WPR17FA035

NTSB accident investigation · Quest Kodiak 100 · Moab, UT · December 12, 2016

Accident · FatalField investigationFinal report
Date
December 12, 2016, 05:37 local (12:37 UTC)
Place
Moab, UT
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Initial climb
Aircraft
N772RTQuest Kodiak 100
Defining event
Initial climb: Loss of control in flight
Weather
Visual (VMC) · Night/dark
Status
Completed · report March 14, 2018
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration, Pratt & Whitney Canada, Quest Aircraft
FAA report
20161212021289A
Case key
94489

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 loss of control shortly after takeoff due to spatial disorientation.

Findings · 3

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotQuest KODIAK 100: 4 casesAll aircraft: 9,295 casesProbable cause
Ceiling/visibility/precipEnvironmental issues › Conditions/weather/phenomena · Effect on operationQuest KODIAK 100: 1 caseAll aircraft: 65 cases

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The commercial pilot was departing on a routine positioning flight in dark night visual meteorological conditions. Footage from a security camera at the airport showed the airplane take off normally and initiate a right turn, which was the established direction of traffic for the takeoff runway. The airplane continued the right turn, then entered an increasingly rapid descent and subsequently impacted terrain about 1 mile southwest from the airport. The wreckage distribution was consistent with a high-energy impact. Examination of the airframe and engine revealed no evidence of any preimpact mechanical malfunctions or anomalies that would have precluded normal operation. Autopsy and toxicology testing of the pilot did not reveal any evidence of impairment or incapacitation. Visual conditions prevailed in the area at the time of the accident; however, the setting Moon was obscured by cloud cover, and the airport was located in an area of remote, sparsely-populated high desert terrain. This would have resulted in few visual references to which the pilot could have oriented the airplane. Although the pilot had experience operating in this environment in night conditions and held an instrument rating, the circumstances of the accident are consistent with the known effects of spatial disorientation. The investigation could not determine the initiating event which led to the pilot's mismatch between the airplane's perceived and actual attitude; however, he likely experienced a sensory illusion as a result of spatial disorientation, which led to a loss of control.

Factual narrative

According to an FAA Safety Team pamphlet, "Spatial Disorientation:" Sight, supported by other senses, allows a pilot to maintain orientation while flying. However, when visibility is restricted (i.e., no visual reference to the horizon or surface detected) the body's supporting senses can conflict with what is seen. When this spatial disorientation occurs, sensory conflicts and optical illusions often make it difficult for a pilot to tell which way is up. Contributing to these phenomena are the various types of sensory stimuli: visual, vestibular (organs of equilibrium located in the inner ear), and proprioceptive (receptors located in the skin, muscles, tendons, and joints). Changes in linear acceleration, angular acceleration, and gravity are detected by the vestibular system and the proprioceptive receptors, and then compared in the brain with visual information. In the flight environment, these stimuli can vary in magnitude, direction, and frequency, resulting in a "sensory mismatch" that can produce illusions and lead to spatial disorientation. The two-seat, high wing, fixed-gear airplane, serial number 100-0140, was manufactured in 2015 and was configured to carry cargo. It was powered by a Pratt and Whitney PT6A-34, 750-horsepower turbine engine equipped with a Hartzell HC-E4N-3P, four-blade, controllable-pitch propeller. The airplane's most recent 200-hour inspection was conducted on November 10, 2016, at an airframe total time of 473.5 hours. At the time of the accident, the airplane had 504.2 total airframe hours. CNY is a non-towered/uncontrolled facility at a field elevation of 4,557 ft mean sea level; the airport was located in an area of remote, sparsely-populated high desert terrain. The airport has one runway, runway 3/21, which is 7,100 ft long and 75 ft wide. The published traffic pattern for runway 21 includes right turns. On December 12, 2016, about 0537 mountain standard time, a Quest Kodiak, N772RT, was destroyed when it impacted terrain shortly after takeoff from Canyonlands Field Airport (CNY), Moab, Utah. The pilot was fatally injured. The airplane was registered to Lease Air LLC, and operated by Aerowest Aviation, dba Redtail Air, under the provisions of 14 Code of Federal Regulations Part 135. Visual meteorological conditions prevailed, and a visual flight rules company flight plan was filed for the positioning flight, which was originating at the time of the accident. The flight's intended destination was Salt Lake City International Airport (SLC), Salt Lake City, Utah. Review of security camera footage showed that the pilot boarded the airplane about 0526, started the engine about 0529, and subsequently taxied to runway 21 for takeoff. The pilot activated the runway lights about 0534, and the airplane took off about 0536. The takeoff appeared normal and the airplane initiated a right turn after becoming airborne. Shortly thereafter, the airplane entered an increasingly rapid descent that continued to ground contact.The Utah Office of the Medical Examiner, Salt Lake City, Utah, performed an autopsy of the pilot. The cause of death was listed as total body blunt force injuries. The FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed forensic toxicology on specimens from the pilot, with no ethanol or tested-for drugs detected in urine. The 0553 weather observation at CNY included wind from 330° at 4 knots, visibility 10 statute miles, clear skies below 12,000 ft, temperature 1°C, dewpoint -2°C, and an altimeter setting of 29.94 inches of mercury. Satellite imagery indicated a broken layer of high cirriform clouds with tops near 21,000 ft. According to the United States Naval Observatory, the Moon phase for the morning of the accident was a waxing gibbous, with about 97% of the Moon's visible disk illuminated. Moonset occurred at 0536; at 0540, the Moon was -1.5 degrees below the horizon at an azimuth of 290°. The pilot held a commercial pilot certificate with ratings for airplane single engine land and instrument airplane; in addition, a flight instructor certificate with ratings for airplane single engine and instrument airplane. He held a Federal Aviation Administration (FAA) second-class medical certificate issued February 1, 2016, with the limitation that he must wear corrective lenses for near and distant vision. The operator reported that the pilot had 4,635 total hours of flight experience, of which 243 hours were in the accident airplane make and model. The pilot had 170 total hours of night experience, and 291 hours in actual instrument conditions. The airplane descended through two 30-40 ft-tall powerlines about 1 mile southwest of the airport before impacting terrain below. The debris field was about 323 ft long and extended beneath the powerlines on a magnetic heading of 359°. The first piece of debris was the flange from the right wheel, followed by outboard right wing components. A large impact crater contained two propeller blades, some instruments, and right wing aileron and flap components. Various pieces of debris from the right wing, instrument panel, and cabin area extended from the impact crater about 134 ft to the main wreckage. The main wreckage included the engine, cabin, fuselage, and empennage, and was consumed by postimpact fire. Beyond the main wreckage were components from the left wing and inboard right wing. The final piece of debris was the right tire. Two of the four propeller blades exhibited striations and damage consistent with impact with powerlines. These blades were fracture-separated from the hub and located in the impact crater. The cabin area was heavily damaged and burned; the flight instruments were heavily fragmented. Continuity of all primary flight controls was established from the cabin area to the respective flight control surfaces. Examination of the engine revealed that both the front and aft sections were bent toward the right side, giving the engine a half-circle appearance.The casing from the power section of the engine was heavily twisted and sustained heavy inward crush damage at the C-flange. Dirt, airframe fragments, stator vanes, and fragmented pieces of the power turbine were removed from this area, revealing the power turbine and a few compressor blades. The visible power turbine blades were fractured about midspan and the outer fragments were found within the exposed area. The fracture surfaces were rough. In addition, scoring was noted along the inside edge of the casing. A few compressor blades could be seen through the stator and the leading edges displayed a "chewed" appearance. An internal examination with a borescope revealed no evidence of heat distress, and several blade fragments were observed forward of the power turbine. Examination of the airframe and engine revealed no evidence of any preimpact mechanical malfunctions or anomalies that would have precluded normal operation.

Aircraft

Registration
N772RT
Reported as
Quest Kodiak 100
Category
Airplane
Serial number
100-0140
Built
2015
Airframe hours
504
Engine
P&W Canada PT6A-34, 750 horsepower, turbo prop
Damage
Destroyed
Fire
On-Ground
Flight
Part 135
Operator
Aerowest Aviation, doing business as Redtail Air
Registered owner
Lease Air LLC
Airworthiness certificate
Standard, Normal
Last inspection
Annual · November 10, 2016 · 31 hours before
Departed
CNY · Moab, UT
Destination
SLC · Salt Lake City, UT
Flight plan
Company VFR
Airport
CNY · Canyonlands Field Airport, runway 21, 7,100 × 75 ft, asphalt
Equipment
Unknown

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
64
Injuries
Fatal
Certificates
Commercial, Flight instructor
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
April 27, 2016
Seat
Left
Restraint
3-point
Toxicology
Performed
Flight hours
4,635 total · 243 in this make and model · 4,635 as pilot in command · 110 in the last 90 days · 31 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Night/dark
Wind
330° at 4 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
34 °F, dew point 28 °F
Altimeter
29.94 inHg
Observed at
KCNY, 1 nm away

Docket · 8

The files NTSB released with the investigation on February 22, 2018, on NTSB’s docket system: statements, records, photos and specialists’ reports. 3.7 MB in all.

FAA reports on this event · 1

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