NTSB Identification: ERA11LA405
Nonscheduled 14 CFR Part 135: Air Taxi & Commuter
Accident occurred Sunday, July 17, 2011 in Matinicus Island, ME
Probable Cause Approval Date: 11/07/2012
Aircraft: CESSNA U206G, registration: N910TA
Injuries: 1 Serious,3 Minor.
NTSB investigators may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.
After takeoff from the island airport for the air taxi flight, the pilot made the initial power reduction when the airplane was at an estimated 200 feet above the ocean. At that time, the engine lost total power, and the pilot ditched the airplane. The pilot and the three passengers were able to exit the airplane before it sank. For about 1 hour until rescuers reached them, they held onto a section of the airplane’s belly cargo pod that had separated during the water impact. At the time of the wreckage recovery, the left and right fuel tank filler caps were found securely installed. The fuel selector was found in the right fuel tank position. About 25 gallons of sea water and 1 pint of aviation fuel were drained from the right fuel tank. About 27 gallons of aviation fuel and 2 gallons of sea water were drained from the left tank. Examination of the wreckage did not reveal any discrepancies that would have prevented normal operation of the airplane. The physical evidence indicates that the engine lost power as a result of fuel starvation due to the position of the fuel selector on the empty right tank.
The operator required the pilot to provide the passengers a safety briefing before takeoff. However, none of the passengers were briefed or were aware that life vests were onboard the airplane. If a piece of wreckage had not been available for the passengers to hold on to, the failure of the pilot to notify the passengers of the availability of life vests could have increased the severity of the accident. As a result of the accident, the operator made numerous safety changes including mandating that the pilot read out loud a pre-takeoff briefing referencing the onboard passenger briefing guide card and offering all passengers a personal flotation device to wear during flights.
The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot’s improper fuel management, which resulted in a total loss of engine power due to fuel starvation.
On July 17, 2011, about 1625 eastern daylight time, a Cessna U206G, N910TA, registered to and operated by Waters Aero Marine, Inc., doing business as Penobscot Island Air, ditched in the ocean near Matinicus Island Airport (35ME), Matinicus Island, Maine. The pilot and two of three passengers received minor injuries, and the third passenger received serious injuries; the airplane sustained substantial damage. Visual meteorological conditions prevailed, and a company flight plan was filed for the on-demand air taxi flight, conducted under the provisions of 14 Code of Federal Regulations Part 135. The flight originated from 35ME, about 1623, with a destination to Knox County Regional Airport (KRKD), Rockland, Maine.
The pilot stated they departed 35ME with good weather with a light wind. The airplane did not show any abnormal indications on the takeoff roll. At approximately 200 feet into the climb, as he was reducing to climb power, the engine began to lose power. He immediately advanced the throttle and turned on the auxiliary fuel pump with no results. The engine lost total power and the pilot ditched the airplane into the ocean. All onboard were able to exit the airplane before it sank. They clung onto a section of the airplane’s belly cargo pod that separated during the water impact.
When the flight did not report in on the company’s frequency as required by the operator’s General Operations Manual (GOM), a search and rescue operation was activated. At about 1655 an emergency locater transmitter (ELT) signal was heard. At 1724 the pilot and three passengers were located in the water by a search plane. At 1737 all were rescued by a fishing boat and taken to shore for medical attention.
The pilot held an Airline Transport pilot certificate with ratings for airplane multiengine land, airplane single-engine land and sea, and rotorcraft helicopter; with type rating for B-757, B767, and BH-212. In addition, he held a flight instructor certificate with ratings for airplane-single engine and instrument airplane. The pilot reported that he accumulated 25,300 total hours of flight experience, of which, 1,000 hour were in the same make and model as the accident airplane. His most recent Federal Aviation Administration (FAA) second-class medical certificate was issued on May 24, 2010.
The Cessna U206G, a six place all metal, high wing, single-engine airplane, variable-pitch propeller, with fix landing gear, serial number U20604102, was manufactured in 1978, and issued a standard airworthiness certificate, in the normal category. The airplane was powered by a Continental IO-520-F, 300-horsepower engine, with a McCauley three bladed propeller. The airplane was equipped with a belly cargo pod and had extended range fuel tanks, with a capacity for 80 gallons of fuel, which 78 gallons are usable. The airplane’s engine was overhauled on June 29, 2009. The engine’s last inspection was performed on July 7, 2011, at which the engine had a total of 1,244.9 hours since major overhauled. The airplane’s last inspection was July 7, 2011 and the airplane had a total of 10,434.6 hours at that time. The airplane was on an annual/100 hour maintenance schedule. At the time of the accident, the airplane had accumulated a total of 10,437 hours.
The wreckage was recovered 5 days after the accident from an estimated ocean floor depth of 80 feet and taken to a storage facility under FAA oversight. The left and right fuel tank filler caps were secured in their respective place. The fuel selector was observed in the right fuel tank position. Approximately 25 gallons of sea water was drained from the right fuel tank and about a pint of aviation fuel was observed. Approximately 27 gallons of aviation fuel and about two gallons of sea water were drained from the left tank. The fuselage reservoir sump tanks were filled with sea water. There was no indication of fuel slick observed on the water’s surface during the recovery.
A wreckage examination by the airframe and engine manufacturer was conducted with FAA oversight. Flight control continuity was confirmed and no preimpact discrepancies were noted with the airframe that would have prevented normal operation. The engine was impact damaged and revealed saltwater submersion corrosion. The alternator, propeller governor, fuel pump, vacuum pump, and upper sparks plug were removed to facilitate an inspection of the engine. The corrosion prevented a rotational continuity confirmation of the accessory gears, valve train, cylinders, fuel system, ignition system, and induction system. The visual inspection of this engine did not reveal any abnormalities that would have prevented normal operation.
Information provided by the pilot and operator to FAA and the manufacturers revealed the airplane began the day’s flight schedule with an estimated 60 gallons of fuel onboard and 10 gallons were later serviced prior to the flight to 35ME. The airplane flew 5 flights prior to the accident; a total of 2.7 hours. The Cessna Pilots Operating Handbook (POH), performance charts, indicates the airplane’s fuel consumption is 16 gallons per hour with two gallons for taxi and takeoff, and one gallon to climb to 2,000 feet for each flight. Utilizing the performance data, the fuel consumption was 58.2 gallons. The airplane’s fuel capacity is 78 gallons usable. The calculated total estimated fuel consumption for the five flights (58.2 gallons) plus the recovered fuel (27 gallons) reflects a total of 85.2 gallons. Based on the operator’s information an exact amount of onboard fuel, and quantities for each fuel tank, could not be determine.
The operator’s FAA approved GOM, section 10, Passenger Handling, requires the pilot to give an oral safety briefing before each takeoff, which includes the location of the onboard survival equipment. In addition, a safety information card must be onboard in a location convenient for use by each passenger onboard.
Interviews with the passengers revealed no safety briefing was provided before the takeoff. None of the passengers were aware that life vests or the safety information card were onboard the airplane.
As a result of this accident the operator has implemented several changes to their GOM with respect to the fleet’s fueling and tracking onboard fuel quantities, guidance when to make initial engine power reduction after takeoff, revised the onboard passenger’s guide card, mandated pilot’s to read out loud a pre-takeoff briefing referencing to the onboard passenger briefing guide card, modified all the fleet’s airplanes ELT the capability to be activated from the cockpit, equipped the fleet’s airplanes with emergency egress air bailout bottles, mandated all of the company’s pilots to attend a offshore survival training course, and offer the passengers the Mustang personnel flotation device (PFD) to wear during the flight.
Eva and Paul Murray
(Courtesy of: Fields Dive Service )
The plane’s damaged nose and landing gear in 92 feet of water.
The plane is lifted clear of the water.
(Courtesy of: Fields Dive Service)
The plane's landing gear and engine compartment had the most apparent damage.
(Photo by: Shlomit Auciello)
At Prock Marine's North End facility in Rockland, Investigator Rich Eilinger of the Federal Aviation Administration's Flight Standards District Office in Portland discusses the plane with members of the Prock Marine crew.
Eva Murray's voice is still raspy, five days after escaping from an airplane sinking deep into the ocean off Matinicus Island. Her thoughts are at times a breathless tumble, as she conveys a narrative of what happened on July 17, when the Midcoast — an island, its fishermen, a team of pilots and dispatchers, and first responders both on Matinicus and the mainland — scrambled to save four who crashed from the sky into the ocean.
Murray believes salt water had irritated her airway, that her head was saturated with the Atlantic as she was thrown about the small Cessna, skull banging against cabin metal and instruments as the aircraft settled into the ocean depths.
Eva and her husband, Paul, visited The Herald Gazette in Camden Friday afternoon, July 22, five days following the airplane crash and two days after she was discharged from Maine Medical Center in Portland. To say she bears the scars is an understatement: Half of her head is shaved of her long brown hair, and yellowing bruises and lines of stitches mark her face with battle wounds.
Murray is a writer, a columnist for this paper and others, and she promises she will put into ink her thoughts about the event; for now, she is marshaling her reserves, recovering from a concussion and slowly retrieving memories of what took place. At the moment, those memories are fragmented, and Paul, and others, are helping to fill in the blanks. Paul carries around an index card in his shirt pocket of Eva's first attempt in the hospital to communicate — "Because," he said, "she was insistent she was going to try to write something."
Unable to talk, she wrote, she thought, a few words; in reality, they are illegible scribbles, the marks of a brain trying to heal.
Some memories are distinct, however, and they are related directly to the people coming to her rescue: A friend, Lori Ames who cradled her to keep her warm, a LifeFlight pilot who grinned reassuringly, and her son, Eric, at the Knox County Regional Airport, finding something to keep her warm.
"I remember hearing her voice behind me, cradling me, trying to keep me warm," said Eva. "She knew what to do. All the responders treated us so well," said Eva. "They were very caring, reassuring, respectful and helpful. It was the best experience with health care I've had." In that, she groups everyone from island rescue to Knox County emergency crews to Maine Medical Center and Pen Bay Medical Center.
But Murray knows her community and understands people want to know what happened, how the four survived. And how they did rests significantly on the skill of pilot Rob Hoffman, on an island community that rushed to save them, and on serendipity, luck, and, if one is religious, the grace of God.
The facts are known: The Cessna 206, owned by the Owls Head-based Penobscot Island Air Service and piloted by Hoffman, took off from the Matinicus Island airfield for what would normally be a 15-minute flight across Penobscot Bay to Knox County Regional Airport. It was a routine flight carrying Murray, Abbie Read and Karen Ford, all residents or visitors to the island.
Eva was heading to the mainland where her son, Eric, was to pick her up. He was working at the Owls Head airport. Paul was on the island, visiting at home with his mother and sister. Eva had parked the Jeep at the airport and climbed through the single passenger door, across the pilot's seat, into the co-pilot's seat to its right. In the back seats were Read and Ford. It was a beautiful July evening as Hoffman lifted the Cessna into the air.
Eva: "He took off normally but didn't get much altitude. The engine failed. It didn't go silent, but he could detect before I could that things weren't right. He went right to work, started doing stuff. And he said, 'We're going to have to get out.'
"I had the head set on and I took the microphone away from my face so that I wouldn't say anything or make any noises that would distract him at all. And I realized we were ditching. It was pretty instant. It was mind over matter, make yourself calm down in order to breathe.
"As soon as the pilot realized he had to ditch it, he did everything he could to make it level and gentle. A lot of credit should go to the pilot, for if he had been a rank amateur, if we had hit the water at some random, crazy angle we probably would have gone a lot deeper and it would have been a lot harder to get out.
"I don't remember it being like a sudden crash, like you'd a expect a car crash. But it also wasn't a nice gradual one. Going 60 knots into water is like hitting an object, but it wasn't like hitting a brick wall."
The plane entered the Atlantic, where it was suddenly dark. The cabin filled with water, and Eva could not tell if they were upside down. It was strictly by feel that she found her way out the pilot's door. The Cessna 206 has but two doors, one on the pilot's side, the other, a cargo door.
Both Hoffman and Eva have similar facial injuries and both the back seat passengers have back injuries, said Murray.
Eva: "It was dark in the water. I remember thinking, yep, I'm going to hold my breath to find a way out of this plane, I've got to make myself. I don't know whether we flipped over. I did not know my face was cut up. I am not sure who actually did what. I remember consciously feeling around, handle, open doors and windows, other people. I remember part of my brain, the rational part, saying, 'You can panic later.' This mental thing: half of you takes over and the other half says, 'You, there, who wants to panic. Shut up.' We have to think."
Paul: "A couple of people have compared it to the ditching on the Hudson. To the best of my knowledge, the plane that went into the Hudson, his gear was up so he landed a fairly decent surface into the water. This plane, once those wheels touched, it's a fixed gear plane, it was going to stop it very quickly."
Eva: "There wasn't any floating into the water gently. We were in the water."
The four of them somehow made their way out of the plane, and Paul thinks they all exited the pilot's door, swimming to the surface. The plane then settled down 92 feet underwater.
"I'm not sure how I got out into the water and got up," said Eva. But once on the surface, she counted heads, three of them, and felt a wave of relief.
Eva: "I was talking to everybody. I did not feel that injured. I probably should have been conserving energy but I was kicking and thinking we were all going to kick and swim to shore. I did not feel that cold and nothing hurt. The only thing I was conscious of after a while was how something was happening to my airway. I am not a good swimmer. I rolled over on my back thinking, I am going to have to tread water a lot.
"I never had any feeling once we got out of the airplane that we were going to die. The scary part was very, very brief.
"And then, if there was anything like a miracle moment, that piece of wreckage came up. Then we had a way of staying together. You don't know how long you can stay warm enough to stay coordinated. The other two people had bad back injuries. Having that object, we did not want to sink it, or climb up on it."
That storage compartment, a cargo pod, was the lone piece of wreckage from the plane that surfaced. Paul ventures that it may have floated up because it was lined with foam; perhaps it contained trapped air, making it buoyant. Whatever the mechanics, it was the second development in a fortunate sequence of circumstances.
The next was the sighting of Paul's truck, a TDS Telecom vehicle, at the end of the airfield runway. The four in the water saw the truck, even though Paul, who had been alerted to the emergency, could not see the four of them in the water from that vantage point.
"People knew we were there, it wasn't terrible weather, we were together," said Eva. "But thank god, no babies. Everybody was able-bodied."
On the island
As the plane went down, and sometime upon its impact with the ocean, a distress signal was automatically sent to the Air Force Rescue Coordination Center at Tyndall Air Force Base in Florida. Each beacon is encoded with the name of its airplane or boat, so Air Force personnel immediately contacted Penobscot Island Air.
Paul: "Eric called me, 'Is Mum there?' I said, 'Well, she should be on your side by now.'"
Eva: "He was waiting for me, and supposed to pick me up at the airport."
Paul: "She left a while ago, I told him. Then I said something to my mother like, did you hear the plane. Everybody on the island listens for the plane. She said she wasn't really sure, and I said I wasn't really sure. Eric said, 'You better talk to Sally.' Sally is the dispatcher for PIA, and she got on and said 'We're not really sure where the plane is.' I said do you want me to go to the airport? She said, 'Would you please.'
"That was a real heart-sinking feeling. I jumped into the truck and went to the airport. It was stomach wrenching. The Jeep that Eva drives was where I expected it to be but no plane on the ground. I drove out toward the edge of the airstrip. I went to the little shed with a phone where you can call the air service. I picked up the phone to dial but there was no dial tone. That's because Eric had already called the island and was coincidentally on the line. It was pure chance. I said, 'There is no plane here.' Sally said, 'We're sending a plane out. It should be over you shortly.' I drove down to the end of the airstrip, which is a big no-no in daylight. When I got down there, I couldn't see anything."
Eva: "But, boy, wasn't it reassuring to see him. A TDS Telecom truck. So at least someone knew there was an emergency. We could see the airstrip."
That's when the island's collective emergency response kicked in. While a PIA plane flew out over the water, circling for any sight of wreckage and survivors, fishermen converged on the waterfront, into boats and a skiff. At full throttle, they headed to the north end of Matinicus.
"We saw [Paul's] truck at the end of the airstrip so we knew that someone knew we were there," said Eva. "Then we saw the other plane circling, and then we saw what looked like the Stonington boat races coming toward us."
Lobsterboat captains Clayton Philbrook and Robert Young used their boats to bring the survivors to safety. Charlie Rogers, Josh Ames, Edwin Mitchell and Philbrook's son, Nick Philbrook, also took boats out to aid those from the downed plane.
Paul: "By then, Sally had told me that the plane was circling and was told there were four people swimming. If there was a best moment in the whole thing, that was it."
And by that time, the four had been in the 60-degree water for 20 minutes or longer, although no one has yet put a definitive finger on exactly how long.
Eva: "I remember everything until climbing up into Robert's boat, grabbing the side of the boat, putting my leg up. I don't know, somebody probably grabbed me, too, because of course, they would have. I remember saying I'm not that badly injured, but my airway is constricted. And then I was at the end of my strength and after that my memory is in pieces.
"I didn't want the rescuers to spend so much time worrying about did I have a back or spine injury, if they didn't know. But I could feel my throat constricted and I remember saying very firmly, 'My airway is constricted.'"
Paul: "Robert [Young] talked to me at the airport and he said you literally were trying to get your leg up on the rail and he had to give you a hand, but he said you did most of the work."
Eva: "When I got into the boat, I thought, 'OK, I'm used up now.' I remember hearing Lori Ames' voice behind me as she cradled me to try to warm me up. I do not remember the flight in, I remember briefly being at the airport at Owls Head where I saw my son, who works there and is also a trained responder. He was running around trying to find tarps and sleeping bags. I remember seeing a LifeFlight pilot who I know, Dave Burr, and I remember his face, a great big grin right close in my face. And that being a wonderful, reassuring thing. Those three things, Lori's voice, Eric's face and Dave's face."
Paul: "And we know they are all separated by quite a bit of time."
The rescue from the water took the efforts of a whole community. Once back in the harbor, hoists with baskets were used to haul two of them from the boats; two others came in by skiff. All were transported in the back of pickup trucks. Then, they were transported back to the airport for their second airplane ride of the day, in PIA aircraft, over to Owls Head.
On the mainland
Paul: "They [PIA] were just flying everything they had. Eric said when his mother and Rob arrived at the airport, ambulances hadn't arrived yet, and that is why they were hunting around for ways to warm them. He found a quilted plane cover, and there was an assortment of things to use to keep them warm until the ambulances arrived.
Once at Pen Bay, LifeFlight was on hand to transport two patients to two different hospitals, Maine Medical Center and Central Maine Medical Center.
Eva: "And I don't remember going to Pen Bay and I don't remember the helicopter ride! But when you are intubated, you have to be completely hammered. They have to drug you."
More than a week later, the plane is also on the mainland, its wreckage under analysis. Eva and Abbie had a reunion.
“That was a good moment for both of them,” said Paul.
Hoffman is recuperating, Read is home in Appleton, and Ford remains in the hospital, and her mother reports she is getting better every day.
Survivor and rescuer praise pilot's reactions
To Eva, it was Hoffman's skill as a pilot that kept them from the clutches of the ocean, "for landing the sucker level so we could get out."
"These guys are either ex-military or retired civil aviation or Alaska bush pilots," she said of the PIA pilots. "They are not beginners and that needs to be underlined."
"I'm glad the pilot is getting his due," said Philbrook, one of the Matinicus residents who participated in the rescue.
"He did a hell of a job getting the plane in the water, getting the people out of the plane and keeping them all together."
Philbrook said he knew the designer of the plane, and that the cargo pod that provided flotation for the survivors was designed to "peel off without damaging the aircraft."
He said it was fortunate that, due to the wind direction, the flight took off over water.
"If it had been uphill and over the island, 200 feet in the air and 200 yards [along its path] it's trees or somebody's house," he said.
Philbrook said that before going to work for Penobscot Island Air Service, pilot Rob Hoffman flew to Europe for American Airlines for many years.
"He has tens of thousands of hours, flying the big ones," said Philbrook. On July 17, "All of his training paid off."
Community responds
Philbrook said he only did what was expected of people.
"It's a very sad commentary on service today, that going to the aid of somebody in distress gets such praise," he said. "It should be the other way around." He said society should call people to task when they fail to help those in need. He said most of his neighbors were brought up to see the actions they took July 17 as their basic responsibility.
"We all know what it's like to fly in those small planes over water," he said.
He said approximately 50 people were at the airstrip to see the four survivors off on their way to mainland hospitals for treatment.
"The reaction from my friends on the island has been 'Thank you for going out' and 'Good job,'" said Philbrook. "We expect people to do the right thing."
Philbrook praised the staff at Pen Bay, and said that everyone involved in the survivors' rescue and care did what they should have done.
"I was raised to think if you see that somebody needs help, you give it to them," he said.
In Eva's mind, they are all heroes. Her mind circles back to those three people she initially recalled, their reassuring faces and voices. And she remembers that piece of wreckage that popped up out of the water.
For Paul, it was simply a community in full support that he will carry in his mind forever. "On Sunday night I was waiting to fly off the island when a few of the guys I don't hitch horses well with came and told me to let them know if I needed anything," he said.
At the heart of the survival is the community, say both Eva and Paul. Community, both on and off the island, pitched in so competently to save four of their family and friends. On Matinicus, they poured down to the wharves to offer help, blankets and water. At the airport, ambulances from five communities responded, and LifeFlight flew in from across the state.
"If there was a best case scenario for this, a lot of it was there," said Paul.
