ANC23LA002

NTSB accident investigation · Piper PA-32-260 · Cordova, AK · October 16, 2022

Accident · FatalClass 3 · LimitedFinal report
Date
October 16, 2022, 14:27 local (22:27 UTC)
Place
Cordova, AK · Side of mountain
Injuries
1 fatal
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N3432WPiper PA-32-260
Defining event
Enroute: VFR encounter with IMC
Weather
Instrument (IMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Alaska Regional Office
Parties
FAA
FAA report
20221016020109A
Case key
106134

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 improper decision to continue visual flight rules flight into instrument meteorological conditions, which resulted in controlled flight into terrain.

Findings · 3

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-32-260: 2 casesAll aircraft: 792 casesProbable cause
Ceiling/visibility/precip: low visibilityEnvironmental issues › Conditions/weather/phenomena · Decision related to conditionPiper PA-32-260: 1 caseAll aircraft: 175 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

After departing on a cross-country flight, the pilot returned to the departure airport due to poor weather conditions along the route. After landing, the pilot discussed the poor weather with a friend and told him he wanted to fly to another airport where he could leave the airplane and continue his trip using a commercial airline. His friend recommended that he stay where he was until the weather improved. The pilot subsequently received two weather briefings informing him that visual flight rules (VFR) flight was not recommended along his planned route due to instrument meteorological conditions (IMC). The pilot departed on the flight and was in communication with flight service while airborne when the communications ended abruptly and an emergency locator transmitter (ELT) activated. An eyewitness saw the airplane flying in and out of clouds before disappearing into the clouds near the accident site location. The airplane wreckage was found along a steep mountainside at an elevation about 1,866 ft mean sea level. Examination of the wreckage did not reveal any anomalies that would have precluded normal operation. The weather forecast information applicable for the accident time indicated that an AIRMET was valid for mountain obscuration conditions, and a Terminal Area Forecast (TAF) near the accident site valid at the accident time stated that IMC conditions were likely. Toxicology testing detected the antidepressant amitriptyline and its active metabolite nortriptyline in the pilot’s blood at therapeutic levels. While these substances are associated with side effects such as drowsiness and dizziness, the operational findings of this accident do not suggest performance issues related to fatigue. Gabapentin and norcyclobenzaprine were detected in the pilot’s urine and not in his blood, so no therapeutic or side effects would be expected. Thus, the effects from the pilot’s use of amitriptyline, gabapentin, and cyclobenzaprine were not likely a factor in this accident. The pilot had high urinary glucose; the cause was unknown but could possibly be dietary, from kidney disease, from diabetes medications, or from being diabetic. However, no glucose was detected in his vitreous fluid and his hemoglobin A1C indicates his average blood glucose levels would be around 120 mg/dL. Thus, it is unlikely that the pilot had low blood glucose, which is the concern for flight safety. Based on the available information, the circumstances of the accident are consistent with the pilot’s decision to conduct a visual flight rules flight into instrument meteorological conditions, which resulted in controlled flight into terrain.

Factual narrative

On October 16, 2022, about 1427 Alaska daylight time, a Piper PA-32-260, N3432W, was substantially damaged when it was involved in an accident near Cordova, Alaska. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight. The pilot departed from Yakutat Airport (PYAK), Yakutat, Alaska, and was traveling along the coast to his home in St Louis, Missouri. Near Ketchikan, Alaska, the pilot turned the airplane around due to poor weather and returned to YAK. The pilot called a friend after landing and they discussed the poor weather along the coast. The pilot told his friend that he was tired of flying in poor weather conditions and was going to return the airplane to Birchwood Airport (PABV), Birchwood, Alaska, leave the airplane there, and fly home commercially. His friend recommended that the pilot stay in Yakutat until the weather improved. The pilot called the Alaska Flight Service Station (AK FSS) about 1220. He was provided weather information and informed that “VFR flight was not recommended.” The pilot told AK FSS that he was having trouble hearing them and said he would call them back on frequency. The pilot subsequently radioed AK FSS about 1224. The pilot was provided an abbreviated weather briefing per his request and was informed again that VFR flight in the Cordova, Alaska, area was not recommended due to the weather conditions. The pilot informed AK FSS he planned to depart PYAK about 1300. At 1426, the pilot contacted AK FSS and provided an update on his position and requested an update on weather in the Anchorage area. During the conversation, the transmission between the pilot and FSS stopped, and an emergency locator transmitter (ELT) activated. An eyewitness saw the airplane flying in and out of the clouds before disappearing into the clouds near the accident site. A search was initiated, and the airplane wreckage was located along a steep mountainside at an elevation about 1,866 ft mean sea level about 6 miles southwest of Cordova Municipal Airport (CKU). The 62-year-old pilot held a second-class medical certificate with the limitation that he must have available glasses for near vision. At his most recent FAA medical examination on March 8, 2022, he reported taking no medications and having no medical conditions. According to the autopsy report, the pilot’s cause of death was multiple blunt force injuries, and the manner of death was accident. The medical examiner reported the pilot had 50% atherosclerotic narrowing of his left anterior descending coronary artery and 50-60% narrowing of his distal right coronary artery. Toxicology testing detected amitriptyline in the pilot’s subclavian blood at 135 nanograms per milliliter (ng/mL) and in his urine at 76 ng/mL. Amitriptyline’s active metabolite nortriptyline was detected in his subclavian blood at 45 ng/mL and in his urine. Gabapentin and norcyclobenzaprine were detected in his urine, but not in his blood.Glucose was detected in the pilot’s urine at 1,491 milligrams per deciliter (mg/dL), but not in his vitreous fluid; his hemoglobin A1C was 5.8%. The pilot’s toxicology detected the antidepressant amitriptyline and its active metabolite nortriptyline in the pilot’s blood at therapeutic levels. Merle K (Mudhole) Smith Airport (PACV), Cordova, Alaska, located 10 miles east-northeast of the accident site, at an elevation of 53 ft, was the closest official weather station to the accident site. PACV had an Automated Surface Observing System (ASOS) whose longline reports were augmented by a Contract Weather Observer. The recorded conditions at 1423 included wind from 110° at 14 knots with gusts to 24 knots, visibility 10 miles or greater, light rain, broken cloud ceiling at 1,000 ft above ground level (agl), broken ceiling at 1,400 ft agl, overcast ceiling at 2,400 ft agl, temperature 11°C, dew point temperature 9°C, and an altimeter setting of 29.50 inches of mercury (inHg). Remarks included that rain began at 1418, with a varying cloud ceiling between 700 and 1,200 ft agl. The 1453 observation included wind from 120° at 16 knots with gusts to 27 knots, visibility 10 miles or greater, overcast ceiling at 1,200 ft agl, temperature 11°C, dew point temperature 9°C, and an altimeter setting of 29.50 inHg. Peak wind from 130° at 27 knots was recorded at 1450. PACV was the closest site with an NWS TAF current at the time of the accident. The TAF was issued at 1302 and was valid for a 21-hour period beginning at 1300. Between 1300 and 1600, the forecast expected wind from 120° at 12 knots with gusts to 20 knots, 6 miles visibility, light rain showers, scattered clouds at 600 ft agl, and an overcast ceiling at 1,000 ft agl. Temporary conditions were forecast between 1300 and 1600 with 4 miles visibility, light rain showers, mist, and a broken ceiling at 600 ft agl. Three days before the accident flight, the pilot underwent a Federal Aviation Administration Part 135 flight test evaluation in the accident airplane. The overall result of the evaluation was unsatisfactory for the tasks of preflight inspection, inflight powerplant failure, system malfunctions, emergency landing, instrument approach, short field landing, and judgment. The wreckage was recovered from the accident site 11 months after the accident. Examination of the airplane revealed that the rudder was attached to all attachment points and moved freely, with minor impact damage to the fiberglass cap on top of the rudder. Rudder flight control cables remained attached to the rudder with an overload break at pulleys located about 5.5 ft from the lower baggage compartment wall. The elevator remained attached at all attachment points and moved freely. Elevator control cable continuity was established from the elevator to the break in the fuselage about 5.5 ft from the beginning of the lower baggage compartment wall. The elevator trim tab was relatively undamaged and was attached to all attachmentpoints. Some movement of the trim tab was possible but was limited by impact damage to the trim cable assembly. Trim tab control continuity was established from the trim tab to the break in the fuselage about 5.5 ft into the airplane from the beginning of the lower baggage compartment wall. The right trim tab control assembly attachment bracket near the trim tab was still attached; the left side bracket was impact damaged with 45° shear lips. Visual inspection from the tail into the empennage revealed that all cables and pulleys were intact. Both sides of the empennage displayed impact damage consistent with impact with the elevator. The right side of the empennage/fuselage exhibited accordion impact damage at about a 45° angle. The engine could be rotated by hand, but rotation was limited due to lack of equipment and personnel. The magnetos remained securely attached to the engine. Broken intake and exhaust connections allowed water to enter into the engine. The engine internals were exposed to the elements for almost a year. The spark plugs and cylinders’ interiors were rusted. All three propeller blades exhibited rotational scoring and bending of the blades consistent with the engine producing power at the time of impact. A Garmin GPSMAP 696 was sent to the NTSB’s Vehicle Recorder Division; however, the device did not contain any data pertaining to the accident flight.

Aircraft

Registration
N3432W
Reported as
Piper PA-32-260
Category
Airplane
Serial number
32-329
Built
1966
Engine
Lycoming O-540 SERIES, 250 horsepower, reciprocating
Damage
Substantial damage
Flight
Positioning · Part 91
Registered owner
Nunak Air Taxi LLC
Airworthiness certificate
Standard, Normal
Departed
PAYA · Yakutat, AK
Destination
PABV · Birchwood, AK
Flight plan
VFR

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
62
Injuries
Fatal
Certificates
Airline transport, Commercial, Flight engineer
Airplane ratings
Single-engine land, Multi-engine land, Single-engine sea
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
October 13, 2022
Seat
Left
Toxicology
Performed

Weather

Conditions
Instrument (IMC) · Day
Wind
110° at 14 knots, gusting 24
Visibility
10 statute miles
Lowest ceiling
1,000 ft broken
Temperature
52 °F, dew point 48 °F
Altimeter
29.50 inHg
Observed at
PACV, 11 nm away
METAR
PACV 162223Z 11014G24KT 10SM -RA BKN010 BKN014 OVC024 11/09 A2950 RMK AO2 RAB18 CIG 007V012 P0000 T01060089

Docket · 13

The files NTSB released with the investigation on March 28, 2024, on NTSB’s docket system: statements, records, photos and specialists’ reports. 135 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 N3432W · 1

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