SEA97FA044

NTSB accident investigation · Piper PA-24-260 · Winston, MT · January 7, 1997

Accident · FatalField investigationFinal report
Date
January 6, 1997, 20:26 local (Jan 7, 1997, 03:26 UTC)
Place
Winston, MT
Injuries
3 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N9080PPiper PA-24-260
Weather
Night/dark
Status
Completed · report April 10, 1998
Report
Approved by Office Director
FAA report
19970106000179A
Case key
42492

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 NTSB’s determination of the probable cause, and any contributing factors.

Pilot incapacitation due to hypoxia. Failure of the pilot to use available oxygen is a factor.

Analysis

An ATC controller observed the night IFR flight with the 68-year old pilot deviating south of course then correcting back a little bit before deviating south again. The deviations were as much as 90 degrees, and altitude varied by about 14,400 feet MSL down to 14,000 feet MSL. Then, approximately 10 southeast of Helena, Montana, radar contact was lost in an area of normally good radar coverage. The airplane sustained an in-flight breakup before impacting in hilly terrain. The flight had been cleared to climb to 12,000 feet at 1936; at 2006 the controlller noted that 'I don't know where he's going...he's all over the place....' During on-scene investigation, it was determined that the portable oxygen bottle being carried in the airplane was not being used by the pilot. The pilot was known to fly at altitudes above 12,500 feet, and as high as 17,000 feet, without using oxygen. An autopsy of the pilot revealed atherosclerosis of coronary arteries with 90% stenosis of left anterior descending coronary artery and 90% stenosis of right coronary artery, as well as multiple blunt force injuries.

Factual narrative

The factual narrative1,335 words

History of flight

On January 6, 1997, at 2026 mountain standard time, a Piper PA-24-260, N9080P, was destroyed when it collided with terrain near Winston, Montana, after an in-flight breakup. The instrument-rated private pilot and his two passengers were fatally injured. The pilot had departed Billings, Montana at 1905, en route to Spokane, Washington, on an instrument flight plan, and was in cruise flight at 14,300 feet mean sea level, according to radar data. The pilot did not report any difficulties. About three sweeps of an ELT signal were noted by Air Traffic Control, but the ELT did not aid in locating the accident site. The aircraft burned after impact.

The pilot had departed Colorado earlier that day with a passenger, picked up another passenger in Wyoming, and had stopped in Billings to eat and refuel. He fueled the airplane with 38.3 gallons of 100 octane fuel, topping off the airplane's fuel tanks. At 1813, the pilot called the Great Falls AFSS by telephone and obtained a preflight pilot weather briefing for an IFR flight from Billings, Montana, via Victor 247 to Helena, then Victor 2 to Spokane, Washington. At 1825, he again called Great Falls AFSS and filed an IFR flight plan from Billings to Spokane.

At 1857, the pilot contacted Billings ground control and requested IFR clearance and taxi instructions. The pilot was issued an IFR clearance to Felts Field, Spokane, Washington, and taxied to runway 28R.

At 1905, N9080P was cleared for takeoff on runway 28R.

At 1908, N9080P was instructed to contact departure control.

At 1909, N9080P established radio contact with departure control, was given radar contact, and was cleared on course via Victor 247 at 10,000 feet.

At 1914, N9080P was told to contact Salt Lake Center on 127.75 mhz. N9080P reported on Salt Lake City ARTCC (ZLC) sector 15 frequency, level at 9000 feet.

At 1916, N9080P was cleared to climb to 11000 feet.

At 1936, N9080P was cleared to climb to 14,000 feet.

At 1938, N9080P was advised that radar contact was lost, and he was told to report 70 miles northwest of Billings.

At 1945, radar contact was reestablished with N9080P, 65 miles northwest of Billings. The pilot reported that his altitude was 13,800 feet.

At 1947, Sector 15 instructed N9080P to contact Salt Lake Center (sector 19) on 133.4 mhz.

At 1947:10, N9080P responded "one-three-three point..." The last portion of the pilot's frequency readback was blocked or cut off. There was no further communication with N9080P, despite repeated attempts by both Salt Lake Center sectors 15 and 19, including attempted relays by three other aircraft in the vicinity, and attempts by Helena approach control.

At 1953, eastbound Alpine Air flight 5031 reported seeing N9080P pass by after the Piper was declared as traffic.

At 2006:45, the sector 19 controller noted in communications with sector 15 that "I don't know where he's going...he's all over the place...."

At 2029, the sector controller being relieved briefed the relieving controller on N9080P, which was believed to be missing at that time; he noted that N9080P had not been flying the airway very well, and had also had difficulty holding his altitude, varying up to 300 feet above and below assigned altitude.

At 2034:37, Helena approach control advised the sector 19 controller that "we had a couple [sweeps] on an ELT that it only hit about three times and then it quit...."

In a written statement, the sector 19 controller stated that:

"I took a handoff from sector 15 on N9080P. The aircraft was on V247 at 140[00] feet. I was either on the land line or another aircraft stepped on him when I thought he tried to check on frequency. I then tried to answer him and give him the HLN [Helena] altimeter. After trying this a couple times with no response from N9080P, I tried to have sector 15 see if he was still on their frequency. I noticed that he had started to deviate south of course about 40-50 miles east of HLN. I then had PPS400 try to raise N9080P. PPS400 had no luck. PPS400 was approx. 5 west of HLN at 100[00] feet. Sector 15 advised that they were unable to contact N9080P and they had also tried to relay through another aircraft. I continued to observe N9080P deviating south of course then he corrected back a little bit and then deviated south again, sometimes as much as 90 degrees. I then alerted the supervisor and also HLN Approach in case he would come on their freq[uency]. Then approximately 10 southeast of HLN radar contact was lost in an area of normally fair radar. I advised the supervisor and was relieved from the sector. During this period I would try to contact N9080P about every 2-3 minutes on BTM, GTF, and QLS transmitters. His altitude was varying by about +400 ft high down to 140[00], but I did not notice him dropping below 140[00]."

Some aircraft wreckage was located about 1247 on January 7, 1997, by the Broadwater County Search and Rescue. The main wreckage was spotted from the air about 1504. Officers arrived on the scene at 1525 and determined that there were no survivors.

A portable oxygen bottle, with its regulator broken off, was found in the wreckage distribution path during the on-scene investigation. The oxygen bottle's regulator was not found until May 13, 1997, during a separate search of the accident scene, after snow melt. The shut-off valve on the regulator was damaged and could not be rotated. The position of the shut-off valve indicated that the valve was on at the time of the accident. The regulator had four connectors for oxygen masks or cannulas. Two of these connectors were capped with red dust covers. The other two connectors were clean and showed no visible damage; no evidence was found that indicated that masks or cannula bayonet-type connectors had been attached to the oxygen bottle regulator during the accident.

The pilot was part-owner of a Piper PA-24 that was not available to the pilot for this trip due to mechanical problems. The pilot's partner was interviewed by an FAA inspector; he stated that the pilot had rented N9080P due to the lack of availability of their airplane for maintenance reasons. He stated that the oxygen bottle had been borrowed from their aircraft for the flight and had been full of oxygen; four masks and two cannulas were also available.

In his statement, the pilot's partner noted that the pilot felt comfortable flying at altitudes above 12,500 feet without using oxygen. He related the pilot's statement that he had been flying in Mexico at 17,000 and did not use the oxygen he had on board, and had not felt any ill effects. He also noted that he had flown with the pilot on trips across the Rocky Mountains where they went to 14,000 feet on short duration flights and the pilot had not used oxygen.

Also in his statement, the pilot's partner noted that the pilot was under a lot of stress, in that a recent return trip from Mexico was delayed because of mechanical problems with their airplane, delaying departure of the accident flight. He noted that this business trip [the accident flight] was extremely important to the pilot as a large construction contract hinged upon its outcome.

Personnel information

The pilot received his private pilot's certificate with single-engine land rating in October 1976, and successfully accomplished a multi-engine rating in March 1978. He successfully accomplished an instrument-airplane rating in July 1978, on his second attempt, with 390 hours total flight time.

On his class three airman's medical certificate exam of March 11, 1993, the pilot had reported light flashes in his left eye, which was cited in his medical records of July 12, 1992, as vertical temporal light flashing lasting a second. He reported 3015 hours total pilot time on the March 11 medical application. He reported 2300 hours total flight time on his class three medical certificate application o

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.

Loss of control - in flightCruise
Oxygen system,portable - not activatedFactor
Aircraft control - uncontrolledPilot in commandCause
Incapacitation(anoxia/hypoxia)Pilot in commandCause
Airframe/component/system failure/malfunctionDescent - uncontrolled

Aircraft

Registration
N9080P
Reported as
Piper PA-24-260
Category
Airplane
Serial number
24-4550
Airframe hours
3,776
Engine
Lycoming IO-540-D4A5, 260 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Business · Part 91
Operator
Dakota Ridge Aviation, Inc.
Registered owner
Java Air, LLC
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · August 21, 1996 · 76 hours before
Departed
BIL · Billings, MT
Destination
SFF · Spokane, WA
Flight plan
IFR

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
68
Certificate
Private
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 3, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
2,300 total

Weather

Conditions
Night/dark
Wind
200° at 4 knots
Visibility
10 statute miles
Lowest ceiling
4,600 ft overcast
Temperature
23 °F, dew point 16 °F
Altimeter
30.00 inHg
Observed at
HLN

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.