# NTSB ANC19FA033: Piper PA 24-180, N5840P, Ketchikan, AK, July 11, 2019

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Class 3 · Field · Final report
- Date: July 11, 2019, 14:19 local (22:19 UTC)
- Place: Ketchikan, AK
- Coordinates: 55.30107, -131.65202 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=55.3011&lon=-131.6520&mi=10
- Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping)
- Defining event: [Maneuvering: Loss of control in flight](https://openairdocs.org/ntsb-events/240)
- Highest injury: Fatal
- Injuries: 1 fatal
- Status: Completed
- Report: Approved by Office Director
- Investigation class: Class 3
- NTSB office: Alaska Regional Office
- Parties: Federal Aviation Administration, Piper Aircraft, Lycoming Engines
- NTSB case key (mKey): 99825
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ANC19FA033
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99825/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99825
- Page: https://openairdocs.org/ntsb/ANC19FA033

## Probable cause

The pilot’s decision to continue visual flight rules into instrument meteorological conditions, which resulted in spatial disorientation and a loss of control.

## Findings

NTSB's coded findings; those marked are part of the probable cause.

- [Ceiling/visibility/precip: low visibility](https://openairdocs.org/ntsb-findings/03035015): Environmental issues › Conditions/weather/phenomena · Decision related to condition (probable cause); cases with it: [Piper PA-24-180, 1 case](https://openairdocs.org/ntsb-findings/03035015/cases.md?model=7102403), [All aircraft, 175 cases](https://openairdocs.org/ntsb-findings/03035015/cases.md)
- [Perception/orientation/illusion: spatial disorientation](https://openairdocs.org/ntsb-findings/02022025): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Piper PA-24-180, 1 case](https://openairdocs.org/ntsb-findings/02022025/cases.md?model=7102403), [All aircraft, 358 cases](https://openairdocs.org/ntsb-findings/02022025/cases.md)
- [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-24-180, 2 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7102403), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md)
- [Ceiling/visibility/precip: low visibility](https://openairdocs.org/ntsb-findings/03035015): Environmental issues › Conditions/weather/phenomena · Effect on operation (probable cause); cases with it: [Piper PA-24-180, 1 case](https://openairdocs.org/ntsb-findings/03035015/cases.md?model=7102403), [All aircraft, 175 cases](https://openairdocs.org/ntsb-findings/03035015/cases.md)
- [Aircraft](https://openairdocs.org/ntsb-findings/01060000): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Piper PA-24-180, 1 case](https://openairdocs.org/ntsb-findings/01060000/cases.md?model=7102403), [All aircraft, 63 cases](https://openairdocs.org/ntsb-findings/01060000/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Maneuvering: VFR encounter with IMC](https://openairdocs.org/ntsb-events/401); cases with it: [Piper PA-24-180, 1 case](https://openairdocs.org/ntsb-events/401/sequence.md?model=7102403), [All aircraft, 392 cases](https://openairdocs.org/ntsb-events/401/sequence.md)
- [Maneuvering: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Piper PA-24-180, 3 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=7102403), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md)

## Analysis

The pilot was conducting a visual flight rules cross-country flight. He filed a flight plan before departure but declined a formal weather briefing. Although the weather information he gathered about the flight could not be determined, he indicated to his spouse before departure that the weather at his intended fuel stop was “not good,” but that he had sufficient fuel onboard to continue to the destination airport without refueling. GPS data showed that the airplane proceeded directly toward the airport where he intended to refuel, and while approaching the airport for landing the pilot reported via radio that he was “hung up” and would maneuver for a left downwind. There were no further radio communications from the pilot. GPS data revealed that, about the time the pilot made the final radio call, the airplane was about 500 ft above ground level; it then banked left and rapidly descended into rising terrain. The wreckage was located on a hillside about 4 nautical miles southeast of the airport. The distribution of the wreckage was consistent with a high speed impact. Examination of the airframe, engine, and associated systems revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. Although the pilot held an instrument rating, his instrument currency could not be determined, and his wife, who flew with him often, stated that he rarely filed or flew instrument flight rules flights. Weather camera images revealed the presence of low cloud layers and limited visibility in the area of the accident site around the time of the accident. Despite his apparent awareness of forecast marginal visual flight rules conditions and temporary instrument meteorological conditions, the pilot chose to depart and continue into an area of low cloud ceilings and rising terrain. It is likely that, while maneuvering at low altitude toward the airport, the pilot's in-flight visibility was limited by the cloud conditions, which resulted in spatial disorientation and a loss of control. The pilot had a history of high blood pressure and diabetes, and toxicology revealed medications that were consistent with appropriate medical treatment and were not considered impairing. The pilot’s downloaded glucometer readings during the flight had no indications of an adverse diabetic event; therefore, the pilot’s diabetes and use of diabetes medication did not contribute to the accident. The coronary artery disease observed during the autopsy was below that generally considered significant. Although the pilot’s medical conditions placed him at increased risk for a sudden impairing or incapacitating cardiovascular event, there is insufficient evidence to determine whether such an event occurred.

## Factual narrative

Spatial Disorientation The FAA Civil Aerospace Medical Institute's publication, "Introduction to Aviation Physiology," defines spatial disorientation as a loss of proper bearings or a state of mental confusion as to position, location, or movement relative to the position of the earth. Factors contributing to spatial disorientation include changes in acceleration, flight in IMC, frequent transfer between VMC and IMC, and unperceived changes in aircraft attitude. The FAA Airplane Flying Handbook describes some hazards associated with flying when the ground or horizon are obscured. The handbook states, in part: The vestibular sense (motion sensing by the inner ear) in particular tends to confuse the pilot. Because of inertia, the sensory areas of the inner ear cannot detect slight changes in the attitude of the airplane, nor can they accurately sense attitude changes that occur at a uniform rate over a period of time. On the other hand, false sensations are often generated; leading the pilot to believe the attitude of the airplane has changed when in fact, it has not. These false sensations result in the pilot experiencing spatial disorientation. 14 CFR Part 93 special air traffic rules for KTN were in effect at the time of the accident. The procedures required that VFR aircraft establish two-way communication with KTN FSS for the purpose of receiving traffic advisories. On July 11, 2019, about 1419 Alaska daylight time, a Piper PA-24-180 airplane, N5840P, sustained substantial damage when it was involved in an accident near Ketchikan, Alaska. The airline transport pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight. The pilot departed Friday Harbor Airport (FHR), Friday Harbor, Washington, about 1010 and was destined for Wrangell Airport (WRG), Wrangell, Alaska. The pilot flew this route often and intended to stop at Ketchikan International Airport (KTN) to purchase fuel before continuing on to WRG. On the morning of the flight, the pilot told his spouse that the forecast weather for KTN was, "not so good," and he intended to fly around KTN and continue to WRG if the weather did not improve. GPS data revealed that the airplane flew a direct route to the KTN terminal area. According to Federal Aviation Administration (FAA) Ketchikan Flight Service Station (FSS) radio transmissions, about 1412, the pilot called KTN FSS 10 miles southeast of KTN with the current weather information for runway 11. About 5 minutes later, the flight crew of an inbound Boeing 737 contacted KTN FSS with intentions to enter a left downwind for KTN runway 11. The accident pilot then reported that he "was hung up" and could not enter a right downwind but would wait for traffic to clear prior to entering a left downwind. There were no further communications from the pilot. Immediately after the pilot’s last radio transmission, the airplane turned left from a heading of about 320° to the southwest. Itdescended from 775 ft mean sea level (msl), about 500 ft above ground level (agl), to 447 ft msl within 10 seconds (about 1,970 ft/min descent rate) while accelerating from 99 knots to over 111 knots. The last data point was at 1418:18 about 100 ft agl. (see Figures 1 and 2.) Figure 1. GPS track (red) in the KTN terminal area with inset photograph of Judy Hill and the accident site. Figure 2. GPS end of flight data. The Alaska State Medical Examiner's Office, Anchorage, Alaska, performed an autopsy of the pilot and determined the cause of death to be multiple blunt force injuries. A focus of calcified atherosclerotic stenosis of no more than 30% was observed in the left main coronary artery. The FAA Forensic Sciences Laboratory performed forensic toxicology that detected chlorpheniramine in a urine sample and 4 ng/mL in heart blood. Hemoglobin A1C was measured at 7.2% in heart blood. Vitreous and urine glucose test were normal. Chlorpheniramine is a sedating antihistamine medication that is available over-the-counter in a variety of cold, allergy and sleep aid products. Its intended effects generally occur at blood levels ranging from 10 to 40 ng/mL. The pilot reported high blood pressure and diabetes on his most recent medical certificate application. He was taking multiple medications to treat the conditions and none of those was considered impairing. He had previously been granted special issuance medical certification because of his diabetes. At his last medical examination the month before the accident, the pilot reported no changes in his medication or health concerns. The aviation medical examiner identified no issues and deferred issuance of a third class medical certificate to the FAA. The prior special issuance expired June 30, 2019. The pilot did not have a valid medical certificate at the time of the accident. Information from the pilot’s glucometer indicated that his blood sugar was tested multiple times during the flight, including 5 minutes before the accident. The measurements ranged from 107 to 157 mg/dL, which were in a normal range. The terminal forecast for PAKT issued at 0923 and current at the time of departure, expected marginal visual flight rules (MVFR) conditions to prevail with visibility greater than 6 miles, rain showers in the vicinity, and cloud ceiling overcast at 2,500 ft agl. An amended forecast was issued two hours into the flight and predicted temporary instrument flight rules (IFR) conditions from 1200 through 1600 of 1.5 statute miles (sm) visibility in light rain showers and mist, with a ceiling broken at 1,000 ft agl, and overcast clouds at 2,000 ft agl. The Area Forecast for southeast Alaska was issued at 0914 and was available before departure. The forecast indicated that southeast Alaska from PAKT and south expected occasional ceilings below 1,000 ft agl with isolated visibilities below 3 miles in mist and included an AIRMET for IFR conditions and mountain obscuration over the region. The PAKT automatedflight information that the pilot received before the approach indicated marginal VFR weather with 10 sm visibility, scattered clouds at 900 ft agl, broken ceiling at 1,400 ft agl, and an overcast layer at 3,500 ft agl. FAA weather cameras at PAKT captured images of the accident area around the time of the accident. The southeast camera view at 1410 and 1420 (1 minute after the accident) revealed that the visibility in that sector was less than 2.5 sm and low clouds obscured the hillside accident site. The south camera images from 1412 and 1422 also showed diminished visibility and obscuration of terrain. (see Figures 3 and 4.) Figure 3. KTN southeast weather camera image on a clear day (left) and at 1420 (2220 UTC) on the accident day (right.) Figure 4. KTN south weather camera image on a clear day (left) and at 1422 (2222 UTC) on the accident day (right.) A search of the FAA Automated Flight Service Station (AFSS) contract provider, Leidos, indicated that the pilot filed a VFR flight plan at 0940. The estimated time of departure was 1000 with an estimated time enroute of 4 hours 30, total fuel on board 6:30, and a planned cruising altitude of 3,500 ft. When asked if the pilot wanted an update of the adverse conditions, the pilot indicated “I think we’re good to go” and the call terminated. The pilot did not request a weather briefing. Third-party weather vendor ForeFlight indicated that the pilot did have an account but did not request any specific weather briefings or review any static weather imagery prior to the flight. The pilot viewed route airports prior to the flight, which could have included airport weather information, but ForeFlight did not have a record of what the pilot viewed on each airport’s page. It is therefore unknown what weather information the pilot viewed prior to the flight. The pilot’s logbook was not located. The pilot’s spouse stated that he used to fly commercially for various operators. She also stated that he flew his airplane often as part of his law business, but rarely in instrument conditions. She stated that she had not witnessed him conducting an actual instrument flight in many years. The wreckage came to rest on the northwest side of Judy Hill at an average elevation of 380 ft in lightly forested terrain. All major components were located at the accident site. The debris path extended about 300 ft on a heading of 193°. The debris field consisted of long, deep ground scars, wing and empennage sections, and terminated at the inverted main fuselage, engine, and inboard portions of the wings. The wing and empennage separations exhibited rearward deformation and some corresponding tree impact indentations. Propeller cuts were observed on two broken tree sections. Flight control continuity was established from the cockpit control cable ends to the stabilator, rudder and left and right ailerons, with the exception of the right rudder cable end at the rudder horn attachment, which was not located. The flaps werein the retracted position and the control cables and bellcrank were continuous. Various fractures in the control rod ends and bellcranks exhibited dull, dimpled surfaces and deformation consistent with overload failure. Numerous control cable skin tears were evident in the empennage, indicative of flight control connectivity at the time of impact. The fuel selector was observed in the “Right Tank” and “To Engine” position. The right fuel tank cap was secure in place and the right fuel tank contained 15 gallons. The left fuel tank was breached due to wing crush damage. The primary attitude indicator/gyro unit was removed and disassembled. The instrument components were intact with no evidence of gyro rotor or case scoring. Engine crankshaft and valvetrain continuity was established. The magnetos produced spark at each terminal and spark plugs indicated normal wear. The carburetor sustained impact damage. No fuel system contamination was observed. The engine-driven vacuum pump drive vanes were intact with no foreign matter present.

## Aircraft

- Registration: [N5840P](https://openairdocs.org/deregistered/N5840P-2021-10-30), registration cancelled 2021-10-30, S/N 24-921, built 1959 (OpenAirDocs)
- Reported make and model: Piper PA 24-180 (Undesignat)
- Registry model: [Piper PA-24-180](https://openairdocs.org/model/piper-pa-24-180) (registry code 7102403) (OpenAirDocs)
- Registry engine: [Lycoming O&VO-360 series](https://openairdocs.org/engine/lycoming-o-vo-360-series) (registry code 41514, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: 24-921
- Year built: 1959
- Airframe hours: 4724.3
- Engines: Lycoming O-360-A1A 180 horsepower reciprocating
- Damage: Substantial damage
- Flight: Personal, Part 91
- Airworthiness certificate: Standard, Normal
- Last inspection: Annual, July 10, 2019, 4.1 hours before
- Departed: FHR, Friday Harbor, WA
- Destination: KTN, Ketchikan, AK
- Flight plan: VFR
- Airport: KTN, Ketchikan Intl, runway 11, 7,500 × 150 ft, asphalt
- Equipment: Handheld GPS, ADS-B, Electronic flight bag or handheld device

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 68; injuries: fatal; airline transport, commercial, flight instructor; airplane ratings: single-engine sea, single-engine land, multi-engine land; instrument ratings: airplane; seat: left; restraint: 4-point; toxicology performed; flight hours: 12,580 total, 400 in this make and model

## Weather

- Conditions: Day
- Wind: 110° at 13 knots
- Visibility: 10 statute miles
- Lowest ceiling: 1,400 ft broken
- Temperature: 63 °F, dew point 61 °F
- Altimeter: 30.09 inHg
- Observed at: PAKT, 4 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 20190711011249A](https://openairdocs.org/incident/20190711011249A), Jul 11, 2019: Piper PA-24-180, Ketchikan, AK, Destroyed, 1 fatal. The pilot departed Friday harbor airport (kfhr) enroute to Ketchikan international airport (ktn) on a personal VFR flight. Last contact between the pilot and…

## Docket (8 files)

The files NTSB released with the investigation on June 15, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99825. 10.2 MB in all.

- NTSB medical factual report (item 1, PDF, 5 pages, 86 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11851870&FileExtension=pdf&FileName=ANC19FA033_MedicalFactualReport-Rel.pdf
- NTSB GPS factual report (item 2, PDF, 4 pages, 823 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11854813&FileExtension=pdf&FileName=GPS%20Factual%20Report-Rel.pdf
- GPS factual attachment 1 (item 3, CSV, 65 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11853259&FileExtension=csv&FileName=GPS%20Factual%20Att%201%20csv%20data-Rel.csv
- Meteorology factual report (item 4, PDF, 38 pages, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8654989&FileExtension=pdf&FileName=ANC19FA033%20-%20Ketchikan%20Factual%20Report-Rel.pdf
- Air traffic control ktn radio transcript (item 5, PDF, 7 pages, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11851819&FileExtension=pdf&FileName=Official%20Transcript%20of%20the%20N5840P%20Accident%20on%207-11-2019%20in%20KTN-Rel.pdf
- Record of conversation (family) (item 6, PDF, 2 pages, 160 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11851860&FileExtension=pdf&FileName=ROC%20wife-Rel.pdf
- NTSB field and examinations summary (item 7, PDF, 11 pages, 4.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11939520&FileExtension=pdf&FileName=NTSB%20Exam%20Summary-Rel.pdf
- Pilot toxicology (item 8, PDF, 1 page, 318 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12008342&FileExtension=pdf&FileName=Tox%20master_Redacted-Rel.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.

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