ANC99FA047

NTSB accident investigation · Cessna 207A · Kotzebue, AK · April 14, 1999

Accident · FatalField investigationFinal report
Date
April 14, 1999, 09:30 local (17:30 UTC)
Place
Kotzebue, AK
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N73188Cessna 207A
Weather
Instrument (IMC) · Day
Status
Completed · report June 23, 2000
Report
Approved by Office Director
NTSB office
Alaska Regional Office
FAA report
19990414003459A
Case key
46095

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 continued VFR flight into instrument meteorological conditions, spatial disorientation, and an inadvertent stall. Factors in the accident were weather conditions consisting of snow and mist, and flat lighting conditions.

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
Weather condition - snow
Vfr flight into imc - continuedPilot in command
Light condition - other
Loss of control - in flightCruise
Vacuum system - failure,partial
Aircraft control - not maintainedPilot in command
Spatial disorientationPilot in command
In flight collision with terrain/waterDescent - uncontrolled

Analysis

The certificated airline transport pilot departed on a flight to a remote village about 37 miles away. The trip was the first since an annual inspection had been completed the day before. The pilot departed with fuel only in the left wing tank. The right wing tank was empty. About 35 minutes later, the pilot was on a return flight to his original departure airport that was within Class E airspace. During the pilot's absence, the airport visibility had decreased to 1 1/2 mile. Instrument meteorological conditions, and special VFR procedures were in use. A 'MAYDAY' was heard over the common traffic advisory frequency, and was monitored by the local flight service station. The voice of the pilot was recognized as the accident pilot. Search personnel found the airplane on a flat area of a frozen, snow-covered lagoon. The weather at the accident site was described as fog, with flat lighting conditions. The wreckage path was oriented away from higher terrain around the destination airport which is located on a peninsula. The airplane had crashed in a nose down attitude, and came to rest inverted. The engine separated completely from the airframe. An examination of the engine revealed fuel throughout, and mechanical continuity. The vacuum pump's internal support post, on which the internal block rotated, was found fractured through 70 percent of its diameter from fatigue, the remaining portion of fracture was overstress. The airplane was equipped with a standby vacuum system. An examination of the airframe located a combination screwdriver in the left wing. The handle was shattered. No flight control cable impingement was observed.

Factual narrative

History of flight

On April 14, 1999, about 0930 Alaska daylight time, a Cessna 207A airplane, N73188, was destroyed after crashing on an ice and snow-covered lagoon, about 10.3 nautical miles east of Kotzebue, Alaska. The airplane was being operated as a visual flight rules (VFR) scheduled domestic flight under Title 14, CFR Part 135, when the accident occurred. The airplane was operated as Flight 303X, by Village Aviation Inc., doing business as Camai Air. The flight was an extra section to scheduled Flight 303. The certificated airline transport pilot, the sole occupant, received fatal injuries. Instrument meteorological conditions prevailed in the area of the accident. A VFR flight plan was filed.

At 0845:44, the pilot contacted the In-Flight One position of the Kotzebue Flight Service Station (FSS) on a frequency of 122.2 MHz. The pilot filed a VFR flight plan to Noorvik, Alaska, with a return to Kotzebue. His planned time en route was one hour, and he said he had three hours of fuel. The pilot departed with cargo consisting of U.S. mail, and opened his flight plan at 0847:19. The distance from Kotzebue to Noorvik is 37 nautical miles, and the operator said the flight usually takes 28 minutes. The weather conditions at Kotzebue included a visibility of 3 miles in light snow and mist.

After the flight departed Kotzebue, the weather conditions deteriorated below basic VFR minimums. At 0908, a special weather observation at Kotzebue included a visibility of 1.5 miles in light snow and mist.

At an estimated time of 0920, the airplane departed the Robert Curtis Memorial Airport, Noorvik, Alaska, with no mail or cargo for the return flight to Kotzebue. There are no weather reporting facilities at Noorvik. Instrument meteorological conditions prevailed at Kotzebue as the accident flight was returning from Noorvik. Special VFR (SVFR) clearances, upon request of pilots, were being granted by Kotzebue FSS personnel for operations in the Class E airspace around the Kotzebue airport.

At 0928:48, Kotzebue FSS personnel and other pilots monitoring the Kotzebue common traffic advisory frequency (CTAF) of 123.6 MHz, heard a radio call of "mayday, mayday, mayday." The pilot's voice was identified by those hearing the radio call. At 0933:48, aircraft in the area reported hearing an emergency locator transmitter (ELT) signal. The ELT was not heard at the Kotzebue FSS.

Ground search personnel departed Kotzebue on snow machines, and located the wreckage on the Hotham Inlet, about 1055. The accident site is about 1/2 nautical mile east of the shoreline of the Baldwin Peninsula.

The accident occurred during the hours of daylight at latitude 66 degrees, 50.908 minutes north, and longitude 162 degrees, 09.965 minutes west.

Crew information

The pilot held an airline transport pilot certificate with airplane single-engine land, single engine sea, multiengine land, and multiengine sea ratings. He also held commercial pilot privileges with a rotorcraft helicopter rating. The most recent second-class medical certificate was issued to the pilot on April 6, 1998, and contained the limitation that the pilot must have available glasses for near vision.

No personal flight records were located for the pilot, and the aeronautical experience listed on page 3 of this report was obtained from the operator's records. The pilot was hired on August 14, 1998. Prior to joining the company, he accrued extensive 14 CFR Part 135 experience flying in Alaska,.

The pilot completed an airman competency/proficiency check flight under Title 14 CFR Part 135.293 (Initial and Recurrent Testing), and 135.299 (Pilot-in-Command Line Check), with the chief pilot for the operator in a Cessna 207 airplane on August 21, 1998. A CFR Part 135.299 (Instrument Proficiency Check) check flight was not performed, nor was it required. The chief pilot noted that the pilot demonstrated basic IFR competency.

According to company records, the pilot's total aeronautical experience exceeded 10,000 hours, of which over 7,800 hours were accrued in the accident airplane make and model. In the preceding 90 and 30 days prior to the accident, the company listed a total of 175 and 66 hours respectively. The accident flight was the pilot's first flight since he last flew on April 10, 1999.

Aircraft information

An annual inspection of the airframe and engine had been completed the day before the accident. At that time, the airplane had accumulated a total time in service of 16,789.2 hours. The airplane then flew an additional .7 hours before the accident. During the annual inspection, the right wing fuel tank was drained of about 30 gallons of fuel to replace a fuel line.

The engine was rebuilt by the Teledyne Continental Motor Company on October 15, 1997. It was installed on the accident airplane by the operator on February 13, 1998. At the time of the annual inspection on April 13, 1999, the engine had accrued 1,179.2 hours since it was rebuilt. It then accrued an additional .7 hours before the accident.

The airplane is equipped with two fuel tanks, one mounted in each wing. Each tank has a capacity of 40 gallons, with 3.5 gallons as unusable fuel. Fuel cannot be used from both tanks simultaneously.

The station manager reported the pilot did not place any fuel into the right wing fuel tank of the airplane before departure to Noorvik. The left wing fuel tank contained an estimated 30 gallons of fuel.

The airplane was equipped with basic instruments for flight in instrument conditions.

The engine was equipped with a dry air pump that provided suction power for the airplane's attitude indicator, and the directional indicator. An Airborne dry pump, overhauled by Rapco Inc., was installed on the engine by the operator on October 19, 1998. At the time of the accident, the pump had accrued 634.0 hours. During the annual inspection on the day before the accident, the operator's inspection run-up sheet contained a notation that the vacuum pressure was 5.1 inches. The normal suction range is between 4.6 and 5.4 inHg.

In the event of a loss of suction from the engine driven vacuum pump, the airplane was equipped with a redundant, standby vacuum system from Precise Flight Inc., Bend, Oregon. The system was installed on March 2, 1990, under Supplemental Type Certificate (STC) number SA216NM. The system consisted of a valve installed in a hose between the engine intake manifold, and the airplane's attitude instruments. A cable was installed between the valve and the instrument panel. The valve was rotated to the open position by pulling on an instrument panel knob. An "instrument source/pump inop warning" light emitting diode (LED) was also installed in the instrument panel to alert the pilot of a primary vacuum system failure.

Meteorological information

The closest official weather observation station is located at Kotzebue. Instrument meteorological conditions existed at the airport as the pilot was returning from Noorvik. At 0908, a special weather observation was reporting in part: Wind, 030 degrees (true) at 7 knots; visibility, 1.5 statute miles in light snow and mist; clouds and sky condition, 2,100 feet scattered, 3,600 feet overcast; temperature, 12 degrees F; dew point, 8 degrees F; altimeter, 30.10 inHg.

Search personnel at the accident scene reported overcast clouds and fog. Flat lighting conditions prevailed with little definition or contrast between the horizon and the ground.

Communications

Review of the air-ground radio communications tapes maintained by the FAA at the Kotzebue FSS facility, revealed the pilot communicated with the position of In-Flight One when he filed a VFR flight plan. The FAA found no record indicating the pilot received a weather briefing. A transcript of the air to ground communications between the airplane and the Kotzebue FSS is included in this report.

Continuous data rec

Aircraft

Registration
N73188
Reported as
Cessna 207A
Category
Airplane
Serial number
20700568
Airframe hours
16,790
Engine
Continental IO-520-F, 300 horsepower, reciprocating
Damage
Destroyed
Flight
Part 135
Registered owner
Village Aviation, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
Annual · April 13, 1999 · 1 hours before
Departed
ORV · Noorvik, AK
Destination
OTZ
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
57
Certificates
Airline transport, Commercial
Airplane ratings
Multi-engine sea, Single-engine land, Multi-engine land, Single-engine sea
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
10,000 total · 7,800 in this make and model · 8,000 as pilot in command · 175 in the last 90 days · 66 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Day
Wind
30° at 7 knots
Visibility
1.5 statute miles
Lowest ceiling
3,600 ft overcast
Temperature
12 °F, dew point 9 °F
Altimeter
30.00 inHg
Observed at
OTZ, 10 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.

Other investigations on N73188 · 1

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