Riverwoods, IL, USA
N59773
PIPER PA-31-350
The airplane was dispatched on an emergency medical services flight. While being vectored for an instrument approach, the pilot declared an emergency and reported that the airplane was out of fuel. He said the airplane lost engine power and that he was heading toward the destination airport. The airplane descended through clouds and impacted trees and terrain short of its destination. No preimpact anomalies were found during a postaccident examination. The postaccident examination revealed about 1.5 ounces of a liquid consistent with avgas within the airplane fuel system. Based on the three previous flight legs and refueling receipts, postaccident calculations indicated that the airplane was consuming fuel at a higher rate than referenced in the airplane flight manual. Based on this consumption rate, the airplane did not have enough fuel to reach the destination airport; however, a 20-knot tailwind was predicted, so it is likely that the pilot was relying on this to help the airplane reach the airport. Regardless, he would have been flying with less than the 45-minute fuel reserve that is required for an instrument flight rules flight. The pilot failed to recognize and compensate for the airplane’s high fuel consumption rate during the accident flight. It is likely that had the pilot monitored the gauges and the consumption rate for the flight he would have determined that he did not have adequate fuel to complete the flight. Toxicology tests showed the pilot had tetrahydrocannabinol and tetrahydrocannabinol carboxylic acid (marijuana) in his system; however, the level of impairment could not be determined based on the information available. However, marijuana use can impair the ability to concentrate and maintain vigilance and can distort the perception of time and distance. As a professional pilot, the use of marijuana prior to the flight raises questions about the pilot’s decision-making. The investigation also identified several issues that were not causal to the accident but nevertheless raised concerns about the company’s operational control of the flight. The operator had instituted a fuel log, but it was not regularly monitored. The recovered load manifest showed the pilot had been on duty for more than 15 hours, which exceeded the maximum of 14 hours for a regularly assigned duty period per 14 Code of Federal Regulations Part 135. The operator stated that it was aware of the pilot’s two driving while under the influence of alcohol convictions, but the operator did not request a background report on the pilot before he was hired. Further, the operator did not list the pilot-rated passenger as a member of the flight crew, yet he had flown previous positioning legs on the dispatched EMS mission as the pilot-in-command.
HISTORY OF FLIGHT On November 28, 2011, about 2250 central standard time, the pilot of Lifeguard N59773, a Piper PA-31-350 Chieftain airplane, declared an emergency, reporting that the airplane was out of fuel, and indicating that the flight was gliding without engine power direct to the destination airport, Chicago Executive Airport (PWK), near Wheeling, Illinois. The emergency medical services (EMS) airplane subsequently sustained substantial damage when it impacted trees and terrain near Riverwoods, Illinois. The airline transport pilot and two passengers on board sustained fatal injuries. A pilot-rated passenger received serious injuries and the medical crew member received minor injuries. The airplane was registered to and operated by Trans North Aviation Ltd. under the provisions of 14 Code of Federal Regulations Part 135 as a non-scheduled, domestic, on-demand, EMS passenger flight. Night visual meteorological conditions prevailed at the time of the accident for the flight, which operated on an activated instrument flight rules (IFR) flight plan. The flight departed from the Jesup-Wayne County Airport (JES), near Jesup, Georgia, about 1900. According to a load manifest form found in the wreckage, dated November 28, 2011, the crew that flew N59773 from the Crawfordsville Municipal Airport (CFJ), near Crawfordsville, Indiana, to the Perry-Houston County Airport (PXE), near Perry, Georgia, and onto the Palm Beach International Airport (PBI), near West Palm Beach, Florida, listed the pilot-rated passenger as the pilot-in-command and listed the pilot and the medical crewmember as “other crew.” This form indicated that this crew started their duty period at 0700 when they flew from CFJ and they ended their duty period at 1430 in PBI. According to another load manifest form, also dated November 28, 2011, the crew that flew N59773 from PBI, to JES, and onto PWK listed the pilot as the pilot-in-command and listed the pilot-rated passenger and the medical crewmember as "other crew." This form indicated that this crew started their duty period at 1430 at PBI. This form indicated that they departed from PBI at 1642 and landed at JES at 1830. Fueling records showed an airplane was fueled at JES with 160 gallons of aviation gasoline (avgas) and an additional 5 gallons of avgas, which totaled a combined servicing of 165 gallons of avgas. This manifest form indicated that they departed from JES at 1900 and were destined for PWK. The duty period ending time was not completed. A review of the recording of the approach controller’s frequency revealed that the pilot representing Lifeguard N59773 requested to fly direct to the outer marker navigation aid named PAMME. The controller indicated that the flight had to be taken on a heading to intercept the approach outside PAMME and the controller denied the request. The flight was given that heading for the instrument approach and the pilot then declared an emergency. The controller inquired if the flight was still landing at PWK. The pilot reported that he was unable, the airplane was out of fuel, and that the airplane was “coasting.” The controller asked if the field was in sight. The pilot reported negative and asked for the cloud tops. The controller indicated that the cloud deck was 1,400 feet overcast. The pilot responded that the flight was coasting down and that the pilot would report visual contact. The pilot further indicated that the flight was flying direct to PWK. The controller advised the flight of a low altitude alert and the flight acknowledged that alert. The controller again asked if the pilot had the field in sight. The pilot reported affirmative. The flight was cleared for the visual approach to runway 16 and the pilot was informed to cancel the flight’s IFR flight plan. The controller further indicated that the change to the airport’s advisory frequency was approved. There was no further recorded radio communication from the Lifeguard EMS flight. A transcript of the air traffic controller’s communications is appended to the docket associated with this investigation. The pilot-rated passenger sat in the front right seat of the airplane. During a postaccident telephone interview, he indicated that the flight from PBI to PWK started out normal. While flying over the lower portion of Lake Michigan, the pilot selected the auxiliary fuel tanks to use up all the fuel in the auxiliary tanks. The last quarter of the main tanks was reportedly consumed “pretty fast” as monitored on the gauges. The right fuel flow warning light came on north of PWK. The pilot selected the crossfeed valve to its ON position. The fuel warning light went out. The pilot asked the air traffic controller to proceed direct to the outer marker and the air traffic control indicated that he was unable to grant that request. The fuel light came on again and the pilot declared an emergency. The pilot-rated passenger said that he had no idea of the amount of fuel that remained in the fuel tanks. The right engine subsequently started to shutter. The flight was cleared direct. The cloud tops were at 3,000 feet above mean sea level (msl). The airplane was turned left and then both engines “died” on a west heading. The airplane “coasted.” The airplane was in clouds during the descent and popped out of the clouds about 1,400 feet msl where there was about 700 feet of altitude left. The pilot rated passenger made some radio calls. The airplane was turned to a southbound heading. The pilot-rated passenger advised the pilot of suitable landing sites but the flight was unable to get to them. The landing gear was up. Flaps were up. The pilot moved the mixture to idle/cutoff and feathered the engines’ propellers. He pointed out a dark spot to the pilot and the pilot turned to it. The airplane scraped the tops of trees. The first tree impacted the pilot’s side and it came through the window. Both the pilot and the pilot-rated passenger were “on the flight controls.” The controls then went limp. The pilot-rated passenger indicated that he tried to keep the airplane away from the houses and both of his yoke handles broke off. A nearby neighbor found him in the wreckage and asked him if he was “ok.” It was about one-half hour before he was placed in an ambulance. During a postaccident telephone interview, the medical crew member indicated that the purpose of the flight was to fly to PBI to pick up a patient and passenger and then fly them to PWK. The patient and passenger were informed that there would be one or maybe two stops for fuel. The airplane appeared to be topped off at JES. The fueling started on the right side of the airplane and continued to the left side. The fuel pump shut off after about 160 gallons were pumped. The pump was restarted and the airplane was fueled with more fuel. The flight was "ok" until it encountered “bad air” and the flight descended to about 7,000 feet. At one point in the flight, the medical crew member saw that a cockpit gauge indicated that there was one-half hour remaining before reaching the destination. The pilot remarked on how fast the airplane was flying and the ground speed was about 250 to 260 mph. The pilot reached down and switched tanks. The pilot also rocked the airplane’s wings. Both the engines shut off at the same time. Trees were observed once the flight descended through the clouds. During the accident sequence, the airplane’s nose pitched up as the airplane impacted trees. The passenger screamed and then the screaming stopped. The pilot-rated passenger sitting in the co-pilot’s seat advised them to brace. He said that the seat belt dug into him and his seat separated from its floor track. He was able to loosen his belt. He felt the door and its bottom half was open. He pushed open the top half. He did not initially see the pilot-rated passenger. He talked to a woman in a nearby house and related that there was an airplane accident. He heard people by the airplane and went to the airplane. He observed a small fire and told responders of the fire extinguisher location. The medical crew member reported that the pilot was in the front left seat, the pilot-rated passenger was in the front right seat, the patient’s wife was in the rear-facing seat behind the pilot, the patient was belted on the gurney, and he was in the forward-facing seat just in front of the rear cabin door. The Riverwoods Police Department received an initial 911 phone call about 2250. The first responders found the wreckage near a residence northwest of the intersection or Portwine and Orange Brace roads. PERSONNEL INFORMATION Pilot The 58-year-old pilot held an airline transport certificate with an airplane multi-engine land rating and he held commercial pilot privileges for single engine land airplanes. He held a flight instructor certificate with single engine, multi-engine, and instrument airplane ratings. He also held a type rating in SA-227 airplanes. A Federal Aviation Administration (FAA) 8410-3 Airman Competency/Proficiency Check Form showed that he passed a 1-hour checkride in the PA-31-350 with the operator’s Chief Pilot on June 7, 2011. The operator reported that the pilot had accumulated 6,607 hours of total flight time, 120 hours of total flight time in the PA-31-350, 171 hours of flight time in the 90 days prior to the accident, 61 hours of flight time in the 60 days prior to the accident, 5 hours of flight time in the 24 hours prior to the accident, and 12 hours of flight time in the Chieftain in the 90 days prior to the accident. He held a first-class medical certificate, dated February 15, 2011, with limitations for hearing amplification and corrective lenses. The pilot reported on his application for that medical certificate that he had accumulated 6,350 hours of total flight time and 20 hours of flight time in the six months prior to that application. The pilot previously reported that he had a history of convictions for driving under the influence on both May 31, 2002, and February 01, 1997. The operator initiated a background check in accordance with the Pilot Records Improvement Act of 1996 (PRIA) on the pilot. This PRIA check showed his training records and checkrides at previous employers and also revealed no legal enforcement actions resulting in a finding of a violation pertaining to the pilot. It listed a possible match and gave contact information for a Department of Transportation Compliance and Restoration Section in reference to checking the pilot's driver’s record. The operator did not get a background check from the Department of Transportation Compliance and Restoration Section on the pilot. However, the operator was aware of the pilot's history of convictions. Pilot-rated Passenger The 24-year-old pilot-rated passenger held a commercial pilot certificate with single engine land, multi-engine land, and instrument airplane ratings. He held a flight instructor certificate with single engine, multi-engine, and instrument airplane ratings. He held a first-class medical certificate, dated February 28, 2011, with no limitations. He recorded in his logbook that he had accumulated 314.3 hours of total flight time, 259.5 hours of pilot in command time, 66.6 hours of multi-engine time, and 7 hours of second in command time in airplanes associated with the operator. The operator’s chief pilot indicated in an e-mail that the pilot-rated passenger was compensated by the operator for the positioning flights to PBI and was considered a passenger on the flights from PBI. AIRCRAFT INFORMATION The airplane, serial number 31-7652044, was a 1976 Piper PA-31-350, Chieftain, with twin-engines, retractable landing gear, and a conventional semi-monocoque design. The airplane had a maximum gross weight of 7,368 pounds. Two 350-horsepower Lycoming TIO-540-J2BD engines, serial number L-7462-61H and serial number L-1701-68A, powered the airplane. Each engine drove a three-bladed, constant speed, controllable pitch, full feathering Hartzell propeller. The airplanes cockpit was equipped with dual pilot flight controls. According to a major repair and alteration form dated February 11, 1999, a Spectrum Aeromed Inc. Air Ambulance conversion had been installed in the airplane in accordance with supplemental type certificate SA1666GL. According to the operator’s accident report, the airplane’s last annual inspection was completed on July 22, 2011. The operator indicated that the airplane had accumulated 17,630 hours of total time at the time of that inspection. An endorsement in the logbook for the airplane’s right engine indicated that an installation of a repaired engine was completed on November 18, 2011, and at that time, the Hobbs meter indicated 2832 hours. The Chieftain’s main cabin door was a two-piece door that separated in the middle. The upper half swung up and was held in the open position by a spring-loaded support. The lower half swung down and it housed the entrance steps. To open from the inside, one must push the lock button beside the handle, pull, and lower the bottom half of the door. Then raise the upper half to the locked position. A 23 by 30 inch emergency exit is located in the right forward side of the fuselage. The fuel system consisted of fuel cell, engine-driven and emergency fuel pumps, fuel boost pumps, control valves, fuel filters, fuel pressure and fuel flow gauges, fuel drains and non-icing fuel tank vents. Fuel could be stored in four flexible fuel cells, two in each wing. The outboard cells hold 40 gallons each and the inboard cells hold 56 gallons each, giving a total of 192 gallons, of which 182 gallons were usable. The emergency fuel pumps were installed for use in case of an engine driven fuel pump failure, or whenever the fuel pressure fell below 34 pounds per square inch (psi). They were also operated during takeoffs, landings, and for priming the engines. Control switches for the emergency fuel pumps were located in the overhead switch panel to the right of the fuel gauges. The fuel boost pumps operated continuously and provided fuel under pressure to the other fuel pumps, improving the altitude performance of the fuel system. The fuel boost pumps were activated when the master switch was turned on and continue to operate until the master switch was turned off or the fuel boost pump circuit breakers were pulled off. Fuel boost pump warning lights, mounted at the bottom of the windshield divider post, illuminated when the fuel boost pump pressure was less than three psi. The fuel management controls were located in the fuel control panel at the base of the pedestal. Located here were the fuel tank selectors, fuel shutoffs and crossfeed controls. During normal operation, each engine was supplied with fuel from its own respective fuel system. The fuel controls on the right controlled the fuel from the right cells to the right engine and the controls on the left controlled the fuel from the left fuel cells to the left engine. For emergencies, fuel from one system can supply the opposite engine through a crossfeed system. The crossfeed valve was intended only for emergencies. The crossfeed control was located in the center of the fuel control panel. A warning light, located on the fuel control panel was incorporated in the firewall fuel shut-off system to indicate that one or both of the shut-off valves were not fully open. A note in the Pilot’s Operating Manual (POM) Description - Airplane and Systems chapter, in part, stated: “The crossfeed system was not to be used for normal operation. When the crossfeed valve was on, be certain fuel selector valve on tank not in use was off. Do not use crossfeed to compensate for an inoperative emergency fuel pump.” Right and left fuel flow warnings lights, mounted at the base of the windshield divider post, illuminated to warn the pilot of an impending fuel flow interruption. The lights were activated by a sensing probe mounted near each inboard fuel tank outlet. In the event the fuel level near the tank outlet dropped to a point where a fuel flow interruption and power loss could occur, the sensing probe would illuminate its corresponding warning light. The warning light would be on for a minimum of 10 seconds and would remain
The pilot's inadequate preflight planning and in-flight decision-making, which resulted in a loss of engine power due to fuel exhaustion during approach. Contributing to the accident was the pilot's decision to operate an airplane after using illicit drugs.
Source: NTSB Aviation Accident Database
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