SEA97FA215

NTSB accident investigation · Cessna 172M · Bremerton, WA · September 24, 1997

Accident · FatalField investigationFinal report
Date
September 23, 1997, 23:30 local (Sep 24, 1997, 06:30 UTC)
Place
Bremerton, WA
Injuries
3 fatal
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N6756HCessna 172M
Weather
Visual (VMC) · Night/dark
Status
Completed · report July 2, 1999
Report
Approved by Office Director
FAA report
19970924028919A
Case key
42514

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 pilot's misjudgment of distance and altitude from the runway, and his subsequent failure to maintain clearance from the terrain. Factors contributing to the accident were dark night conditions, the pilot's improper decision to conduct the flight at night, his lack of recent experience in the type of operation (night flying), his lack of familiarity with the geographical area, the inoperative airport visual approach slope indicator, and the improper dispatch of the airplane by the operator.

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.

UndershootApproach - vfr pattern - final approach
Light condition - dark nightFactor
Airport facilities,visual apch slope ind(vasi) - inoperativeFactor
Distance/altitude - misjudgedPilot in commandCause
Lack of recent experience in type operationPilot in commandFactor
Lack of familiarity with geographic areaPilot in commandFactor
Planning/decision - inadequatePilot in commandFactor
Dispatch - improperPilot in commandFactor
In flight collision with objectApproach - vfr pattern - final approach
Object - tree(s)Factor
Clearance - not maintainedPilot in commandCause
Shoulder harness - not used

Analysis

While visiting friends, the private pilot arrived at an unfamiliar airport and requested the authorization to rent airplanes from an operator. The pilot intended on flying his friends on a cross country night flight, but he did not inform the flight instructor who flew with him for the authorization. The instructor reviewed the pilot's logbook, but did not notice that it had been about 2 years since the pilot had logged any of his 3 hours of total night flying time. The operator's dispatcher subsequently allowed the pilot to rent the airplane for the flight, despite published night flying requirements which the pilot did not meet. During the return flight back to the airport, the pilot told controllers the he had difficulty locating the airport. During final approach, the airplane impacted trees and came to rest in a 3-foot-deep pond, about 1/2-mile short of the runway. The visual approach slope indicator (VASI) lighting for the runway was out of service for routine maintenance, and a Notice To Airmen (NOTAM) had been issued. Examination of the wreckage did not reveal any evidence of preimpact mechanical malfunction. The front seat occupants, who were not wearing shoulder harnesses, drowned.

Factual narrative

History of flight

On September 23, 1997, at 2330 Pacific daylight time, N6756H, a Cessna 172M, operated by Pegasus Air, Inc., collided with a tree and impacted a pond during final approach to the Bremerton National Airport near Bremerton, Washington. The airplane was substantially damaged and there was no fire. The private pilot and his two passengers were fatally injured. Visual meteorological conditions prevailed and no flight plan had been filed. The personal flight departed from Friday Harbor, Washington, and was destined for the Bremerton National Airport. The flight was conducted at night under 14 CFR 91.

According to a flight instructor (interview synopsis attached), the accident pilot arrived at the Pegasus Air office, located at the Bremerton National Airport, one day before the accident. The accident pilot told the instructor that he wanted to "get checked out" to rent airplanes at Pegasus Air. The instructor stated that the accident pilot told him that he was visiting the area from California and wanted to fly around the local area with friends. The instructor further stated that the pilot had been scheduled for only one hour for the check-out, and that the instructor had another scheduled activity after that hour.

About 25 minutes into the check-out, while the instructor and the accident pilot were in the Pegasus office during the oral portion of the check-out, the instructor told the accident pilot that there was not enough time to complete both the ground and flight portions of the check-out during the scheduled time. The two agreed that only the ground portion would be completed that day, and that the flight portion would be rescheduled for the following day during a one-hour flight. The instructor also asked the pilot to complete a Pegasus Air Aircraft Rental Application (attached).

The instructor stated that he examined the accident pilot's license, medical certificate, and personal flight log book during the ground portion of the check-out, but that he "did not pay attention" to the accident pilot's night flying experience. The instructor stated that he was unaware that the pilot wanted to fly at night, and was under the impression that the check-out was for day flights only under visual flight rules (VFR). The instructor further stated that the accident pilot never mentioned that he had intended on flying at night, nor did he ask any questions about night flying requirements for Pegasus Air.

The instructor stated that the accident pilot "showed up early" on the following day (the day of the accident) and performed a preflight inspection of the airplane. The instructor arrived at the airplane about 1500 and the two went flying around the local area. The instructor stated that the accident pilot performed power-on and power-off stalls, slow flight at minimum controllable airspeed, steep turns, and a simulated forced landing approach. The instructor stated that the accident pilot "did fine" during the maneuvers, and that he was "safe." The accident pilot then performed five landings back at the Bremerton National Airport as the instructor was evaluating him from the right front seat. The instructor stated that the landings were "fine" and "safe," and that the accident pilot's airport traffic pattern work needed some "polishing." Immediately after the flight, the instructor had to leave for an appointment, but it was understood that the accident pilot had successfully completed the check-out flight. After the check-out flight, the accident airplane was dispatched to the accident pilot by the president of Pegasus Air. In an interview with the Safety Board (synopsis attached), the president stated that she was unaware of the pilot's night flying experience before the accident, and was also unaware that the flight instructor had checked out the pilot for day VFR flights only.

The president stated that she was aware that the accident pilot had scheduled the airplane from 1500 until 1600 on the day of the accident to receive the check-out with the instructor, and then from 1600 until 2200 for a personal flight with his wife and friend. She stated that the pilot had called one day before the accident to schedule the airplane for these times. She further stated that she told the accident pilot that she would be closing up the office around 2130 and that the pilot should return the airplane keys to a "drop box" located outside of the Pegasus Air office after he returned from the flight.

Entries in the Pegasus Air flight authorization sheet (copy attached) for the accident flight that were completed by the pilot and the president of Pegasus indicate that the pilot's destination was Friday Harbor. The pilot signed his name under a block that stated that he read and understood the Aircraft Rental Agreement (attached). The signature of the president's first name also appeared on the form underneath a block titled "FLIGHT AUTHORIZED BY." The Hobbs out time was recorded as 267.2 hours on the form, and the tachometer time was recorded as 101.0 hours.

The Pegasus Air Aircraft Rental Agreement cites the following: "All flights shall be during daylight hours between sunrise and sunset.... Night operation must be approved by the operator prior to takeoff.... For flights exceeding 50 miles at night, the following will apply: A) Instrument rating. B) Authorization from a company flight instructor."

The president stated that she dispatched the accident airplane to the accident pilot about 1630, and that the flight departed about 1730 with the accident pilot, his wife and his friend on board. A receipt (copy attached) found on one of the passengers after the accident indicated that it was from a restaurant in the town of Friday Harbor, located 63 nautical miles to the north of the Bremerton National Airport. The receipt indicated that all three occupants had completed dinner about 2000 hours on the evening of the accident. The activities of the three occupants between 2000 and 2255 could not be determined.

According to recorded radar data and voice communications (data and transcripts attached) from the Federal Aviation Administration (FAA), the accident pilot contacted Whidbey Island Radar Approach Control at 2255 for routine VFR flight following. The pilot was then handed off to Seattle Approach Control at 2309 for flight following as the airplane flew toward the Bremerton National Airport from the northwest at an altitude of about 5,000 feet above mean sea level (msl).

At 2312:54, as the airplane was gradually descending through an altitude of 4,000 feet msl, the controller asked the pilot if the pilot had listened to the automated weather observation station (AWOS) recording for the Bremerton National Airport. The pilot acknowledged that he had. At 2320:21, after the airplane had descended to an altitude of about 500 feet above the ground (900 feet msl), the controller asked the pilot: "...do you have Bremerton in sight?" The pilot responded with "...we don't have Bremerton in sight quite yet, I don't think, but we're right on course." During this time, the airplane was located about 15 nautical miles north-northwest of the Bremerton National Airport. The airplane then initiated a gradual climb and turned toward the southeast.

At 2324:42, the airplane leveled at 2,600 feet msl (about 2,200 feet above terrain) and turned to a ground track of 162 degrees. At 2325:30, the controller said "good night" to a Northwest Airlines pilot, and the accident pilot responded with "good night five six hotel." The controller replied: "Cessna five six hotel, that was for another aircraft, sir. If you want, you can remain this frequency. Let me know when you have Bremerton in sight." The accident pilot responded with: "Okay, will do."

At 2327:15, the controller asked the accident pilot: "... the airport would be at twelve o'clock and two and a half miles. Do you h

Aircraft

Registration
N6756H
Reported as
Cessna 172M
Category
Airplane
Serial number
17265569
Airframe hours
3,519
Engine
Lycoming O-320-E2D, 150 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Registered owner
Pegasus Air, Inc.
Airworthiness certificate
Standard, Normal; Standard, Utility
Last inspection
100 hour · August 15, 1997 · 69 hours before
Departed
FHR · Friday Harbor, WA
Destination
PWT · WA

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
46
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Valid Medical--no waivers/lim.
Seat
Left
Toxicology
Performed
Flight hours
132 total · 80 in this make and model · 15 as pilot in command · 4 in the last 90 days · 3 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Night/dark
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
None
Temperature
55 °F, dew point 48 °F
Altimeter
29.00 inHg
Observed at
PWT, 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.