Kenai, AK, USA
N9941M
Cessna 207A
The commercial certificated pilot prepared for a VFR cross-country nonscheduled cargo flight under Title 14, CFR Part 135, by preflighting the wheel-equipped airplane and starting the engine. The airplane had been parked on the airport ramp overnight, with an electric engine heater and an engine cover on. A portion of the flight was over ocean waters to a remote village. After engine start, the pilot contacted the company owner and reported that the engine oil pressure appeared to be low, but within the operating range. The owner and the pilot discussed the possible reasons, such as cold ambient temperatures, which was about -20 degrees F. The pilot then departed, and reported to his company that the engine pressure was good. About 10 minutes later, he declared an emergency and stated he was ditching in the water, about 18 miles west of the departure airport. Retrieved track data from the pilot's GPS showed the airplane's maximum altitude was 1,439 feet msl, while crossing the ocean in an area that was about 22 miles wide. A review of the manufacturer's maximum glide distance chart revealed that from an altitude of about 1,500 feet, the airplane could glide about 2.1 nautical miles. The airplane was located about two hours after the accident, floating nose down next to a segment of pan ice, about 8.8 miles from the initial accident location. The pilot was not recovered with the airplane, and subsequent searches did not locate him. Following recovery of the airplane, examination of the engine revealed a 8 X 5 inch hole in the top of the case, adjacent to the number 2 cylinder. The number 2 connecting rod was broken from its crankshaft journal, and broken from the bottom of the piston. The number 1 connecting rod bearing was missing from its normal position on the crankshaft journal and the rod had evidence of high heat. Evidence of oil starvation and high heat signatures to several crankshaft and connecting rod bearings was found throughout the engine, along with a large amount of fragmented bearing material. The pilot was not wearing any personal flotation equipment, and the expected survival time in the 29 degree F ocean water was about 30 minutes. The company's operations manual does not contain a written policy requiring pilot's to maintain sufficient altitude to reach shore when crossing ocean waters.
HISTORY OF FLIGHT On January 9, 2007, about 1035 Alaska Standard time, a wheel-equipped Cessna 207A airplane, N9941M, sustained substantial damage when it ditched in the ocean waters of the Cook Inlet during an emergency forced landing, about 18 miles west of Kenai, Alaska. The airplane was being operated as a visual flight rules (VFR) cross-country nonscheduled cargo flight under Title 14, CFR Part 135, when the accident occurred. The airplane was operated by Air Supply Alaska Inc., Kenai. The commercial certificated pilot, the sole occupant, was not located at the accident scene, and is presumed to have received fatal injuries. At the time of the accident, visual meteorological conditions prevailed over the Cook Inlet. As search operations progressed, the weather conditions deteriorated, and instrument meteorological conditions prevailed over the inlet. VFR company flight following procedures were in effect. The flight originated at the Kenai Airport about 1023, and was en route to Kokhanok, Alaska. The company director of operations/owner reported that the pilot began the day by preparing for the accident flight. This included preflight and engine start. The airplane had been parked on the airport ramp overnight, with an electric engine heater plugged in, and an engine cover installed. After engine start, the pilot contacted the Federal Aviation Administration (FAA) air traffic control personnel at the Kenai air traffic control tower (ATCT) and said that he was taxiing for takeoff. He then returned to the company ramp, shut down the engine, and contacted the company owner. The pilot indicated that the engine oil pressure appeared to be lower than normal, but still in the operating range. The owner indicated that he and the accident pilot discussed the possible reasons, such as cold ambient temperatures. The owner said the pilot indicated he would monitor the oil pressure prior to crossing the Cook Inlet, en route to Kokhanok. At 1020, the pilot again contacted the Kenai ATCT, and said that he was taxiing for takeoff. At 1022, the pilot advised he was ready for departure, and was cleared for takeoff at 1023. After departure, he contacted a company employee on the company radio and advised that his departure time was 1025, and his flight time was anticipated to be 1 hour and 15 minutes. The pilot also reported that he intended to "go down" from his normal crossing point across the Cook inlet, and indicated that the engine pressure was "up in the green and good to go." At 1033:54, the pilot contacted Kenai tower and stated, "Yes, I have a mayday. I've, ah, substantial vibration has occurred, ah, I can't see, ah, problem, I'm mid-channel, descending." The Kenai tower controller asked for the pilot's position, and the pilot said, "I'm mid-channel headed for the (unintelligible.) At 1035:06, the pilot stated, "I'm headed into the water, 60:40.94 [degrees north latitude] 151:43.542 [degrees west longitude], Mayday, Mayday." No further communication was received from the pilot. The operator's director of operations was preparing to depart Kenai in another company airplane, and he monitored the mayday call. He asked about the accident location, departed from Kenai at 1039, and headed toward the area of the accident. Kenai ATCT personnel indicated that there was a possible radar target approximately 12 miles northwest of Kenai. That location was between Nikiski, Alaska, on the west shore of the Kenai Peninsula, and Redoubt Bay, on the east shore of the Alaska Peninsula. At 1046, Air Route Traffic Control Center (ARTCC) personnel, Anchorage, Alaska, contacted Kenai tower personnel via telephone, stating, "..I see that, ah, for this downed aircraft is 12 miles northwest of the VOR. Do you have anything better than that." Kenai tower personnel responding by stating, "Really, not at this time. Unofficially, we think we had a target on our radar. We got possible coordinates on him, but we have to check the tapes to make sure." ARTCC personnel inquired about a radial (magnetic direction) from the VOR, and Kenai personnel stated, "A good guess would be looked like the 310 to 330 [radial] off the East Forelands, maybe." Several aircraft heard the unfolding emergency situation and responded to the area of the crash. The Air Force Rescue Coordination Center (AFRCC) was notified and search personnel were dispatched to the area. About 1218, an emergency locator transmitter (ELT) signal was detected by U.S. Coast Guard search aircraft. About 1241, the tail of the partially submerged airplane was spotted floating vertically in about 60 feet of water, and the vessel "Sea Bulk Nevada" was directed to the area. The location was about 8.8 miles southwest of the initial accident site reported by the pilot. The 215 foot long vessel recovered the airplane about 1453 from the inlet, which had wide areas of floating ice and ice fog. The airplane was intact, with the exception of the nose wheel assembly, which was missing. A crewmember on the vessel reported that he saw what appeared to be two tire tracks on the pan ice, about 50 to 60 feet long, to the edge of the ice where the airplane was located. The pilot was not recovered with the airplane, and subsequent searches did not locate him. PERSONNEL INFORMATION Pilot Information The pilot held a commercial pilot certificate with airplane single-engine land, single-engine sea, and instrument airplane ratings. He also held private pilot privileges with a multiengine land rating. The most recent second-class medical certificate was issued to the pilot on April 3, 2006, and contained the limitation that the pilot must wear corrective lenses. The pilot was hired by the operator on April 8, 2006. He completed his initial ground and flight training on May 5, 2006. He took a CFR Part 135.293 and Part 135.299 airman competency/proficiency flight check with an FAA inspector from the Anchorage Flight Standards District Office (FSDO), Anchorage, Alaska, on May 4, 2006. The inspector indicated that the result of the flight check was unsatisfactory in emergency procedures and judgment, and disapproved the checkride. The following day, after another flight check, the inspector approved the pilot. No personal flight records were located for the pilot, and the aeronautical experience listed on page 3 of this report was obtained from the operator's records, and from an insurance company application completed by the pilot. The operator indicated that the pilot's total aeronautical experience consisted of about 5,291 hours, of which 512 hours were accrued in the accident airplane make and model. Company Information The company is a cargo-only operator, and does not carry passengers. The owner of the company is designated as the Chief Pilot and Director of Operations. The company operations specifications, issued by the FAA, states that operational control of flight operations are specified in the company's operations manual, Section 2. Section 2 of the company's operations manual states, in part: "The director of operations, the chief pilot, and the pilot-in-command (PIC) are responsible and authorized to independently suspend or terminate the initiation or continuation of a flight assignment under any of the following conditions: 1. If the flight release procedures have not been met; or, 2. If any conditions at the time of flight release are not compliant with FAR(s) and the procedures of this manual; or, 3. If any unsafe conditions pose a hazard to flight. The PIC is responsible and authorized to suspend or modify the continuation of a flight assignment to the extent necessary to avoid any conditions that are hazardous to flight. If it is not possible to continue a flight assignment safely, the PIC shall terminate the flight assignment." The owner reported that he usually crossed the Cook Inlet in a Cessna 207 between the East Foreland of the Kenai Peninsula, (about 12 miles northwest of Kenai) and the West Foreland of the Alaska Peninsula, at a minimum altitude of about 3,200 feet msl. The distance between these two points is approximately 9.5 miles. The company owner stated that Page 2-1 of the company's training manual, "Pilot-in-Command, Single Engine Reciprocating Aircraft," contains subjects and lessons, which include the topics of emergency situations, decision making, and emergency procedures. Page 3-10 of the training manual contains the lesson plan for emergency procedures. The elements of the lesson plan include recognition of emergencies and assignments, emergency and forced landing policies and procedures, basic first aid and physiology, survival principles and survival gear. The topic of survival principles include food, water, fire, signaling, and arctic and sea survival considerations. The topic of survival gear include ELT, location and the contents of aircraft survival gear, and other available survival equipment and resources. AIRCRAFT INFORMATION Examination of the maintenance records revealed that the most recent annual inspection of the airframe and engine was accomplished on February 11, 2006. At that time, the airplane had 13,468.6 hours. The engine had 2,469.3 hours, and 770.4 hours since a major overhaul. The engine was removed from the airframe on November 19, 1999, having accrued 1,698.9 hours. The engine case, including the crankshaft, camshaft, connecting rods, oil pump and starter assembly, was overhauled on May 28, 2002, by an engine overhaul facility. On November 1, 2003, a mechanic utilizing a mix of new and overhauled components, completed assembly of the engine with the installation of the cylinders and accessories, and reinstalled the engine. During the annual inspection on February 11, 2006, the number 2 engine cylinder was removed and replaced with an overhauled cylinder by the operator's director of maintenance. The cylinder change included new piston rings, piston pin, exhaust valve, and valve springs. The valve guides were replaced, the valve seats were ground, and the cylinder bore was honed. The intake valve was serviceable. The most recent inspection was a 100 hour inspection on November 1, 2006, 63.2 hours before the accident. At that time, the airframe had 13,773.8 hours. The engine had 1,075.6 hours since overhaul, and 305.2 hours since the number 2 cylinder was changed. At the time of the accident, the airplane had a total time in service of 13,837 hours. The engine had accrued 1,138.8 hours since overhaul, and 368.4 hours since the number 2 cylinder was changed. The operator reported that the airplane departed on the accident flight with about 50 gallons of fuel. The accident airplane was parked overnight on the operator's ramp, next to the company office and hangar. The airplane was equipped with a "Little Buddy" brand engine heater, which has electrical heating coils and fan, installed beneath the engine. The operator reported that the heater will maintain about 100 degrees in the engine compartment. The engine heater was plugged into an electrical outlet, and the engine was covered by a quilted engine cover. The airplane manufacturer's information manual, Section 3, "Emergency Procedures, Engine Failure," states, in part: "After an engine failure in flight, the best glide speed as shown in Figure 3-1 should be established as quickly as possible." Figure 3-1 contains best glide speeds for three airplane weights, and lists the following: 3,800 pounds gross weight - 80 knots; 3,400 pounds - 75 knots; 3,000 pounds - 70 knots. Figure 3-1 also has a maximum glide distance chart depicting a ratio of ground distance (nautical miles) vs height above terrain (feet). The glide ratio of altitude to distance, is about 8 to 1. METEOROLOGICAL INFORMATION At 1045, a special weather observation at Kenai was reporting, in part: Wind, 060 degrees (true) at 6 knots; visibility, 10 statute miles; clouds and sky condition, clear; temperature, -20 degrees F; dew point, -27 degrees F; altimeter, 30.56 inHg. Following the accident, search personnel reported that fog moved in the area of the search, with visibilities of about 1/8 mile. The terminal forecast for the Kenai Airport, issued at 0808, and valid until 0300 on January 10, was reporting: "Wind, 020 degrees at 4 knots; visibility, greater than 6 statute miles; clouds and sky condition, variable ceilings due to fog, 1,000 feet scattered. Temporary conditions between 0800 and 1100, visibility 5 statute miles in mist, 500 feet broken, variable overcast ceilings of 1,000 feet. The area forecast for Cook Inlet and Susitna Valley, issued at 0750, and valid until 1800, was reporting, in part: AIRMET for IFR conditions, from the east side of Palmer, Alaska, to the Turnagain Arm of the Cook Inlet, occasional ceilings below 1,000 feet, tops at 1,200 feet, visibility below 3 statute miles in ice crystals and mist, improving, valid until 1200. Otherwise, from the east side of Palmer to Turnagain Arm, 300 feet scattered, visibility 4 statute miles in mist. From Turnagain Arm to Kenai, 400 feet scattered, 1,600 feet broken to overcast, tops at 2,500 feet. Elsewhere, sky clear. From 1400, few clouds at 1,500 feet. Between 1600 to 1800, from the east side of Palmer to Turnagain Arm, isolated ceilings below 1,000 feet, visibility below 3 statute miles in ice crystals and mist. Outlook, valid between 1800 to 1200 on January 10, VFR. From 0600 (January 10) between Anchorage, Alaska, and Palmer, IFR due to ceilings in mist. COMMUNICATIONS A transcript of all radio communications between the accident airplane and the Kenai ATCT facility, between 1015 and 1102, is included in the public docket of this report. RADAR DATA The FAA reported that no discreet radar data pertaining to the accident airplane was found. A private company, utilized by the airframe manufacturer, analyzed unofficial primary radar data provided by the FAA's ARTCC that began at 1028:37, and ended at 1035:26. The radar data closely matched track data recovered from the pilot's personal global positioning system (GPS) receiver. The radar data did not show any altitude information, or transponder code information. WRECKAGE AND IMPACT INFORMATION On January 10, 11, and 12, the National Transportation Safety Board investigator-in-charge (IIC), and the parties noted in this report, examined the airplane after it was retrieved from the ocean. The airplane fuselage was intact and relatively undamaged, except for the missing nose wheel assembly, and some crushing near the vertical stabilizer where a nylon strap was used to lift the airplane from the water. During the hoisting operation to remove the airplane from the vessel on January 10, and place it on a trailer, a portion of an engine connecting rod was discovered wedged below the propeller spinner, between the forward edge of the engine cowling, and the aft end of the propeller spinner bulkhead. The connecting rod was intact at its upper end to include the piston wristpin retaining hole, but was missing the lower end, adjacent to the connecting rod bolt holes. The connecting rod cap was missing, as was the piston wristpin. The airplane was transported to a nearby hangar for the postaccident examination. Examination of the connecting rod revealed that it was not jammed or pinned between the cowling and the propeller assembly, but merely hanging there, retained only by the outer lip of the piston wristpin hole. It was easily removed by hand. Minor rotational scratches were noted on the forward face of the upper engine cowling, on either side of the propeller spinner. There were no punctures of the upper engine cowling. There was a hole in the forward portion of the lower cowling, just below the propeller spinner, with outward tearing and folding of the cowling material. Oil streaking was noted along the left side of the engine cowling. The instrument panel was coated with silt. Cleaning of the silt revealed the instrument gauges. No thermal damage was found to the airplane. The generator circuit breaker was the only breaker to have tripped. The instrument clock was stopped at 1034. The transponder was set to 1200, but was in the stand-by position. The thr
The total loss of engine power during cruise flight due to the disintegration of engine bearings and the fracture of a connecting rod, which resulted in a ditching into ice covered ocean water. Factors contributing to the survivability of the accident were the pilot's improper decision to fly over frigid water without sufficient altitude to reach a suitable landing area, the lack of written policy and procedures by the operator requiring sufficient altitude to reach shore when crossing ocean waters, temperature extremes consisting of sub-zero air and below freezing water temperatures, and the lack of personal flotation/survival equipment.
Source: NTSB Aviation Accident Database
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