Juneau, AK, USA
N7304S
CESSNA 182P
The pilot and his wife were on a personal, cross-country flight between two airports separated by areas of coastal waterways and mountainous terrain. The flight was conducted under visual flight rules, but weather conditions in the area were low ceilings and reduced visibility due to rain, fog, and mist. There is no record that the pilot received a weather briefing. The pilot advised an air traffic control tower specialist at the destination airport that he was about 10 miles southwest of the airport for landing. Moments later, a faint emergency locator transmitter signal was detected. No further radio contact from the pilot was received. The next day, the wreckage was found in an area of mountainous terrain about 6 miles southeast of the airport. A postaccident examination disclosed no evidence of any preimpact mechanical anomalies with the airplane. Examination of the pilot's portable global positioning system (GPS) receiver revealed that he was apparently following a straight-line flight path from the departure airport to a secondary airport that was close to the larger, primary (destination) airport. This flight path was directly over mountainous terrain, whereas a track from the departure airport to the primary airport would have been over lower terrain. It is unknown if the pilot was aware he was flying toward an airport other than his proclaimed destination. The purpose of the flight was to take his wife to the primary airport to connect with a scheduled commercial flight that was due to depart only 43 minutes from the time the accident occurred. Given the lack of mechanical deficiencies with the airplane, the absence of any distress communications, and the pilot's self-induced pressure to get his wife to the airport to avoid missing her flight, it is likely the pilot flew into instrument meteorological conditions while tracking his portable GPS receiver to the wrong destination and subsequently collided with mountainous terrain.
HISTORY OF FLIGHT On July 24, 2011, about 0645 Alaska daylight time, a Cessna 182P airplane, N7304S, impacted mountainous terrain about 6 miles southeast of the Juneau International Airport, Juneau, Alaska. The commercial pilot and the sole passenger were fatally injured, and the airplane sustained substantial damage. The airplane was being operated as a 14 CFR Part 91 visual flight rules (VFR) cross-country personal flight when the accident occurred. Visual meteorological conditions prevailed at the airplane's point of departure. The flight originated at the Hoonah Airport, Hoonah, Alaska, about 0629, and was en route to the Juneau International Airport. At the time of the accident, marginal visual meteorological conditions were reported at the Juneau Airport. The weather conditions at the accident site are not known. However, witnesses in Juneau reported that weather conditions to the southeast, and specifically in the direction of the accident site, were much worse than that being reported at the airport. No flight plan was filed, and there is no record that a weather briefing was obtained. The area between Hoonah and Juneau consists of remote inland fjords, coastal waterways, and steep mountainous terrain. According to a Juneau air traffic control tower (ATCT) specialist on duty at the time of the accident, the pilot contacted the ATCT about 0643, reporting that he was about 10 miles southwest of the airport for landing. The ATCT specialist instructed the pilot to report 4 miles southwest of the airport. Moments later, a faint emergency locator transmitter (ELT) was heard on 121.5 MHz by the Juneau ATCT specialist, as well as personnel at the Juneau Flight Service Station. No further radio contact from the accident airplane was received. The Federal Aviation Administration (FAA) issued an alert notice (ALNOT) at 0757 Alaska daylight time. Continuous poor weather conditions prevented search crews from locating the airplane until the next day. The fragmented airplane wreckage was in an area of steep mountainous terrain. PERSONNEL INFORMATION The pilot, age 77, held a commercial pilot certificate with airplane single engine land and instrument airplane ratings. His most recent third-class medical certificate was issued February 5, 2010, and contained the limitation that he must wear corrective lenses. No personal flight records were located for the pilot, and the aeronautical experience listed on page 3 of this report was obtained from a review of the FAA’s airmen records on file in the Airman and Medical Records Center in Oklahoma City. On the pilot's application for medical certificate, dated February 5, 2010, he indicated that his total aeronautical experience consisted of 8,300 flight hours, of which 40 were logged during the previous 6 months. AIRCRAFT INFORMATION At the time of the accident the airplane had a total time in service of 6,448.7 flight hours. A review of the maintenance records revealed that the most recent annual inspection of the airframe and engine was on May 26, 2011, about 7.9 flight hours before the accident. The airplane was equipped with a Teledyne Continental Motors O-470-S engine, rated at 230 horsepower. The engine was overhauled about 332.0 hours before the accident. METEOROLOGICAL INFORMATION The closest weather reporting facility was the Juneau International Airport, 5 miles north-northwest of the accident site. About 10 minutes before the accident, at 0635, a weather observation from the Juneau Airport was reporting, in part: Wind, 090 degrees (true) at 8 knots; visibility, 5 statute miles with light rain and mist; clouds and sky condition, 2,800 feet broken, 3,600 feet overcast; temperature, 55 degrees F; dew point, 55 degrees F; altimeter, 29.89 inches Hg. The next closest official weather observation station was Hoonah, the accident airplane's departure airport, about 31 miles south-southwest of the accident site. About 24 minutes before the airplane departed, an Aviation Routine Weather Report (METAR) was reporting, in part: Wind, calm; visibility, 10 statute miles; clouds and sky condition, 3,500 feet overcast, temperature, 57 degrees F; dew point, 55 degrees F; altimeter, 29.89 inHg. WRECKAGE AND IMPACT INFORMATION On July 25, two NTSB investigators, along with two FAA aviation safety inspectors from the Juneau Flight Standards District Office (FSDO), examined the wreckage at the accident site, but high winds, rain, and low ceilings limited the available time at the scene. All of the airplane's major components were found at the main wreckage site. The accident site was in an area of steep, mountainous, tundra and rock-covered terrain, with sparsely populated areas of low trees/scrubs, at an elevation of about 3,100 feet msl. The main debris path was on a 035 degree heading, and downhill (All headings/bearings noted in this report are magnetic). An area believed to be the initial impact point, about 130 feet above the main wreckage site, was marked by broken shrubs and disrupted tundra atop a rock knoll. The airplane's left aileron and the left wingtip fairing were found next to the initial impact point. After initial impact, the fragmented wreckage continued down the backside of the rock knoll, coming to rest on a narrow mountainous outcropping, surrounded by vertical rock cliffs on three sides. The engine, propeller, and nose landing gear were torn from the airplane's firewall, and continued off the ledge, falling about 800 to 1,000 feet and into the valley floor below. Scattered downslope, in a line between the initial impact point, and the final resting point of the main wreckage, were small portions of wreckage debris, paint chips, broken Plexiglas, and personal effects. The airplane's severed left wing was atop the main wreckage, and it had extensive spanwise leading edge aft crushing and bending. The wing's flap remained connected to its attaching points. The airplane's right wing remained attached to the fuselage attaching points, but the entire wing had extensive spanwise leading edge aft crushing. The wing's flight control surfaces remained connected to their respective attach points, except for the right ailerons inboard hinge which was torn free. The airplane's empennage was severed just behind the aft passenger seats, but all of the flight control surfaces remained connected to their respective attach points. Due to extensive impact damage, continuity of the flight control cables could not be established. There were no preaccident mechanical problems discovered during the NTSB IIC's on-scene wreckage examination. Continuous poor weather conditions prevented recovery crews from reaching the accident site until July 30, 2011. After recovery, the airplane wreckage was taken to the Juneau airport. On August 11, 2011, an FAA airworthiness inspector from the Juneau FSDO examined the accident airplane's engine, propeller and nose landing gear assembly. The FAA inspector reported that the propeller bolts attaching the propeller to the engine crankshaft remained attached to the crankshaft flange, but the crankshaft was fractured just aft of the flange. Both propeller blades were loose in the propeller hub, but remained attached to the hub assembly. The inspector noted that both propeller blades had extensive leading edge gouges, substantial torsional "S" twisting, and chordwise scratching. The FAA inspector also reported that the engine sustained significant impact damage, but no preaccident engine anomalies were found during his examination. MEDICAL AND PATHOLOGICAL INFORMATION A postmortem examination was conducted under the authority of the Alaska State Medical Examiner, Anchorage, Alaska, on August 1, 2011. The cause of death for the pilot was attributed to blunt force, traumatic injuries. The FAA's Civil Aeromedical Institute performed toxicological examinations for the pilot on November 21, 2011, which was negative for alcohol. The toxicological examination revealed unspecified levels of Tamsulosin in the pilot's blood, and unspecified levels of the same substances in his urine. Tamsulosin (trade name Flomax) is a prescription medication commonly used to treat an enlarged prostate. SEARCH AND RESCUE After being notified of an overdue airplane, and after learning about reports of an emergency locator transmitter (ELT) signal along the accident pilot's anticipated flight route, search and rescue personnel from Juneau Mountain Rescue, U.S. Coast Guard, and the Alaska State Troopers, began an extensive ground and airborne search. Rescue personnel tracked an ELT signal to an area of mountainous terrain, but poor weather conditions prohibited a U.S. Coast Guard HH-60 helicopter from searching the upper levels of the search area. About 1700, ground search personnel from the Juneau Mountain Rescue tracked the ELT signal, and discovered the airplane's engine, propeller, and various fragmented portions of wreckage at the base of a 900 foot high rock wall, but were unable to locate the fuselage or the airplane's occupants. On July 25, about 1200, members of the Juneau Mountain Rescue, along with two investigators from the NTSB's Alaska Regional office, three safety inspectors from the Juneau FSDO, and an Alaska State Trooper, found the main wreckage site at the 3,100 feet level of north Douglas Island, and confirmed that the airplane's occupants had sustained fatal injuries. TESTS AND RESEARCH At the time of the accident, the pilot was using two personal Garmin GPS receivers, a Garmin GPSMAP 195 and a Garmin GPSMAP 495. Both units were recovered at the accident site by the NTSB IIC, and both were sent to the NTSB's Vehicle Recorder Division for examination. Several minutes of stored GPS position data was retrieved from each of the GPS track logs, and a Senior NTSB Electronic Engineer was able to reconstruct the entire route of flight for the accident airplane. The combined GPS data logs for July 24, 2011, revealed that at 0628 the airplane departed from the Hoonah Airport. After departure, the airplane turned north north-east toward the Juneau Airport, and it gradually climbed to a maximum altitude of 3,619 feet global navigation satellite system (GNSS) altitude. The airplane continued north north-east, eventually passing over the ocean waters of Icy Straight and Chatham Canal. As the airplane neared the Mansfield Peninsula, it momentarily deviated to the north and climbed up and over Robert Baron Peak, then descended slightly while continuing towards Juneau, over the Stephens Channel. As the airplane passed over the southwest shoreline of Douglas Island, it begins a gradual climb, and the GPS-derived groundspeed begins to decrease slightly as the airplane approaches an area of steep, mountainous terrain. The final GPS position was recorded at 0645:34 ADT, which placed the airplane near the accident site. The last GPS-derived groundspeed and direction of travel was 47 mph on a 067 degrees (True) course. The terrain elevation in the vicinity of the crash site is about 3,900 feet msl, and the airplane wreckage was found at 3,100 feet msl. According to the NTSB Electronic Engineer that reviewed the stored GPS data, the Garmin GPSMAP 495 unit had a preselected flight route for a flight between Hoonah and the Juneau Harbor Seaplane Base, and back to Hoonah. The Juneau Harbor Seaplane Base is situated about 6 miles east-southeast of the Juneau International Airport. The accident site is in an area of mountainous terrain, about 5 miles southwest of the Juneau Harbor Seaplane Base, and along a straight-line flight path between the Hoonah Airport and the Juneau Harbor Seaplane Base. The flight path from Hoonah to the Juneau Seaplane Base required the airplane to pass over higher terrain, but a flight path from Hoonah to the Juneau International Airport would have been over water. The details of the GPS data is included in the public docket of this accident. ADDITIONAL DATA / INFORMATION A personal friend of the family reported that the pilot and his wife were moving from Anchorage, Alaska to Hoonah, requiring that the airplane be moved to Hoonah. The friend noted that the pilot and his wife flew from Anchorage to Juneau on July 23, the day before the accident, and the wife was planning to return to Anchorage that same day on a commercial airline flight. According to an FAA operations inspector from the Juneau FSDO, the accident airplane arrived in Juneau on the evening of July 23, about 1940. He said that the airplane had flow from Anchorage, direct to Juneau, on an Instrument Flight Rules (IFR) flight plan, arriving in Juneau later than originally anticipated. He noted that the pilot's wife had a confirmed reservation aboard Alaska Airlines, Flight 67, scheduled to depart for Anchorage at 1945, which was the last flight of the day between Juneau and Anchorage. Witnesses at the airport reported seeing the accident airplane arrive just as Flight 67 was departing. The FAA inspector noted that the pilot's wife was rebooked on Alaska Airlines, Flight 73, departing Juneau at 0728 the next morning. According to the fuel vendor at the Juneau International Airport, the accident pilot purchased 58.1 gallons of 100LL fuel, and as he was servicing the airplane, the pilot mentioned that he would be flying to Hoonah for the night, and then returning to Juneau early the next morning so his wife could catch the first flight back to Anchorage. The accident occurred at 0645, 43 minutes before Alaska Airlines Flight 73 was scheduled to depart.
The pilot's continued visual flight into instrument meteorological conditions, which resulted in an in-flight collision with mountainous terrain. Contributing to the accident was the pilot's self-induced pressure to reach his destination.
Source: NTSB Aviation Accident Database
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