ANC07FA073

NTSB accident investigation · Piper PA-46-350P · Sitka, AK · August 6, 2007

Accident · FatalField investigationFinal report
Date
August 6, 2007, 12:55 local (20:55 UTC)
Place
Sitka, AK
Injuries
4 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N35CXPiper PA-46-350P
Weather
Instrument (IMC) · Day
Status
Completed · report June 30, 2008
Report
Approved by Office Director
NTSB office
Alaska Regional Office
Parties
Piper Aircraft Inc., Pratt and Whitney Canada, FAA-AL-JNU FSDO 05
FAA report
20070806014849A
Case key
66396

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The pilot's failure to maintain altitude/distance from obstacles during an IFR circling approach, and his failure to follow the instrument approach procedure. Contributing to the accident was clouds.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

In flight collision with objectCircling (ifr)
Object - tree(s)
Altitude/clearance - not maintainedPilot in commandCause
Wing - separation
Ifr procedure - not followedPilot in commandCause
Object - residence
Weather condition - cloudsFactor

Analysis

The private, instrument-rated pilot, was on an IFR cross-country flight, and had been cleared for a GPS approach. He reported that he was 5 minutes from landing, and said he was circling to the left, to land the opposite direction from the published approach. The traffic pattern for the approach runway was right traffic. Instrument meteorological conditions prevailed, and the weather conditions included a visibility of 3 statute miles in light rain and mist; few clouds at 400 feet, 1,000 feet overcast; temperature, 55 degrees F; dew point, 55 degrees F. The minimum descent altitude, either for a lateral navigation approach, or a circling approach, was 580 feet, and required a visibility of 1 mile. The missed approach procedure was a right climbing turn. A circling approach north of the runway was not approved. Witnesses reported that the weather included low clouds and reduced visibility due to fog and drizzle. The airplane was heard, but not seen, circling several times over the city, which was north of the runway. Witnesses saw the airplane descending in a wings level, 30-45 degree nose down attitude from the base of clouds, pitch up slightly, and then collide with several trees and an unoccupied house. A postcrash fire consumed the residence, and destroyed the airplane. A review of FAA radar data indicated that as the accident airplane flew toward the airport, its altitude slowly decreased and its flight track appeared to remain to the left side (north) of the runway. The airplane's lowest altitude was 800 feet as it neared the runway, and then climbed to 1,700 feet, where radar contact was lost, north of the runway. During the postaccident examination of the airplane, no mechanical malfunction was found. Given the lack of any mechanical deficiencies with the airplane, it is likely the pilot was either confused about the proper approach procedures, or elected to disregard them, and abandoned the instrument approach prematurely in his attempt to find the runway. It is unknown why he decided to do a circle to land approach, when the tailwind component was slight, and the shorter, simpler, straight in approach was a viable option. Likewise, it is unknown why he flew towards rising terrain on the north side of the runway, contrary to the published procedures. From the witness statements, it appears the pilot was "hunting" for the airport, and intentionally dove the airplane towards what he perceived was an area close to it. In the process, he probably saw trees and terrain, attempted to climb, but was too low to avoid the trees.

Factual narrative

History of flight

On August 6, 2007, about 1255 Alaska daylight time, a Piper PA-46 airplane, N35CX, was destroyed by impact and postimpact fire when it collided with trees and a residence during an instrument landing approach to the Sitka Rocky Gutierrez Airport, Sitka, Alaska. The airplane was operated by the pilot as an instrument flight rules (IFR) cross-country personal flight under Title 14, CFR Part 91, when the accident occurred. The private certificated, instrument-rated pilot, and the three passengers, received fatal injuries. Instrument meteorological conditions prevailed in the area at the time of the accident. The flight originated at the Victoria International Airport, Victoria, Canada, about 1100, and an IFR flight plan was filed.

According to Federal Aviation Administration (FAA) personnel, the pilot requested the RNAV GPS 11 approach to Sitka about 1209 from controllers at the Anchorage Air Route Traffic Control Center (ARTCC). About 1221, the pilot requested ceiling information from a departing airplane at Sitka, and was told that it was 1,700 feet msl. About 1229, the pilot was instructed to maintain at or above 6,000 feet until established on a published portion of the approach, and was cleared for the GPS 11 approach to Sitka. At 1236, ARTCC controllers provided the pilot with a special weather observation from Sitka at 1227, which included; wind 260 degrees (true) at 11 knots, visibility 5 miles in mist, and few clouds at 800 feet. The ceiling was broken at 1,400 feet, overcast at 2,300 feet, with a temperature of 57 degrees F, dew point temperature of 55 degrees F, and the altimeter was 29.87 inHg. About 1247, the pilot was instructed to contact the Sitka Flight Service Station (FSS).

At 1247, the pilot contacted Sitka FSS personnel and reported that he was "inbound, GPS 11, circle to land, left hand pattern." The Sitka FSS specialist inquired if the pilot had heard the most recent automated terminal information system (ATIS), which was Hotel, and requested an estimated time of arrival. The pilot indicated he had the ATIS information, gave his ETA as 5 minutes, and said, "landing on 29."

A Learjet medevac airplane was holding on the ramp at Sitka to depart on an IFR flight. The crew of the Learjet inquired several times from Sitka FSS personnel about the status of the accident airplane as it proceeded inbound on the instrument approach, as they could not depart until the accident airplane arrived.

About 1257, Sitka FSS personnel contacted Anchorage ARTCC, and inquired if they were in contact with the accident airplane, and they said that they were not. Sitka FSS personnel began trying to locate the airplane, and received notification about 1303 that it had crashed in the city.

Witnesses on the ground in Sitka, both near the harbor and in the city, reported that the weather included low clouds and reduced visibility due to rain. The airplane was heard, but not seen, circling several times over the city, which is north of the runway. One witness saw the airplane descending in a nose down attitude from the base of clouds that he estimated as 500 feet above the ground. Other witnesses saw the airplane descending at an estimated 30 to 45 degree nose low attitude, pitch up, and collide with several trees, separating the outboard portion of the left wing. The inboard section of the left wing separated from the fuselage just prior to the airplane's collision with a house.

The first person to arrive at the crash site reported that the airplane crashed through the front door area of the home. The tail of the airplane was lying in the street, and the fuselage had penetrated the floor. A fire began near the left front portion of the residence, and electrical wires were alive and sparking. About 2 minutes after the crash, the fire spread throughout the house.

An extensive postcrash fire destroyed the airplane.

Other damage

The residence was destroyed by impact and postimpact fire. No one was in the residence at the time of the collision.

Personnel information

Pilot Information

The pilot held a private pilot certificate with airplane single-engine land, multiengine land, and instrument airplane ratings. His recent third-class medical certificate was issued on October 7, 2005, and contained no limitations.

FAA records on file in the Airman and Medical Records Center in Oklahoma City, revealed that on the pilot's application for medical certificate, dated October 7, 2005, he indicated that his total aeronautical experience was about 1,200 hours, of which 150 were in the previous 6 months.

The pilot's logbook was found in the wreckage, but it sustained extensive fire damage. The logbook had a page entry of about 1,800 hours of total experience, with about 1,672 hours as pilot-in-command. The pilot completed a flight review and an instrument proficiency check on April 16, 2007.

Aircraft information

The six-seat, pressurized airplane had been modified under a supplemental type certificate (STC) for installation of a turboprop engine by JetProp LLC, Spokane, Washington. The engine was installed under STC ST 00541SE, on February 28, 2003. At the most recent annual inspection, the engine had 1,198.8 hours.

Examination of the maintenance records revealed that the most recent annual inspection was on June 1, 2007. At that time, the airplane had 1,987.9 hours. In addition, a 100 hour inspection was completed on July 27, 2007, 10 days before the accident, at a total time of 2,042.3 hours.

The most recent inspection of the pitot/static system, to include the altimeters and transponder, was on April 7, 2006.

The airplane's instrument panel included, among other equipment, a Garmin GNS 480 communication and navigation unit, a GNS 530 communications and navigation unit, a Garmin MX-20 multifunction display with Garmin Chart View, which had electronic instrument approach charts and airport diagrams, a Garmin GDL-69 satellite weather receiver, a Honeywell KAS-297 altitude/vertical speed selector, an autopilot, HSI, and flight director with a GDC-31 roll/steering adapter that allowed heading selection from either the flight director or a GPS unit. In addition, the airplane was equipped with weather radar. Once programmed, the navigation and communications equipment was capable of flying the approach and missed approach profiles. For the missed approach, the pilot would have to select a vertical speed and altitude. Among other features, terrain depiction information, weather information, approach charts, and the airplane's flight track, were available for display on either of the communication and navigation units, and/or the multifunction display.

Meteorological information

At 1253, an aviation routine weather report (METAR) at Sitka, Alaska, was reporting, in part: Wind, 290 degrees (true) at 5 knots; visibility, 3 statute miles in light rain and mist; clouds and sky condition, few at 400 feet, 1,000 feet overcast; temperature, 55 degrees F; dew point, 55 degrees F; altimeter, 29.88 inHg; remarks, rain began at 1228.

Several witnesses reported that the weather conditions included overcast skies, with fog and drizzle, and the visibility as low as 500 yards over the city.

Communications

A transcript of the air to ground communications between the airplane, and the Anchorage ARTCC facility is included in the public docket of this accident.

Radar data

In a review of continuous data recording (CDR) radar data, maintained by the Anchorage ARTCC facility, and recorded from the Biorka Island radar site, the accident airplane appeared to cross the Biorka Island VORTAC, and proceed to the HESOK FIX at 5,000 feet, which is the initial approach fix. The airplane made a left teardrop turn and flew inbound from HESOK toward the airport. Its altitude slowly decreased, and the flight track appeared to remain to the left side (north) of the runway. The airplane's lowest altitude was 800

Aircraft

Registration
N35CX
Reported as
Piper PA-46-350P
Category
Airplane
Serial number
4636127
Airframe hours
2,042
Engine
Pratt & Whitney Canada PT6A-35, 560 horsepower, turbo prop
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Operator
Robert Hendrickson
Registered owner
Hendrickson Aviation LLC
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · July 1, 2007
Departed
CYYJ · Victoria
Destination
PASI · Sitka, AK
Flight plan
IFR
Airport
PASI · Sitka Rocky Gutierrez

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
45
Injuries
Fatal
Certificate
Private
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Without waivers/limitations
Last flight review
April 1, 2007
Seat
Left
Toxicology
Performed
Flight hours
1,800 total · 1,672 as pilot in command

Weather

Conditions
Instrument (IMC) · Day
Wind
290° at 5 knots
Visibility
3 statute miles
Lowest ceiling
1,000 ft overcast
Temperature
55 °F, dew point 55 °F
Altimeter
29.87 inHg
Observed at
PASI, 1 nm away

Docket · 24

The files NTSB released with the investigation on June 2, 2008, on NTSB’s docket system: statements, records, photos and specialists’ reports. 8.7 MB in all.

Witness StatementsItem 1 · .PDF · 370 KBMapsItem 2 · .PDF · 458 KBLat/Long of Radar ReturnsItem 3 · .PDF · 437 KBWeatherItem 4 · .PDF · 29 KBANC ARTCC TranscriptsItem 5 · .PDF · 267 KBSitka FSS Report of ServicesItem 6 · .PDF · 54 KBFAA Personnel StatementsItem 7 · .PDF · 151 KBCDR PrintoutsItem 8 · .PDF · 890 KBAirport and RNAV Approach ChartsItem 9 · .PDF · 513 KBStatement of Party Representatives to NTSB InvestigationItem 10 · .PDF · 76 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 11 · .PDF · 48 KBToxicological ReportItem 12 · .PDF · 58 KBImage 1. View of airplane at point of rest, within the destroyed residence.Item 13 · .PDF · 483 KBImage 2. View of the fuselage, after recovery.Item 14 · .PDF · 454 KBImage 3. Inboard segment of the right wing that was cut off the wreckage for transport. Note tree impact crush in the leading edge.Item 15 · .PDF · 446 KBImage 4. Inboard segment of the left wing, found behind residence across the street from the crash scene. Note tree impact crush in the leading edge.Item 16 · .PDF · 436 KBImage 5. Outboard section of the right wing, found at crash scene.Item 17 · .PDF · 405 KBImage 6. Outboard section of the left wing, found 451 feet from the inboard section.Item 18 · .PDF · 440 KBImage 7. View of tail cone, horizontal stabilizers and elevators, and trim tab.Item 19 · .PDF · 458 KBImage 8. Vertical stabilizer and rudder.Item 20 · .PDF · 454 KBImage 9. View of engine, separated from the accessory case.Item 21 · .PDF · 457 KBImage 10. View of 1st stage compressor blades. Note curling of the blade tips.Item 22 · .PDF · 458 KBImage 11. View of power turbine and stator. Note destruction of turbine blades.Item 23 · .PDF · 447 KBImage 12. Closer view of power turbine.Item 24 · .PDF · 447 KB

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.