# NTSB ANC19TA014: Piper PA32R, N40449, Anchorage, AK, February 13, 2019 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Class 3 · Final report - Date: February 13, 2019, 12:45 local (21:45 UTC) - Place: Anchorage, AK - Coordinates: 61.3, -150.54 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=61.3000&lon=-150.5400&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-descent: Turbulence encounter](https://openairdocs.org/ntsb-events/360) - Highest injury: Serious injuries - Injuries: 1 serious, 2 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Alaska Regional Office - NTSB case key (mKey): 99022 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ANC19TA014 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99022/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99022 - Page: https://openairdocs.org/ntsb/ANC19TA014 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA-32R-300, 3 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md?model=7103213), [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md) - [Turbulence: clear air turbulence](https://openairdocs.org/ntsb-findings/03032015): Environmental issues › Conditions/weather/phenomena · Effect on personnel (probable cause); cases with it: [Piper PA-32R-300, 1 case](https://openairdocs.org/ntsb-findings/03032015/cases.md?model=7103213), [All aircraft, 78 cases](https://openairdocs.org/ntsb-findings/03032015/cases.md) - [Turbulence: clear air turbulence](https://openairdocs.org/ntsb-findings/03032015): Environmental issues › Conditions/weather/phenomena · Response/compensation (probable cause); cases with it: [Piper PA-32R-300, 1 case](https://openairdocs.org/ntsb-findings/03032015/cases.md?model=7103213), [All aircraft, 78 cases](https://openairdocs.org/ntsb-findings/03032015/cases.md) - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Passenger (probable cause); cases with it: [Piper PA-32R-300, 4 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=7103213), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-descent: Turbulence encounter](https://openairdocs.org/ntsb-events/360) (defining event); cases with it: [Piper PA-32R-300, 2 cases](https://openairdocs.org/ntsb-events/360/sequence.md?model=7103213), [All aircraft, 423 cases](https://openairdocs.org/ntsb-events/360/sequence.md) ## 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](https://openairdocs.org/aircraft/N40449), registered now, S/N 32R-7780519 (OpenAirDocs) - Reported make and model: Piper PA32R (300) - Registry model: [Piper PA-32R-300](https://openairdocs.org/model/piper-pa-32r-300) (registry code 7103213) (OpenAirDocs) - Registry engine: [Lycoming TI0-540 series](https://openairdocs.org/engine/lycoming-ti0-540-series) (registry code 41533, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: 32R-7780519 - Year built: 1977 - Airframe hours: 22163 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 51; injuries: none; 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 ## 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 20190213010179A](https://openairdocs.org/incident/20190213010179A), Feb 13, 2019: Piper PA-32R-300, Anchorage, AK, No damage. Flight was returning from lime village (2AK). On decent in the vicinity of figure eight lake, N40449 encountered severe turbulence. One passenger sustained… ## Other investigations on N40449 (1) 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. - [NTSB ANC02LA117](https://openairdocs.org/ntsb/ANC02LA117), Sep 4, 2002: Piper PA-32R (N40449), Manley Hot Spgs, AK, substantial damage. Probable cause: A bird strike during takeoff, which resulted in substantial damage to the right wing. ## Docket (4 files) The files NTSB released with the investigation on June 18, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99022. 2.2 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 10 pages, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12394829&FileExtension=pdf&FileName=Point%20One_Redacted-Rel.pdf - Record of conversation (passenger) (item 2, PDF, 1 page, 39 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11790717&FileExtension=pdf&FileName=ROC%20pax%20(Macar)-Rel.pdf - National weather service forecast graphics (item 3, PDF, 1 page, 537 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11790341&FileExtension=pdf&FileName=weather%20images-Rel.pdf - Pireps (item 4, PDF, 1 page, 66 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11791172&FileExtension=pdf&FileName=PIREPS-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. --- 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.