# NTSB ANC93LA096: Piper PA-32-300, N30505, Juneau, AK, June 18, 1993 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: June 18, 1993, 14:30 local (22:30 UTC) - Place: Juneau, AK - Coordinates: 58.580017, -134.770874 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=58.5800&lon=-134.7709&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Minor injuries - Injuries: 1 minor, 5 uninjured - Status: Completed, report September 15, 1994 - Report: Approved by Office Director - NTSB office: Alaska Regional Office - NTSB case key (mKey): 2363 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ANC93LA096 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/2363/pdf - Page: https://openairdocs.org/ntsb/ANC93LA096 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight encounter with weather, cruise - normal - terrain condition - mountainous/hilly (contributing factor) - weather condition - clouds (contributing factor) - became lost/disoriented - inadvertent, pilot in command (contributing factor) - lack of familiarity with geographic area, pilot in command (contributing factor) - vfr flight into imc - continued, pilot in command (cause) - procedures/directives - inadequate, company/operator management (contributing factor) - insufficient standards/requirements, faa(organization) (contributing factor) - Forced landing, landing - 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](https://openairdocs.org/deregistered/N30505-1999-05-20), registration cancelled 1999-05-20, S/N 32-7840199 (OpenAirDocs) - Reported make and model: PIPER PA-32-300 (PA-32=300) - Registry model: [Piper PA-32-300](https://openairdocs.org/model/piper-pa-32-300) (registry code 7103212) (OpenAirDocs) - Category: Airplane - Serial number: 32-7840199 - Airframe hours: 1594 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 26; 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 (OpenAirDocs). - [Accident 19930618019709A](https://openairdocs.org/incident/19930618019709A), Jun 18, 1993: Piper PA32300, Juneau, AK, Substantial damage. Entered clouds trying to fly through a pass. Made 180 turn. Impacted on glacier. Inadequate training manual a factor ## Other investigations on N30505 (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 ANC98FA006](https://openairdocs.org/ntsb/ANC98FA006), Oct 23, 1997: Piper PA-32-300 (N30505), Juneau, AK, destroyed, 2 fatal. Probable cause: The pilot's intentional flight into adverse weather. Related factors were the low ceilings, mountainous terrain, and self induced pressure by the pilot to complete the flight and return for the… 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.