measured about 575 feet long. (All headings/bearings noted in this report are magnetic.) All of the airplane's major components were located at the main wreckage site. Flight control system continuity could not be confirmed due to extensive impact related damage. The first point of ground contact was marked by an elongated depression in the snow-covered terrain, which measured about 45 feet long, with a heading of 135 degrees. The elongated depression led to a crater, measuring about 15 feet long, 8 feet wide, and 4 feet deep. Portions of the engine firewall, a seat rail track, and portions of the lower cockpit floor, were discovered within the crater. Extensive fuselage fragmentation was evident along the debris path between the crater and the main wreckage. The engine firewall, instrument panel, and main cabin were obliterated. The engine and propeller were located within the debris path, about 400 feet from the first point of ground impact. The engine sustained extensive impact damage to the underside, and front portion of the engine. The exhaust tubes were extensively crushed, bent, and folded, producing sharp creases that were not cracked or broken along the creases. The engine driven vacuum pump remained attached to engine. The propeller blades and propeller hub assembly remained attached to the engine crankshaft. The first propeller blade was underneath the engine, and bent aft. The two remaining propeller blades had minor leading edge gouging, and extensive "S" bending. The entire empennage was separated from the main cabin area, about midway between the airplane baggage area and the elevator attach point. The elevator assembly remained attached to fuselage attach points. The elevator assembly had extensive leading edge aft crushing, and upward buckling of the underside of the elevator. Both wings separated from the main fuselage. The right wing leading edge was compressed aft about 20 inches. The left wing leading edge was crushed aft about 8 inches. No preaccident mechanical anomalies were noted with the airplane. MEDICAL AND PATHOLOGICAL INFORMATION A postmortem examination of the pilot was conducted under the authority of the Alaska State Medical Examiner, 4500 South Boniface Parkway, Anchorage, Alaska, on December 18, 2006. The examination revealed the cause of death for the pilot was attributed to multiple traumatic injuries. The FAA's Civil Aeromedical Institute (CAMI) conducted a toxicological examination on January 22, 2007, which was negative for any alcohol or drugs. TESTS AND RESEARCH Instrumentation On January 4, 2007, the accident airplane's vacuum driven gyroscopic attitude indicator was disassembled and inspected under the direction of the NTSB IIC, at Aircraft Instrument Repair, Inc., Anchorage, Alaska. In attendance were an airworthiness inspector from the FAA's Anchorage FSDO, and a representative from Peninsula Airways. The attitude indicator sustained extensive impact damage. The indicator was disassembled which revealed rotational scoring marks on the gimbal, and gimbal housing assembly. The attitude indicator's internal filter screen was inspected, which revealed trace amounts of carbon-like material. Additionally, the accident airplane's engine driven vacuum pump was internally inspected, which revealed that the plastic drive gear was intact. The internal vacuum pump block was also intact, and the pump vanes were not broken or chipped. Airframe On January 2, 2007, the airplane wreckage was retrieved from the accident site and transported to Wasilla, Alaska, by company and insurance personnel. On January 30, 2007, an airframe wreckage reconstruction and inspection was accomplished under the direction of the NTSB IIC, at Alaska Claims Services, Wasilla. In attendance were an airworthiness inspector from the FAA's Anchorage FSDO, as well as air safety investigators from Textron Lycoming and Piper Aircraft, and a representative from Peninsula Airways. The examination of the airframe did not reveal any evidence of a preimpact mechanical malfunction. Engine On January 30, 2007, an engine tear down and inspection was conducted under the direction of the NTSB IIC, at B.J. Custom Aircraft Engines, in Palmer, Alaska. Also present was an airworthiness inspector from the FAA's Anchorage FSDO, air safety investigators from Textron Lycoming and Piper Aircraft, and a representative from Peninsula Airways. Once the propeller hub and blade assembly was removed from the crankshaft flange, the engine was bolted vertically to an engine stand by its crankshaft flange. The engine examination revealed that the forward portion of the engine had impact damage to the forward cylinders, the left intake tubes, and the intake plenum was breached. The right magneto remained attached to its respective mounting flange. Once removed, the right magneto produced spark on all outlet points when it was rotated by hand. Impact forces destroyed the left magneto. The fuel injector assembly was torn from its mounting flange. The exhaust tubes had several points of bending and crushing that produced sharp folded creases that were not cracked or broken along the crease. Gear and valve train continuity was established when the engine case was rotated by hand around the stationary crankshaft. The examination of the engine did not reveal any evidence of a preimpact mechanical malfunction. Garmin GPS According to family members of the accident pilot, he had recently received a GARMIN, model 296, hand held unit as a gift, and they expected that he was using the GPS unit at the time of the accident. While on scene, the NTSB IIC was unable to locate the handheld GPS unit due to snow covering the wreckage path. On May 18, 2007, recovery crews returned to the accident site to continue recovery efforts, and recover small wreckage fragments previously covered by snow, and subsequently discovered the impact damaged GARMIN hand held GPS unit. The damaged GPS unit was shipped to the NTSB vehicle recorder laboratory in Washington, D.C., in an attempt to recover the accident pilot's preaccident route of flight information. A senior Safety Board electronics engineer reported that impact damage sustained during the accident precluded the recovery of any flight information data. WRECKAGE RELEASE The Safety Board released the wreckage to the owner's representatives on December 18, 2006. The airplane's attitude indicator and vacuum pump were retained by the Safety Board for examination until their release on December 17, 2007.
The pilot's failure to maintain control of the airplane during cruise flight, which resulted in an uncontrolled descent, and an in-flight collision with snow-covered terrain. Contributing to the accident were the pilot's spatial disorientation, and dark night conditions.
Source: NTSB Aviation Accident Database
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