# NTSB ANC07FA013: Cessna 207A, N9941M, Kenai, AK, January 9, 2007 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: January 9, 2007, 10:35 local (14:35 UTC) - Place: Kenai, AK - Coordinates: 60.681945, -151.72583 - Nearby events: https://openairdocs.org/map.md?lat=60.6819&lon=-151.7258&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report December 20, 2007 - Report: Approved by Office Director - NTSB office: Alaska Regional Office - Parties: Air Supply Alaska Inc., Teledyne Continental Motors, FAA-AL-ANC FSDO 03, Cessna Aircraft Company - NTSB case key (mKey): 65149 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ANC07FA013 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/65149/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=65149 - Page: https://openairdocs.org/ntsb/ANC07FA013 ## Probable cause The total loss of engine power during cruise flight due to the disintegration of engine bearings and the fracture of a connecting rod, which resulted in a ditching into ice covered ocean water. Factors contributing to the survivability of the accident were the pilot's improper decision to fly over frigid water without sufficient altitude to reach a suitable landing area, the lack of written policy and procedures by the operator requiring sufficient altitude to reach shore when crossing ocean waters, temperature extremes consisting of sub-zero air and below freezing water temperatures, and the lack of personal flotation/survival equipment. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(total) - mech failure/malf, cruise - engine assembly,bearing - disintegrated (cause) - engine assembly,connecting rod - fractured (cause) - Forced landing, emergency descent/landing - altitude - inadequate, pilot in command (contributing factor) - in-flight planning/decision - improper, pilot in command (contributing factor) - procedures/directives - inadequate, company/operator management (contributing factor) - Ditching, emergency descent/landing - terrain condition - weak ice - survival equipment - unavailable, pilot in command (contributing factor) - weather condition - temperature,low (contributing factor) ## Analysis The commercial certificated pilot prepared for a VFR cross-country nonscheduled cargo flight under Title 14, CFR Part 135, by preflighting the wheel-equipped airplane and starting the engine. The airplane had been parked on the airport ramp overnight, with an electric engine heater and an engine cover on. A portion of the flight was over ocean waters to a remote village. After engine start, the pilot contacted the company owner and reported that the engine oil pressure appeared to be low, but within the operating range. The owner and the pilot discussed the possible reasons, such as cold ambient temperatures, which was about -20 degrees F. The pilot then departed, and reported to his company that the engine pressure was good. About 10 minutes later, he declared an emergency and stated he was ditching in the water, about 18 miles west of the departure airport. Retrieved track data from the pilot's GPS showed the airplane's maximum altitude was 1,439 feet msl, while crossing the ocean in an area that was about 22 miles wide. A review of the manufacturer's maximum glide distance chart revealed that from an altitude of about 1,500 feet, the airplane could glide about 2.1 nautical miles. The airplane was located about two hours after the accident, floating nose down next to a segment of pan ice, about 8.8 miles from the initial accident location. The pilot was not recovered with the airplane, and subsequent searches did not locate him. Following recovery of the airplane, examination of the engine revealed a 8 X 5 inch hole in the top of the case, adjacent to the number 2 cylinder. The number 2 connecting rod was broken from its crankshaft journal, and broken from the bottom of the piston. The number 1 connecting rod bearing was missing from its normal position on the crankshaft journal and the rod had evidence of high heat. Evidence of oil starvation and high heat signatures to several crankshaft and connecting rod bearings was found throughout the engine, along with a large amount of fragmented bearing material. The pilot was not wearing any personal flotation equipment, and the expected survival time in the 29 degree F ocean water was about 30 minutes. The company's operations manual does not contain a written policy requiring pilot's to maintain sufficient altitude to reach shore when crossing ocean waters. ## Factual narrative HISTORY OF FLIGHT On January 9, 2007, about 1035 Alaska Standard time, a wheel-equipped Cessna 207A airplane, N9941M, sustained substantial damage when it ditched in the ocean waters of the Cook Inlet during an emergency forced landing, about 18 miles west of Kenai, Alaska. The airplane was being operated as a visual flight rules (VFR) cross-country nonscheduled cargo flight under Title 14, CFR Part 135, when the accident occurred. The airplane was operated by Air Supply Alaska Inc., Kenai. The commercial certificated pilot, the sole occupant, was not located at the accident scene, and is presumed to have received fatal injuries. At the time of the accident, visual meteorological conditions prevailed over the Cook Inlet. As search operations progressed, the weather conditions deteriorated, and instrument meteorological conditions prevailed over the inlet. VFR company flight following procedures were in effect. The flight originated at the Kenai Airport about 1023, and was en route to Kokhanok, Alaska. The company director of operations/owner reported that the pilot began the day by preparing for the accident flight. This included preflight and engine start. The airplane had been parked on the airport ramp overnight, with an electric engine heater plugged in, and an engine cover installed. After engine start, the pilot contacted the Federal Aviation Administration (FAA) air traffic control personnel at the Kenai air traffic control tower (ATCT) and said that he was taxiing for takeoff. He then returned to the company ramp, shut down the engine, and contacted the company owner. The pilot indicated that the engine oil pressure appeared to be lower than normal, but still in the operating range. The owner indicated that he and the accident pilot discussed the possible reasons, such as cold ambient temperatures. The owner said the pilot indicated he would monitor the oil pressure prior to crossing the Cook Inlet, en route to Kokhanok. At 1020, the pilot again contacted the Kenai ATCT, and said that he was taxiing for takeoff. At 1022, the pilot advised he was ready for departure, and was cleared for takeoff at 1023. After departure, he contacted a company employee on the company radio and advised that his departure time was 1025, and his flight time was anticipated to be 1 hour and 15 minutes. The pilot also reported that he intended to "go down" from his normal crossing point across the Cook inlet, and indicated that the engine pressure was "up in the green and good to go." At 1033:54, the pilot contacted Kenai tower and stated, "Yes, I have a mayday. I've, ah, substantial vibration has occurred, ah, I can't see, ah, problem, I'm mid-channel, descending." The Kenai tower controller asked for the pilot's position, and the pilot said, "I'm mid-channel headed for the (unintelligible.) At 1035:06, the pilot stated, "I'm headed into the water, 60:40.94 [degrees north latitude] 151:43.542 [degrees west longitude], Mayday, Mayday." No further communication was received from the pilot. The operator's director of operations was preparing to depart Kenai in another company airplane, and he monitored the mayday call. He asked about the accident location, departed from Kenai at 1039, and headed toward the area of the accident. Kenai ATCT personnel indicated that there was a possible radar target approximately 12 miles northwest of Kenai. That location was between Nikiski, Alaska, on the west shore of the Kenai Peninsula, and Redoubt Bay, on the east shore of the Alaska Peninsula. At 1046, Air Route Traffic Control Center (ARTCC) personnel, Anchorage, Alaska, contacted Kenai tower personnel via telephone, stating, "..I see that, ah, for this downed aircraft is 12 miles northwest of the VOR. Do you have anything better than that." Kenai tower personnel responding by stating, "Really, not at this time. Unofficially, we think we had a target on our radar. We got possible coordinates on him, but we have to check the tapes to make sure." ARTCC personnel inquired about a radial (magnetic direction) from the VOR, and Kenai personnel stated, "A good guess would be looked like the 310 to 330 [radial] off the East Forelands, maybe." Several aircraft heard the unfolding emergency situation and responded to the area of the crash. The Air Force Rescue Coordination Center (AFRCC) was notified and search personnel were dispatched to the area. About 1218, an emergency locator transmitter (ELT) signal was detected by U.S. Coast Guard search aircraft. About 1241, the tail of the partially submerged airplane was spotted floating vertically in about 60 feet of water, and the vessel "Sea Bulk Nevada" was directed to the area. The location was about 8.8 miles southwest of the initial accident site reported by the pilot. The 215 foot long vessel recovered the airplane about 1453 from the inlet, which had wide areas of floating ice and ice fog. The airplane was intact, with the exception of the nose wheel assembly, which was missing. A crewmember on the vessel reported that he saw what appeared to be two tire tracks on the pan ice, about 50 to 60 feet long, to the edge of the ice where the airplane was located. The pilot was not recovered with the airplane, and subsequent searches did not locate him. PERSONNEL INFORMATION Pilot Information The pilot held a commercial pilot certificate with airplane single-engine land, single-engine sea, and instrument airplane ratings. He also held private pilot privileges with a multiengine land rating. The most recent second-class medical certificate was issued to the pilot on April 3, 2006, and contained the limitation that the pilot must wear corrective lenses. The pilot was hired by the operator on April 8, 2006. He completed his initial ground and flight training on May 5, 2006. He took a CFR Part 135.293 and Part 135.299 airman competency/proficiency flight check with an FAA inspector from the Anchorage Flight Standards District Office (FSDO), Anchorage, Alaska, on May 4, 2006. The inspector indicated that the result of the flight check was unsatisfactory in emergency procedures and judgment, and disapproved the checkride. The following day, after another flight check, the inspector approved the pilot. No personal flight records were located for the pilot, and the aeronautical experience listed on page 3 of this report was obtained from the operator's records, and from an insurance company application completed by the pilot. The operator indicated that the pilot's total aeronautical experience consisted of about 5,291 hours, of which 512 hours were accrued in the accident airplane make and model. Company Information The company is a cargo-only operator, and does not carry passengers. The owner of the company is designated as the Chief Pilot and Director of Operations. The company operations specifications, issued by the FAA, states that operational control of flight operations are specified in the company's operations manual, Section 2. Section 2 of the company's operations manual states, in part: "The director of operations, the chief pilot, and the pilot-in-command (PIC) are responsible and authorized to independently suspend or terminate the initiation or continuation of a flight assignment under any of the following conditions: 1. If the flight release procedures have not been met; or, 2. If any conditions at the time of flight release are not compliant with FAR(s) and the procedures of this manual; or, 3. If any unsafe conditions pose a hazard to flight. The PIC is responsible and authorized to suspend or modify the continuation of a flight assignment to the extent necessary to avoid any conditions that are hazardous to flight. If it is not possible to continue a flight assignment safely, the PIC shall terminate the flight assignment." The owner reported that he usually crossed the Cook Inlet in a Cessna 207 between the East Foreland of ## Aircraft - Registration: [N9941M](https://openairdocs.org/aircraft/N9941M), registered now, S/N 20700748, built 1982 (OpenAirDocs) - Reported make and model: Cessna 207A - Registry model: [Cessna 207A](https://openairdocs.org/model/cessna-207a) (registry code 2073605) (OpenAirDocs) - Registry engine: [Continental IO-520-F](https://openairdocs.org/engine/continental-io-520-f) (registry code 17237, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 20700748 - Airframe hours: 13774 - Engines: Continental IO-520-F27B 300 horsepower reciprocating - Damage: Substantial damage - Flight: Part 135 - Operator: Air Supply Alaska Inc. - Registered owner: Alaska Aircraft Leasing LLC - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, November 1, 2006, 64 hours before - Departed: PAEN, Kenai, AK - Destination: 9K2, Kokhanok, AK - Flight plan: Company VFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 52; injuries: fatal; commercial; airplane ratings: single-engine sea, multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review May 1, 2006; seat: left; flight hours: 5,291 total, 512 in this make and model, 4,330 as pilot in command, 96 in the last 90 days, 27 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 38° at 6 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: -20 °F, dew point -27 °F - Altimeter: 30.55 inHg - Observed at: PAEN, 18 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 20070109001339A](https://openairdocs.org/incident/20070109001339A), Jan 9, 2007: Cessna 207A, Kenai, AK, Substantial damage, 1 fatal. (-23) The pilot departed the Kenai airport in a Cessna 207, N9941M, on a cargo flight to kokhanok, Alaska, approximately 75 minutes west. Approximately 15… ## Docket (28 files) The files NTSB released with the investigation on November 30, 2007, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=65149. 9.0 MB in all. - GPS 17 - GPS Study (item 1, .PDF, 291 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40275226&FileExtension=.PDF&FileName=GPS%2017%20-%20GPS%20Study-Master.PDF - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 2, .PDF, 288 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285590&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Witness Statement (item 3, .PDF, 46 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285591&FileExtension=.PDF&FileName=Witness%20Statement-Master.PDF - Area Maps (item 4, .PDF, 820 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285592&FileExtension=.PDF&FileName=Area%20Maps-Master.PDF - Weather Data (item 5, .PDF, 121 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285593&FileExtension=.PDF&FileName=Weather%20Data-Redacted.PDF - Transcript of Radio Communications (item 6, .PDF, 259 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285594&FileExtension=.PDF&FileName=Transcript%20of%20Radio%20Communications-Redacted.PDF - FAA Personnel Statements (item 7, .PDF, 214 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285595&FileExtension=.PDF&FileName=FAA%20Personnel%20Statements-Redacted.PDF - Alaska State Trooper's Report (item 8, .PDF, 289 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285596&FileExtension=.PDF&FileName=Alaska%20State%20Trooper%27s%20Report-Redacted.PDF - Radar Data Extraction Report - Michael McDermott, LTD. (item 9, .PDF, 54 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285597&FileExtension=.PDF&FileName=Radar%20Data%20Extraction%20Report%20-%20Michael%20McDermott,%20LTD.-Redacted.PDF - Cessna 207 Informational Manual - Emergency Procedures (item 10, .PDF, 45 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285598&FileExtension=.PDF&FileName=Cessna%20207%20Informational%20Manual%20-%20Emergency%20Procedures-Master.PDF - Air Supply Alaska Training Manual Pages (item 11, .PDF, 60 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285599&FileExtension=.PDF&FileName=Air%20Supply%20Alaska%20Training%20Manual%20Pages-Master.PDF - Email Correspondence - Air Supply Alaska (item 12, .PDF, 31 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285600&FileExtension=.PDF&FileName=Email%20Correspondence%20-%20Air%20Supply%20Alaska-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 13, .PDF, 74 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285601&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 14, .PDF, 79 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285602&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Image 1. View of accident airplane on-deck of recovery vessel. Note missing nose gear. (item 15, .PDF, 443 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285603&FileExtension=.PDF&FileName=Image%201.%20%20View%20of%20accident%20airplane%20on-deck%20of%20recovery%20vessel.%20%20Note%20missing%20nose%20gear.-Master.PDF - Image 2. View of front of airplane with connecting rod hanging from the prop spinner. (item 16, .PDF, 455 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285604&FileExtension=.PDF&FileName=Image%202.%20%20View%20of%20front%20of%20airplane%20with%20connecting%20rod%20hanging%20from%20the%20prop%20spinner.-Master.PDF - Image 3. Close-up view of number 2 cylinder connecting rod. (item 17, .PDF, 450 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285605&FileExtension=.PDF&FileName=Image%203.%20%20Close-up%20view%20of%20number%202%20cylinder%20connecting%20rod.-Master.PDF - Image 4. View of hole in the top of the engine case. (item 18, .PDF, 483 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285606&FileExtension=.PDF&FileName=Image%204.%20%20View%20of%20hole%20in%20the%20top%20of%20the%20engine%20case.-Master.PDF - Image 5. View of hole in the engine case at the engine examination. (item 19, .PDF, 448 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285607&FileExtension=.PDF&FileName=Image%205.%20%20View%20of%20hole%20in%20the%20engine%20case%20at%20the%20engine%20examination.-Master.PDF - Image 6. View of hole in case with cracks radiating down to the number 1 cylinder. (item 20, .PDF, 448 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285608&FileExtension=.PDF&FileName=Image%206.%20%20View%20of%20hole%20in%20case%20with%20cracks%20radiating%20down%20to%20the%20number%201%20cylinder.-Master.PDF - Image 7. View of metal fragments found in the engine oil sump. (item 21, .PDF, 455 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285609&FileExtension=.PDF&FileName=Image%207.%20%20View%20of%20metal%20fragments%20found%20in%20the%20engine%20oil%20sump.-Master.PDF - Image 8. View of underside of number 2 piston, jammed in the number 2 cylinder. Note fractured wristpin hole radius. (item 22, .PDF, 439 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285610&FileExtension=.PDF&FileName=Image%208.%20%20View%20of%20underside%20of%20number%202%20piston,%20jammed%20in%20the%20number%202%20cylinder.%20%20Note%20fractured%20wristpin%20hole%20radius.-Master.PDF - Image 9. View of engine connecting rods. (item 23, .PDF, 459 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285611&FileExtension=.PDF&FileName=Image%209.%20%20View%20of%20engine%20connecting%20rods.-Master.PDF - Image 10. Close-up view of the number 1 connecting rod cap. Note missing rod bearing. (item 24, .PDF, 461 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285612&FileExtension=.PDF&FileName=Image%2010.%20%20Close-up%20view%20of%20the%20number%201%20connecting%20rod%20cap.%20%20Note%20missing%20rod%20bearing.-Master.PDF - Image 11. View of number 2 main bearing. Note its movement within the bearing saddle. (item 25, .PDF, 447 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285613&FileExtension=.PDF&FileName=Image%2011.%20%20View%20of%20number%202%20main%20bearing.%20%20Note%20its%20movement%20within%20the%20bearing%20saddle.-Master.PDF - Image 12. Close-up view of number 2 main bearing. Note fretting of case halves. (item 26, .PDF, 429 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285614&FileExtension=.PDF&FileName=Image%2012.%20%20Close-up%20view%20of%20number%202%20main%20bearing.%20%20Note%20fretting%20of%20case%20halves.-Master.PDF - Image 13. View of number 2 connecting rod bearing pieces. (item 27, .PDF, 468 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285615&FileExtension=.PDF&FileName=Image%2013.%20%20View%20of%20number%202%20connecting%20rod%20bearing%20pieces.-Master.PDF - Image 14. View of number 2 connecting rod crankshaft journal and oil galley hole. (item 28, .PDF, 444 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285616&FileExtension=.PDF&FileName=Image%2014.%20%20View%20of%20number%202%20connecting%20rod%20crankshaft%20journal%20and%20oil%20galley%20hole.-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.