Kodiak, AK, USA
N509FN
PIPER PA-31-350
The airline transport pilot and nine passengers were departing in a twin-engine airplane on a 14 Code of Federal Regulations Part 135 air taxi flight from a runway adjacent to an ocean bay. According to the air traffic control tower specialist on duty, the airplane became airborne about midway down the runway. As it approached the end of the runway, the pilot said he needed to return to the airport, but gave no reason. The specialist cleared the airplane to land on any runway. As the airplane began a right turn, it rolled sharply to the right and began a rapid, nose- and right-wing-low descent. The airplane crashed about 200 yards offshore and the fragmented wreckage sank in the 10-foot-deep water. Survivors were rescued by a private float plane. A passenger reported that the airplane's nose baggage door partially opened just after takeoff, and fully opened into a locked position when the pilot initiated a right turn towards the airport. The nose baggage door is mounted on the left side of the nose, just forward of the pilot's windscreen. When the door is opened, it swings upward, and is held open by a latching device. To lock the baggage door, the handle is placed in the closed position and the handle is then locked by rotating a key lock, engaging a locking cam. With the locking cam in the locked position, removal of the key prevents the locking cam from moving. The original equipment key lock is designed so the key can only be removed when the locking cam is engaged. Investigation revealed that the original key lock on the airplane's forward baggage door had been replaced with an unapproved thumb-latch device. A Safety Board materials engineer's examination revealed evidence that a plastic guard inside the baggage compartment, which is designed to protect the door's locking mechanism from baggage/cargo, appeared not to be installed at the time of the accident. The airplane manufacturer's only required inspection of the latching system was a visual inspection every 100 hours of service. Additionally, the mechanical components of the forward baggage door latch mechanism were considered "on condition" items, with no predetermined life-limit. On May 29, 2008, the Federal Aviation Administration issued a safety alert for operators (SAFO 08013), recommending a visual inspection of the baggage door latches and locks, additional training of flight and ground crews, and the removal of unapproved lock devices. In July 2008, Piper Aircraft issued a mandatory service bulletin (SB 1194, later 1194A), requiring the installation of a key lock device, mandatory recurring inspection intervals, life-limits on safety-critical parts of forward baggage door components, and the installation of a placard on the forward baggage door with instructions for closing and locking the door to preclude an in-flight opening. Postaccident inspection discovered no mechanical discrepancies with the airplane other than the baggage door latch. The airplane manufacturer's pilot operating handbook did not contain emergency procedures for an in-flight opening of the nose baggage door, nor did the operator's pilot training program include instruction on the proper operation of the nose baggage door or procedures to follow in case of an in-flight opening of the door. Absent findings of any other mechanical issues, it is likely the door locking mechanism was not fully engaged and/or the baggage shifted during takeoff, and contacted the exposed internal latching mechanism, allowing the cargo door to open. With the airplane operating at a low airspeed and altitude, the open baggage door would have incurred additional aerodynamic drag and further reduced the airspeed. The pilot's immediate turn towards the airport, with the now fully open baggage door, likely resulted in a sudden increase in drag, with a substantive decrease in airspeed, and an aerodynamic stall.
HISTORY OF FLIGHT On January 5, 2008, about 1343 Alaska standard time, a twin-engine Piper PA-31-350 airplane, N509FN, received substantial damage when it collided with ocean water following a loss of control shortly after takeoff from Runway 36 at the Kodiak Airport, Kodiak, Alaska. The airplane was being operated by Servant Air, Inc., Kodiak, as a visual flight rules (VFR) on-demand charter flight under the provisions of Title 14 Code of Federal Regulations (CFR) Part 135, when the accident occurred. Of the 10 people aboard, the airline transport pilot and 5 passengers died at the scene, 3 passengers sustained serious injuries, and 1 passenger sustained minor injuries. Visual meteorological conditions prevailed, and company flight following procedures were in effect. The flight was en route to Homer, Alaska. During an initial hospital room interview with the National Transportation Safety Board (NTSB) investigator-in-charge (IIC), on January 5, about 2200, a passenger related that the purpose of the flight was to transport a group of commercial fishermen from Kodiak to Homer for Russian Christmas. He added that many of the passengers were family members that lived in the same community near Homer. The passenger stated that he was seated in the third row on the right side of the airplane. He said that shortly after becoming airborne, he saw the airplane's nose baggage door open slightly, which he said initially startled the pilot. He said that while the airplane was still over the departure end of Runway 36, the pilot initiated a shallow right turn, presumably to return to the airport. He said that as soon as the pilot started the right turn, the baggage door swung open to the full open position, and it remained in that position. The passenger said that as the airplane continued the right turn, it rolled sharply to the right, and began a rapid, nose and right wing low descent. It collided with the water adjacent to the departure end of Runway 36. The passenger said that during the collision the fuselage fragmented, and the airplane sank shortly after impact. He said that he was able to free himself from the sinking wreckage by swimming though a large void in the airplane's fuselage. According to the contract Air Traffic Control Tower (ATCT) specialist that was on duty at the time of the accident, the accident airplane departed from runway 36, and became airborne about midway along the 5,013-foot long runway. The ATCT specialist said that as the airplane continued to climb approaching the departure end of the runway, the pilot calmly stated that he needed to return to the airport, but gave no reason for his need to return. The ATCT specialist reported that as the airplane began a right turn, it began a steep roll to the right, and descended nose-low into the water. He said that immediately after witnessing the accident, he alerted airport fire rescue crew of the accident, and contacted the U.S. Coast Guard's Air Station Kodiak, which is located adjacent to the Kodiak airport. The ATCT specialist noted that just after the accident, another Kodiak-based operator in a float-equipped de Havilland DHC-2 Beaver airplane contacted him on the tower radio frequency and said, in part: "[Kodiak] tower, Beaver five forty five's by the Crash Harbor, um can I help there?" The ATCT specialist responded by saying: "Beaver five forty five, yeah, you may be able to uh, you may be the first one that can get to those people that are in the water, they are right off the approach end of runway one eight, just off Buskin Beach, and uh you can transition into the airspace at your discretion." The ATCT specialist said that the pilot of the float-equipped de Havilland DHC-2 went directly to the accident site, then landed near the partially submerged wreckage. During an interview with the NTSB IIC, on January 8, the pilot of the de Havilland DHC-2 Beaver airplane reported that at the time of the accident he was doing a postmaintenance engine run following a 100-hour inspection of his airplane. He said that while parked in a bay locally known as "Crash Harbor" adjacent to the Kodiak Airport, he initially overheard the radio conversation between the accident pilot and ATCT specialist, followed by the conversations between the ATCT specialist and the fire rescue crews, so he offered his assistance. The pilot said that once he found the partially submerged wreckage, he landed, and then taxied close as he could to the sinking wreckage. He said he discovered two passengers swimming in the water next to the submerged wreckage, and two other passengers clinging to the airplane's exposed vertical stabilizer. He said that wind conditions at the time of the rescue made it very difficult to maneuver his airplane next to the wreckage. Once he had the four severely hypothermic passengers aboard, he departed to the north, and flew directly to the Kodiak boat harbor where an ambulance was waiting. The pilot noted that when he departed the accident site, no other passengers were visible on the surface of the water. Pilot Preflight During an interview with the NTSB IIC on January 8, an employee of Servant Air reported that the accident pilot loaded the airplane himself, while his passengers waited in the operator's lounge. The employee noted that he watched the pilot load various items into the forward baggage area, closed and latched the baggage door, then continued loading the remaining items in the aft baggage area, and wing lockers. He said that when the pilot was done loading the airplane, he saw him do a "walk around" the entire airplane. He said that when the pilot approached the forward baggage area, the pilot slide his open left hand across the closed door, then while making a loose fist, he lightly tapped the door, just above the door's handle and lock assembly, then continued around the airplane's right wing. PERSONNEL INFORMATION Pilot Information The pilot held an airline transport pilot certificate with airplane multiengine land and sea, and helicopter ratings. He also held a flight instructor certificate with airplane single-engine land, multiengine land, instrument airplane, and helicopter ratings. His most recent first-class medical certificate was issued August 7, 2007, and contained no limitations. According to the NTSB Pilot/Operator Aircraft Accident Report (NTSB Form 6120.1) submitted by Servant Air, dated January 18, 2008, the pilot's total flight time was 9,437 hours, of which 400 were in the accident airplane make and model, and 1,108 in multiengine airplanes. His most recent airman competency/proficiency check (CFR Part 135.293) check ride was on September 1, 2007, the company president, who was a company check airman, administered the check ride in the accident airplane. A review of the flight and duty records for the pilot revealed in the 30 days before the accident, he flew about 47.5 hours. His flight time in the previous 90 days was about 179.6 hours. According to the operator, the company hired the pilot on June 1, 2004, and at that time, his total combined (helicopter and airplane) flight experience was about 6,555 flight hours, with 36 hours in multiengine airplanes. Before being hired by Servant Air, the pilot was a full-time helicopter pilot for the United States Coast Guard. During his time in service with the Coast Guard, he was stationed in various theaters around the world, including Alaska. While in the Coast Guard, he accumulated about 6,000 flight hours in helicopters, and about 465 hours in airplanes. Company Information The operator is a Federal Aviation Regulations (FAR) Part 135 Air Carrier, and holds scheduled commuter and on-demand operations specifications. Company facilities are in Kodiak and Anchorage, Alaska. The president/director of maintenance and chief pilot reside in Kodiak. The vice president/director of operations resides in Anchorage. A review of the company's operations specification, issued by the FAA, indicate that flights shall only be initiated, diverted, or terminated under the authority of the director of operations, who may delegate his authority, but retains responsibility. At the time of the accident, the company president was out of town, and the vice president/director of operations was in Kodiak in his absence. A review of Servant Air's FAA approved training program revealed no specific training requirements concerning the proper operation of the nose baggage door. In addition, there were no emergency procedures training concerning an inadvertent opening of the nose baggage door. AIRCRAFT INFORMATION The airplane was equipped with two Lycoming TIO-540-J2B engines that were each rated at 350 horsepower. The airplane's original maximum gross weight was 7,000 pounds, but it had been modified to 7,368 pounds in accordance with an FAA-approved supplemental type certificate (STC). According to the load manifest computed by the pilot just before departure, the airplane's gross weight was 7,221 pounds, or 147 pounds below its maximum gross weight. The airplane was not equipped with a cockpit voice recorder, or a flight data recorder. Maintenance records revealed that the last recorded inspection event of the engine and airframe was a 100-hour inspection, completed on December 18, 2007, 18 days and 27 service hours before the accident. At that time, the airplane had a total of 13,102 service hours. The left engine had about 615 service hours since the last major overhaul, and the right engine had about 1,151 service hours since the last major overhaul. The most recent annual inspection of the engines and airframe was on August 15, 2007, at which the airplane had 12,914 service hours. The left engine had about 427 service hours since a major overhaul, and the right engine had about 1,363 service hours since major overhaul. The left engine overhaul was done by Aero Recip Alaska, on June 14, 2006. The engine was installed on the accident airplane on June 29, 2006, and remained there until the accident. The right engine overhaul was done by Aero Recip Alaska, on December 8, 2003. The engine was installed on the accident airplane on January 5 2004, and remained there until the accident. METEOROLOGICAL INFORMATION The closest official weather observation station is located at the Kodiak Airport. At 1353, an Aviation Routine Weather Report (METAR) was reporting, in part: Wind, 300 degrees (true) at 17 knots with gusts to 26 knots; visibility, 10 statute miles; clouds and sky condition, 1,600 feet few, 25,000 feet scattered; temperature, 25 degrees F; dew point, 14 degrees F; altimeter, 29.96 inHg. COMMUNICATIONS Review of the air-ground radio communications tapes maintained by the FAA at the Kodiak Airport, revealed the pilot contacted the Kodiak Air Traffic Control Tower (ATCT), about 1337, and requested a clearance to taxi from the commercial ramp for a northbound departure. The ATCT specialist on duty responded by saying: "Navajo niner Foxtrot November Kodiak tower, runway three six position and hold, taxi via the runways." According to the ATCT specialist, the airplane taxied to runway 36 as instructed, then held short at the end of the runway. At 1340, the ATCT specialist said: "Navajo niner Foxtrot November, wind two eight zero at one six, runway three six, cleared for takeoff." The pilot said: "Cleared for takeoff, [runway] three six, nine foxtrot November." At 1342, the pilot said: "and tower, nine foxtrot November, I need to return for landing." The ATCT specialist on duty responded by saying: "Navajo niner Foxtrot November, wind three zero zero at one seven, and you can land on any runway you please." The pilot responded and said: "nine fox November." No further radio contact from the accident airplane was received. A transcript of all communications between the accident pilot and the ATCT specialist is included in the public docket of this accident. AERODROME AND GROUND FACILITIES The Kodiak airport, elevation 73 feet msl, is equipped with three, intersecting hard-surfaced runways. Runway 36 is 5,013 feet long by 150 feet wide. The departure end of runway 36 is positioned at the edge of Chiniak Bay. The airport is near the base of Barometer Mountain, which rises to 2,506 feet west of the airport. The Kodiak Airport is the home of the U.S. Coast Guard's Air Station Kodiak. The Air Station is the major tenant of Integrated Support Command (ISC) Kodiak, and the largest Coast Guard command in the Pacific area. Air Station Kodiak operates a fleet of HC-130H's airplanes, as well as a fleet of HH-60J, and HH-65A rescue helicopters. WRECKAGE AND IMPACT INFORMATION The NTSB IIC, and a Federal Aviation Administration (FAA) airworthiness inspector, Anchorage Flight Standards District Office, traveled to Kodiak on January 5. The NTSB IIC and the FAA inspector were aboard the recovery vessel when the airplane wreckage was recovered January 6. All of the airplane's major components were found at the main wreckage site. The airplane's fragmented wreckage sank in the shallow, tidal waters of Chiniak Bay, about 200 yards offshore, and about 30 degrees to the right of the centerline of Runway 36. The airplane received substantial damage during impact and recovery. Divers who arrived on scene shortly after the accident described the condition of the airplane as severely damaged. The divers described the nose and forward section of the airplane as "fragmented." The airplane was found resting upright on the ocean floor in 10 feet of water at high tide. The divers noted that the upper portion of the airplane was visible during low tide. The airplane's landing gear was in the extended position. The airplane's right wing remained partially attached to the fuselage by cables, and the fragmented left wing was found torn from its fuselage to wing attachment points. The airplane's right engine assembly was torn from the airplane's firewall, and was found among the submerged wreckage. The right engine sustained impact damage to the front and underside portions. The exhaust tubes were crushed upward, and the folded edges of the exhaust tubes did not exhibit any cracking or bending. The right propeller hub remained attached to the crankshaft flange. All three propeller blades were loose in the propeller hub, but remained attached to the propeller hub assembly. The three propeller blades were bent aft, and all had torsional "S" twisting. The airplane's left engine assembly remained attached to the airplane's firewall. The engine sustained impact damage to the front and underside portions. The exhaust tubes were crushed upward, and the folded edges of the exhaust tubes did not exhibit any cracking or bending. The left propeller hub remained attached to the crankshaft flange. All three propeller blades were loose in the propeller hub, but remained attached to the propeller hub assembly. The three propeller blades were bent aft, and all had torsional "S" twisting. During recovery efforts, ropes and cables were attached to the engine nacelles, fuselage, and landing gear to hoist the wreckage onto a recovery barge. While being hoisted, the airplane broke apart in numerous areas, and the left wing separated. The right wing remained attached by cables. The accident airplane's nose baggage door was recovered along with the main wreckage, and it sustained relatively minor damage. The twisted, broken, and distorted nose baggage doorframe was found in the fragmented wreckage of the nose section. The nose baggage door handle was found in the closed position, and both the forward and aft latching arms were extended [closed position]. The nose baggage door lock cam assembly was found partially engaged into the baggage door handle slot. The plastic guard, which is designed to cover the door's locking mechanism components and the latch tube assembly on the inside portion of the door, was missing. The painted surface of the latch tube assembly had areas of chipped paint, with areas of corrosion and rust on the exposed areas. During recovery, it was noted that the nose baggage door's original equipment key lock had been replaced with a
The failure of company maintenance personnel to ensure that the airplane's nose baggage door latching mechanism was properly configured and maintained, resulting in an inadvertent opening of the nose baggage door in flight. Contributing to the accident were the lack of information and guidance available to the operator and pilot regarding procedures to follow should a baggage door open in flight and an inadvertent aerodynamic stall.
Source: NTSB Aviation Accident Database
Aviation Accidents App
In-Depth Access to Aviation Accident Reports
