ANC93LA096

NTSB accident investigation · Piper PA-32-300 · Juneau, AK · June 18, 1993

Accident · Minor injuriesLimited investigationFinal report
Date
June 18, 1993, 14:30 local (22:30 UTC)
Place
Juneau, AK
Injuries
1 minor, 5 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N30505Piper PA-32-300
Weather
Instrument (IMC) · Day
Status
Completed · report September 15, 1994
Report
Approved by Office Director
NTSB office
Alaska Regional Office
FAA report
19930618019709A
Case key
2363

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 continuing VFR flight into instrument meteorological conditions. Factors which contributed to the accident were: the mountainous terrain, the cloudy weather conditions in the pass, the pilot becoming disoriented, his lack of familiarity with the area, the company's inadequate procedures concerning mountain operations, and insufficient standards set by the federal aviation administration.

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 encounter with weatherCruise - normal
Terrain condition - mountainous/hillyFactor
Weather condition - cloudsFactor
Became lost/disoriented - inadvertentPilot in commandFactor
Lack of familiarity with geographic areaPilot in commandFactor
Vfr flight into imc - continuedPilot in commandCause
Procedures/directives - inadequateCompany/operator managementFactor
Insufficient standards/requirementsFaa(organization)Factor
Forced landingLanding - flare/touchdown

Analysis

The pilot stated he was following a company airplane, which was 3-5 mi ahead, through a pass. He lost sight of the airplane, flew through the wrong pass and entered clouds. He started a 180-DEG turn, slowed the airplane and began a descent. Upon seeing the snow covered glacier, he landed on the surface. The pass he was supposed to fly through was to his right, and he did not make the right turn. He flew straight ahead into a canyon. The chief pilot had flown a training flight with the pilot and showed him the pass and procedures to be used. The company requires their pilots to watch a video outlining the company policy and procedures for mountain flying and pass penetration. The company's training manual shows no reference to training in mountainous terrain or mountain pass operation, nor does it reference the video. In addition, the company operations manual does not address minimum weather operations, mountain operations, or mountain pass operations.

Factual narrative

On June 18, 1993, at 1430 Alaska daylight time, a wheel equipped Piper PA-32-300 airplane, N30505, registered to and operated by L.A.B. Flying Service of Haines, Alaska, crashed into a glacier while attempting to fly through a pass near the Mendenhall Glacier near Juneau, Alaska. The air taxi flight, operating under 14 CFR Part 135, departed Skagway, Alaska and the destination was Juneau. A company visual flight rules flight plan had been filed and instrument meteorological conditions prevailed at the accident site. The airplane was substantially damaged and the Pilot-in-Command and 4 passengers were not injured. One passenger received minor injuries.

According to the Pilot-in-Command, he was following another airplane through the pass. He attempted to follow that airplane, but lost sight of it and flew through the wrong pass. The pilot stated he inadvertently flew into the clouds. He started a 180 degree turn and he slowed the airplane's speed and began a descent. He saw the snow and landed under control on the surface of the glacier.

According to the Chief Pilot, he had flown a training flight with the pilot and showed him the pass and the procedures to be used. The company also has a video tape which outlines the company policy and procedures for mountain flying and pass penetration. The company training manual does not reference the video tape, however, the Chief Pilot stated he ensures that every pilot views the video tape annually.

According to the Chief Pilot the pass in which the accident occurred is one that is commonly used. The procedure they use is to approach the pass in such a fashion that a pilot would be able to turn away and exit the pass. When this procedure is used, the airplane would have to make a slight turn to go through the pass. In this case, the airplane would have made a right turn to go through the pass. The Pilot-in-Command estimated his following distance behind as 3 to 5 miles.

A review of the company training manual showed no reference to training in mountainous terrain or mountain pass operation, however, the "Transition Ground Training" check sheet and the "Initial Ground Training" check sheet make reference to "procedures for recognizing and avoiding severe weather situations; escaping from severe weather situations, in case of inadvertent encounters, including low-altitude windshear...."

The Company Operations Manual does not address minimum weather operations, mountain operations, or mountain pass operations.

The toxicological results were negative.

Aircraft

Registration
N30505
Reported as
Piper PA-32-300 (PA-32=300)
Category
Airplane
Serial number
32-7840199
Airframe hours
1,594
Engine
Lycoming IO-540-KIGS, 300 horsepower, reciprocating
Damage
Substantial damage
Flight
Part 135
Operator
L.A.B. Flying Service
Registered owner
Lab Flying Service
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · June 1, 1993 · 39 hours before
Departed
SGY · Skagway, AK
Flight plan
Company 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
26
Certificates
Commercial, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--no waivers/lim.
Seat
Left
Toxicology
Performed
Flight hours
963 total · 75 in this make and model · 871 as pilot in command · 160 in the last 90 days · 73 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Day
Temperature
37 °F, dew point -0 °F

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 N30505 · 1

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