# NTSB ANC97FA097: Piper PA-32, N15199, Skagway, AK, July 4, 1997 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: July 3, 1997, 17:30 local (Jul 4, 1997, 01:30 UTC) - Place: Skagway, AK - Coordinates: 59.570816, -135.349029 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=59.5708&lon=-135.3490&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 4 fatal, 1 minor, 1 uninjured - Status: Completed, report July 13, 1998 - Report: Approved by Office Director - NTSB office: Alaska Regional Office - Safety recommendations: Yes - NTSB case key (mKey): 2937 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ANC97FA097 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/2937/pdf - Page: https://openairdocs.org/ntsb/ANC97FA097 ## Probable cause jamming/failure of the left magneto impulse coupling, which stopped rotation of the magneto gear, and resulted in subsequent shearing of the accessory intermediate idler gear. Factors relating to the accident were: the lack of suitable terrain for a forced landing, which necessitated ditching of the aircraft; the passenger's lack of awareness concerning access to life vests, due to the pilot's inadequate briefing and the seat covers being installed over pouches that held the life vests; insufficient company standards/procedures regarding access to life vests. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(total) - mech failure/malf, approach - ignition system,magneto - jammed (cause) - accessory drive assy,drive gear - sheared (cause) - Forced landing, emergency descent/landing - Ditching, emergency landing - terrain condition - none suitable (contributing factor) - terrain condition - water (contributing factor) - passenger briefing - inadequate, pilot in command (contributing factor) - misc eqpt/furnishings,survival equipment - restricted (contributing factor) - emergency equipment - not obtained, passenger (contributing factor) - insufficient standards/requirements, company/operator mgmt (contributing factor) ## Analysis The aircraft (acft) was on an air taxi/sightseeing flight (flt), which was an optional tour to a cruise liner trip. After viewing glaciers, flt was returning to land. Approach to airport (arpt) was along inlet shore, which had steep mountains descending to the water & infrequent areas of small beach. About 1,200' above water & 1-1/2 mi from arpt, engine lost power. Acft was ditched about 100' from shore near small cliffs. Passengers (pax) exited 1st into 39 deg water, but none exited with life vests. Plt threw one life vest out & exited as acft sank. With help from her husband, a pax donned the life vest that was thrown out; she partially inflated it using oral inflation tube, although it had CO2 cylinder for rapid inflation. Rescue helicopter arrived in about 10 min. Pax with life vest & plt were rescued; 2 pax drowned; other 2 pax were not found. Surviving pax did not recall briefing about location or use of life vests. Life vests were stored in seat-back pouches, but pouch openings were covered by slip-cover type seat covers. Exam of engine revealed left magneto impulse coupling had failed, stopping rotation of magneto drive gear. Several gear teeth on intermediate idler gear were damaged, disconnecting crankshaft from accessory gear train. ## Factual narrative HISTORY OF FLIGHT On July 3, 1997, about 1730 Alaska daylight time, a wheel equipped Piper PA-32 airplane, N15199, ditched in the ocean about 1 1/2 miles southwest of Skagway, Alaska. The airplane was being operated as a visual flight rules (VFR) sightseeing flight under Title 14 CFR Part 135 when the accident occurred. The airplane, registered to and operated by Haines Airways Inc., Haines, Alaska, sank after ditching. The certificated commercial pilot was not injured. One passenger sustained minor injuries. Two passengers received fatal injuries. Two additional passengers were not located, and are presumed to have received fatal injuries. Visual meteorological conditions prevailed. VFR company flight following procedures were in effect. The flight originated at the Haines Airport, at 1640. The flight was one of several airplanes utilized to provide sightseeing flights for cruise liner passengers. The passenger's cruise ship was docked in Skagway, and the accident flight was the second portion of an eagle viewing/glacier tour from Skagway to Haines, and return. Following the departure from Haines, the flight proceeded to overfly several glaciers, and then flew north into the Taiya Inlet. The terrain in the inlet is comprised of steep mountains that descend to the water with infrequent areas of small beach. Voluntary traffic flow procedures for airplanes operating into, and out of Skagway, have been established by agreement with the Federal Aviation Administration (FAA), and operators in the area. In-bound airplanes to Skagway fly northbound along the west shoreline of the Taiya Inlet. Position reports are usually made by arriving pilots at Taiya Point, Long Falls, and Burrow Creek. The pilot reported she was proceeding northbound along the west side of the Taiya Inlet about 1,500 feet mean sea level. She was slowly descending for landing with the airplane positioned between 1/4 to 1/2 mile from the shore. As the flight was approaching Burro Creek, a VFR reporting point that is about 2 miles southwest of Skagway, the engine began to lose fuel pressure, and then stopped. At that time, the airplane was about 1,200 feet msl. Emergency procedures failed to restore engine power. The pilot transmitted several radio calls for assistance, stating among other calls, "I need help" several times. Other company pilots heard the radio calls from the accident airplane, and attempted to offer suggestions over the radio. The pilot initially made a right turn in a northeast direction, toward runway 01 at Skagway. The pilot determined the airplane lacked sufficient altitude to glide across the inlet to the Skagway Airport, and made a left turn toward the west shore of the Taiya Inlet. The pilot selected full flaps, and ditched the airplane about 100 feet from the west shoreline of the inlet. Following water contact, the pilot indicated the front seat and middle seat occupants exited the airplane through the right front door. The rear seat occupants exited through the left rear door. All occupants successfully evacuated the airplane into the water. The water temperature was estimated at 39 degrees F. Following water impact, the pilot of the accident airplane was heard over the radio to yell, "get out" several times. A tour helicopter based in Skagway was following the accident airplane into Skagway, and was about 1 mile behind the airplane. The pilot of the helicopter observed the airplane in the water and orbited over the scene. The helicopter pilot reported observing five persons near the sinking airplane. The occupants of the helicopter threw several life vests into the water in an attempt to aid the survivors. The helicopter pilot requested additional help, and a second helicopter responded to the scene within 10 minutes. The two survivors were pulled from the water by the crew of the second helicopter, and air-lifted to Skagway. The accident occurred during the hours of daylight at latitude 59 degrees, 26.98 minutes north, and longitude 135 degrees, 21.76 minutes west. CREW INFORMATION The pilot holds a commercial pilot certificate with airplane single-engine land, single-engine sea, multiengine land, and instrument airplane ratings. In addition, the pilot holds a flight instructor certificate with airplane single-engine, and instrument airplane ratings. The most recent first-class medical certificate was issued to the pilot on September 10, 1996, and contained no limitations. The pilot completed her basic indoctrination training on April 15, 1997. She received her Part 135 pilot check-flight on April 21, 1997, and her route check flights on April 24, 1997. According to the operator, the pilot's total aeronautical experience consists of about 1,815 hours, of which 200 hours were accrued in the accident airplane make and model. In the preceding 90 and 30 days prior to the accident, the pilot accrued a total of 189 and 106 hours respectively. A review of the pilot's flight and duty records revealed that on June 30, 1997, the pilot worked from 0500 to 1430, and accrued 3.17 flight hours. On July 1 and July 2, 1997, the pilot worked from 0500 to 1830. The flight hours accrued on those days were not noted. The pilot began work at 0500 on the day of the accident. AIRCRAFT INFORMATION The airplane had accumulated a total time in service of 4,688.9 hours. Examination of the maintenance records revealed the most recent annual inspection was accomplished on October 14, 1996, 747.8 hours before the accident. In addition, a 100-hour inspection was completed on June 26, 1997, 47.5 hours before the accident. The airplane was equipped with a Lycoming, IO-540-K1A5, engine. The engine was purchased from West Star Aviation Inc., Grand Junction, Colorado on September 25, 1996, as an exchanged, "0" time engine. West Star Aviation certified the engine as a: "Gold Star zero time equivalent engine per Lycoming manual 60294-7-4. Engine and accessories were remanufactured to factory new tolerances." The previous total time on the engine was 3,742.2 hours. According to West Star personnel, the engine crankcase was cracked adjacent to the number 4 cylinder. The crankcase was sent to Div Co, Inc., Tulsa, Oklahoma, for welding and machining. Div Co personnel reported the crankcase was repaired on September 5, 1996. The repair included machining of the case-half mating surfaces, and welding and reboring of the magneto bearing bore holes, located at the aft end of the crankcase. Since the engine was installed in the accident airplane on October 14, 1996, the engine had accrued 747.8 hours. The engine annual and 100 hour inspections, coincided with the airframe inspections. The engine is equipped with Slick magnetos, part number 6351 for the left magneto, and part number 6350 for the right. The left magneto is equipped with an impulse coupling, part number M3333. The magnetos are subject to a recurring 500 hour inspection. That inspection was conducted by the operator on May 16, 1997, at 500.7 hours of service. During normal operation, the engine accessory gears are turned either by the starter (during engine start), or by normal engine operation. When viewed from the aft end of the engine, looking forward, the crankshaft gear rotates clockwise. The crankshaft gear drives two intermediate idler gears in a counterclockwise direction. The idler gears drive the left and right engine magneto drive gears clockwise. The magneto drive gear mates to a rotating bearing installed in a bearing bore hole. The bearing bore is drilled into the aft end of the engine crankcase. An impulse coupling is utilized to delay magneto spark during engine starting until the engine pistons have reached top dead center. The coupling consists of a hub assembly mounted on the magneto shaft. The hub assembly is comprised of a heel plate, on which two impulse pawls are attached by rivets. The rivets serve a ## Aircraft - Registration: [N15199](https://openairdocs.org/deregistered/N15199-2015-05-18), registration cancelled 2015-05-18, S/N 32-7340021, built 1972 (OpenAirDocs) - Reported make and model: Piper PA-32 - Registry model: [Piper PA-32-300](https://openairdocs.org/model/piper-pa-32-300) (registry code 7103212) (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: 32-7340021 - Airframe hours: 4689 - Engines: Lycoming IO-540-K1A5 300 horsepower reciprocating - Damage: Destroyed - Flight: Part 135 - Registered owner: Haines Airways Inc. - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, June 26, 1997, 48 hours before - Departed: HNS, HAINES, AK - Destination: SGY - Flight plan: Company VFR - Airport: SGY, Skagway ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 42; commercial, flight instructor; airplane ratings: multi-engine land, single-engine sea, single-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; seat: left; flight hours: 1,815 total, 200 in this make and model, 189 in the last 90 days, 106 in the last 30 days, 4 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 73° at 14 knots - Visibility: 10 statute miles - Lowest ceiling: 5,500 ft overcast - Temperature: 64 °F, dew point 52 °F - Altimeter: 30.00 inHg - Observed at: SGY, 1 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 19970704016899A](https://openairdocs.org/incident/19970704016899A), Jul 4, 1997: Piper PA32300, Skagway, AK, Destroyed, 4 fatal. A sightseeing plane carrying cruise ship passengers crashed into water. (.4)the aircraft (acft) was on an air taxi/sightseeing flight (flt), which was an… 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.