ANC19TA014

NTSB accident investigation · Piper PA32R · Anchorage, AK · February 13, 2019

Accident · Serious injuriesClass 3Final report
Date
February 13, 2019, 12:45 local (21:45 UTC)
Place
Anchorage, AK
Injuries
1 serious, 2 uninjured
Damage
No damage
Phase of flight
Enroute
Aircraft
N40449Piper PA32R
Defining event
Enroute-descent: Turbulence encounter
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Alaska Regional Office
FAA report
20190213010179A
Case key
99022

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

On this page

Probable cause

The pilot’s failure to ensure that the passenger’s lap belt was appropriately fastened for the forecast turbulent conditions, and the passenger’s failure to tighten her lap belt appropriately, which resulted in the passenger’s serious injury during an encounter with turbulence.

Findings · 4

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Action: lack of actionPersonnel issues › Action/decision · PilotPiper PA-32R-300: 3 casesAll aircraft: 792 casesProbable cause
Turbulence: clear air turbulenceEnvironmental issues › Conditions/weather/phenomena · Effect on personnelPiper PA-32R-300: 1 caseAll aircraft: 78 casesProbable cause
Turbulence: clear air turbulenceEnvironmental issues › Conditions/weather/phenomena · Response/compensationPiper PA-32R-300: 1 caseAll aircraft: 78 casesProbable cause
Use of equip/info: use of equip/systemPersonnel issues › Task performance · PassengerPiper PA-32R-300: 4 casesAll aircraft: 1,391 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The pilot reported that the airplane encountered momentary severe turbulence while descending toward the destination airport. A passenger in the second row hit her head on the cabin ceiling and sustained a serious injury to her neck. The passenger stated that she was familiar with the operation of the seat belt and flew in the airplane about once or twice a month for many years, but on this flight, she did not tighten the lap belt sufficiently. Weather forecasts indicated that occasional to constant moderate turbulence was expected in the area; however, the pilot did not ensure that the passenger’s lap belt was appropriately fastened.

Factual narrative

On February 13, 2019, about 1245 Alaska standard time, a Piper PA-32R-300 airplane, N40449, sustained no damage when it was involved in an accident near Anchorage, Alaska. One passenger received a serious injury, and the pilot and other passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 135 non-scheduled passenger flight. The pilot reported that during a visual flight rules flight from Lime Village Airport (AK2) to Merrill Field Airport (MRI), Anchorage, Alaska, the airplane encountered momentary severe turbulence as it descended through 3,500 feet mean sea level (msl) about 22 miles northwest of Anchorage. One of the two passengers, who was seated in the second row right seat, hit her head on the cabin ceiling. The flight landed at MRI without incident and the passenger was treated at a medical facility, where it was determined that she sustained serious injuries. The injured passenger stated that her lap belt was fastened, but she did not tighten it enough. She was familiar with the use of the lap belt and flew with the company in the accident airplane once or twice a month for many years. She recalled that the pilot provided a passenger briefing, but could not remember if seat belt use was included. The pilot reported that they experienced occasional light turbulence during most of the flight and that significant turbulence was not forecast. The unexpected severe turbulence lasted about 5 seconds. A review of National Weather Service graphical forecast products for the area revealed a turbulence forecast issued at 0900 and valid for the time of the accident for occasional to constant moderate turbulence below 6,000 ft msl. The forecast issued at 1200 and valid for the time of the accident indicated isolated moderate turbulence transitioning to occasional to constant moderate turbulence from the surface to 8,000 ft msl with low level wind shear. A review of pilot reports indicated that the pilot of a similar airplane type experienced continuous moderate turbulence in the area of the encounter from 900 ft to 500 ft about 15 minutes after the occurrence.

Aircraft

Registration
N40449
Reported as
Piper PA32R (300)
Category
Airplane
Serial number
32R-7780519
Built
1977
Airframe hours
22,163
Engine
Lycoming IO-540 K1A5, 300 hp, reciprocating
Damage
No damage
Flight
Part 135
Operator
Sound Aviation
Registered owner
Marsan William B
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · February 28, 2019
Departed
2AK · Lime Village, AK
Destination
MRI · Anchorage, AK
Flight plan
Company VFR
Equipment
Satellite tracking device, Handheld GPS

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
51
Injuries
None
Certificate
Airline transport
Airplane ratings
Multi-engine land, Single-engine land, Single-engine sea
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
May 25, 2018
Seat
Front
Restraint
3-point
Flight hours
21,000 total · 13,000 in this make and model · 200 in the last 90 days · 75 in the last 30 days · 5 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
30° at 9 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
21 °F, dew point 9 °F
Altimeter
29.84 inHg
Turbulence
Severe
Observed at
PANC, 18 nm away

Docket · 4

The files NTSB released with the investigation on June 18, 2021, on NTSB’s docket system: statements, records, photos and specialists’ reports. 2.2 MB in all.

FAA reports on this event · 1

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

Other investigations on N40449 · 1

Matched to the same aircraft by N-number and date.