Alaska

The commercial certificated pilot was returning from a remote village after a round robin flight of about 130 miles over a frozen and snow-covered river. He was in cruise flight about 500 feet agl, but then circled while holding between 6 or 7 miles east of his destination airport, awaiting a special VFR (SVFR) clearance. The weather condition in that area was about 1 mile visibility, with a ceiling of about 1,000 feet agl. After receiving his SVFR clearance, the pilot flew toward the airport, but the engine fuel pressure began fluctuating. The engine rpm began decreasing, along with the airplane's altitude. The pilot switched fuel tanks, selected full flaps, and prepared for a forced landing. He said the weather was near white-out conditions, but he could see the bank of the river. After switching fuel tanks from the left to the right tank, the engine power suddenly returned to full power. He applied forward flight control pressure to prevent the airplane from climbing too fast, but the airplane collided with the surface of the river. The airplane sustained structural damage to the wings and fuselage. At the time of the accident, the ceiling at the airport was 600 feet obscured, with a visibility of 1/2 mile in snow. Neither the fuel status of the accident airplane, nor the mechanical condition of the engine, were verified by either the NTSB or FAA.

The airline transport pilot and nine passengers were departing in a twin-engine airplane on a 14 Code of Federal Regulations Part 135 air taxi flight from a runway adjacent to an ocean bay. According to the air traffic control tower specialist on duty, the airplane became airborne about midway down the runway. As it approached the end of the runway, the pilot said he needed to return to the airport, but gave no reason. The specialist cleared the airplane to land on any runway. As the airplane began a right turn, it rolled sharply to the right and began a rapid, nose- and right-wing-low descent. The airplane crashed about 200 yards offshore and the fragmented wreckage sank in the 10-foot-deep water. Survivors were rescued by a private float plane. A passenger reported that the airplane's nose baggage door partially opened just after takeoff, and fully opened into a locked position when the pilot initiated a right turn towards the airport. The nose baggage door is mounted on the left side of the nose, just forward of the pilot's windscreen. When the door is opened, it swings upward, and is held open by a latching device. To lock the baggage door, the handle is placed in the closed position and the handle is then locked by rotating a key lock, engaging a locking cam. With the locking cam in the locked position, removal of the key prevents the locking cam from moving. The original equipment key lock is designed so the key can only be removed when the locking cam is engaged. Investigation revealed that the original key lock on the airplane's forward baggage door had been replaced with an unapproved thumb-latch device. A Safety Board materials engineer's examination revealed evidence that a plastic guard inside the baggage compartment, which is designed to protect the door's locking mechanism from baggage/cargo, appeared not to be installed at the time of the accident. The airplane manufacturer's only required inspection of the latching system was a visual inspection every 100 hours of service. Additionally, the mechanical components of the forward baggage door latch mechanism were considered "on condition" items, with no predetermined life-limit. On May 29, 2008, the Federal Aviation Administration issued a safety alert for operators (SAFO 08013), recommending a visual inspection of the baggage door latches and locks, additional training of flight and ground crews, and the removal of unapproved lock devices. In July 2008, Piper Aircraft issued a mandatory service bulletin (SB 1194, later 1194A), requiring the installation of a key lock device, mandatory recurring inspection intervals, life-limits on safety-critical parts of forward baggage door components, and the installation of a placard on the forward baggage door with instructions for closing and locking the door to preclude an in-flight opening. Post accident inspection discovered no mechanical discrepancies with the airplane other than the baggage door latch. The airplane manufacturer's pilot operating handbook did not contain emergency procedures for an in-flight opening of the nose baggage door, nor did the operator's pilot training program include instruction on the proper operation of the nose baggage door or procedures to follow in case of an in-flight opening of the door. Absent findings of any other mechanical issues, it is likely the door locking mechanism was not fully engaged and/or the baggage shifted during takeoff, and contacted the exposed internal latching mechanism, allowing the cargo door to open. With the airplane operating at a low airspeed and altitude, the open baggage door would have incurred additional aerodynamic drag and further reduced the airspeed. The pilot's immediate turn towards the airport, with the now fully open baggage door, likely resulted in a sudden increase in drag, with a substantive decrease in airspeed, and an aerodynamic stall.

About 0800, the commercial pilot did a preflight inspection of the accident airplane, in preparation for a cargo flight. Dark night, visual meteorological conditions prevailed. He indicated that the weather conditions were clear and cold, and frost was on the airplane. He said the frost was not bonded to the skin of the airplane, and he was able to use a broom to clean off the frost, resulting in a clean wing and tail surface. He reported that no deicing fluid was applied. After takeoff, he retracted the flaps to about 5 degrees at 110 knots of airspeed. The airplane then rolled to the right about three times in a manner he described as a wave, or vortex-like movement. He applied left aileron and lowered the flaps to 20 degrees, but the roll to the right was more severe. The pilot said the engine power was "good." He then noticed that the airplane was descending toward the ground, so he attempted to put the flaps completely down. His next memory was being outside the airplane after it collided with the ground. The airplane's information manual contains several pages of limitations and warnings about departing with even small amounts of frost, ice, snow, or slush on the airplane, as it adversely affects the airplane's flight characteristics. The manufacturer requires a visual or tactile inspection of the wings, and horizontal stabilizer to ensure they are free of ice or frost if the outside air temperature is below 10 degrees C, (50 degrees F), and notes that a heated hangar or approved deicing fluids should be used to remove ice, snow and frost accumulations. The weather conditions included clear skies, and a temperature of -11 degrees F. Post accident examination of the airplane revealed no observed mechanical malfunction. An examination of the engine revealed internal over-temperature damage, and minor external fire damage consistent with a massive spike of fuel flow at the time of ground impact. Damage to the propeller blades was consistent with high power at the time of ground impact. The rolling/vortex motion of the airplane was consistent with airframe contamination due to frost.

The airline transport pilot was departing in a twin engine turboprop airplane on a ferry flight from a remote lodge airstrip that was about 1,000 feet long and 40 feet wide. The airplane had previously received substantial damage to the nose wheel assembly on a previous flight to the airstrip. Repairs were made to the airframe, and the pilot was departing for a maintenance facility. The pilot had flown in and out of the airstrip on numerous occasions, but not in the accident type airplane. The lodge owner reported that the pilot started both engines and taxied the length of the airstrip, stopping momentarily several times. The pilot ran the engines for about 20 minutes, and then began a takeoff to the south. The airplane appeared to accelerate and remain on the centerline of the airstrip, but did not liftoff until the very end of the airstrip. The owner did not notice any unusual sounds or appearance of the engines. After liftoff, the wheels of the airplane struck and broke off the tops of trees and shrubs, that were about 6 to 7 feet above the ground. The airplane immediately veered to the right, and went out of the lodge owner's sight, but he continued to hear the airplane hitting trees until final impact. The airplane crashed in a shallow lake, coming to rest about 300 feet from shore, in about 5 feet of water. The entire cockpit area, forward of the wings, was torn off the airframe. The validity of any postaccident cockpit and instrument findings was unreliable due to the extensive damage to the cockpit. Likewise, structural damage to the airframe precluded determining wing flap settings during takeoff. Performance calculations indicated that the airplane's takeoff distance would have been about 950 feet, although the lodge owner said that in his experience, the accident airplane was capable of lifting off about half way down the airstrip without difficulty. The circumstances of the takeoff indicated that the left engine had been producing sufficient power to chop through several trees during the crash. Testing and inspection of the right engine was inconclusive, and although it was run on a test stand at reduced power, full power could not be attained due to ingestion of foreign material during the test run.

The float-equipped airplane was departing from a remote bay 20 miles north of Ketchikan, Alaska, to return air taxi passengers to Ketchikan after a ground tour. The accident pilot, who reported that he had 17,000 flight hours and 7,000 hours in the make and model of the accident airplane, said that southeasterly winds had begun to increase while he was waiting at the bay for the passengers to return from the tour. He said that, unlike when he had landed about 2.5 hours earlier, it was no longer “nice and calm” when the passengers returned. The pilot noticed choppy waves in parts of a nearby cove. To avoid some of the wind and waves, the pilot elected to take off toward the interior of the bay, in the direction of rising terrain. The pilot said that he had never taken off in that direction before. The pilot also said that he had intended to make a shallow, right-climbing turn toward the mouth of the bay and away from the terrain, but shortly after takeoff, he saw numerous choppy waves concentrated along his proposed departure flightpath, which he said indicated to him that strong winds were likely along that path. The pilot decided to change his plan and continue flying straight temporarily, away from the waves, and to make a left, 180-degree turn inside the bay, which was surrounded by high terrain. The pilot indicated that when the turn was initiated, the airplane was about 400 feet above the water, and he did not recall the indicated airspeed. The attempted 180-degree turn was within the airplane’s performance capabilities but placed it closer to rising terrain. While attempting this turn, the pilot encountered a downdraft, was unable to climb above the terrain, and stalled the airplane about 60 feet above the ground. The downdraft likely made it more difficult to avoid descending into the rising terrain. A weather study by the National Transportation Safety Board confirmed that there was a gust front in the area and an abrupt wind change about the time of the accident. Pilots flying nearby also reported low-level windshear, strong winds, and turbulence. No mechanical anomalies were discovered during postaccident inspections by the Safety Board. Five passengers including two children were killed. A month later, one of the survivor died from his injuries.

The private, instrument-rated pilot, was on an IFR cross-country flight, and had been cleared for a GPS approach. He reported that he was 5 minutes from landing, and said he was circling to the left, to land the opposite direction from the published approach. The traffic pattern for the approach runway was right traffic. Instrument meteorological conditions prevailed, and the weather conditions included a visibility of 3 statute miles in light rain and mist; few clouds at 400 feet, 1,000 feet overcast; temperature, 55 degrees F; dew point, 55 degrees F. The minimum descent altitude, either for a lateral navigation approach, or a circling approach, was 580 feet, and required a visibility of 1 mile. The missed approach procedure was a right climbing turn. A circling approach north of the runway was not approved. Witnesses reported that the weather included low clouds and reduced visibility due to fog and drizzle. The airplane was heard, but not seen, circling several times over the city, which was north of the runway. Witnesses saw the airplane descending in a wings level, 30-45 degree nose down attitude from the base of clouds, pitch up slightly, and then collide with several trees and an unoccupied house. A postcrash fire consumed the residence, and destroyed the airplane. A review of FAA radar data indicated that as the accident airplane flew toward the airport, its altitude slowly decreased and its flight track appeared to remain to the left side (north) of the runway. The airplane's lowest altitude was 800 feet as it neared the runway, and then climbed to 1,700 feet, where radar contact was lost, north of the runway. During the postaccident examination of the airplane, no mechanical malfunction was found. Given the lack of any mechanical deficiencies with the airplane, it is likely the pilot was either confused about the proper approach procedures, or elected to disregard them, and abandoned the instrument approach prematurely in his attempt to find the runway. It is unknown why he decided to do a circle to land approach, when the tailwind component was slight, and the shorter, simpler, straight in approach was a viable option. Likewise, it is unknown why he flew towards rising terrain on the north side of the runway, contrary to the published procedures. From the witness statements, it appears the pilot was "hunting" for the airport, and intentionally dove the airplane towards what he perceived was an area close to it. In the process, he probably saw
trees and terrain, attempted to climb, but was too low to avoid the trees.

The air taxi float-equipped airplane was the second of three airplanes on an air tour flight over a remote scenic area in southeast Alaska. As the flight of three airplanes flew into mountainous terrain, the first pilot reported low clouds, with rain and fog, which required him to descend to 700 feet msl to maintain VFR flight conditions. The pilot of the third tour airplane, which was about 5 minutes behind the accident airplane, stated that as he approached the area around the accident site, he encountered "a wall of weather" which blocked his intended flight route, and he turned around. The accident airplane's fragmented wreckage was discovered in an area of steep, tree-covered terrain, about 2,500 feet msl, near the area where the third airplane turned around. The NTSB discovered no mechanical problems with the airplane during postaccident inspections. An NTSB weather study revealed instrument meteorological conditions in the area at the time of the accident. Photographs recovered from a passenger's camera depicted deteriorating weather conditions as the flight progressed. A charter boat captain, who had seen numerous float-equipped tour airplanes operating in adverse weather conditions, called the local FAA Flight Standards District Office (FSDO) 9 days before the accident, to report his sightings. According to the FAA, no specific tour operator could be identified during their ensuing investigation, and no enforcement actions or additional surveillance of any operators was initiated. According to the FSDO manager, the local FSDO had lost inspectors due to downsizing. He reported they had not attempted to observe operators' adherence to weather minimums via ground-based viewing locations along the heavily traveled tour routes, and noted that FAA inspectors used to purchase air tour tickets to provide en route, on-board surveillance, but had not done so for approximately the last 10 years. He noted that additional inspector assistance from other FAA offices was not requested

The captain was making a VFR landing approach to a remote mining airstrip in a modified Douglas DC-4 airplane at the end of a cross-country nonscheduled cargo flight. The modified airplane had a raised cockpit above the fuselage to accommodate an upward swinging nose door. During the landing flare/touchdown, the airplane undershot the runway threshold, and right main landing gear struck the lip of the runway. The right main landing gear was torn off, which allowed the nose and right wing to collide with the runway surface. The right wing was torn off the fuselage and caught fire. The fuselage, containing the cargo of fuel bladders, slid to a stop and rolled about 90 degrees to the left. The pilot indicated that due to the additional cockpit height of the modified airplane, versus a standard Douglas DC-4 airplane, the airplane was lower than he perceived.

The flight crew was delivering a cargo of fuel in the four-engine airplane under Title 14, CFR Part 125, when the airplane lost power in the number 2 engine. The captain elected to shut the engine down and return to the airport. He said during the shutdown procedure, the engine caught fire, and that the fire extinguishing system was activated. The crew thought the fire was out, but it erupted again, and the captain elected to land the airplane gear-up on the snow covered tundra. Once on the ground, the left wing was consumed by fire. An inspection by company maintenance personnel revealed that an overhauled engine cylinder had failed at its base, resulting in a fire. The airplane was not examined by the NTSB due to its remote location.

The commercial certificated pilot prepared for a VFR cross-country nonscheduled cargo flight under Title 14, CFR Part 135, by preflighting the wheel-equipped airplane and starting the engine. The airplane had been parked on the airport ramp overnight, with an electric engine heater and an engine cover on. A portion of the flight was over ocean waters to a remote village. After engine start, the pilot contacted the company owner and reported that the engine oil pressure appeared to be low, but within the operating range. The owner and the pilot discussed the possible reasons, such as cold ambient temperatures, which was about -20 degrees F. The pilot then departed, and reported to his company that the engine pressure was good. About 10 minutes later, he declared an emergency and stated he was ditching in the water, about 18 miles west of the departure airport. Retrieved track data from the pilot's GPS showed the airplane's maximum altitude was 1,439 feet msl, while crossing the ocean in an area that was about 22 miles wide. A review of the manufacturer's maximum glide distance chart revealed that from an altitude of about 1,500 feet, the airplane could glide about 2.1 nautical miles. The airplane was located about two hours after the accident, floating nose down next to a segment of pan ice, about 8.8 miles from the initial accident location. The pilot was not recovered with the airplane, and subsequent searches did not locate him. Following recovery of the airplane, examination of the engine revealed a 8 X 5 inch hole in the top of the case, adjacent to the number 2 cylinder. The number 2 connecting rod was broken from its crankshaft journal, and broken from the bottom of the piston. The number 1 connecting rod bearing was missing from its normal position on the crankshaft journal and the rod had evidence of high heat. Evidence of oil starvation and high heat signatures to several crankshaft and connecting rod bearings was found throughout the engine, along with a large amount of fragmented bearing material. The pilot was not wearing any personal flotation equipment, and the expected survival time in the 29 degree F ocean water was about 30 minutes. The company's operations manual does not contain a written policy requiring pilot's to maintain sufficient altitude to reach shore when crossing ocean waters.