# NTSB ANC06FA018: Aero Vodochody L-39MS, N104XX, Ketchikan, AK, January 25, 2006 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: January 25, 2006, 12:50 local (16:50 UTC) - Place: Ketchikan, AK - Coordinates: 55.358333, -131.695831 - Nearby events: https://openairdocs.org/map.md?lat=55.3583&lon=-131.6958&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal, 5 minor; on the ground: 5 minor - Status: Completed, report February 26, 2007 - Report: Approved by Office Director - NTSB office: Alaska Regional Office - Parties: FAA-AL-JNU FSDO 05, Federal Bureau of Investigation, Air USA Inc. - NTSB case key (mKey): 63161 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ANC06FA018 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/63161/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=63161 - Page: https://openairdocs.org/ntsb/ANC06FA018 ## Probable cause The pilot's failure to follow published instrument landing procedures and his descent below approach minimums during an IFR circle to land approach, which resulted in the airplane striking the ocean and a loss of engine power. Factors contributing to the accident were low clouds and snow. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight collision with terrain/water, circling (ifr) - ifr procedure - not followed, pilot in command (cause) - weather condition - below approach/landing minimums (contributing factor) - terrain condition - water - Loss of engine power(total) - mech failure/malf, circling (ifr) - compressor assembly,forward fan - fractured (cause) - compressor assembly,stator vane - fractured (cause) - Forced landing, emergency descent/landing - In flight collision with terrain/water, emergency descent/landing - bail-out/emergency ejection - not successful, pilot in command - terrain condition - residential area ## Analysis The airline transport certificated pilot was on a Title 14, CFR Part 91 ferry flight in a military jet surplus warbird when the airplane collided with water and a residential area during an instrument approach to land. During the circle-to-land contact approach, the pilot was advised by an FAA flight service station specialist at the island airport that the weather did not look favorable for a contact approach due to low clouds and visibility. A pilot-rated witness on the shore across from the island reported seeing the airplane descend from the clouds and strike the ocean three times before it climbed out of sight. The witness described the visibility as about 3/4 mile in blowing snow. The airplane continued to fly for approximately 2.3 miles, until other witnesses near a town on the shore heard the engine stop, and saw the jet and a parachute at a low altitude. The airplane collided with the ground in a large lot, and continued into an occupied trailer home and parked vehicles. A postcrash fire ensued. Inspection of the airplane disclosed no preimpact mechanical problems with the airplane. The loss of engine power was consistent with the water impact which damaged the inlet fan and compressor stator. The circle-to-land minimum descent altitude for aircraft with a 120 knot approach speed is 2,500 feet msl, and requires 3 miles visibility. Prior to impact, the pilot attempted to eject from the airplane at a low altitude. The ejection was unsuccessful, and the pilot struck a tree while still in the ejection seat. Inspection of the ejection apparatus disclosed no evidence of any preimpact malfunction. ## Factual narrative HISTORY OF FLIGHT On January 25, 2006, about 1250 Alaska Standard time, an Aero Vodochody L-39MS airplane, N104XX, a surplus military warbird built in the Czech Republic, was destroyed by impact and postimpact fire when it collided with the ground and an occupied trailer home during an instrument approach/circle to land at the Ketchikan International Airport, Ketchikan, Alaska. The experimental airplane was being operated as an instrument flight rules (IFR) cross-country ferry flight under Title 14, CFR Part 91, when the accident occurred. The airplane was operated by Air USA Inc., Quincy, Illinois. The airline transport certificated pilot, the sole occupant, received fatal injuries, and five persons on the ground received minor injuries. The flight departed in VFR conditions about 1141 from the Sitka Rocky Gutierrez Airport, Sitka, Alaska. While en route, the pilot obtained an IFR flight plan to Ketchikan. Instrument meteorological conditions prevailed in the area of the accident. According to Federal Aviation Administration (FAA) personnel, the airplane was issued a special ferry permit by an inspector with the Van Nuys Flight Standards District Office (FSDO), Van Nuys, California, on January 23, 2006, with options to fly under visual flight rules (VFR) or instrument flight rules (IFR), day or night, from Anchorage, Alaska, to Seattle, Washington. A ferry permit was required because the accident airplane's most recent experimental airworthiness certificate had expired. The ferry permit application was signed by an FAA certificated mechanic who was hired by the operator, certifying that the airplane was safe for ferry flight. According to the operator, the accident airplane departed Palmer, Alaska, on January 23, about 1500, with another L-39MS airplane (N106XX), with an intended destination of Ketchikan. Due to adverse weather conditions in Ketchikan, the two airplanes diverted to Sitka, and remained there throughout the day of January 24. Because of a personal time commitment, the pilot of N106XX departed for his residence, leaving the airplane parked at Sitka. On January 25, at 0710, the accident airplane pilot contacted the Sitka Flight Service Station (FSS) via telephone, stating he had tried to leave Sitka the previous day, and indicated he was trying to get to Bellingham, Washington. The FSS specialist provided weather conditions at Sitka and Bellingham, which were VFR at both locations. The pilot requested the winds aloft forecast for 24,000 and 27,000 feet, and after a discussion about where he would encounter the most adverse headwinds, the FSS specialist examined U.S. and Canadian weather charts and reported winds from 190 degrees at 84 knots at 24,000 feet, and from 190 degrees at 90 knots at 30,000 feet. The specialist also noted that there were AIRMETS for occasional moderate rime icing for the coastal waters of Alaska. The FSS specialist stated that the current weather for Ketchikan was: "...wind, 140 [degrees] at 13 [knots], gusts 23 [knots]; visibility, 4 [statute miles] light rain and mist; ceiling, 1,200 [feet] broken, 1,700 [feet] overcast; temperature, 7 [degrees C], dew point 6 [degrees C]; altimeter, 29.23 [inHg]. What they've got there is basically the south end of a cold front from a low that's off to the east of us towards British Columbia and the Yukon, then, and so they're forecast to get a little bit of wind and snow today, diminishing basically towards the afternoon." The pilot commented: "O.K. so there, they'll be right above ah my mins to go in there..." The pilot commented again about the forecast weather conditions at Ketchikan, stating: "...so just, man, I wish Ketchikan's weather was gonna be better, it's not any, not any better a thousand and three...just right at mins, hum." The FSS specialist stated: "and again, that wind that's outa the southeast at 13, gust up ta 23, that's a fair amount of wind for Ketchikan." The pilot replied: "yeah, that's a s### load of wind." The specialist jokingly inquired how the pilot liked Sitka, to which the pilot replied: "yeah, no kiddin, I just can't make Bellingham with those winds, I mean it's, I just can't do it." The briefing was concluded at 0721. At 0855, the pilot again telephoned the Sitka FSS and inquired about the weather conditions in Ketchikan. The FSS specialist reported: "...wind, 340 [degrees] at 8 [knots]; visibility, 10 [statute miles] light rain and mist; ceiling 2,300 [feet] overcast; temperature 3 [degrees C], dew point temperature 1 [degree C]; altimeter, 29.29 [inHg]. ...I just got a pilot report from Ketchikan as well...from the top of the hour, a deHavilland Beaver, 6 miles west of Ketchikan reported 700 [feet] scattered; flight visibility 10 [miles], wind outa the west at 20 [knots], with higher cloud layers which were probably above 12,000 feet." The distance from Sitka to Ketchikan is about 160 nautical miles. The operator reported that the normal range for planning purposes in the L-39 was about 750 nautical miles. The pilot confirmed that the Ketchikan airport was utilizing runway 29 because of the wind direction and then stated: "and again, you said that METAR, that was 3,500 [feet] over [cast], that's what they were callin it." The FSS specialist initially agreed, stating: "3,200 overcast, yeah," but corrected himself, stating: "and that ceiling at 2,400 [feet] broken, this was, actually this is a new observation from 2 minutes ago, they just put another observation, ah, visibility, 10 [miles] light rain; 900 [feet] scattered, ceiling 2,400 [feet] broken, 3,200 [feet] overcast. ...ah I am showing AIRMETS for mountain obscuration and IFR conditions for southern, southeast Alaska, and I have an AIRMET for occasional moderate rime icing from 1,500 [feet] up ta 12,000 [feet]." The pilot thanked the specialist and concluded the call at 0859. At 1140, the pilot contacted the Sitka FSS via radio and reported he was beginning to taxi, and at 1148, the pilot stated: "Sitka traffic, N104XX is departing VFR to the southeast, left turn out Sitka." While en route to Ketchikan, the pilot contacted the Anchorage Air Route Traffic Control Center (ARTCC) at 1210. He reported that he was 90 miles northwest of Ketchikan at 17,500 feet, and requested the ILS approach to runway 11 at Ketchikan with a circle to land on runway 29. The controller verified the airplane was equipped with a GPS receiver (global positioning system), and cleared the airplane to the Ketchikan Airport, via DOOZI intersection, at 17,000 feet. DOOZI intersection is 40 nautical miles from the Annette Island VOR, on the 303 degree radial. At 1217, the ARTCC controller verified that the pilot had the current weather information from Ketchikan, and cleared the airplane at the pilot's discretion to descend and maintain 7,000 feet. At 1223, the ARTCC controller contacted the pilot and requested he slow down if he could, and told the pilot that he may have to hold at the DOOZI intersection for arrival aircraft ahead of him into Ketchikan. One minute later, the ARTCC controller amended the previous clearance, advising the pilot to maintain 8,000 feet and cleared him to hold at the 17 mile fix on the Ketchikan localizer, and to expect further clearance at 1240. The pilot responded by stating: "Roger that sir, is there any way you could hold us at DOOZI, my DME (distance measuring equipment) is intermittent for the leg." The controller then cleared the airplane to hold at DOOZI, and to maintain 8,000 feet. At 1228, the pilot inquired whether the controller would prefer a left or right turn in holding, and the controller approved either direction. One minute later, the pilot contacted ARTCC and stated: "And ah center from 104XX, just be advised we are picking up some ah ice out here, and if you can give us a descent that would be great." The controller responded by stating: "N104XX ah roger, after you get back establis ## Aircraft - Registration: [N104XX](https://openairdocs.org/deregistered/N104XX-2016-08-11), registration cancelled 2016-08-11, S/N 040004, built 1992 (OpenAirDocs) - Reported make and model: Aero Vodochody L-39MS - Registry model: [Aero Vodochody L-39MS](https://openairdocs.org/model/aero-vodochody-l-39ms) (registry code 056113X) (OpenAirDocs) - Registry engine: [Amateur-built UNKNOWN ENG](https://openairdocs.org/engine/amateur-built-unknown-eng) (registry code 99999) (OpenAirDocs) - Category: Airplane - Serial number: 040004 - Airframe hours: 749 - Engines: Povazske Stroguarne DV-2 4850 lbs thrust turbo fan - Damage: Destroyed - Fire: On-Ground - Flight: Ferry, Part 91 - Registered owner: Air USA Inc. - Airworthiness certificate: Special, Special flight (Special); Special, Experimental (Special) - Last inspection: AAIP, January 1, 2005, 3 hours before - Departed: PASI, Sitka, AK - Destination: PAKT, Ketchikan, AK - Flight plan: IFR - Airport: PAKT, Ketchikan International, runway 29, 7,500 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 39; injuries: fatal; commercial, airline transport; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review August 1, 2005; seat: front; toxicology performed; flight hours: 3,584 total, 129 in this make and model, 3,473 as pilot in command, 90 in the last 90 days, 12 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Instrument (IMC), Day - Wind: 307° at 14 knots, gusting 18 - Visibility: 4 statute miles - Lowest ceiling: 1,200 ft broken - Temperature: 36 °F, dew point 34 °F - Altimeter: 29.32 inHg - Observed at: PAKT, 1 nm away ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20060125001579A](https://openairdocs.org/incident/20060125001579A), Jan 25, 2006: Aerovd L39MS, Ketchikan, AK, Destroyed, 1 fatal. (-23) N104XX was on the ils/dme rwy 11 at Ketchikan international (ktn) pilot is believed to have requested a contact approach to circle to rwy 29. Apparently… ## Docket (32 files) The files NTSB released with the investigation on December 9, 2006, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=63161. 17.8 MB in all. - Materials Laboratory Factual Report 06-054 (item 1, .PDF, 1 photo, 72 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40262241&FileExtension=.PDF&FileName=Materials%20Laboratory%20Factual%20Report%2006-054-Master.PDF - Powerplants 8 - Factual Report of Group Chairman (item 2, .PDF, 41 photos, 3.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40263898&FileExtension=.PDF&FileName=Powerplants%208%20-%20Factual%20Report%20of%20Group%20Chairman-Master.PDF - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 3, .PDF, 254 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40269474&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - NTSB Interviews and Statements (item 4, .PDF, 414 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40466926&FileExtension=.PDF&FileName=NTSB%20Interviews%20and%20Statements-Master.PDF - FAA Interviews and Statements (item 5, .PDF, 292 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40466927&FileExtension=.PDF&FileName=FAA%20Interviews%20and%20Statements-Master.PDF - Accident Maps and Diagrams (item 6, .PDF, 3.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40269477&FileExtension=.PDF&FileName=Accident%20Maps%20and%20Diagrams-Master.PDF - Weather Information (item 7, .PDF, 158 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40269478&FileExtension=.PDF&FileName=Weather%20Information-Master.PDF - FAA Transcripts (item 8, .PDF, 829 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40269479&FileExtension=.PDF&FileName=FAA%20Transcripts-Master.PDF - FAA Personnel Statements (item 9, .PDF, 247 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40269480&FileExtension=.PDF&FileName=FAA%20Personnel%20Statements-Redacted.PDF - FAA Ferry Permit (item 10, .PDF, 48 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40269481&FileExtension=.PDF&FileName=FAA%20Ferry%20Permit-Redacted.PDF - Ketchikan Fire and Police Reports (item 11, .PDF, 763 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40466928&FileExtension=.PDF&FileName=Ketchikan%20Fire%20and%20Police%20Reports-Master.PDF - PAKT Approach Plates (item 12, .PDF, 351 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40269483&FileExtension=.PDF&FileName=PAKT%20Approach%20Plates-Master.PDF - Fueling Records - Sitka (item 13, .PDF, 79 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40269484&FileExtension=.PDF&FileName=Fueling%20Records%20-%20Sitka-Redacted.PDF - L-39MS Minimum Altitude for Ejection Chart (item 14, .PDF, 38 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40269485&FileExtension=.PDF&FileName=L-39MS%20Minimum%20Altitude%20for%20Ejection%20Chart-Master.PDF - Toxicological Report (item 15, .PDF, 76 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40466929&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 16, .PDF, 288 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40269487&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 17, .PDF, 91 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40269488&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Image 1. View of canopy and initial impact location in empty lot, looking east. (item 18, .PDF, 454 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40269728&FileExtension=.PDF&FileName=Image%201.%20%20View%20of%20canopy%20and%20initial%20impact%20location%20in%20empty%20lot,%20looking%20east.-Master.PDF - Image 2. Initial impact marks near west edge of Carlanna Creek, looking east. Impact point with a trailer is in "U" shaped empty spot across the creek. (item 19, .PDF, 471 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40269729&FileExtension=.PDF&FileName=Image%202.%20%20Initial%20impact%20marks%20near%20west%20edge%20of%20Carlanna%20Creek,%20looking%20east.%20%20Impact%20point%20with%20a%20trailer%20is%20in%20%22U%22%20shaped%20empty%20spot%20across%20the%20creek.-Master.PDF - Image 3. Western edge of Carlanna Creek, note sheared bushes and trees. Impact area with trailer is on opposite side of the creek. (item 20, .PDF, 506 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40269730&FileExtension=.PDF&FileName=Image%203.%20%20Western%20edge%20of%20Carlanna%20Creek,%20note%20sheared%20bushes%20and%20trees.%20%20Impact%20area%20with%20trailer%20is%20on%20opposite%20side%20of%20the%20creek.-Master.PDF - Image 4. View from trailer area, looking west toward initial impact point at Carlanna Creek and open lot. (item 21, .PDF, 449 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40269761&FileExtension=.PDF&FileName=Image%204.%20%20View%20from%20trailer%20area,%20looking%20west%20toward%20initial%20impact%20point%20at%20Carlanna%20Creek%20and%20open%20lot.-Master.PDF - Image 5. View from trailer impact looking west. (item 22, .PDF, 470 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40269762&FileExtension=.PDF&FileName=Image%205.%20%20View%20from%20trailer%20impact%20looking%20west.-Master.PDF - Image 6. View of separated horizontal stabilizer, torn off the fuselage. A damaged vehicle is in the background. (item 23, .PDF, 510 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40269763&FileExtension=.PDF&FileName=Image%206.%20%20View%20of%20separated%20horizontal%20stabilizer,%20torn%20off%20the%20fuselage.%20%20A%20damaged%20vehicle%20is%20in%20the%20background.-Master.PDF - Image 7. Fuselage at point of rest against hillside and empty dumpster in empty lot beyond the trailer impact point. (item 24, .PDF, 537 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40269764&FileExtension=.PDF&FileName=Image%207.%20%20Fuselage%20at%20point%20of%20rest%20against%20hillside%20and%20empty%20dumpster%20in%20empty%20lot%20beyond%20the%20trailer%20impact%20point.-Master.PDF - Image 8. View of fire damage to fuselage and engine along right side of airplane. (item 25, .PDF, 513 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40269765&FileExtension=.PDF&FileName=Image%208.%20%20View%20of%20fire%20damage%20to%20fuselage%20and%20engine%20along%20right%20side%20of%20airplane.-Master.PDF - Image 9. View of ejection seat drogue and stabilizing parachute in foreground, with pilot's ejection seat in the background. Straps were cut by rescue personnel. (item 26, .PDF, 498 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40269766&FileExtension=.PDF&FileName=Image%209.%20%20View%20of%20ejection%20seat%20drogue%20and%20stabilizing%20parachute%20in%20foreground,%20with%20pilot%27s%20ejection%20seat%20in%20the%20background.%20%20Straps%20were%20cut%20by%20rescue%20personnel.-Master.PDF - Image 10. View of impact damaged headrest portion of pilot's ejection seat with un-deployed parachute. Note packing/retaining pin still in-place. (item 27, .PDF, 471 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40269767&FileExtension=.PDF&FileName=Image%2010.%20%20View%20of%20impact%20damaged%20headrest%20portion%20of%20pilot%27s%20ejection%20seat%20with%20un-deployed%20parachute.%20%20Note%20packing%2Fretaining%20pin%20still%20in-place.-Master.PDF - Image 11. View of nose section and left side of the fuselage after recovery. (item 28, .PDF, 446 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40269768&FileExtension=.PDF&FileName=Image%2011.%20%20View%20of%20nose%20section%20and%20left%20side%20of%20the%20fuselage%20after%20recovery.-Master.PDF - Image 12. View of fire damaged right side of engine after removal from the airframe. (item 29, .PDF, 442 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40269769&FileExtension=.PDF&FileName=Image%2012.%20%20View%20of%20fire%20damaged%20right%20side%20of%20engine%20after%20removal%20from%20the%20airframe.-Master.PDF - Image 13. View of inlet fan. Note damage to leading edges. (item 30, .PDF, 405 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40269770&FileExtension=.PDF&FileName=Image%2013.%20%20View%20of%20inlet%20fan.%20%20Note%20damage%20to%20leading%20edges.-Master.PDF - Image 14. Closer view of damaged inlet fan. (item 31, .PDF, 295 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40269771&FileExtension=.PDF&FileName=Image%2014.%20%20Closer%20view%20of%20damaged%20inlet%20fan.-Master.PDF - Image 15. View of fractured and damaged stator vanes. (item 32, .PDF, 413 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40269772&FileExtension=.PDF&FileName=Image%2015.%20%20View%20of%20fractured%20and%20damaged%20stator%20vanes.-Master.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.