Flagstaff, AZ, USA
N82806
PIPER PA 34-200T
The airline transport pilot regularly used his twin-engine airplane to conduct volunteer flights for a non-profit organization dedicated to transporting medical cargo. On the day of the accident, he departed his home airport about 0945, made a planned interim stop at one airport, and then flew to a second airport, where he waited for his next cargo pickup. The cargo was delivered to him, as scheduled, about 2100, and he departed shortly thereafter on a night visual flight rules (VFR) cross-country flight. The air traffic control tower was closed at the time of the pilot's departure. The airport was situated in semi-rural, mountainous terrain, and both the sun and the moon had set about 2 hours before takeoff. Ground-based tracking radar data indicated that the airplane departed to the southwest, turned west, then south, and then north before it descended rapidly and impacted trees and terrain about 2.5 minutes after takeoff. The first segment of the radar-derived trajectory was consistent with a normal takeoff and initial climb. About 1 minute after takeoff, some undetermined occurrence(s) or circumstance(s) interrupted the climb and resulted in the course deviations and the extreme descent. Examination of the accident site indicated that the airplane was in a banked attitude when it impacted the trees. The available evidence indicated that both engines were developing significant power at impact, and that the propellers were operating normally. No evidence of a bird strike or an in-flight fire was observed. With the exception that one of the two instrument air pressure pumps were inoperative, the investigation did not discover evidence of any pre-impact mechanical deficiencies with the airplane or its equipment. However, the wreckage was highly fragmented, which could have masked or destroyed such evidence. The artificial horizon and the directional gyro were two of the flight instruments that were driven by the air pressure pumps. Although the two air pressure pumps and associated valving were designed to provide automatic continued normal system operation in the event of a single air pressure pump failure, the severity of the damage precluded determination of the pre-accident functionality of the instrument air system. Therefore, it is possible that a failure of the valving system could have resulted in the loss of valid artificial horizon and directional gyro information, which in turn, due to the dark night and scarcity of ground lights, could have resulted in the accident. Damage also precluded testing of the autopilot system. However, the pilot typically hand-flew the airplane to cruise altitude before engaging the autopilot; therefore, the accident was likely not due to an autopilot malfunction. Although the departure airport automated weather observation reported 10 miles visibility with no clouds less than 10,000 ft above the airport, the heavy rain earlier in the day, combined with nighttime cooling and the lack of a temperature-dew point spread, suggested the potential for localized low altitude clouds or fog. Given the dark night and the lack of significant ground lighting, pilot disorientation for a variety of reasons could not be discounted. The most likely possible reasons included: - Distraction from some unknown event inside or outside the airplane - Malfunction or failure of one or more flight instruments - Inadvertent encounter with localized instrument meteorological conditions The medical investigation of the pilot was significantly limited by the degree of injury, and it could not be determined whether the pilot experienced an acute medical event during the flight. Due to the pilot's age, his reported pre-existing medical conditions, and the paucity of autopsy findings, physiological impairment or incapacitation of the pilot could not be eliminated as a possible reason for the accident. Because it has no direct psychoactive effects, it is unlikely that the pilot's use of metoprolol contributed to the accident. The absence of ethanol in the kidney tissue indicates that the identified ethanol in muscle tissue was from post-mortem sources, and therefore did not contribute to the accident. Although the pilot was the president of the organization for which he was flying, and that the organization published flight operations guidance intended to ensure a minimum level of operational safety, the pilot's history demonstrated repeated deviations from that guidance. One of those deviations concerned the number of pilots on board. On the accident flight, as well as on most of his other night missions for the organization, the pilot flew solo, even though the guidance recommended that night flights use two pilots. Although the investigation was unable to determine the specific reason for the accident, it is possible that a second pilot might have been able to assist in some way to prevent the accident.
HISTORY OF FLIGHTOn August 2, 2016, about 2122 mountain standard time, a Piper PA-34-200T Seneca II airplane, N82806, was destroyed when it impacted trees and terrain shortly after takeoff from Flagstaff Pulliam Airport (FLG), Flagstaff, Arizona. The airline transport pilot received fatal injuries. The personal flight was being conducted as a medical delivery mission for the volunteer organization Flights for Life (FFL) under the provisions of Title 14 Code of Federal Regulations Part 91. Night visual meteorological conditions prevailed at FLG at the time of the accident, and no flight plan was filed for the cross-country flight that was destined for Falcon Field (FFZ), Mesa, Arizona. The pilot owned the airplane and based it at FFZ. Commercial flight tracking data indicated that the airplane departed FFZ about 0945 and landed at Show Low Regional Airport (SOW), Show Low, Arizona, about 1030. The airplane then departed SOW about 1055, arriving at FLG about 1140. According to the line service technician at FLG who met the airplane at the time of its arrival, it was "pouring" rain. The technician, who was an employee of Wiseman Aviation, a FLG fixed base operation (FBO), reported that the pilot did not want any fuel, and that the pilot unloaded some of his personal items about 30 minutes after landing, once the rain had stopped. The pilot then spent the day in the FBO, generally working on his computer, while awaiting a United Blood Service (UBS) delivery that was expected about 2100. About 1900, the pilot and technician relocated the airplane closer to the terminal, and the pilot began "cleaning" and/or rearranging some contents in the airplane to make room for the expected cargo. The technician later asked the pilot again if he needed fuel, and he declined. He and the FBO owner reported that it was a "dark night" and that it was cloudy, but not raining, when they left the airport, which was before the accident airplane departed. The UBS employee who delivered the cargo reported that the total load was four "large" boxes and two "small" boxes. She stated that full large boxes weigh about 30 pounds (lbs) each; small boxes weigh about 10 lbs each; and two of the large boxes were not full. The pilot loaded all the boxes via the aft left-side cargo door(s). He placed the large boxes on the floor of the aft cabin and the two small boxes on top of them. The UBS employee reported that the pilot then closed the door(s) and that he did not restrain the boxes with a net or by any other means. The FLG air traffic control tower was closed by the time the pilot was ready for engine start and departure. While the airplane was still on the ground, the pilot contacted Phoenix approach control by radio, and requested visual flight rules (VFR) flight following services for a flight to FFZ. The controller provided altimeter and transponder information, and shortly thereafter, the airplane departed. At 2119:44, the pilot radioed Phoenix approach that he was "off [runway] two one" and climbing to 11,500 feet. At 2120:17 the controller advised the pilot of "radar contact one mile south" of FLG and instructed him to maintain VFR. At 2120:21 the pilot radioed his acknowledgement; this was the last radio transmission from the flight. At 2122:57, the controller advised the pilot that radar contact had been lost and instructed him to report leaving 9,000 feet. There was no response from the pilot to that instruction, nor were there any distress calls or other abnormal communications from the pilot. The controller attempted multiple times to contact the flight, and also had Albuquerque ARTCC (ZAB) attempt contact. There was no response by the flight to either facility. The first ground-based tracking radar return was acquired at 2119:49. At that time, the airplane was located approximately midfield, with a transponder-indicated altitude of 7,300 feet. The radar location and heading data were consistent with a departure from runway 21. The radar track indicated that the airplane initially maintained the approximate runway heading. The track then turned right about 30°, and then nearly 90° left, to a southerly track. The track then made a near-180° right turn to the north before radar contact was lost. The last radar return was received about 2122:19 and showed the airplane descending through an altitude of 7,400 ft. The radar returns indicated that, for about the first 60 seconds of the flight, the airplane climbed at a rate of about 1,000 feet per minute (fpm). This climb rate was consistent with the airplane's normal, two-engine climb rate. The climb rate then decreased to and remained about 400 fpm the next 60 seconds. By the end of that period, the airplane reached a maximum transponder-indicated altitude of 8,400 ft. It then descended about 3,000 fpm during the next 20 seconds, when the radar data ended at an altitude similar to the terrain elevation. The final segment of the radar track and the position of the last radar data target were consistent with the observed orientation and location of the debris field. The impact site was located adjacent to a road, about 2.6 miles southwest of FLG. The airplane was highly fragmented, and earwitnesses reported that the engines were operating at high power just prior to impact. Ground scar and propeller signatures were consistent with both engines operating at impact. Initial post-recovery evaluation of the wreckage did not reveal any mechanical anomalies, including fire, that would have precluded continued normal operation. PERSONNEL INFORMATIONThe 76-year-old pilot held multiple certificates and ratings, including an airline transport pilot certificate with an airplane multiengine land rating. He held an FAA second-class medical certificate dated March 1, 2016, with the limitation that he must have glasses available for near vision. On his application for the medical certificate, the pilot reported a total flight experience of 11,858 hours, including 77 hours in the previous 6 months. According to the pilot's son, who was a pilot for a major US airline, the pilot flew 4 to 5 FFL missions per month, and about 200 hours per year. The son reported that the pilot usually hand-flew the airplane to cruise altitude before engaging the autopilot and would hand-fly the descents as well. The son reported that, in addition to the autopilot's wing leveling/navigation functions, the pilot also used the autopilot altitude hold function. Finally, the son stated that the airplane "was a very stable platform." To the son's knowledge, the pilot only operated VFR, in part because FFL "did not allow [instrument flight rules] IFR." The pilot's instrument and night currency were unable to be determined. AIRCRAFT INFORMATIONAccording to FAA records, the airplane was manufactured in 1980 and was equipped with two Continental Motors TSIO-360-series engines. The engines rotated in opposite directions; when viewed from behind, the left propeller rotated clockwise, and the right propeller rotated counterclockwise. The pilot purchased the airplane in March 2015. Maintenance records indicated that the most recent annual inspection was completed in May 2016, when the airframe had a total time (TT) in service of about 7,453 hours. The left engine had a TT of about 3,993 hours, with about 342 hours since overhaul. The right engine had a TT of about 353 hours since new. According to the pilot's son, the airplane was equipped with a KFC 200 two-axis autopilot and a flight director, and both "worked very well." All annunciators worked normally, and the horizontal situation indicator had recently been overhauled. The son reported that the pilot was "a stickler" for ensuring that all mechanical items were in proper working condition, and that he "was not aware of [any] vacuum [gyro instrument air] issues." Review of the maintenance records for the 16 months preceding the accident did not reveal any uncorrected maintenance deficiencies, or any entries that warranted additional investigation. Review of the weight and balance records and the loading data indicated that the airplane was within its weight and balance envelope for the accident flight. METEOROLOGICAL INFORMATIONFlagstaff Information The 2057 FLG automated weather observation included calm winds, visibility 10 miles, scattered clouds at 10,000 ft above ground level (agl), temperature 15°C, dew point 14°C, and an altimeter setting of 30.35 inches of mercury. The 2157 observation included winds from 240° at 3 knots (kts), visibility 10 miles, a broken cloud layer at 11,000 ft, with unchanged temperature, dew point, and altimeter setting. The National Weather Service (NWS) surface analysis chart station model for Flagstaff for 2000 indicated a light westerly wind about 5 kts, clear skies, temperature 16°C, and dew point 12°C. The NWS national composite radar image at 2125 for the Flagstaff area depicted only very light intensity echoes associated with a dissipating area of echoes. Data from the NWS Flagstaff Weather Surveillance Radar-1988, Doppler (WSR-88D), which was located 41 miles southeast of the accident site, indicated the absence of any significant weather echoes. Geostationary Operational Environmental Satellite number 15 (GOES-15) data indicated that a broken to overcast layer of altocumulus to altostratus type clouds extended over the Flagstaff area and the accident site. The measured cloud top temperatures corresponded to cloud tops near 29,000 ft above mean sea level (msl) in that region. The terminal area forecast (TAF) for FLG, which has a coverage area radius of 5 statute miles, called for light and variable winds at 5 kts or less, visibility better than 6 miles, scattered clouds at 6,000 ft agl, broken ceiling at 10,000 ft agl, with a temporary period (between 1700 and 2000) of light rain showers and a broken ceiling at 7,000 ft agl. The area forecast for northern Arizona for the period of the accident was for a broken ceiling between 12,000 and 14,000 ft msl, cloud layers to 25,000 ft msl, with widely scattered light rain showers and thunderstorms. Solar and Lunar Illumination Information Local sunset occurred at 1928, and civil twilight ended at 1756. The moon rose at 0527 and set at 1922; the phase of the moon was new (unilluminated disk). Enroute and Destination Weather Information The 12-hour surface prognostic chart valid for 0500 on August 3, 2016, depicted a high-pressure system over northern Arizona with a thermal low-pressure system over southeastern California and a trough extending southward. A large area of scattered thunderstorms and rain showers was depicted over almost all of Arizona. No TAFs are issued for the destination airport, FFZ. The closest airport to FFZ that issues TAFs was Phoenix-Mesa Gateway Airport (IWA), located about 10 miles south of FFZ. The IWA forecast, valid from 1900 August 2 to 1700 August 3 was as follows: - Wind 350° at 18 kts with gusts to 30 kts, visibility 6 statute miles, thunderstorms in the vicinity, scattered clouds at 6,000 ft agl, scattered cumulonimbus at 10,000 ft agl, and broken ceiling at 12,000 ft agl - Temporary (from 1900 to 2100): wind variable direction at 20 kts with gusts to 40 kts, visibility 3 statute miles, thunderstorms and rain, broken cumulonimbus ceiling at 8,000 ft agl, overcast at 12,000 ft agl - From 2200 on: wind 120°, visibility 6 statute miles, showers in the vicinity, scattered clouds at 10,000 ft agl, and broken ceiling at 20,000 ft agl The 2125 NWS national composite radar image depicted a band of light to moderate echoes extending from eastern Arizona southwestward through the Phoenix area. The GOES-15 satellite image depicted a large area of cumulonimbus clouds over the Phoenix and Mesa areas, with the anvil extending northward to the Sedona area. AIRPORT INFORMATIONAccording to FAA records, the airplane was manufactured in 1980 and was equipped with two Continental Motors TSIO-360-series engines. The engines rotated in opposite directions; when viewed from behind, the left propeller rotated clockwise, and the right propeller rotated counterclockwise. The pilot purchased the airplane in March 2015. Maintenance records indicated that the most recent annual inspection was completed in May 2016, when the airframe had a total time (TT) in service of about 7,453 hours. The left engine had a TT of about 3,993 hours, with about 342 hours since overhaul. The right engine had a TT of about 353 hours since new. According to the pilot's son, the airplane was equipped with a KFC 200 two-axis autopilot and a flight director, and both "worked very well." All annunciators worked normally, and the horizontal situation indicator had recently been overhauled. The son reported that the pilot was "a stickler" for ensuring that all mechanical items were in proper working condition, and that he "was not aware of [any] vacuum [gyro instrument air] issues." Review of the maintenance records for the 16 months preceding the accident did not reveal any uncorrected maintenance deficiencies, or any entries that warranted additional investigation. Review of the weight and balance records and the loading data indicated that the airplane was within its weight and balance envelope for the accident flight. WRECKAGE AND IMPACT INFORMATIONThe accident site was located on Coconino National Forest property on the east side of Arizona Hwy 89A, about 2.6 nautical miles (nm), on a true bearing of 236º, from the FLG runway 3 threshold. The elevation of the accident site was about 6,950 ft msl. The wreckage trajectory/debris field was oriented on a true heading of 042º. The debris field site terrain was level, with moderately spaced trees (primarily pines, about 60 to 100 ft tall) and generally sparse undergrowth. A residential neighborhood, with widely-spaced homes and an integral golf course, was situated about 1/3 of a mile east of the accident site. The wreckage was highly fragmented. The debris field measured about 60 ft by 600 ft. The airplane cut/broke the tops off eight trees; these tree locations, and their remaining heights, were catalogued. Some of the fractured tree trunks were 12 to 15 inches in diameter at their separation points. Some tree limbs, up to about 4 inches in diameter, displayed clean angular cuts at their ends, consistent with being severed by a rotating propeller. The largest wreckage elements included the mid-forward fuselage, the right-wing root and aft nacelle section, and a section that included the left firewall, engine mount, wing spar section, and left main landing gear (LMLG) assembly. These three elements comprised the main wreckage. The engines had separated from the airplane, and the propellers had separated from the engines. Each propeller hub retained all three blades, and all three blades in each hub were significantly damaged. This damage was consistent with both engines developing power at impact. A few flight and engine instruments were identified in the wreckage. Damage to the flight gyroscopic instruments precluded determination of their functionality, or whether they were operating during the flight or impact. Several hundred pages of maintenance records and other airplane documentation were scattered throughout the debris field. Some pages were loose, and some were partially- or wholly-contained in notebooks. Multiple computers and other portable electronic devices were present at the accident site. Some were intact and in flight/travel bags, and some were extensively damaged and/or not contained in any cases. The debris field was mapped. Left-side airplane/engine components were generally located towards the left side of the debris field, and right-side airplane/engine components were generally located towards the right side of the debris field; overall, this was consistent with the airplane not being inverted at impact. Refer to the separate "Debris Field" document in the NTSB public docket for this accident for detailed information. The wreckage was recovered and transported to a secure facility. A two-dimensional layout of some of the wreckage was conducted, and all flight control surfaces were accounted for. The flap setting at impact could not be determined. Damage precluded determination of flight control system
A departure flight path that consisted of several unexplained turns during the initial climbout, and terminated in a high-speed descent and ground impact. The reason(s) for the turns and descent could not be determined due to lack of definitive evidence.
Source: NTSB Aviation Accident Database
Aviation Accidents App
In-Depth Access to Aviation Accident Reports
