# NTSB SEA03FA028: Piper PA-28-181, N7282C, Eastsound, WA, January 19, 2003 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: January 18, 2003, 20:10 local (Jan 19, 2003, 04:10 UTC) - Place: Eastsound, WA - Coordinates: 48.701946, -122.945831 - Nearby events: https://openairdocs.org/map.md?lat=48.7019&lon=-122.9458&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal, 1 serious, 1 minor, 1 uninjured - Status: Completed, report September 30, 2003 - Report: Approved by Office Director - Parties: Seattle FSDO - NTSB case key (mKey): 56413 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=SEA03FA028 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/56413/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=56413 - Page: https://openairdocs.org/ntsb/SEA03FA028 ## Probable cause The pilot's failure to maintain clearance from the water and his failure to reset the altimeter to the local barometric pressure. Contributing factors were fog and night conditions. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight collision with terrain/water, maneuvering - clearance - not maintained, pilot in command (cause) - procedures/directives - improper, pilot in command (contributing factor) - weather observation - not obtained, pilot in command (contributing factor) - light condition - night (contributing factor) - weather condition - fog (contributing factor) ## Analysis At the time of departure for the 30 minute night flight to an island destination, the pilot set his altimeter to field elevation instead of to the broadcast barometric pressure from the nearby Automated Surface Observation System (ASOS). During the climbout, the pilot contact Air Traffic Control, which gave him an altimeter barometric pressure setting and advised him of radar contact passing 2,500 feet. At that point the pilot set his altimeter to an indicated altitude of 2,500 feet instead of at the correct barometric pressure setting. Upon arriving in the area of the destination airport, the pilot found it covered by a low-level fog layer. Without acquiring an updated altimeter setting from the ASOS on the neighboring island, or from the Automatic Terminal Information Service (ATIS) on the nearby mainland, he descended over the water in order to try to find a way to get to the airport underneath the fog. Just after leveling off at what his altimeter indicated was 500 feet, the aircraft impacted the water. It was ultimately determined that at no time during the flight did the pilot set the aircraft's altimeter in reference to an issued barometric pressure. ## Factual narrative HISTORY OF FLIGHT On January 18, 2003, approximately 2010 Pacific standard time, a Piper PA-28-181, N7282C, impacted the waters of President Channel about one-third mile west of Orcas Island, Washington. The private pilot received serious injuries, the passenger in the right front seat received minor injuries, one passenger in the rear seat was uninjured, and the other rear seat passenger was still strapped in the seat when the aircraft sank to the bottom. The aircraft, which was owned and operated by the pilot, was destroyed by the impact sequence and the effects of the salt-water immersion. The 14 CFR Part 91 personal pleasure flight, which departed Sequim, Washington, about 30 minutes prior to the accident, was being operated in an area where fog and low ceilings had been reported. No flight plan had been filed. There was no report of an ELT activation. According to the pilot, on the day of the accident, he flew his immediate family from Orcas Island to Sequim, landing there between 0900 and 0915. He and his passengers spent the day with extended family members and attended a church activity in the early evening. They arrived back at the Sequim Valley Airport about 1930, and after a normal preflight, during which the pilot found no anomalies or discrepancies, the flight departed for Orcas Island around 1940. According to the pilot, prior to departure, instead of setting his altimeter to the barometric pressure being transmitted from the Fairchild International Airport Automated Surface Observation System (ASOS), which is located approximately 12 miles west of Sequim Valley, he moved the altimeter-setting knob until the needles on the altimeter matched the published field elevation at Sequim Valley. After departure, he turned to the north and contacted Whidbey Approach as the aircraft was approaching an indicated altitude of 2,000 feet. Upon initial contact with the Whidbey controller, the pilot stated he was "…requesting flight following from Sequim Valley, presently 2,000, climbing to five point five, to Orcas Island eastbound." The controller immediately responded by instructing the pilot to squawk 0441 (mode C code), and advising him that the Whidbey altimeter was 30.18. The pilot repeated the mode C code, but did not make the required read-back of the altimeter setting. Thirteen seconds after the pilot stated that he was "presently 2,000," the controller advised him that Approach had radar contact at 2,500 feet, three miles northeast of Sequim. In a telephone conversation with the NTSB Investigator-In-Charge (IIC), the pilot stated that he then immediately set his altimeter so that it would read 2,500 feet. When asked, he said that he did not set in the barometric pressure provided to him by Whidbey Approach, nor did he check to see what the difference was between the barometric pressure setting now showing on his altimeter (after setting it to 2,500 feet) and that given by the controller. After setting 2,500 feet on his altimeter, the pilot climbed to an indicated altitude of 5,500 feet, and continued on toward his destination. Approximately 15 minutes later, the Whidbey controller advised the pilot that he was eight miles east of Eastsound, and that radar service was being terminated. Soon thereafter, as he flew past the town of Orcas, the pilot noticed that there was an area of low-level fog in the vicinity of the airport. He then continued his descent toward the destination, but did not update his altimeter using the barometric pressure setting transmitted by the Friday Harbor, Washington, ASOS or the Bellingham, Washington Automatic Terminal Information Service (ATIS). When he arrived in the area of the airport itself, he determined that the fog covered the airport, the town of Eastsound, the northern portion of Eastsound Inlet, and an area that extended about three miles north to the southern tip of Sucia Island. The pilot therefore overflew the airport from south to north, proceeded to a point just south of Sucia Island, and then made a left turn back to a point west of Eastsound over President Channel (between Orcas Island and Waldron Island). From there he turned back north again with the intention of looking for a place where he could descend below the fog in order to attempt to proceed to the airport (see pilot's diagrams with 6120.1/2). As he proceeded north, the pilot continued to descend over the water until he reached a point where his altimeter read approximately 600 feet indicated. He then turned on the landing light because he could not see the surface of the water. According to the pilot, just after he leveled at 500 feet indicated, his wife remarked that the water looked close, and then almost immediately thereafter, the left wing of the aircraft impacted the surface of the water. The pilot then immediately pulled up and rapidly added full power. Although he attempted to climb away from the water, he had a hard time determining the attitude of the aircraft because the wing's impact with the water had splashed a considerable amount of salt water on the windshield. Although the engine momentarily sputtered during the rapid throttle increase, according to the pilot, it seemed to quickly accelerate to full power. The pilot then attempted to keep the wings level, but was having trouble doing so. He was not sure if that was because of a lack of visual references on the dark night or because damage to the wing was making the aircraft hard to control. He therefore checked his attitude indicator, which showed that the aircraft was in a left wing-low attitude. Just as he was starting to make an input to roll the aircraft to the right, the left wing again impacted the surface of the water and the aircraft cartwheeled nose first into the channel. At that point, because the cabin entry door had come off, the front windscreen had broken out, and one wing had separated, the aircraft rapidly filled with water. As the aircraft filled with water and began to sink, both front occupants and one person in the rear were able to get out and come to the surface. Although the pilot dove down and attempted to retrieve the other back seat passenger, he was unable to do so before the fuselage sank to the bottom. Individuals on the shore, who heard the impact and yells for help, rescued the survivors in small boats. PERSONNELL INFORMATION The pilot holds a private pilot certificate with a single engine land rating. He does not hold an instrument rating. Of his total 292 hours of pilot time, 162 were in this make and model aircraft, and 28 hours were logged as night time. In a telephone conversation with the IIC, the pilot, who keeps his aircraft at the Orcas Island Airport, said that he had landed at the subject airport at night a number of times in the past. He said that a few times he found it necessary to maneuver under low clouds in order to land there, and that once he diverted to Friday Harbor because the clouds were too low. In the 90 days prior to the accident, he had logged 10 hours of night time. METEOROLOGICAL INFORMATION The 1953 aviation surface observation (METAR) at Friday Harbor, which is located about 12 miles south of the accident site, reported winds of 360 degrees at three knots, clear, seven statute miles visibility, temperature three degrees Celsius, dew point three degrees Celsius, and a barometric pressure of 30.17. The 2053 METAR at Bellingham, which is located about 15 miles northeast of the accident site, indicated winds from ten degrees at three knots, few clouds at 9,000 feet, mist, and a visibility of six miles. Both the temperature and the dew point were one degree, and the barometric pressure was 30.18. The 2022 METAR at Victoria Airport, Victoria, Canada, which is located about 18 miles southwest of the impact area, reported calm winds, one statute mile visibility, mist, few clouds at 100 feet, and a broken ceiling at 400 feet. Approximately one hour and twenty minutes earlier, th ## Aircraft - Registration: [N7282C](https://openairdocs.org/deregistered/N7282C-2008-04-11), registration cancelled 2008-04-11, S/N 28-7690065, built 1975 (OpenAirDocs) - Reported make and model: Piper PA-28-181 - Registry model: [Piper PA-28-181](https://openairdocs.org/model/piper-pa-28-181) (registry code 7102807) (OpenAirDocs) - Registry engine: [Lycoming O&VO-360 series](https://openairdocs.org/engine/lycoming-o-vo-360-series) (registry code 41514, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 7690065 - Airframe hours: 3210 - Engines: Lycoming O-360-A4M 180 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Registered owner: Michael D. Triplett - Airworthiness certificate: Standard, Normal - Last inspection: Annual, July 26, 2002, 79 hours before - Departed: W28, Sequim, WA - Destination: ORS, Eastsound, WA ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 43; injuries: serious; private; airplane ratings: single-engine land; medical: class 3, valid medical--w/ waivers/lim; last flight review April 13, 2001; seat: left; flight hours: 292 total, 162 in this make and model, 236 as pilot in command, 32 in the last 90 days, 13 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Night - Wind: calm - Visibility: 20 statute miles - Lowest ceiling: none - Temperature: 39 °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 20030118001919A](https://openairdocs.org/incident/20030118001919A), Jan 18, 2003: Piper PA28181, Orcusisland, WA, Destroyed, 1 fatal. (-23) The Piper PA-28-181, N7282C was flown fro squim, WA towards orcus island, WA. The pilot reported the airport and town of eastsound were covered by… ## Docket (7 files) The files NTSB released with the investigation on July 23, 2003, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=56413. 1.0 MB in all. - Supplement S (item 1, .PDF, 28 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40184213&FileExtension=.PDF&FileName=Supplement%20S-Master.PDF - Accident Area Map (item 2, .PDF, 251 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40184215&FileExtension=.PDF&FileName=Accident%20Area%20Map-Master.PDF - Photo 1. View of left side of aircraft. (item 3, .PDF, 164 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40187529&FileExtension=.PDF&FileName=Photo%201.%20%20View%20of%20left%20side%20of%20aircraft.-Master.PDF - Photo 2. View of right side of aircraft. (item 4, .PDF, 140 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40187530&FileExtension=.PDF&FileName=Photo%202.%20%20View%20of%20right%20side%20of%20aircraft.-Master.PDF - Photo 3. Close-up view of cabin area. (item 5, .PDF, 140 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40187531&FileExtension=.PDF&FileName=Photo%203.%20%20Close-up%20view%20of%20cabin%20area.-Master.PDF - Photo 4. Underside of left wing. (item 6, .PDF, 125 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40187534&FileExtension=.PDF&FileName=Photo%204.%20%20Underside%20of%20left%20wing.-Master.PDF - Photo 5. Instrument panel (inverted on boat deck). (item 7, .PDF, 163 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40187539&FileExtension=.PDF&FileName=Photo%205.%20%20Instrument%20panel%20(inverted%20on%20boat%20deck).-Master.PDF 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.