SALT LAKE CITY — Before the flight got off the ground, one of the flight attendants acknowledged all of the police officers on the plane and noted to passengers, "You will never have a safer flight."
Turns out all of those officers were needed.
A little more than 30 minutes into the flight, as Unified detective Cody Stromberg noted, "It was very much a street fight at 30,000 feet."
Three Unified police officers flying home late Sunday into early Monday after attending the funeral of slain New York police officer Wenjian Liu were unexpectedly called into duty on a Jet Blue flight to Salt Lake City.
A couple who were having a heated disagreement had to be separated.
The 32-year-old Long Island woman was reportedly intoxicated before getting on the plane and was having an intense dispute with her husband, said Unified police detective Robert Odor. At one point, the flight attendant, knowing that Odor was a police officer and that he had an open seat next to him in the front row, asked if it would be OK if they moved the woman next to him.
As soon as she sat next to him, Odor said he could tell she "was obviously having emotional distress." Then the woman started taking prescription medication out of her backpack and putting pills into her mouth.
About 30 minutes later, when the woman started writing in a notebook and putting a second bottle of pills in her mouth, Odor decided he needed to take action.
"She started writing a note on a spiral notebook. It was in large letters. It was kind of in shaky writing. And what it turned out to be was a suicide note. So I was reading it as she was writing it. She tried to take the remainder of the pills, I don't know how many. She tried to take the whole bottle. So at that point I intervened and took the bottle away from her, took the note away from her," he said.
"There's a fine line between intervening with someone's medication and knowing that they're overdosing. She wrote on the note how many pills she had taken."
But as soon as Odor grabbed the notebook and pills, the woman became violent.
"She was yelling, she was kicking at us, she was quite combative," he recalled Monday. "She's emotional, she's crying, she's kicking, I mean she was quite distraught to say the least."
Several officers, and a doctor from the Huntsman Cancer Institute who was also on the flight, tried to get the pills out of her mouth. The woman bit down on the doctor.
"We had to actually open her jaw so she would let go of his hand," Odor said.
As Odor and Stromberg held the woman down, Unified Police Sgt. Terry Wall attempted to talk to her, letting her know that she did matter. Wall is a Crisis Training Intervention specialist who is typically called into action when officers have to deal with a mentally ill person.
"Each individual has a stake in what goes on in the world and we need her here," Wall told her.
The woman's husband tried to walk to the front while the officers were trying to restrain her, but "she was very adamant he was not anywhere near her," Stromberg said, noting that "he was clearly making it worse" by being there. The husband was asked to go back to his seat.
Over the next 90 minutes, as the flight was being diverted to Chicago, the two officers held the woman as Wall talked to her. They felt that handcuffing her would have further exacerbated the situation.
One of the problems they faced was that she would calm down so much that she would fall asleep and become semi-comatose, he said. The officers, fearing the worst, kept waking her which would cause her to get angry again.
But the time the plane landed in Chicago where paramedics were waiting, Wall said the woman's cries of, "I want to die, I want to die. Let me die," had significantly changed.
"She was very calm and asking for help at that point. She wanted her stomach pumped and she wanted her daddy, is what she kept saying," he said.
The woman also wanted her husband.
By the end of it she was asking for him again. We had got her calmed down so much that she wanted to take her life in a different direction," Wall said.
In Chicago, the officers got cleaned up and the flight crew bought them snacks in the airport. Most of the passengers applauded with appreciation for the officers as the woman was taken off the plane.
"I can only speculate what would have happened if we hadn't noticed that and the flight would have continued for four more hours," Odor said.
Story, Comments, Video and Photo Gallery: http://www.ksl.com
Tuesday, January 06, 2015
15-year-old sole survivor of plane crash
13abc.com Toledo (OH) News, Weather and Sports
15-year old Joel Hutchison is a gifted straight A Freshman at Shawnee High School in Lima, Ohio. To meet him in person you'd never imagine the trauma he endured as 7-year old. That's when the small Cessna plane his father Jeff was piloting crashed in the waters just off the shores of Kelly's Island on September 3rd, 2007. Joe's father and his 9-year old brother Jeremy were both killed in the crash. “I stood on the plane wing and I looked to see where everyone was, and my dad was floating in the water about 15-feet away,” says Joel. “I knew Jeremy was gone because there was no response and I didn't see him anywhere.”
Joel says the plane went underwater and he was left to tread water about a mile from the shore. “Luckily, my dad told to me to yell for help before he went under,” says Joel. “At that point, I was decently sure I'd never see them again.”
Island Resident Chuck Herndon and his wife saw the crash from shore. Chuck grabbed his row boat and headed out with a flashlight to help any survivors. “I heard a small voice crying for help and I said keep screaming.” Says Herndon. “I don't even know how I did it myself, the chances of like almost no wounds on me besides some small scrapes, I don't understand it myself, and it really is a miracle.” Says Joel.
Story and Video: http://www.13abc.com
NTSB Identification: CHI07FA290
The docket is stored in the Docket Management System (DMS). Please contact Records Management Division
Accident occurred Monday, September 03, 2007 in Kelleys Island, OH
Probable Cause Approval Date: 09/26/2008
Aircraft: Cessna 172C, registration: N1301Y
Injuries: 2 Fatal, 1 Serious.
NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.
The non-instrument rated pilot departed to the east from the island airport at night. Witnesses reported seeing the airplane descend into Lake Erie shortly after takeoff. A resident of the island used his rowboat to rescue the surviving passenger. Post accident inspection of the airframe and engine failed to reveal any mechanical failure/malfunction that would have resulted in the accident. The departure end of the runway is approximately 200 feet from the lakeshore. The closest ground reference would have been the Ohio shoreline located about 10 miles south (to the right of) of the airplane's position.
The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The pilot's failure to maintain control of the airplane due to spatial disorientation. Contributing to the accident were the water and dark night conditions which resulted in the lack of ground references during the takeoff.
15-year old Joel Hutchison is a gifted straight A Freshman at Shawnee High School in Lima, Ohio. To meet him in person you'd never imagine the trauma he endured as 7-year old. That's when the small Cessna plane his father Jeff was piloting crashed in the waters just off the shores of Kelly's Island on September 3rd, 2007. Joe's father and his 9-year old brother Jeremy were both killed in the crash. “I stood on the plane wing and I looked to see where everyone was, and my dad was floating in the water about 15-feet away,” says Joel. “I knew Jeremy was gone because there was no response and I didn't see him anywhere.”
Joel says the plane went underwater and he was left to tread water about a mile from the shore. “Luckily, my dad told to me to yell for help before he went under,” says Joel. “At that point, I was decently sure I'd never see them again.”
Island Resident Chuck Herndon and his wife saw the crash from shore. Chuck grabbed his row boat and headed out with a flashlight to help any survivors. “I heard a small voice crying for help and I said keep screaming.” Says Herndon. “I don't even know how I did it myself, the chances of like almost no wounds on me besides some small scrapes, I don't understand it myself, and it really is a miracle.” Says Joel.
Story and Video: http://www.13abc.com
NTSB Identification: CHI07FA290
The docket is stored in the Docket Management System (DMS). Please contact Records Management Division
Accident occurred Monday, September 03, 2007 in Kelleys Island, OH
Probable Cause Approval Date: 09/26/2008
Aircraft: Cessna 172C, registration: N1301Y
Injuries: 2 Fatal, 1 Serious.
NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.
The non-instrument rated pilot departed to the east from the island airport at night. Witnesses reported seeing the airplane descend into Lake Erie shortly after takeoff. A resident of the island used his rowboat to rescue the surviving passenger. Post accident inspection of the airframe and engine failed to reveal any mechanical failure/malfunction that would have resulted in the accident. The departure end of the runway is approximately 200 feet from the lakeshore. The closest ground reference would have been the Ohio shoreline located about 10 miles south (to the right of) of the airplane's position.
The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The pilot's failure to maintain control of the airplane due to spatial disorientation. Contributing to the accident were the water and dark night conditions which resulted in the lack of ground references during the takeoff.
AutoGyro Calidus, N50NE, Airgyro Aviation LLC: Accident occurred January 06, 2015 in Grand Junction, Colorado and accident occurred May 20, 2016 in Fruitland, Utah
AIRGYRO AVIATION LLC: http://registry.faa.gov/N50NE
FAA Flight Standards District Office: FAA Salt Lake City FSDO-07
NTSB Identification: WPR16LA114
14 CFR Part 91: General Aviation
Accident occurred Friday, May 20, 2016 in Fruitland, UT
Aircraft: MICHAEL BURTON Calidus, registration: N50NE
Injuries: 2 Serious.
This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.
On May 20, 2016, about 1100 mountain daylight time, an experimental amateur-built Michael Burton (AutoGyro GmbH) Calidus, N50NE, collided with mountainous terrain near Fruitland, Utah. The gyrocopter was registered to the builder and operated by the pilot under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The private pilot and passenger were seriously injured, and the gyrocopter sustained substantial damage. The cross-country personal flight departed Duchesne Municipal Airport, Duchesne, Utah, about 30 minutes prior, with a planned destination of Spanish Fork Airport-Springville-Woodhouse Field, Spanish Fork, Utah. Visual meteorological conditions prevailed, and no flight plan had been filed.
The pilot reported that they departed from Glenwood Springs Municipal Airport, Glenwood Springs, Colorado, earlier that morning and stopped at Duchesne for fuel. They then departed west towards Spanish Fork on a route over the Wasatch Mountain Range. As they approached the last ridge, about 200 ft above its peak, they encountered a strong downdraft and the gyrocopter descended 500 ft and into a box canyon. Unable to out climb the terrain, the pilot guided the gyrocopter over a river at the base of the canyon until he could see a landing spot on the shore. As he approached the site and initiated the landing flair, the right wheel struck a bolder and the gyrocopter rolled over, coming to rest in the river.
A witness, who was fishing in the river, called 911 after climbing to a peak where he was able to receive cell phone reception. Due to the remoteness of the site, the pilot and passenger were not recovered until later in the evening.
WASATCH COUNTY, Utah (ABC4 Utah) - A man and woman have been rescued after a Autogyro GMBH Calidus went down in the Uinta National Forest.
The Wasatch County Sheriff's Office said the crash happened sometime around 11 a.m.
The office received a call from a fisherman at 11:30 a.m. alerting them of the crash.
Chief Deputy Jared Rigby with WCSO said, "He saw this gyrocopter go down. That it clipped the trees and that it went into the Strawberry River."
The fisherman would rush to the area to help get the pilot and his passenger to safety.
He told deputies he was able to get the man out from the pilot seat but had a harder time with the woman on the passenger side.
"He said that they had to move the aircraft around a little bit in order to help get the female passenger out because she was, she was pinned in," said Chief Deputy Rigby.
The fisherman got the two to the shore of Strawberry River. Then he had to hike out two miles to get to cell service along U.S. 40. Once he did he called for search and rescue.
"This is a really rugged area from what I’m being told. They are not able to get any vehicles in there," the Chief Deputy added.
Search and Rescue teams called in two medical helicopters to hoist the man and woman out of the area.
"The injuries I’m being told are minor to moderate and so I think that these folks thus far have been very fortunate," said Chief Deputy Rigby.
The two were taken to the Utah Regional Valley Medical Center to be treated for their injuries.
Search and rescue teams said the woman may be suffering from a possible broken leg and injured back.
The man suffered from hypothermia.
"It really sounds like these people are truly fortunate to have that fisherman there and if infact he did see this aircraft go down, to be right there to help them, especially if they were stuck in that aircraft in the water," he added.
The FAA and NTSB have been notified of the crash. It's still unclear why the gyrocopter went down.
The Wasatch Health Department was called in because the crash happened on the Strawberry River and fuel could have been leaked into the water.
Story and video: http://www.good4utah.com
WASATCH COUNTY, Utah -- A Autogyro GMBH Calidus crash about two miles south of the Soldier Creek dam in Wasatch County has left a pilot and a passenger injured.
Search and Rescue crews were called to the downed aircraft just before noon in the Strawberry River.
Jared Riby with the Wasatch County Sheriff's Office said the man and woman have a few broken bones but no life-threatening injuries.
Deputies said a fisherman in the area heard the Autogyro GMBH Calidus having difficulties and saw it go down.
Officials said he went to check on the victims and then had to hike out to get cell service to call emergency crews.
Riby said the crash site is in a difficult area to reach and the only way crews could get to the victims was by air or on foot.
Rescue crews treated the pair and worked to get them out in a medical helicopter.
Authorities have not said what led to the crash.
The names of those involved have not been released.
Story and video: http://fox13now.com
WASATCH COUNTY — Two people were injured when a Autogyro GMBH Calidus crashed in Wasatch County Friday.
The two people, who sustained “minor to moderate injuries,” were in the Strawberry River for about five minutes, according to the Wasatch County Sheriff’s Office. The cause of the crash, which occurred in a remote location in the Soldier Creek area, is not yet known.
A fisherman saw the Autogyro GMBH Calidus crash into the water, according to the sheriff's office. He reportedly called emergency services after finding a spot with cell service and helped guide the search crew to the crash site.
The male pilot and female passenger were in the water for about five minutes after crashing into the river around 11:30 a.m., according to the sheriff's office.
"Life Flight sent two medical helicopters, hoisted the two patients out of the area, and are transporting them to Utah Valley (Hospital)," the department reported.
The Wasatch County Search and Rescue team and medical services responded to the crash. The two people were transported to the hospital by a medical helicopter.
Their injuries are not expected to be life threatening, although both people are being treated for hypothermia, according to the sheriff's office. One person had a possible broken leg and injured back, while the other only sustained minor injuries.
The Federal Aviation Administration and National Transportation Safety board will be involved in investigating the cause of the crash, according to the sheriff's office.
Story and video: https://ksl.com
NTSB Identification: CEN15CA128
14 CFR Part 91: General Aviation
Accident occurred Tuesday, January 06, 2015 in Grand Junction, CO
Probable Cause Approval Date: 03/10/2015
Aircraft: BURTON CALIDUS, registration: N50NE
Injuries: 1 Serious, 1 Minor.
NTSB investigators used data provided by various entities, including, but not limited to, the Federal Aviation Administration and/or the operator and did not travel in support of this investigation to prepare this aircraft accident report.
The pilot stated that during a flight to the destination airport, the gyrocopter was in a slow climb at about 60 knots due to higher terrain that he knew was approaching along the route. As the gyrocopter approached a ridge, the pilot noticed that more altitude was needed, so he turned left of course along the ridge while continuing the climb, expecting to turn right at an area that he saw had lower terrain. The pilot said that things were still going well, but the climb rate had decreased somewhat. As the gyrocopter approached the area of lower terrain, the gyrocopter started to descend quickly with a best rate of climb speed of 52 knots. The gyrocopter descended lower than the surrounding trees and "brushed" the tree tops, tipping the gyrocopter forward and to the right. The pilot saw a small clearing and applied corrective control input to maintain an upright attitude of the gyrocopter and to reach the clearing. Just before entering the clearing, the gyrocopter contacted oak brush with its rotor blades, which sustained substantial damage. The gyrocopter landed in the clearing and slid with minimal forward speed to a stop. The aircraft fuselage had a fractured nose and collapsed nose gear. The pilot sustained serious injuries and the passenger sustained minor injuries. The pilot stated that if he had turned right at the approach of the ridge where the terrain was lower, he could have gone around the south end of the ridge. He said he should have expected a down draft on the lee side of the ridge and could also have executed an escape route earlier by turning away from the ridge before the area of down flowing air.
The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The pilot's failure to maintain clearance with terrain that was along the planned route of flight.
AIRGYRO AVIATION LLC: http://registry.faa.gov/N50NE
On Tuesday night a Gyroplane carrying 2 passengers crashed leaving both men injured. But many are questioning the safety behind these unique aircrafts that are a mix between a helicopter and an airplane.
The two men in the crash were 53 year old Mike Burton of Pleasant Grove Utah, and 30 year old Josh Humphries from Payson Utah. The men were on their way back to Utah from Montrose when the crash happened.
Records on file with the FAA said the plane was registered to Mike Burton through Air-Gyro Aviation in Utah. Records show Burton built this Calidus 2 seater aircraft himself.
Troy Atwood is a Gyroplane pilot who said he is close friends with Mike Burton the pilot involved in the gyroplane crash Tuesday night.
Atwood was in another gyro-plane last night, flying ahead them, when the crash happened.
“The aircraft was performing properly, the motor wasn't putting out enough energy and he started to climb over that mountain and the mountain came up faster than he could climb and it was like a box canyon so there was nowhere for him to turn around," said Atwood.
The group was on their way back from a plane demonstration trip to Telluride and Montrose.
They'd started back to Utah, taking off from the Montrose airport around 3:30pm for what was expected to be a 3 hour flight.
The plane ran into trouble about an hour later, but Atwood had to keep flying even after the crash.
"It was pretty difficult but I've been in this business for a long time and I knew Mike and Josh would be okay because, it's Mike," said Atwood.
Gyroplanes are regulated a lot like any fixed wing aircraft, and these planes just like any other have to be licensed and registered.
Dick Knapinski with the Experimental Aircraft Association says that a lot of inspection and training goes into planes like Gyroplanes, before they can ever leave the ground.
"Anything with an air number or an N number that is registered with the FAA is under the same specifications for inspection, recurrent training and so forth, pilot training the same as a fixed wing aircraft," said Knapinski.
The requirements for a kit Gyroplane or one that you build yourself are a little bit more in-depth, once the plane is build it has to go through a federal inspection with the FAA.
"the FAA designated inspector will come and not only inspects the aircraft as it is but they also look at what's called a builders log how the aircraft went together, what timeline was used, what techniques were used," said Knapinski.
These aircraft's are required to go through inspection every year or every 100 hours of flight whichever comes first and pilots of these Gyroplanes must still complete training to fly one similar to that of another pilot.
The FAA and many pilots that fly these aircraft do consider them to be safe.
Story and Video: http://www.nbc11news.com
PAYSON — "Crashed."
That was the text Norky Humphreys received Tuesday afternoon at her home in Payson from her husband, Josh Humphreys.
"You are kidding right?" Norky Humphreys replied.
But he wasn't.
Josh Humphreys was flying back to Utah from Telluride, Colorado, with veteran pilot Mike Burton in their gyroplane — a kind of helicopter, airplane combination — when it crashed in a remote area near Glade Park shortly before 5:30 p.m., according to the Mesa County Sheriff's Office.
Both Humphreys and Burton survived. Rescuers took them to a hospital in Grand Junction where they were treated for back and neck injuries not considered to be life threatening. The two were being picked up by co-workers and driven back to Utah Wednesday.
Burton, of Pleasant Grove, is a pilot with Airgyro Aviation. On Monday, he was in one of two gyroplanes that flew to Telluride to show off the new aircraft to clients. Humphreys was there to film the event for the company.
On their way home, the two aircraft stopped in Montrose, Colorado, to fuel up. Shortly after takeoff again, the Burton and Humphreys gyroplane got caught in a downdraft and didn't have the turbo chargers needed to get over the mountain, according to Troy Atwood, who was in the gyroplane ahead of them.
Rescue teams reached the crash site on snowmobiles shortly after 8:20 p.m.
Humphreys reportedly had to hike a quarter-mile away from the crash site to get cellphone reception while Burton stayed with the aircraft. Humphreys tried calling his wife before texting her.
"He told me, 'I'm OK. We're fine. But we crashed,'" she said.
But reception was lost shortly after. After Humphreys texted that he had crashed, he again lost reception.
"Baby, answer the phone please, I am freaking out," Norky Humphreys texted back.
Finally, Josh Humphreys got reception again and Norky got the word she was waiting for.
"We're fine," the text said.
"I'm feeling fine now, but it was scary," Norky Humphreys said Wednesday.
The Federal Aviation Administration is investigating the incident.
Humphreys said the crash will not deter either man from flying a gyroplane again.
MESA COUNTY, Colo. UPDATE: 53-year-old Mike Burton, of Pleasant Grove, Utah, was piloting the gyroplane that crashed Tuesday night on Glade Park. Burton was transported to an area hospital via CareFlight helicopter.
The passenger of the plane was 30-year-old Josh Humphries, of Payson, Utah. Humphries initially refused medical services, but he was eventually transported via snowmobile to a waiting ambulance, which then took them to the hospital.
Inquiries have been made of the hospital Burton and Humphries were taken to, however they have not released any information regarding their conditions.
________________________________________
As darkness descended upon the Grand Valley, authorities rushed to the scene of a gyroplane crash Tuesday night.
According to the Mesa County Sheriff’s Office, two Utah men were traveling back to Spanish Fork, Utah when the gyroplane crashed on Glade Park.
The initial call came in around 5:30 p.m. and was made from a person inside the aircraft. Delta County Dispatch was able to determine that there were two men on board the gyrocopter-type aircraft, and the caller was able to provide an approximate GPS location of the crash.
After staging in the area, officials with the Glade Park Fire Department determined they would need help finding the crash victims.
They called in the CareFlight helicopter to perform a search using night vision equipment.
CareFlight was able to locate the crash site – a remote, canyon-laden area approximately 12 miles southeast of the Glade Park Fire Station – however they were unable to land.
Heavy snow on the ground in the area meant a snowmobile rescue effort was required to reach the scene. A ground rescue team used the snowmobiles to reach the crash sight and begin treatment and removal of both victims.
At approximately 10:15 p.m. the ground team found a place for the CareFlight helicopter to land and requested transport of one man to an area hospital.
The second man initially refused medical services, but he was eventually transported via snowmobile to a waiting ambulance, which then took them to the hospital.
Authorities with the Glade Park Fire Department, Grand Junction Fire Department, Mesa County Sheriff’s Department, and Mesa County Search and Rescue all respond to the incident.
FAA Flight Standards District Office: FAA Salt Lake City FSDO-07
NTSB Identification: WPR16LA114
14 CFR Part 91: General Aviation
Accident occurred Friday, May 20, 2016 in Fruitland, UT
Aircraft: MICHAEL BURTON Calidus, registration: N50NE
Injuries: 2 Serious.
This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.
On May 20, 2016, about 1100 mountain daylight time, an experimental amateur-built Michael Burton (AutoGyro GmbH) Calidus, N50NE, collided with mountainous terrain near Fruitland, Utah. The gyrocopter was registered to the builder and operated by the pilot under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The private pilot and passenger were seriously injured, and the gyrocopter sustained substantial damage. The cross-country personal flight departed Duchesne Municipal Airport, Duchesne, Utah, about 30 minutes prior, with a planned destination of Spanish Fork Airport-Springville-Woodhouse Field, Spanish Fork, Utah. Visual meteorological conditions prevailed, and no flight plan had been filed.
The pilot reported that they departed from Glenwood Springs Municipal Airport, Glenwood Springs, Colorado, earlier that morning and stopped at Duchesne for fuel. They then departed west towards Spanish Fork on a route over the Wasatch Mountain Range. As they approached the last ridge, about 200 ft above its peak, they encountered a strong downdraft and the gyrocopter descended 500 ft and into a box canyon. Unable to out climb the terrain, the pilot guided the gyrocopter over a river at the base of the canyon until he could see a landing spot on the shore. As he approached the site and initiated the landing flair, the right wheel struck a bolder and the gyrocopter rolled over, coming to rest in the river.
A witness, who was fishing in the river, called 911 after climbing to a peak where he was able to receive cell phone reception. Due to the remoteness of the site, the pilot and passenger were not recovered until later in the evening.
The Wasatch County Sheriff's Office said the crash happened sometime around 11 a.m.
The office received a call from a fisherman at 11:30 a.m. alerting them of the crash.
Chief Deputy Jared Rigby with WCSO said, "He saw this gyrocopter go down. That it clipped the trees and that it went into the Strawberry River."
The fisherman would rush to the area to help get the pilot and his passenger to safety.
He told deputies he was able to get the man out from the pilot seat but had a harder time with the woman on the passenger side.
"He said that they had to move the aircraft around a little bit in order to help get the female passenger out because she was, she was pinned in," said Chief Deputy Rigby.
The fisherman got the two to the shore of Strawberry River. Then he had to hike out two miles to get to cell service along U.S. 40. Once he did he called for search and rescue.
"This is a really rugged area from what I’m being told. They are not able to get any vehicles in there," the Chief Deputy added.
Search and Rescue teams called in two medical helicopters to hoist the man and woman out of the area.
"The injuries I’m being told are minor to moderate and so I think that these folks thus far have been very fortunate," said Chief Deputy Rigby.
The two were taken to the Utah Regional Valley Medical Center to be treated for their injuries.
Search and rescue teams said the woman may be suffering from a possible broken leg and injured back.
The man suffered from hypothermia.
"It really sounds like these people are truly fortunate to have that fisherman there and if infact he did see this aircraft go down, to be right there to help them, especially if they were stuck in that aircraft in the water," he added.
The FAA and NTSB have been notified of the crash. It's still unclear why the gyrocopter went down.
The Wasatch Health Department was called in because the crash happened on the Strawberry River and fuel could have been leaked into the water.
Story and video: http://www.good4utah.com
Search and Rescue crews were called to the downed aircraft just before noon in the Strawberry River.
Jared Riby with the Wasatch County Sheriff's Office said the man and woman have a few broken bones but no life-threatening injuries.
Deputies said a fisherman in the area heard the Autogyro GMBH Calidus having difficulties and saw it go down.
Officials said he went to check on the victims and then had to hike out to get cell service to call emergency crews.
Riby said the crash site is in a difficult area to reach and the only way crews could get to the victims was by air or on foot.
Rescue crews treated the pair and worked to get them out in a medical helicopter.
Authorities have not said what led to the crash.
The names of those involved have not been released.
Story and video: http://fox13now.com
WASATCH COUNTY — Two people were injured when a Autogyro GMBH Calidus crashed in Wasatch County Friday.
The two people, who sustained “minor to moderate injuries,” were in the Strawberry River for about five minutes, according to the Wasatch County Sheriff’s Office. The cause of the crash, which occurred in a remote location in the Soldier Creek area, is not yet known.
A fisherman saw the Autogyro GMBH Calidus crash into the water, according to the sheriff's office. He reportedly called emergency services after finding a spot with cell service and helped guide the search crew to the crash site.
The male pilot and female passenger were in the water for about five minutes after crashing into the river around 11:30 a.m., according to the sheriff's office.
"Life Flight sent two medical helicopters, hoisted the two patients out of the area, and are transporting them to Utah Valley (Hospital)," the department reported.
The Wasatch County Search and Rescue team and medical services responded to the crash. The two people were transported to the hospital by a medical helicopter.
Their injuries are not expected to be life threatening, although both people are being treated for hypothermia, according to the sheriff's office. One person had a possible broken leg and injured back, while the other only sustained minor injuries.
The Federal Aviation Administration and National Transportation Safety board will be involved in investigating the cause of the crash, according to the sheriff's office.
Story and video: https://ksl.com
14 CFR Part 91: General Aviation
Accident occurred Tuesday, January 06, 2015 in Grand Junction, CO
Probable Cause Approval Date: 03/10/2015
Aircraft: BURTON CALIDUS, registration: N50NE
Injuries: 1 Serious, 1 Minor.
NTSB investigators used data provided by various entities, including, but not limited to, the Federal Aviation Administration and/or the operator and did not travel in support of this investigation to prepare this aircraft accident report.
The pilot stated that during a flight to the destination airport, the gyrocopter was in a slow climb at about 60 knots due to higher terrain that he knew was approaching along the route. As the gyrocopter approached a ridge, the pilot noticed that more altitude was needed, so he turned left of course along the ridge while continuing the climb, expecting to turn right at an area that he saw had lower terrain. The pilot said that things were still going well, but the climb rate had decreased somewhat. As the gyrocopter approached the area of lower terrain, the gyrocopter started to descend quickly with a best rate of climb speed of 52 knots. The gyrocopter descended lower than the surrounding trees and "brushed" the tree tops, tipping the gyrocopter forward and to the right. The pilot saw a small clearing and applied corrective control input to maintain an upright attitude of the gyrocopter and to reach the clearing. Just before entering the clearing, the gyrocopter contacted oak brush with its rotor blades, which sustained substantial damage. The gyrocopter landed in the clearing and slid with minimal forward speed to a stop. The aircraft fuselage had a fractured nose and collapsed nose gear. The pilot sustained serious injuries and the passenger sustained minor injuries. The pilot stated that if he had turned right at the approach of the ridge where the terrain was lower, he could have gone around the south end of the ridge. He said he should have expected a down draft on the lee side of the ridge and could also have executed an escape route earlier by turning away from the ridge before the area of down flowing air.
The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The pilot's failure to maintain clearance with terrain that was along the planned route of flight.
AIRGYRO AVIATION LLC: http://registry.faa.gov/N50NE
MESA COUNTY,Colo. Gyroplanes while considered experimental aircraft must still go through heavy regulation and inspection before ever being able to get off the ground, and the pilots that fly them must go through training before they can fly one.
On Tuesday night a Gyroplane carrying 2 passengers crashed leaving both men injured. But many are questioning the safety behind these unique aircrafts that are a mix between a helicopter and an airplane.
The two men in the crash were 53 year old Mike Burton of Pleasant Grove Utah, and 30 year old Josh Humphries from Payson Utah. The men were on their way back to Utah from Montrose when the crash happened.
Records on file with the FAA said the plane was registered to Mike Burton through Air-Gyro Aviation in Utah. Records show Burton built this Calidus 2 seater aircraft himself.
Troy Atwood is a Gyroplane pilot who said he is close friends with Mike Burton the pilot involved in the gyroplane crash Tuesday night.
Atwood was in another gyro-plane last night, flying ahead them, when the crash happened.
“The aircraft was performing properly, the motor wasn't putting out enough energy and he started to climb over that mountain and the mountain came up faster than he could climb and it was like a box canyon so there was nowhere for him to turn around," said Atwood.
The group was on their way back from a plane demonstration trip to Telluride and Montrose.
They'd started back to Utah, taking off from the Montrose airport around 3:30pm for what was expected to be a 3 hour flight.
The plane ran into trouble about an hour later, but Atwood had to keep flying even after the crash.
"It was pretty difficult but I've been in this business for a long time and I knew Mike and Josh would be okay because, it's Mike," said Atwood.
Gyroplanes are regulated a lot like any fixed wing aircraft, and these planes just like any other have to be licensed and registered.
Dick Knapinski with the Experimental Aircraft Association says that a lot of inspection and training goes into planes like Gyroplanes, before they can ever leave the ground.
"Anything with an air number or an N number that is registered with the FAA is under the same specifications for inspection, recurrent training and so forth, pilot training the same as a fixed wing aircraft," said Knapinski.
The requirements for a kit Gyroplane or one that you build yourself are a little bit more in-depth, once the plane is build it has to go through a federal inspection with the FAA.
"the FAA designated inspector will come and not only inspects the aircraft as it is but they also look at what's called a builders log how the aircraft went together, what timeline was used, what techniques were used," said Knapinski.
These aircraft's are required to go through inspection every year or every 100 hours of flight whichever comes first and pilots of these Gyroplanes must still complete training to fly one similar to that of another pilot.
The FAA and many pilots that fly these aircraft do consider them to be safe.
Story and Video: http://www.nbc11news.com
That was the text Norky Humphreys received Tuesday afternoon at her home in Payson from her husband, Josh Humphreys.
"You are kidding right?" Norky Humphreys replied.
But he wasn't.
Josh Humphreys was flying back to Utah from Telluride, Colorado, with veteran pilot Mike Burton in their gyroplane — a kind of helicopter, airplane combination — when it crashed in a remote area near Glade Park shortly before 5:30 p.m., according to the Mesa County Sheriff's Office.
Both Humphreys and Burton survived. Rescuers took them to a hospital in Grand Junction where they were treated for back and neck injuries not considered to be life threatening. The two were being picked up by co-workers and driven back to Utah Wednesday.
Burton, of Pleasant Grove, is a pilot with Airgyro Aviation. On Monday, he was in one of two gyroplanes that flew to Telluride to show off the new aircraft to clients. Humphreys was there to film the event for the company.
On their way home, the two aircraft stopped in Montrose, Colorado, to fuel up. Shortly after takeoff again, the Burton and Humphreys gyroplane got caught in a downdraft and didn't have the turbo chargers needed to get over the mountain, according to Troy Atwood, who was in the gyroplane ahead of them.
Rescue teams reached the crash site on snowmobiles shortly after 8:20 p.m.
Humphreys reportedly had to hike a quarter-mile away from the crash site to get cellphone reception while Burton stayed with the aircraft. Humphreys tried calling his wife before texting her.
"He told me, 'I'm OK. We're fine. But we crashed,'" she said.
But reception was lost shortly after. After Humphreys texted that he had crashed, he again lost reception.
"Baby, answer the phone please, I am freaking out," Norky Humphreys texted back.
Finally, Josh Humphreys got reception again and Norky got the word she was waiting for.
"We're fine," the text said.
"I'm feeling fine now, but it was scary," Norky Humphreys said Wednesday.
The Federal Aviation Administration is investigating the incident.
Humphreys said the crash will not deter either man from flying a gyroplane again.
MESA COUNTY, Colo. UPDATE: 53-year-old Mike Burton, of Pleasant Grove, Utah, was piloting the gyroplane that crashed Tuesday night on Glade Park. Burton was transported to an area hospital via CareFlight helicopter.
The passenger of the plane was 30-year-old Josh Humphries, of Payson, Utah. Humphries initially refused medical services, but he was eventually transported via snowmobile to a waiting ambulance, which then took them to the hospital.
Inquiries have been made of the hospital Burton and Humphries were taken to, however they have not released any information regarding their conditions.
________________________________________
As darkness descended upon the Grand Valley, authorities rushed to the scene of a gyroplane crash Tuesday night.
According to the Mesa County Sheriff’s Office, two Utah men were traveling back to Spanish Fork, Utah when the gyroplane crashed on Glade Park.
The initial call came in around 5:30 p.m. and was made from a person inside the aircraft. Delta County Dispatch was able to determine that there were two men on board the gyrocopter-type aircraft, and the caller was able to provide an approximate GPS location of the crash.
After staging in the area, officials with the Glade Park Fire Department determined they would need help finding the crash victims.
They called in the CareFlight helicopter to perform a search using night vision equipment.
CareFlight was able to locate the crash site – a remote, canyon-laden area approximately 12 miles southeast of the Glade Park Fire Station – however they were unable to land.
Heavy snow on the ground in the area meant a snowmobile rescue effort was required to reach the scene. A ground rescue team used the snowmobiles to reach the crash sight and begin treatment and removal of both victims.
At approximately 10:15 p.m. the ground team found a place for the CareFlight helicopter to land and requested transport of one man to an area hospital.
The second man initially refused medical services, but he was eventually transported via snowmobile to a waiting ambulance, which then took them to the hospital.
Authorities with the Glade Park Fire Department, Grand Junction Fire Department, Mesa County Sheriff’s Department, and Mesa County Search and Rescue all respond to the incident.
Flatbread Will Shutter Its Vineyard Operation: Martha's Vineyard Airport (KMVY), Vineyard Haven, Massachusetts
Flatbread, the popular wood-fired pizza franchise near the Martha’s Vineyard Airport that has hosted fundraisers, family dance parties and concerts, will not reopen this summer, owner Jay Gould has confirmed.
“The season is too short for us. We do very well in July and August, but it’s not enough,” Mr. Gould told the Gazette in an email early Tuesday.
Mr. Gould, who owns the building along with Brion McGroarty, the owner of MV Wine and Spirits next door, said he hopes someone may want to take over the restaurant as a new franchise owner. “As an independent franchise it may be financially viable without all our corporate overhead. This would be our first choice,” he wrote.
Flatbread has been operating since 2010 in the space that formerly housed the Hot Tin Roof and Outerland nightclubs. For the first two years Mr. Gould partnered with Nectar’s, the Burlington, Vt., nightclub, but in 2012 the music promoter bowed out and Flatbread took over as the sole owner. Mr. Gould is the chief executive officer of the Flatbread Co., a franchise of the American Flatbread Company in Vermont.
The first Flatbread pizza restaurant under Mr. Gould’s ownership opened in Amesbury in 1998; Flatbread restaurants can now be found from the Hamptons to Maui. The pizza is baked in a handmade clay wood-fired oven using organic flour and ingredients sourced from local farms. The environment is deliberately casual and all Flatbreads host weekly fundraisers for local organizations.
But in his email Mr. Gould said the extreme seasonality of the Vineyard has been an obstacle.
“There was only one problem — the short season — and this is something we cannot fix,” he wrote. “We loved the Island and in a way it was the perfect place for Flatbread — and as most of us at Flatbread are surfers and beach lovers, having a store on the Vineyard seemed great. We were only open in the summer and the Island has an abundance of local and organic farms. Using local and organic food was something we pioneered 16 years ago before it became popular.”
He concluded on a note of thanks:
“We would like to thank our fantastic local Island crew and Tina Miller our manager, Julia Celeste our assistant manager and Karen Dutton our kitchen manager. We would also like to thank all of our Island supporters.”
- Story, Comments and Photo: http://vineyardgazette.com
“The season is too short for us. We do very well in July and August, but it’s not enough,” Mr. Gould told the Gazette in an email early Tuesday.
Mr. Gould, who owns the building along with Brion McGroarty, the owner of MV Wine and Spirits next door, said he hopes someone may want to take over the restaurant as a new franchise owner. “As an independent franchise it may be financially viable without all our corporate overhead. This would be our first choice,” he wrote.
Flatbread has been operating since 2010 in the space that formerly housed the Hot Tin Roof and Outerland nightclubs. For the first two years Mr. Gould partnered with Nectar’s, the Burlington, Vt., nightclub, but in 2012 the music promoter bowed out and Flatbread took over as the sole owner. Mr. Gould is the chief executive officer of the Flatbread Co., a franchise of the American Flatbread Company in Vermont.
The first Flatbread pizza restaurant under Mr. Gould’s ownership opened in Amesbury in 1998; Flatbread restaurants can now be found from the Hamptons to Maui. The pizza is baked in a handmade clay wood-fired oven using organic flour and ingredients sourced from local farms. The environment is deliberately casual and all Flatbreads host weekly fundraisers for local organizations.
But in his email Mr. Gould said the extreme seasonality of the Vineyard has been an obstacle.
“There was only one problem — the short season — and this is something we cannot fix,” he wrote. “We loved the Island and in a way it was the perfect place for Flatbread — and as most of us at Flatbread are surfers and beach lovers, having a store on the Vineyard seemed great. We were only open in the summer and the Island has an abundance of local and organic farms. Using local and organic food was something we pioneered 16 years ago before it became popular.”
He concluded on a note of thanks:
“We would like to thank our fantastic local Island crew and Tina Miller our manager, Julia Celeste our assistant manager and Karen Dutton our kitchen manager. We would also like to thank all of our Island supporters.”
- Story, Comments and Photo: http://vineyardgazette.com
Beech V35B Bonanza, N246JT, J & J Air LLC: Accident occurred January 06, 2015 near Hickory Regional Airport (KHKY), North Carolina
NTSB Identification: ERA15LA092
14 CFR Part 91: General Aviation
Accident occurred Tuesday, January 06, 2015 in Long View, NC
Probable Cause Approval Date: 09/08/2015
Aircraft: BEECH V35B, registration: N246JT
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.
The pilot reported that, during initial climb, he heard a big “bang,” which was followed by a total loss of engine power. He subsequently performed a forced landing straight ahead into trees. Teardown examination of the engine revealed that the lower rear crankshaft counterweight had separated. During a subsequent examination, all four snap rings from the lower rear crankshaft counterweight were found loose in the engine, and one of the rings was found broken in half. Three of the lower rear counterweight retaining plates were found, but the fourth retaining plate was not recovered. Two snap rings that were still in place on the upper rear crankshaft counterweight were examined. The examination revealed that the width between the snap ring ears on one of the snap rings did not meet the manufacturer-prescribed width, indicating that the snap ring was not properly seated. After that snap ring was removed and its groove was cleaned of deposits with a wire brush, it seated properly when reinstalled. A review of maintenance records revealed that, about 16 years before the accident, the engine had been rebuilt and had accumulated about 1,600 hours since it was rebuilt and that, about 8 years before the accident, a top overhaul was performed on the engine. The crankshaft was inspected about 6 months after the factory rebuild in accordance with an airworthiness directive (AD); however, there likely would have been little to no deposits in the crankshaft so soon after the factory rebuild. Before the issuance of the AD, the engine manufacturer had issued a mandatory service bulletin, which included a warning that the “failure to properly install counterweight retaining plates and snap rings may result in engine damage and possible failure.” It is likely that the lower rear crankshaft counterweight snap rings were not properly installed; however, it could not be determined when or by whom they were improperly installed.
The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The improper installation of the lower rear crankshaft counterweight snap rings by unknown maintenance personnel, which resulted in the separation of the counterweight and a subsequent total loss of engine power during initial climb.
On January 6, 2015, about 1710 eastern standard time, a Beech V35B, N246JT, operated by a private individual, was substantially damaged during a forced landing into trees in Long View, North Carolina, following a total loss of engine power during initial climb from Hickory Regional Airport (HKY), Hickory, North Carolina. The commercial pilot was seriously injured and the three passengers incurred minor injuries. The personal flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and no flight plan was filed for the planned flight to Pitt-Greenville Airport (PGV), Greenville, North Carolina.
The pilot stated that during initial climb, about 300 feet above ground level, he heard a loud bang followed by a total loss of engine power. He subsequently performed a forced landing straight ahead into trees.
Examination of the wreckage by a Federal Aviation Administration inspector revealed substantial damage to the fuselage. The inspector also noted a hole in the engine case near the No. 2 cylinder.
A teardown examination of the engine was performed at a recovery facility, under the supervision of an NTSB investigator. The examination revealed that the lower rear crankshaft counterweight had separated and the No. 1 connecting rod separated. Oil was present throughout the engine and there was no evidence of lack of lubrication. The No. 2 cylinder, crankshaft, and camshaft could not be separated from the engine case half for examination due to rotational damage that occurred following the separation of the crankshaft counterweight. Those components were then forwarded to the manufacturer's facility for further examination as the teardown examination could not be completed at the recovery facility.
The subsequent examination at the manufacturer's facility was also performed under the supervision of an NTSB investigator. The examination revealed that all four snap rings from the lower rear crankshaft counterweight were found loose in the engine, and one of the rings had separated in half. Three of the lower rear counterweight retaining plates were found, but the fourth was not recovered. For comparison purposes, two snap rings were examined on the upper rear crankshaft counterweight. According to the manufacturer's mandatary service bulletin (MSB 99-3C), the minimum width between the snap ring ears must be 0.179 inch or more; a smaller width was indicative of a snap ring that was not properly seated in its groove. For one of the two upper rear counterweight snap rings, a 0.179 inch gap gauge could not be inserted as there was less than the prescribed space between the snap ring ears. However, when that snap ring was removed and its groove was cleaned of deposits by a wire brush, the snap ring then seated properly when reinstalled. Subsequently, the 0.179 inch gap gauge fit between the ears of the reinstalled snap ring.
Review of maintenance records revealed that the airplane's most recent annual inspection was completed on July 16, 2014. At that time, the airframe had accumulated 3,394 total hours of operation. The engine was a factory rebuild in 1998 and had accumulated 1,561 total hours at the time of the annual inspection. The airplane flew about 46 hours from the time of the inspection, until the accident.
Maintenance records show the engine received a top overhaul in 2006. The maintenance records also revealed that the crankshaft was inspection in June, 1999 in accordance with airworthiness directive 99-09-17. Continental Engines Service Bulletin MSB 99-3C states, "WARNING Do not use plates that have a loose fit. Failure to properly install counterweight retaining plates and snap rings may result in engine damage and possible failure."
J & J AIR LLC: http://registry.faa.gov/N246JT
NTSB Identification: ERA15LA092
14 CFR Part 91: General Aviation
Accident occurred Tuesday, January 06, 2015 in Long View, NC
Aircraft: BEECH V35B, registration: N246JT
Injuries: 1 Serious, 3 Minor.
This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.
On January 6, 2015, about 1630 eastern standard time, a Beech V35B, N246JT, operated by a private individual, was substantially damaged during a forced landing into trees in Long View, North Carolina, following a total loss of engine power during initial climb from Hickory Regional Airport (HKY), Hickory, North Carolina. The commercial pilot was seriously injured and the three passengers incurred minor injuries. The personal flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and no flight plan was filed for the planned flight to Pitt-Greenville Airport (PGV), Greenville, North Carolina.
The pilot stated that during initial climb, about 300 feet above ground level, he heard a loud bang followed by a total loss of engine power. He subsequently performed a forced landing straight ahead into trees.
Examination of the wreckage by a Federal Aviation Administration inspector revealed substantial damage to the fuselage. The inspector also noted a hole in the engine case near the No. 1 cylinder.
The engine was retained for further examination.
BURKE COUNTY, NC (WBTV) - A teenager from North Carolina is speaking out after he survived a plane crash in Long View Tuesday afternoon wh ere three other people, including the pilot, were injured.
A single-engine plane crashed in Hickory on Tuesday evening, injuring the pilot and three passengers on board.
Cody Good heard a noise outside his home just after 5 p.m. Tuesday evening. "Just a big ole bang." Cody rushed outside to see what it was and saw a mangled plane in the woods across the street.
Nineteen-year-old Brian Teague was back out at the crash site Wednesday morning with a bandage on his nose and a limp in his step.
"Its just kind of a miracle that everyone made it out alive," he said while looking at the area.
Teague was headed to Spartanburg with three other people from the Hickory Regional Airport when the plane ran into issues.
"We got about 300 feet off the ground and the engine just gave out and there was not place to go," he said.
According to Teague, the pilot, Jayson Jarvis did "everything perfectly." He even credits Jarvis for saving their lives.
"If it wasn't for him we probably wouldn't be here today," he said.
Teague says Jarvis was able to control the airplane once the engine failed and was able to maneuver the plane away from nearby homes.
He says everyone on the plane remained calm during the incident.
"There's not much you can do at that point," Teague said. "We were just all told to brace."
Since the plane was so low to the ground, he said it only took second to hit the ground.
"It happened so fast. but at the same time it was such a slow descent. It felt like it took forever to get from here to the crash site," he said. "It was just a very abrupt impact and there wasn't a whole lot [of time] to think about anything. I mean, of course you think about your family and what could happen, but it didn't. And he did a good job of putting it where he did."
Jarvis was seriously injured in the crash and was later airlifted to Carolinas Medical Center-Main in Charlotte.
Teague says another passenger in the plane was able to pull him and another person on board out of the plane. People from nearby homes came out to the crash to help the men.
"It hasn't really changed my perspective on what I want to do with my life. I really enjoy [flying]," he said. "It is a freak accident. Anything can happen at any time. You are not guaranteed tomorrow. I'm going to keep flying."
Story, Video and Photo Gallery: http://www.wbtv.com
The call came in just before 5:15 Tuesday evening; authorities say a plane crashed in a small field near a house, south of the Hickory Regional Airport in Long View. Catawba County EMS has been called to the scene at the request of Burke County.
The FAA says four people were on board. One person has been airlifted from the scene.
The FAA says Beech BE-35 aircraft lost power on departure from Hickory Regional Airport before it went down in the residential area.
The airport is located in both Catawba and Burke Counties; the crash happened on the Burke County side.
The FAA is investigating, while the NTSB will determine probable cause.
http://www.wcnc.com
14 CFR Part 91: General Aviation
Accident occurred Tuesday, January 06, 2015 in Long View, NC
Probable Cause Approval Date: 09/08/2015
Aircraft: BEECH V35B, registration: N246JT
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.
The pilot reported that, during initial climb, he heard a big “bang,” which was followed by a total loss of engine power. He subsequently performed a forced landing straight ahead into trees. Teardown examination of the engine revealed that the lower rear crankshaft counterweight had separated. During a subsequent examination, all four snap rings from the lower rear crankshaft counterweight were found loose in the engine, and one of the rings was found broken in half. Three of the lower rear counterweight retaining plates were found, but the fourth retaining plate was not recovered. Two snap rings that were still in place on the upper rear crankshaft counterweight were examined. The examination revealed that the width between the snap ring ears on one of the snap rings did not meet the manufacturer-prescribed width, indicating that the snap ring was not properly seated. After that snap ring was removed and its groove was cleaned of deposits with a wire brush, it seated properly when reinstalled. A review of maintenance records revealed that, about 16 years before the accident, the engine had been rebuilt and had accumulated about 1,600 hours since it was rebuilt and that, about 8 years before the accident, a top overhaul was performed on the engine. The crankshaft was inspected about 6 months after the factory rebuild in accordance with an airworthiness directive (AD); however, there likely would have been little to no deposits in the crankshaft so soon after the factory rebuild. Before the issuance of the AD, the engine manufacturer had issued a mandatory service bulletin, which included a warning that the “failure to properly install counterweight retaining plates and snap rings may result in engine damage and possible failure.” It is likely that the lower rear crankshaft counterweight snap rings were not properly installed; however, it could not be determined when or by whom they were improperly installed.
The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The improper installation of the lower rear crankshaft counterweight snap rings by unknown maintenance personnel, which resulted in the separation of the counterweight and a subsequent total loss of engine power during initial climb.
On January 6, 2015, about 1710 eastern standard time, a Beech V35B, N246JT, operated by a private individual, was substantially damaged during a forced landing into trees in Long View, North Carolina, following a total loss of engine power during initial climb from Hickory Regional Airport (HKY), Hickory, North Carolina. The commercial pilot was seriously injured and the three passengers incurred minor injuries. The personal flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and no flight plan was filed for the planned flight to Pitt-Greenville Airport (PGV), Greenville, North Carolina.
The pilot stated that during initial climb, about 300 feet above ground level, he heard a loud bang followed by a total loss of engine power. He subsequently performed a forced landing straight ahead into trees.
Examination of the wreckage by a Federal Aviation Administration inspector revealed substantial damage to the fuselage. The inspector also noted a hole in the engine case near the No. 2 cylinder.
A teardown examination of the engine was performed at a recovery facility, under the supervision of an NTSB investigator. The examination revealed that the lower rear crankshaft counterweight had separated and the No. 1 connecting rod separated. Oil was present throughout the engine and there was no evidence of lack of lubrication. The No. 2 cylinder, crankshaft, and camshaft could not be separated from the engine case half for examination due to rotational damage that occurred following the separation of the crankshaft counterweight. Those components were then forwarded to the manufacturer's facility for further examination as the teardown examination could not be completed at the recovery facility.
The subsequent examination at the manufacturer's facility was also performed under the supervision of an NTSB investigator. The examination revealed that all four snap rings from the lower rear crankshaft counterweight were found loose in the engine, and one of the rings had separated in half. Three of the lower rear counterweight retaining plates were found, but the fourth was not recovered. For comparison purposes, two snap rings were examined on the upper rear crankshaft counterweight. According to the manufacturer's mandatary service bulletin (MSB 99-3C), the minimum width between the snap ring ears must be 0.179 inch or more; a smaller width was indicative of a snap ring that was not properly seated in its groove. For one of the two upper rear counterweight snap rings, a 0.179 inch gap gauge could not be inserted as there was less than the prescribed space between the snap ring ears. However, when that snap ring was removed and its groove was cleaned of deposits by a wire brush, the snap ring then seated properly when reinstalled. Subsequently, the 0.179 inch gap gauge fit between the ears of the reinstalled snap ring.
Review of maintenance records revealed that the airplane's most recent annual inspection was completed on July 16, 2014. At that time, the airframe had accumulated 3,394 total hours of operation. The engine was a factory rebuild in 1998 and had accumulated 1,561 total hours at the time of the annual inspection. The airplane flew about 46 hours from the time of the inspection, until the accident.
Maintenance records show the engine received a top overhaul in 2006. The maintenance records also revealed that the crankshaft was inspection in June, 1999 in accordance with airworthiness directive 99-09-17. Continental Engines Service Bulletin MSB 99-3C states, "WARNING Do not use plates that have a loose fit. Failure to properly install counterweight retaining plates and snap rings may result in engine damage and possible failure."
J & J AIR LLC: http://registry.faa.gov/N246JT
NTSB Identification: ERA15LA092
14 CFR Part 91: General Aviation
Accident occurred Tuesday, January 06, 2015 in Long View, NC
Aircraft: BEECH V35B, registration: N246JT
Injuries: 1 Serious, 3 Minor.
This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.
On January 6, 2015, about 1630 eastern standard time, a Beech V35B, N246JT, operated by a private individual, was substantially damaged during a forced landing into trees in Long View, North Carolina, following a total loss of engine power during initial climb from Hickory Regional Airport (HKY), Hickory, North Carolina. The commercial pilot was seriously injured and the three passengers incurred minor injuries. The personal flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and no flight plan was filed for the planned flight to Pitt-Greenville Airport (PGV), Greenville, North Carolina.
The pilot stated that during initial climb, about 300 feet above ground level, he heard a loud bang followed by a total loss of engine power. He subsequently performed a forced landing straight ahead into trees.
Examination of the wreckage by a Federal Aviation Administration inspector revealed substantial damage to the fuselage. The inspector also noted a hole in the engine case near the No. 1 cylinder.
The engine was retained for further examination.
BURKE COUNTY, NC (WBTV) - A teenager from North Carolina is speaking out after he survived a plane crash in Long View Tuesday afternoon wh ere three other people, including the pilot, were injured.
A single-engine plane crashed in Hickory on Tuesday evening, injuring the pilot and three passengers on board.
Cody Good heard a noise outside his home just after 5 p.m. Tuesday evening. "Just a big ole bang." Cody rushed outside to see what it was and saw a mangled plane in the woods across the street.
Nineteen-year-old Brian Teague was back out at the crash site Wednesday morning with a bandage on his nose and a limp in his step.
"Its just kind of a miracle that everyone made it out alive," he said while looking at the area.
Teague was headed to Spartanburg with three other people from the Hickory Regional Airport when the plane ran into issues.
"We got about 300 feet off the ground and the engine just gave out and there was not place to go," he said.
According to Teague, the pilot, Jayson Jarvis did "everything perfectly." He even credits Jarvis for saving their lives.
"If it wasn't for him we probably wouldn't be here today," he said.
Teague says Jarvis was able to control the airplane once the engine failed and was able to maneuver the plane away from nearby homes.
He says everyone on the plane remained calm during the incident.
"There's not much you can do at that point," Teague said. "We were just all told to brace."
Since the plane was so low to the ground, he said it only took second to hit the ground.
"It happened so fast. but at the same time it was such a slow descent. It felt like it took forever to get from here to the crash site," he said. "It was just a very abrupt impact and there wasn't a whole lot [of time] to think about anything. I mean, of course you think about your family and what could happen, but it didn't. And he did a good job of putting it where he did."
Jarvis was seriously injured in the crash and was later airlifted to Carolinas Medical Center-Main in Charlotte.
Teague says another passenger in the plane was able to pull him and another person on board out of the plane. People from nearby homes came out to the crash to help the men.
"It hasn't really changed my perspective on what I want to do with my life. I really enjoy [flying]," he said. "It is a freak accident. Anything can happen at any time. You are not guaranteed tomorrow. I'm going to keep flying."
Story, Video and Photo Gallery: http://www.wbtv.com
LONG VIEW, N.C. — A plane crash Tuesday evening next to a house in Long View sent four people to local hospitals with varying severity of injuries.
The mangled single-engine Beechcraft was taking off from Hickory Regional Airport with four people on board — officials were not releasing names at the scene — when it fell. Three of the passengers were taken by ambulance to different hospitals and the fourth was airlifted to the Charlotte area.
The initial call came in about 5:15 p.m. The caller said a plane crashed into his yard.
Marc Bailey was at the scene a few hours after the crash was reported. He said he saw from his office window the plane taxi off the runway. Bailey, a pilot himself, said everything looked fine at take off.
Moments later, Kristy Hammonds said she heard the plane crash into a wooded area next to a house at 3710 First Ave. NW. Hammonds lives across the street from where the accident happened. One of the plane’s wings was torn completely off and the fuselage was scrunched and ripped apart.
Terri Byers, a spokeswoman for the Hickory Fire Department, could not confirm at the scene why the airplane went down. The Federal Aviation Administration will investigate the wreck, she said, which could start as early as Wednesday.
The end of Hickory’s runway is about half a mile from where the plane ended up. It was so close that other planes could be seen taking off from the same runway. The father of one of the passengers said the plane that crashed was en route to the Greenville-Spartanburg airport when the engine failed.
Several different departments responded to the call, including Catawba County EMS, Long View Fire Department, Long View Police Department, Hickory Fire Department and Burke County EMS.
The plane is owned by Jayson Scott Jarvis, according to the FAA’s website. A phone message for him was not returned Tuesday night. Jarvis recently received “inclusion in the prestigious FAA Airmen Certification Database,” according to an online report. Jarvis is listed as a "certified registered nurse anesthetist" in Hickory on multiple websites.
http://www.hickoryrecord.com
http://www.wsoctv.com
Brian Teague
HICKORY, NC (WBTV) - Four people were injured when a plane crashed in Long View Tuesday. The crash happened around 5 p.m. near the Hickory Regional Airport and involved a single-engine plane.
Officials say there were four people on board at the time.
The pilot was airlifted from the scene with serious injuries. The other three on board were injured but are expected to be okay.
One of the people on board the plane, which was en route to Greenville-Spartanburg, told officials that the plane's engine quit right after takeoff when the aircraft was about 300 ft in the air.
The pilot attempted to bring the plane back in and was reportedly able to just miss several houses before crashing into a tree.
The names of the people on board have not been released.
The mangled single-engine Beechcraft was taking off from Hickory Regional Airport with four people on board — officials were not releasing names at the scene — when it fell. Three of the passengers were taken by ambulance to different hospitals and the fourth was airlifted to the Charlotte area.
The initial call came in about 5:15 p.m. The caller said a plane crashed into his yard.
Marc Bailey was at the scene a few hours after the crash was reported. He said he saw from his office window the plane taxi off the runway. Bailey, a pilot himself, said everything looked fine at take off.
Moments later, Kristy Hammonds said she heard the plane crash into a wooded area next to a house at 3710 First Ave. NW. Hammonds lives across the street from where the accident happened. One of the plane’s wings was torn completely off and the fuselage was scrunched and ripped apart.
Terri Byers, a spokeswoman for the Hickory Fire Department, could not confirm at the scene why the airplane went down. The Federal Aviation Administration will investigate the wreck, she said, which could start as early as Wednesday.
The end of Hickory’s runway is about half a mile from where the plane ended up. It was so close that other planes could be seen taking off from the same runway. The father of one of the passengers said the plane that crashed was en route to the Greenville-Spartanburg airport when the engine failed.
Several different departments responded to the call, including Catawba County EMS, Long View Fire Department, Long View Police Department, Hickory Fire Department and Burke County EMS.
The plane is owned by Jayson Scott Jarvis, according to the FAA’s website. A phone message for him was not returned Tuesday night. Jarvis recently received “inclusion in the prestigious FAA Airmen Certification Database,” according to an online report. Jarvis is listed as a "certified registered nurse anesthetist" in Hickory on multiple websites.
http://www.hickoryrecord.com
http://www.wsoctv.com
Brian TeagueHICKORY, NC (WBTV) - Four people were injured when a plane crashed in Long View Tuesday. The crash happened around 5 p.m. near the Hickory Regional Airport and involved a single-engine plane.
Officials say there were four people on board at the time.
The pilot was airlifted from the scene with serious injuries. The other three on board were injured but are expected to be okay.
One of the people on board the plane, which was en route to Greenville-Spartanburg, told officials that the plane's engine quit right after takeoff when the aircraft was about 300 ft in the air.
The pilot attempted to bring the plane back in and was reportedly able to just miss several houses before crashing into a tree.
The names of the people on board have not been released.
HICKORY, N.C. -- Authorities say a plane has crashed near the Hickory Regional Airport.
The call came in just before 5:15 Tuesday evening; authorities say a plane crashed in a small field near a house, south of the Hickory Regional Airport in Long View. Catawba County EMS has been called to the scene at the request of Burke County.
The FAA says four people were on board. One person has been airlifted from the scene.
The FAA says Beech BE-35 aircraft lost power on departure from Hickory Regional Airport before it went down in the residential area.
The airport is located in both Catawba and Burke Counties; the crash happened on the Burke County side.
The FAA is investigating, while the NTSB will determine probable cause.
http://www.wcnc.com
Cessna 195B Businessliner, N2125C: Accident occurred January 06, 2015 at Llano Municipal Airport (KAQO), Texas
NTSB Identification: CEN15LA099
14 CFR Part 91: General Aviation
Accident occurred Tuesday, January 06, 2015 in Llano, TX
Aircraft: CESSNA 195B, registration: N2125C
Injuries: 2 Uninjured.
NTSB investigators may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.
On January 6, 2015, about 1545 Central Standard Time, a Cessna 195B, N2125C, lost engine power during the takeoff roll from Llano Municipal Airport, Llano (KAQO), Texas. The nose pitched forward and the propeller struck the runway and nosed over. The pilot and his passenger were not injured, but the airplane was substantially damaged. The airplane was registered to and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed at the time of the accident, and no flight plan had been filed. The cross-country flight was originating at the time of the accident.
According to the pilot's accident report, right at liftoff the engine went from full power to idle power and the pilot thought the engine had quit. The airplane pitched forward and the propeller struck the asphalt runway. The airplane turned slightly to the right, went off the runway and nosed over.
Federal Aviation Administration inspectors went to the accident site and reported finding numerous propeller strike marks in the runway pavement. They also documented tire tracks and propeller strikes going off the right side of the runway and into the dirt and terminating at the inverted airplane.
http://registry.faa.gov/N2125C
LLANO — A husband and wife from Keller walked away with no reported injuries from a plane crash at 3:35 p.m. Jan. 6 at the Llano Municipal Airport, according to the Department of Public Safety.
The man flying the plane, 54-year-old Timothy Patrick Sager, a pilot with American Airlines, and his wife, 53-year-old Karen Long Sager, were not injured in the crash, DPS reported.
The single-engine Cessna 195 attempted to take off from the runway when the accident occurred, officials said.
“(The) pilot was attempting to take off southbound. (He) reported the engine malfunctioned, and the plane crashed soon after becoming airborne,” the report stated. “(The) plane came to rest upside down facing northeast.”
DPS and the Federal Aviation Administration are continuing the investigation.
Source: http://www.dailytrib.com
The pilot was not injured in a crash at the Llano Municipal Airport.
The pilot of a four-seat aircraft was uninjured when the plane flipped on its head at the Llano Municipal Airport on Tuesday, Jan. 6, Llano County Sheriffs Department Officials said.
Llano County Sheriff Bill Blackburn confirmed the accident and said there was “pretty good damage to the plane but none to the pilot.”
The female pilot is currently unidentified.
Blackburn said the aircraft will have to remain in place until representatives from the Federal Aviation Administration arrive at the scene. Texas DPS Troopers are also working the scene.
14 CFR Part 91: General Aviation
Accident occurred Tuesday, January 06, 2015 in Llano, TX
Aircraft: CESSNA 195B, registration: N2125C
Injuries: 2 Uninjured.
NTSB investigators may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.
On January 6, 2015, about 1545 Central Standard Time, a Cessna 195B, N2125C, lost engine power during the takeoff roll from Llano Municipal Airport, Llano (KAQO), Texas. The nose pitched forward and the propeller struck the runway and nosed over. The pilot and his passenger were not injured, but the airplane was substantially damaged. The airplane was registered to and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed at the time of the accident, and no flight plan had been filed. The cross-country flight was originating at the time of the accident.
According to the pilot's accident report, right at liftoff the engine went from full power to idle power and the pilot thought the engine had quit. The airplane pitched forward and the propeller struck the asphalt runway. The airplane turned slightly to the right, went off the runway and nosed over.
Federal Aviation Administration inspectors went to the accident site and reported finding numerous propeller strike marks in the runway pavement. They also documented tire tracks and propeller strikes going off the right side of the runway and into the dirt and terminating at the inverted airplane.
LLANO — A husband and wife from Keller walked away with no reported injuries from a plane crash at 3:35 p.m. Jan. 6 at the Llano Municipal Airport, according to the Department of Public Safety.
The man flying the plane, 54-year-old Timothy Patrick Sager, a pilot with American Airlines, and his wife, 53-year-old Karen Long Sager, were not injured in the crash, DPS reported.
The single-engine Cessna 195 attempted to take off from the runway when the accident occurred, officials said.
“(The) pilot was attempting to take off southbound. (He) reported the engine malfunctioned, and the plane crashed soon after becoming airborne,” the report stated. “(The) plane came to rest upside down facing northeast.”
DPS and the Federal Aviation Administration are continuing the investigation.
Source: http://www.dailytrib.com
The pilot of a four-seat aircraft was uninjured when the plane flipped on its head at the Llano Municipal Airport on Tuesday, Jan. 6, Llano County Sheriffs Department Officials said.
Llano County Sheriff Bill Blackburn confirmed the accident and said there was “pretty good damage to the plane but none to the pilot.”
The female pilot is currently unidentified.
Blackburn said the aircraft will have to remain in place until representatives from the Federal Aviation Administration arrive at the scene. Texas DPS Troopers are also working the scene.
Cold weather not grounding pilots: Manistee County-Blacker Airport (KMBL), Manistee, Michigan (with video)
MANISTEE COUNTY -- With snow returning to northern Michigan, plows are working to keep not just the roads clear, but runways clear as well.
The Manistee County Blacker Airport Authority just bought a new snow brush and blower to make clearing the runways go a little more quickly.
And it’s not just for the commercial flights, but the private pilots and students pilots as well.
Granted, traffic this time of year at Manistee’s Blacker Airport isn’t what it is in the middle of summer.
“Plenty of people will hibernate during the winter,” says Robert Ericson, a charter pilot and flight instructor for Orchard Beach Aviation. “But usually aircraft rentals are more available. And all of sudden on a very nice sunny day with no wind, all of a sudden people will come back out and decide to go flying. ”
For those pilots, new and experienced, not to mention the daily commercial flights to Chicago, the airport needs to stay ready.
“You’ve got to start worrying about runway, airport conditions typically,” says Ericson. “Airframe icing while flying; those are the primary concerns during the winter months.”
For the runways: plows, that new brush, snow blowers and chemicals are used to clear the snow and control the ice.
And pilots are asked to report on runway conditions as the fly in and out.
For the planes, there is a de-icing truck that is available to melt any ice that might build up overnight or while the plane is sitting outside.
“Cold weather can wreak havoc on any aircraft, big or small,” says Ericson. “But usually there are some ways around it, whether it be de-icing, heated hangers, or even pre-heating the cabin for passenger comfort.”
And once airborn, Ericson says the cold air can actually be a good thing as it improves the plane’s flight characteristics.
“The colder, more dense air really helps an aircraft,” says Ericson. “So, usually, they can take off with much more weight than they typically would, say than on a hot day in Denver.”
During last year’s record snowfall, the FAA shut down a portion of the airport’s instrument landing system because the snow was so deep.
It was the first time that happened in nearly 20 years.
The Manistee County Road Commission used bull dozers to clear away the snow so that equipment could be turned back on.
The downside to flying this time of year: many planes, especially older planes, have a very, shall we say, basic system of heating the cabin.
So if you can handle that, there’s no reason not to go flying.
Story, Video and Photo: http://www.upnorthlive.com
Piper PA-32-300 Cherokee Six, N4599X: Accident occurred April 19, 2019 in Saipan, MP
NTSB Identification: GAA19CA268
Scheduled 14 CFR Part 135: Air Taxi & Commuter
Accident occurred Friday, April 19, 2019 in Saipan, MP
Aircraft: Piper PA32, registration: N4599X
NTSB investigators will use data provided by various entities, including, but not limited to, the Federal Aviation Administration and/or the operator, and will not travel in support of this investigation to prepare this aircraft accident report.
Piper PA-32-300 Cherokee Six B, Star Marianas Air (Marianas Air Transfer Inc.), N4267R: Accident occurred November 19, 2012, near Saipan International Airport (SPN/PGSN) - Northern Mariana Islands
NTSB Identification: WPR13LA045
Nonscheduled 14 CFR Part 135: Air Taxi & Commuter
Accident occurred Sunday, November 18, 2012 in Obyan, MP
Probable Cause Approval Date: 07/07/2015
Aircraft: PIPER PA-32, registration: N4267R
Injuries: 1 Fatal, 5 Serious, 1 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.
The 14 Code of Federal Regulations Part 135 airline operated a fleet of single-engine airplanes that shuttled passengers between two islands located about 10 minutes’ flying time apart. The flight was carrying six passengers and was being conducted in visual meteorological conditions at dawn. After a normal start, taxi-out, and engine run-up, the airplane departed using the full length of the 8,000-ft-long runway. About 4 minutes after takeoff, the pilot radioed the air traffic control tower that he wanted to “come back in for an immediate landing”; the airplane landed uneventfully on the departure runway about 3 minutes later.
The airplane exited the runway at the first taxiway, situated about 3,150 ft past the runway threshold, and the pilot subsequently conducted an engine run-up. The pilot returned to the runway and initiated an intersection takeoff using the 5,550 ft of remaining runway. About 45 seconds after the pilot began the takeoff, the airplane experienced a partial loss of engine power, so he began a second turnback. During the turnback, the airplane stalled at low altitude and impacted airport property near the end of a runway parallel to the departure runway. A postimpact fire ensued; one passenger did not exit the airplane and died.
The pilot did not recall making the first turnback, and the investigation was unable to determine the reason for the first turnback. One passenger reported that the pilot was using his mobile telephone at an inappropriate time during the beginning of the flight, and two other passengers reported that the cabin door became unlatched at some point during the flight. Neither passenger reported that any door problems occurred after the second takeoff. Although there was no evidence to support the passengers’ allegations regarding the telephone or the cabin door events, an airline representative suggested that the first turnback was conducted due to the door coming open and that the subsequent engine run-up was conducted to conceal the actual reason for the turnback. The representative added that the second turnback may have been due to the pilot’s distraction and loss of situational awareness as he attempted to relatch the door that might have become unlatched again.
Postaccident on-site wreckage examination and test runs and examination of the engine did not reveal any preimpact mechanical deficiencies that could be directly linked to the power loss. Although anomalies with the engine-driven fuel pump and one magneto were detected during their respective examinations, the units performed satisfactorily during bench testing. However, there were a sufficient number of undetermined details regarding the preimpact configuration and condition of the airframe and the engine to preclude a determination of the preaccident functionality and airworthiness of the airplane. Those details included the magneto-to-engine timing, the internal timing of the right magneto, the fuel selector valve takeoff setting, and the fuel quantity in the selected tank.
Review of airplane performance data indicated that the 5,550 ft of runway beyond the taxiway intersection was more than sufficient for the takeoff. The performance data showed a rapid roll into a sustained bank angle during the turnback, which did not support the airline’s scenario that the airplane veered off course due to the pilot’s loss of situational awareness. The investigation was unable to determine the initiation altitude of the turnback or whether there was sufficient altitude for the safe execution of such a maneuver. However, deductions of the airplane location, altitude, and heading based on the ground scar information indicated that a safe landing would not have been possible from the point in the flightpath where the airplane stalled. Neither the airline nor the airplane manufacturer provided any specific guidance to pilots regarding minimum safe turnback altitudes.
The pilot’s decision to conduct an intersection takeoff, instead of a full-runway-length takeoff, left 3,150 ft less runway. Although he did not state it explicitly, the apparent reason that the pilot opted for the intersection takeoff was for schedule expediency, by obviating the need for the extra few minutes required to taxi back for a full-runway-length takeoff. Based on the accident flightpath, the additional 3,150 ft of runway likely would have been sufficient to enable a straight-ahead landing after the power loss rather than a turnback. By foregoing the taxi-back, the pilot reduced his margin of safety by decreasing his options in the event of an engine anomaly or power loss. Review of aerial imagery revealed that, beyond the airport’s northeast boundaries, there were very few locations suitable for an emergency landing following a low-altitude power loss, which likely contributed to the pilot’s decision to attempt to return to the airport. Although the airline published the preferred flight tracks between the two airports that it primarily served, it did not provide any guidance regarding preferred flightpaths or emergency landing sites following an engine failure at low altitude.
The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
A partial loss of engine power shortly after takeoff for reasons that could not be determined because postaccident examination did not reveal any anomalies that would have precluded normal operation and the pilot’s failure to maintain airplane control during the unsuccessful attempt to return for landing on the airport. Contributing to the accident was the pilot’s decision to conduct his second takeoff using less than the full runway length available and the airline’s lack of guidance regarding how to respond to engine failures at low altitudes.
HISTORY OF FLIGHT
On November 19, 2012, about 0618 local time (2018 November 18 Universal Coordinated Time), a Piper PA-32-300, N4267R, was destroyed when it impacted airport terrain during an attempted turnback immediately after takeoff from Francisco C. Ada/Saipan International Airport (PGSN), Obyan, Saipan, Northern Mariana Islands, a United States territory. One passenger sustained fatal injuries, the pilot and four passengers sustained serious injuries, and one passenger sustained minor injuries. The on-demand charter flight was operated by Star Marianas Air, Inc. (SMA), under the provisions of Title 14 Code of Federal Regulations Part 135. Dawn visual meteorological conditions prevailed, and no Federal Aviation Administration (FAA) flight plan was filed for the flight.
According to a representative of the airline, the airline typically shuttled tourists between Saipan and Tinian, an island about 10 minutes' flying time south of Saipan. The passengers on the accident flight included five Chinese nationals and one Filipino national, and the flight was destined for Tinian.
According to information from the FAA and Serco, the PGSN air traffic control tower (ATCT) service provider, the pilot first contacted the ATCT at 0604, requesting taxi clearance. The flight was instructed to taxi to the end of runway 7, and was cleared for takeoff about 4 minutes later. About 4 minutes after takeoff, the pilot radioed the ATCT that he wanted to "come back in for an immediate landing if possible." About 3 minutes later, the airplane landed uneventfully on runway 7, and exited the runway at taxiway B. The pilot briefly ran up the engine, and about 3 minutes after landing, informed the ATCT that he was ready for an intersection departure from runway 7. About 45 seconds after that, the airplane was observed turning back to the left, and some garbled radio transmissions were received from the airplane. Shortly thereafter, the airplane impacted airport property near the northeast end of runway 6, a smaller parallel runway situated northwest of runway 7.
The bulk of the airplane came to rest at the treeline northwest of runway 6, and a post-accident fire began. The pilot and most passengers exited or were helped from the airplane, but the female passenger seated in the front right seat remained in the airplane, and was fatally injured.
About 2 days after the accident, the wreckage was examined on scene by personnel from the FAA, and was then recovered to a secure location.
PERSONNEL INFORMATION
Pilot Experience and Medical Information
FAA and airline information indicated that the pilot held a commercial pilot certificate, with an instrument airplane rating. The pilot began flying for SMA in January 2012. The airline initially qualified the pilot for "PIC" (pilot-in-command) authority in the PA-32-300 on January 11, 2012, and for flight instructor/check airman authority in the airplane on February 3, 2012. His most recent flight review was completed in January 2012, and his most recent FAA first-class medical certificate was issued in August 2012.
The pilot had a total flight experience of about 1,238 hours, including about 674 hours in the accident airplane make and model. Airline records indicated that the pilot had flown about 54 hours in October 2012, and about 31 hours in November, the month of the accident. According to the airline's records, the pilot was on duty from 0200 to 0500 on November 15, and did not have another duty period until 1900 on November 17. He was then on duty for 11 hours, had a rest period of 12 hours and 40 minutes, and then went back on duty at 1840 the evening before the accident. At the time of the accident, the pilot had been on duty for almost 12 hours.
The FAA Civil Aeromedical Institute conducted forensic toxicology examinations on "blood, serum" specimens from the pilot, and reported that no carbon monoxide, ethanol, or any screened drugs were detected.
Pilot Flight Recollections
A brief telephone interview was conducted with the accident pilot about 2 weeks after the accident. The pilot remembered most of the accident flight, including events leading up to it, but he had no recollection of the takeoff and return just prior to the accident takeoff.
According to the pilot, the flight/load manifest was satisfactory, and he did not note any defects during his preflight inspection, taxi-out, or engine runup. The initial takeoff and climbout was normal, but when the airplane reached an altitude of about 400 to 500 feet above ground level (agl), he noticed a "significant change" in engine sound and power. He observed that the manifold pressure and rpm gauges did not indicate full takeoff power, but stated that the engine gauges in the airline's fleet are "never accurate." He did not observe any unusual instrument indications, but his sense was that the engine's power and sound was less than that normally experienced for the indicated power settings.
Upon sensing the power loss, the pilot immediately pushed the throttle, propeller, and mixture controls full forward, but the power continued to decrease. The pilot then turned on the electric fuel boost pump, and switched the fuel selector valve from the left to the right tank.
The pilot stated that because he had conducted an intersection takeoff, he did not believe that there was enough runway remaining to land on, and he was therefore faced with the choice of putting the airplane in the ocean ahead, or attempting a turnback for landing on the airport property. He decided to attempt a turnback, and was cognizant of the decreasing power, airspeed, and altitude, as well as the danger of stalling. Initially the pilot intended to land on runway 24, but he overflew that, and then decided to try to land on the ramp. He said that he maintained a bank angle of about 35 to 45 degrees in the turn, but when the airplane was about 15-20 feet above the ground, the airplane suddenly "dropped to the ground." That was the last item he recalled about the accident sequence.
When asked about the air turnback, landing, and runup that he had conducted just prior to the accident takeoff, the pilot recalled such an event, but he could not recall whether that event was the night before, or 2 weeks prior to, the accident flight. Regarding that event, the pilot recalled that on departing Saipan, he experienced a "slight power loss" of about 100 rpm, but was able to climb to 1,500 feet on the right downwind traffic pattern leg, and therefore, elected to return to the departure runway. He "landed long," but otherwise normally. He exited the runway, leaned the mixture to "clean the plugs," conducted an engine runup, and determined that the airplane was "fine." The pilot then departed uneventfully, and landed successfully at Tinian, where he informed maintenance or company personnel about the engine event.
When informed during a telephone interview with NTSB and FAA personnel that the ATCT records indicated that he had conducted a successful air turnback just prior to the accident, again the pilot had no specific recollection of that event. The pilot did not reconcile his lack of recollection of a previous turnback with his recollection that he had conducted an intersection takeoff during the accident flight.
AIRCRAFT INFORMATION
General Information
The airplane was manufactured in 1969, and was equipped with a Lycoming IO-540 series engine. It was an all-metal low-wing monoplane design with fixed, tricycle-style landing gear. The airplane seated seven persons in a 2-3-2 arrangement from front to back. The cabin was equipped with two entrance doors, one on the front right side (for pilot and co-pilot/front seat passenger), and one at the left rear for the other five passengers. The airplane had two baggage compartments, one forward and one aft.
Flap positions include retracted (up/0 degrees), 10, 25, and 40 degrees, and were selected by moving the flap handle to one of the corresponding pre-select notches. The flaps were spring-loaded to the retracted position.
Fuel System and Usage Procedures
The airplane was equipped with four individually-selectable fuel tanks; left tip/aux, left main, right main, and right tip/aux. Total fuel capacity was 84 gallons. The four-position wing flaps were manually actuated via a cockpit handle and torque tube arrangement.
The manufacturer's Owner's Handbook (OH) specified that for takeoff, the fuel selector valve should be set to the "fullest main tank." The OH specified that once in cruise, "in order to keep the airplane in best lateral trim...the fuel should be used alternately from each tip tank" until the tip tank quantities were "nearly exhausted." At that point the OH specified switching to the main tanks.
Maintenance Information
According to the maintenance records, the airplane had accumulated a total time (TT) in service of about 6,805 hours at the time of the accident. An overhauled engine was installed in July 2012, when the airplane had a TT of about 6,290 hours.
The airline maintained the airplane on a progressive, cyclic inspection program which included four elements or segments, designated as "AAIP-1" through "AAIP-4." The most recent completed inspection cycle was the AAIP-1, which was completed on November 17, 2012, at an airframe TT of about 6,799 hours, and an engine time since overhaul of about 516 hours.
METEOROLOGICAL INFORMATION
The PGSN 0554 automated weather observation included winds from 060 degrees at 10 knots, visibility 10 miles, scattered clouds at 2,000 feet, broken cloud layer at 5,000 feet, overcast cloud layer at 11,000 feet, temperature 27 degrees C, dew point 23 degrees C, altimeter setting of 29.91 inches of mercury.
COMMUNICATIONS
PGSN was equipped with an ATCT that was operating at the time of the accident, and was operated and staffed under contract to the FAA by Serco Management Services, Inc. A transcript of the communications between the ATCT and the accident airplane was prepared and provided by Serco.
According to the transcript, the pilot first contacted the ATCT at 0604:32, and advised that he was at the "commuter ramp" with the terminal information, and was ready to taxi. The controller cleared the airplane to taxi to the "end" of runway 7 via taxiway B and runway 6. The pilot acknowledged "full length," and was advised to expect a 2-minute delay for wake turbulence separation. At 0608:27, the flight was cleared for takeoff and an "early right turnout," which the pilot read back correctly. At 0612:08, the pilot radioed "Saipan tower, uh" but did not continue. At 0612:35, the pilot radioed that he wanted to come back for an "immediate landing if possible," and after a brief discussion about his position, was cleared to land on runway 7. When asked if he required emergency assistance, the pilot replied "negative."
After the airplane landed, at 0614:28, the controller instructed the pilot to exit the runway at taxiway B, and remarked that this was the "second time it happened to you in less than two weeks, huh?" to which the pilot responded in the affirmative, and stated that he "just want[ed] to make sure everything's good to go." At 0614:54, the pilot told the controller that he just wanted to do a "quick run-up," and the controller told him to do so on taxiway B, and to advise when ready for departure.
At 0616:17, the pilot advised the controller that he was ready for an intersection departure, and was cleared a few second later. At 0617:17, the pilot radioed "six seven romeo would like" but he did not complete that request. At 0617:27, in response to observing the airplane turning and descending, the controller cleared the airplane to land, and a partial, unintelligible response was received from the airplane. Shortly after that, the controller initiated the accident response procedures.
AIRPORT INFORMATION
PGSN was equipped with two parallel runways, designated as 6/24 and 7/25. Runway 7/25, which was the primary runway and the one used for the two departures, measured 8,700 by 200 feet. Taxiway B, which was perpendicular to the two runways, was located about 3,150 feet beyond the threshold of runway 7. A runway 7 intersection departure from taxiway B would have about 5,550 feet of available runway. The specified traffic pattern direction for runway 7 was left-hand.
Runway 6/24 was a designated portion of the pavement that paralleled the full length of runway 7/25. Runway 6/24 measured 7,000 by 100 feet, and the threshold of runway 24 was directly abeam that of runway 25. The centerline of runway 6/24 was offset about 750 feet northwest of that of runway 7/25.
The shoreline to the northeast of the airport was oriented approximately perpendicular to the runways, and was situated approximately 2,600 feet beyond the end of runway 7. The shoreline to the southwest of the airport was also oriented approximately perpendicular to the runways, and was situated approximately 4,300 feet prior to the runway 7 threshold. The airport elevation was listed as 211 feet above mean sea level.
Review of commercially-available aerial imagery revealed that beyond the northeast airport boundaries, most of the vicinity was either ocean or heavily-vegetated terrain, with very few roads or open fields.
WRECKAGE AND IMPACT INFORMATION
According to information provided by FAA inspectors who responded to the accident site, the main wreckage came to rest at the junction of the grassy area adjoining runway 6 and the parallel treeline situated about 290 feet northwest of the centerline or runway 6/24. The main wreckage was located about 1,050 feet from the runway 7/25 centerline, and about 700 feet before the departure ends of runways 6 and 7.
The main wreckage consisted of the majority of the airplane, excluding the left wing, some cockpit/cabin transparencies, some miscellaneous airplane components, and some luggage. The evidence was consistent with the left wing striking the ground first, while the airplane was in a left turn. The ground scars and debris path were oriented to the northwest, and curved about 15 degrees to the left.
The first ground scar was located in the grass about 35 feet from the northwest side of runway 6. The left wing was located about 108 feet beyond the first impact point; the wing was fracture-separated from the airplane at the root, and was lying inverted. The left main landing gear was fracture-separated from the wing; it was found about 10 feet beyond the left wing. The main wreckage was about 114 feet beyond the left wing, and a passenger suitcase was located between the left wing and main wreckage. The airplane came to rest upright against and parallel to the tree line, oriented on a heading of approximately 240 degrees. The cockpit and cabin contents were fire damaged or consumed by fire, as was the outboard half of the right wing.
The aft fuselage and empennage were essentially intact. Pitch and rudder control continuity was established from the cockpit area to the respective aft control surfaces. The pitch trim tab was set so that its trailing edge was about 1/2 inch below the stabilator trailing edge. The right wing flap was found in the retracted position, but the left flap was fracture-separated from its actuation linkage and therefore not fixed in any position. Photographs taken several hours after the accident, and subsequent to recovery of the front-right seat passenger, depict the cockpit flap handle to appear to be in the flaps-retracted position. The investigation was unable to determine if the flap handle was disturbed during or subsequent to the accident.
The ignition key remained in the ignition and its orientation appeared consistent with it being in the "BOTH" position, but fire damage precluded positive determination. The fuel selector handle appeared to be set to a right side tank, but visual inspection did not permit determination of whether it was set to right main tank, or the right tip tank. The engine control quadrant was fire- and impact-damaged, but the three levers appeared to be near their full-forward positions.
The engine was displaced aft and nose-down, but the engine was relatively undamaged. There was no evidence of any catastrophic internal engine failures. The three propeller blades remained attached to the hub, which remained attached to the engine. Two blades were bent aft, and one exhibited S-bending and chordwise scoring. The propeller did not exhibit any evidence of any pre-impact mechanical failures.
The left tip tank was compromised, and contained no fuel, but some fuel was recovered from the left inboard tank. That fuel was not visually contaminated. The right tip tank was impact and fire damaged, and contained no fuel. The right inboard tank was impact damaged. Attempts to sump it for fuel resulted in only a few drops, possibly due to the post-accident orientation.
MEDICAL AND PATHOLOGICAL INFORMATION
The FAA CAMI conducted forensic toxicology examinations of cavity blood and multiple tissue specimens from the right front seat passenger, and reported that no cyanide, ethanol, or any screened drugs were detected. However, the CAMI reported that a carbon monoxide level of 25 percent was detected in the passenger's femoral blood.
TEST AND RESEARCH
Engine Examination and Test Run
The engine was removed, crated and shipped to the Lycoming Engines facility in Pennsylvania for examination and testing. The engine did not exhibit any significant thermal damage. The propeller blades remained attached to the hub, and the hub remained attached to the engine. The magnetos were discovered to have been removed and loosely reinstalled. Follow-up investigation revealed that the mechanic who removed and crated the engine had to remove the magnetos in order to separate the engine from the airframe. The magneto-to-engine timing was not determined prior to their initial removal, nor were the magnetos marked in order to enable subsequent determination of their timing relative to the engine.
The airplane fuel selector valve was included in the crate. Examination indicated that it was set to the right outboard fuel tank, and that the valve was unable to be repositioned by hand due to damage.
The cooling baffles were removed to facilitate visual examination of the engine, which indicated that the engine appeared to be in sufficient condition to allow it to be run in a test cell. Several components were either removed outright, or replaced with serviceable or test-cell specific ('slave') hardware to facilitate an engine test run. These included, but were not limited to, the propeller (damage), right magneto (damage), and the air inlet housing for the fuel servo (test cell compatibility). The magnetos were set to the specified magneto-to-engine timing values for the test runs.
After mounting in the test cell and filling with warmed oil, an engine start was attempted. After six attempts the start was suspended, and examination revealed that fuel was exiting the engine driven fuel pump drain port. The pump was bypassed, and fuel was provided via the test cell hardware. After four more attempts, the engine started, but the automated test cell safety system shut the engine down due to high oil pressure, which was determined to be a result of the engine's 18-month dormancy.
The engine was restarted and ran for 5 minutes, but would not idle smoothly. The engine was again shut down, and cylinders 2 and 6 were determined by manual touch to be running significantly cooler than the other four cylinders. The fuel injector nozzles for cylinders 2 and 6 were removed, and found to be about 75 and 100 percent occluded, respectively. The age of, and the reasons for, the occlusions were not determined. The nozzles were cleaned and reinstalled.
The engine was restarted, and successfully completed Lycoming's Production Engine test sequence. The engine developed full rpm and manifold pressure, ran normally with only minor anomalies, and no deficiencies or problems that would have precluded continued operation were noted. Complete details are provided in a separate document in the NTSB public docket for this accident.
The magnetos and the engine driven fuel pump were sent to their respective manufacturers for detailed examination.
Magneto Information
Review of the maintenance records revealed that at the time of the accident, the magnetos had accumulated the following times on the airplane:
Left: 28 hours (installed 11/13/2012)
Right: 409 hours (installed 8/16/2012)
No other documentation regarding the previous history of the magnetos was located, and the investigation did not determine how much time the magnetos had accumulated since their overhaul, or on any other aircraft, if any. Therefore, the times cited herein can only be considered as minimum values.
Both magnetos were shipped to their manufacturer, Continental Motors in Mobile, Alabama, for examination and testing.
The left magneto's internal timing was found to be correct by both using a timing light and by visually examining the distributor gear position through the timing port. The magneto was placed on a test bench, and each lead produced a spark across a 7mm gap throughout all operating speeds. The impulse coupling functioned properly. The magneto was disassembled. Examination of the distributor gear while the axle was installed in the distributor block bushing revealed no discernable radial or axial play. There were no anomalies noted with the left magneto's internal components.
The right magneto's internal timing was checked using a timing light and by visually examining the distributor gear position through the timing port. The internal timing was trailing by three distributor gear teeth. The magneto was placed on a test bench and each lead produced a spark across a 7mm gap throughout all operating speeds, in the correct firing order. According to a Continental Motors (CMI) representative, the bench test spark gap was significantly larger than would be expected to be found in service, and that based upon the bench test results, the magneto in its as-tested condition would not have adversely affected engine performance.
The right magneto was disassembled. Examination of the distributor gear while it was still installed on the distributor block axle/shaft revealed that there was a significant angular displacement between the gear and the block. Four of the six fixed electrodes were mechanically damaged. Some of the material had been shaved off the electrodes, and electrode shavings and chips were found on the inside circumference of the distributor block. The distributor gear teeth displayed a worn condition on the carbon-brush-end of the gear. A number of the distributor gear teeth apexes displayed mechanical deformation damage consistent with imprints of the drive gear teeth. Examination of the distributor block revealed that the bushing in which the distributor gear axle rides, and which is normally molded into the block, was loose. Visible gaps were noted between the bushing and the housing, and fragmented block material was noted under the felt strip and felt washer. Representatives of CMI indicated that they had become aware of other similar magneto block failures. In February 2015, CMI issued two related Service Bulletins (SB 15-1 and SB-669) to provide relevant magneto inspection guidance.
The loose bushing permitted the distributor gear axle to tilt enough to disengage the distributor gear from the drive gear, permitting changes to the internal timing. Although the loose bushing and resulting off-plane freeplay of the timing gear was necessary to enable the mis-timing, it was not sufficient. The investigation did not determine the forcing mechanism(s) for the mis-timing. Therefore, the investigation was unable to determine whether any internal timing change was a gradual migration, a random step function, or some combination of the two. As a result, the investigation was unable to determine whether the as-found internal timing was representative of the magneto internal timing, either during the accident flight or any previous flights. Refer to the magneto examination report in the NTSB accident docket for additional details.
In August 1994, Lycoming issued Mandatory Service Bulletin SB516, which specified the inspection, and replacement at overhaul, of certain magnetos. The left magneto on the accident engine was subject to that SB. According to a Lycoming representative, any Lycoming-accomplished/approved overhaul requires compliance with all Lycoming Mandatory SBs. The accident engine was overhauled in 2012 by a commercial maintenance facility, and the accompanying FAA Form 8130-3 stated that the engine was "overhauled, tested, and certified" in accordance with all Lycoming specifications. However, the airplane's maintenance records indicate that a magneto that was subject to the SB was installed at overhaul, which was not in accordance with Lycoming standards. The investigation was unable to determine the reason for this discrepancy.
According to the FAA inspector for this accident, Part 135 operators are not required to comply with manufacturer's Service Bulletins (SBs) unless the SB is either incorporated into an Airworthiness Directive (AD), or is incorporated into any other operator document that is FAA approved. That same inspector reported that in his review of the airline's relevant guidance, he did not locate any requirements for compliance with manufacturer's SBs (excluding manufacturer's recommendations for overhaul of airframes, engines, propellers, and accessories).
Engine-Driven Fuel Pump Information
Review of the maintenance records and other documentation revealed that the pump was manufactured prior to 1992, and that it was installed on the engine on October 8, 2012. At the time of the accident, the pump had accumulated about 345 hours in service on the airplane. No other documentation regarding the history of the pump was located, and the investigation did not determine how much time the pump had accumulated since its overhaul, or on any other aircraft, if any. Therefore, the time cited herein can only be considered as a minimum value.
The fuel pump data plate indicated that it was manufactured by Romec. The pump was shipped to a Crane Aerospace facility in Ohio, of which Romec had become a subsidiary. Examination of the pump revealed that it had been overhauled by a company other than Crane/Romec, and that the overhaul had been accomplished on an unknown date subsequent to March 2010.
The pump was subjected to the Crane acceptance test procedure (ATP) for new pumps. The pump passed the performance portion of the ATP, but failed the static leak portion of the ATP; the pump shaft seal was found to be compromised. There were several anomalies detected with the assembly of the pump, most of which were consistent with being artifacts of the overhaul. These included improperly torqued screws, misidentified components, and lubricant or grease in improper locations. Although some anomalies had the potential to result in pump malfunction or failure, there was no evidence that the detected anomalies were associated with the subject accident.
In addition to those anomalies, areas of wear, and particulate contamination were observed in the pump. The shaft seal had significant rust-colored contaminants, which could have contributed to the shaft seal failure. The possibility that the rust developed or increased during the unpreserved engine's dormant period between the accident and the pump examination could not be excluded. According to a Crane representative, the "shaft seal leak has little impact on pump performance."
The leak was between the interior wetted portion of the pump and the gearbox cavity on the engine, and there was provision for the leaking fluid to be vented overboard or back to the intake. That scenario was consistent with the engine test cell observations. Some additional details can be found in the NTSB accident docket for this accident.
ORGANIZATIONAL AND MANAGEMENT INFORMATION
Airline Background Information
According to information provided by company representatives, SMA was an FAR Part 135 operator based on Tinian. SMA operated primarily as a passenger shuttle between Tinian and Saipan, which was approximately a 10-minute flight. The Tinian offices included SMA's headquarters, maintenance and dispatch facilities and personnel. SMA maintained an outstation on Saipan, which included passenger facilities, station agents, as well as technicians and pilots on an as-needed basis.
SMA operated about 4,500 flights per month, which representatives variously characterized as about 800 hours per month, and as about 125 hours per airplane per month. SMA had completed about 100,000 flights prior to the accident, and SMA representatives reported that SMA had had only two "incidents" (including the subject accident).
At the time of the accident, SMA operated a fleet of seven PA-32-300, two C-172, one C-172RG, and one Piper Navajo airplanes. Not all the airplanes were on the Part 135 certificate, and the Cessnas were used to transport company personnel and goods between Tinian and Saipan
SMA had approximately 22 pilots, each of whom was hired on a 1-year contractual basis. Pilots were typically scheduled for 12-hour shifts that began and ended at 7 am and 7 pm, and the normal schedule cycle was a repeat of 3 days on, 1 day off, 3 days on, and 2 days off. Pilots were released from schedules when traffic loads did not warrant their use/retention.
SMA conducted its own maintenance on its airplanes. SMA had a total of 12 aircraft technicians, including 5 certificated mechanics with airframe and powerplant ratings, and 1 with inspection authorization. The airplanes on the Part 135 certificate, including the accident airplane, were maintained in accordance with an FAA-approved inspection program.
Airline Dispatch, Release, and Loading Procedures
FAR Part 135 did not require SMA to maintain or use FAA-defined dispatch personnel or procedures. According to SMA representatives, SMA did maintain and use personnel in a dispatch-like capacity, but those personnel did not hold FAA dispatch certificates. SMA variously referred to those personnel as "dispatchers" and "flight followers." Those personnel performed weather briefings, airplane releases, and exercised "operational control."
Normal SMA dispatch procedures included assigning pilots to specific airplanes and providing printed weather information to the pilot. The dispatcher would then issue the pilot the airplane "can," which was a metal clipboard and container that held the aircraft flight log (AFL), other related paperwork, and the airplane keys.
SMA station agents, who were direct employees of SMA, would conduct passenger check in and loading. Their responsibilities included weighing of passengers and bags, seat assignments, baggage compartment loading determinations, issuance of boarding passes, and supervision or conduct of baggage and passenger loading. Station agents also presented load manifest to pilots, who verified and signed.
Airline Fuel Procedures
SMA maintained its primary fuel supply on Saipan, with some on Tinian. The "standard" first flight of each day fuel loads were 17 gallons (g) in each tip tank, and 7g in each main (inboard) tank. Although SMA conducted late night and very early morning flights, they did not indicate what their demarcation point for the beginning of each "day" was. Each flight between Tinian and Saipan typically consumed about 3 gallons. After the third or fourth "rotation" (a round trip between the islands), if the airplane was scheduled for additional flights, the dispatcher would advise the fuel truck of the potential need for fuel. Dispatchers arranged for fueling, and fuel truck personnel fueled the airplanes.
The airline's flight manifest records indicated that the airplane had 48 gallons of fuel on board for the flight. The airplane had most recently been fueled with 20.7 gallons on the day of the accident. The provided records did not indicate whether, or how many times, the airplane had flown subsequent to the refueling, or permit an independent determination of the fuel quantity on board for the accident flight. There were no reports of any fuel-related problems with any of the airline's airplanes in the days surrounding the accident.
According to SMA personnel and the General Operations Manual (GOM) checklist, the PA-32 pilots flying between Saipan and Tinian were supposed to adhere to standardized fuel-tank usage procedures, which, per the GOM, required the cockpit fuel tank selector handle to point "East for Enroute," which was towards Hawaii. Tinian was situated south of Saipan, and Hawaii was to the east of both. Therefore, on a southbound flight to Tinian, the selector would be set to the left tank, and on a northbound flight to Saipan, the selector would be set to the right tank.
Airline Airplane Airworthiness
Pilots were responsible for conducting daily 'first flight' checks, pre-flight inspections, and engine run ups. Once the pilot determined that an airplane was in satisfactory condition for flight, s/he would taxi it to the passenger terminal area to receive passengers.
Airplane airworthiness status was indicated in an electronic calendar, as well as on a manual display board in the Tinian dispatch office. SMA procedures prohibited the release of an "unairworthy" airplane to a pilot, and pilots are prohibited from flying an airplane with an "open" (uncorrected) maintenance item, unless it is indicated as acceptable per the applicable Minimum Equipment List (MEL). Pilots communicated airplane anomalies to the maintenance group by physically logging the item on the airplane copy of the AFL.
Airline Maintenance Writeup Procedures
In response to questions from the NTSB, SMA representatives provided the following information regarding maintenance writeup procedures.
Prior to a flight, station ground staff observe the general condition of the airplane, and notify the pilot if they have any concerns. The pilot checks the item in question, to determine whether a maintenance discrepancy exists. If the pilot determines that no maintenance discrepancy exists, s/he accepts the airplane, and conducts the flight. If a maintenance discrepancy does exist, the discrepancy is logged in the AFL, and the airplane is removed from service until the discrepancy is cleared by maintenance.
If a pilot notes a problem after taxiing out or during flight, the pilot decides whether to continue the flight or return. If the airplane returns to the departure airport, but does not return to the station (gate) because the pilot determines that no maintenance discrepancy exists and the situation can be corrected by the pilot, the pilot corrects the item, and departs without notice to dispatch or the station. Examples of such situations included unclosed doors, improperly inserted microphone or headset jacks, and insecure seat belts. If the pilot returns to the departure station (gate), dispatch is notified. If the airplane requires maintenance, dispatch is notified, and coordination with maintenance is required to determine when the airplane can be further utilized. Similarly, if the pilot continues the flight to the destination airport and then reports a mechanical irregularity, dispatch is notified, and coordination with maintenance is required to determine when the airplane can be further utilized.
Maintenance discrepancies are to be entered on the AFL sheets either before or after the discussions with maintenance. Except for MEL items, all maintenance discrepancies must be cleared by maintenance personnel before the airplane can be released back into service. MEL items may be deferred by the pilot in accordance with the MEL. Every MEL item must be carried forward onto each subsequent AFL until the item is cleared by maintenance.
SMA personnel stated that occasionally, "the items of interest that delay or cancel an aircraft from taking a specific flight are not determined to be" maintenance discrepancies that necessitate an AFL entry, citing a flooded engine as an example. They also noted that items detected and corrected by maintenance personnel would not appear on the AFL sheets. Instead, those items would be captured by the maintenance work order system, and appear as "Unscheduled Maintenance"' in the documentation.
Airline Flight Monitoring Procedures
SMA station agents were required to observe and monitor departures and arrivals. Saipan station agents had the capability to monitor PGSN ATCT communications. The station agents were required to then radio each flight departure and arrival to the dispatchers, who would log those departure and arrival times. SMA did not have any specific procedures requiring the capture of information regarding air turnbacks and subsequent departures, such as occurred on the accident flight. Neither the station agent nor the dispatchers noted the first turnback of the accident flight in any official records. The investigation did not locate any evidence to indicate that either the station agent or the dispatchers were aware of the first turnback until after the accident occurred.
Airline GOM Takeoff and Landing Information
The GOM explicitly stated that pilots were prohibited from substituting "personal" procedures for GOM procedures.
The Normal Procedures checklist from the SMA GOM specified a takeoff flap setting of 10 degrees. Although that checklist did not specify a landing flap setting, the GOM did contain guidance that indicated that landings were to be conducted using full flaps.
The GOM contained some guidance regarding pilots' use of full runway length versus intersection takeoffs from Saipan (PGSN). No similar information for departures from Tinian was provided, because those taxiways only accessed the runway at either end. The GOM guidance was consistent with conducting PGSN runway 7 takeoffs from the intersection of taxiway B and runway 7, instead of full length. That intersection was the closest point of runway 7 to the terminal ramp used by SMA. The GOM guidance for departures from PGSN runway 25 stated that pilots could conduct their takeoffs either full-length or from the taxiway D intersection. The terminal was closer to the taxiway D intersection than it was to the runway end.
The GOM runway takeoff guidance was consistent with minimizing taxi distances and times, and also with ensuring that, by the time an airplane reached mid-channel between the two islands, it would have sufficient altitude to be able to glide back to land in the event of an engine power loss.
Previous Airline Turnbacks
The ATCT communications transcript indicated that shortly after the pilot completed the turnback and landing prior to the runup and accident takeoff, the controller radioed that the turnback was the pilot's second one in as many weeks, which the pilot acknowledged. As a result of that exchange, on November 28, 2012, the FAA requested the ATCT records regarding any SMA turnbacks. The ATCT service provider representative responded that their records only dated back through November 12, 2012, and that there was one event in those records. The event occurred on November 13 local date (November 12 UTC), involving SMA PA-32 flight "TN4254R that departed 1842UTC (0442L) and landed 1845 UTC (0445L)." Review of the airline's records revealed that the accident pilot was on duty from 2000 on November 12, 2012, until 0610 on November 13, 2012 (dates and times local), that he was the pilot for a Saipan to Tinian leg in that airplane at the time of the ATC-reported turnback, and that the flight time was about 23 minutes, instead of the usual 10- to 15-minute durations. All this information was consistent with the pilot conducting the air turnback cited in the ATC records.
Despite the pilot's statement that he reported a recent previous turnback event to the airline, no recent anomaly reports or maintenance writeups for any such event associated with the pilot or N4254R were located in the airline's records. The only relevant maintenance record located was for a different airplane and different pilot. According to airline's records, on July 16, 2012, another pilot in another of the airline's PA-32 airplanes (N4599X) made an "immediate return" to the airport when the engine began "missing." That landing was uneventful, and the airplane returned to the gate. That event was subsequently attributed by the airline to water contamination of the fuel.
Airline Turnback Training Information
The airline's flight training manual that was available and in effect at the time of the accident provided the following guidance regarding engine failures on takeoff: "Airborne but not at a safe altitude to maneuver: Land straight ahead on the remaining runway if able, otherwise the best option is to land straight ahead considering the terrain." The flight training manual "Acceptable Performance Guidelines" for engine failure during takeoff stated that in the case of "no runway remaining," the pilot should "maintain straight flight path...and make the best choice of where to land."
According to an airline representative, the airline's PA-32 emergency checklist contained the following guidance regarding an engine power loss during takeoff: "If area ahead is rough... make only a shallow turn if necessary to avoid obstructions." However, review of the emergency procedures checklist revealed that the checklist that was available and in effect at the time of the accident did not contain the cited guidance. A revised version of that checklist, published in December 2014, did contain the cited verbiage.
Airline-Suggested Accident Scenario
A representative of the airline reported that the upper latches of the forward right cabin doors on their PA-32 airplanes have previously become unsecured after takeoff. The representative suggested that the first turnback was to enable the pilot to secure the door, and that the engine runup was intended to conceal the actual reason for the turnback. The representative suggested that the left turn and accident after the second takeoff was possibly due to the door becoming unlatched again, and the pilot's subsequent distraction and loss of situational awareness during his efforts to re-secure the door during the initial climb. Impact and thermal damage precluded a determination of the status (open/closed/locked etc.) of the door at the time of the accident, and the pilot never reported any cabin door problems to investigators. Review of airplane performance data and accident site ground scars indicated that a sustained bank angle of approximately 55 degrees, initiated at an altitude of about 150 to 200 feet agl, would be required to yield the observed ground scar location and heading.
ADDITIONAL INFORMATION
Passenger Accounts
The passengers consisted of five Chinese females and one Filipino male. The one female who reportedly spoke some English did not survive the accident. The male spoke some English. Three female passengers were interviewed shortly after the accident by U.S. Federal Bureau of Investigation (FBI) personnel, and with the knowledge of the NTSB. Two of those passengers were interviewed twice by the FBI; a total of five FBI interviews with the three female passengers were conducted. Those passengers agreed that the pilot did not inform them of the reasons for either the first or second turnback. Those passengers' accounts of the maximum altitude reached after the second takeoff ranged between 20 and 100 meters above ground level. None reported any in-flight smoke or fire. In one of the second interviews, one passenger reported that the pilot used his mobile telephone during boarding and after the first takeoff.
A few days after the accident, at the request of the airline's chairman, an SMA pilot attempted to interview all the surviving passengers. Two female passengers refused to be interviewed, because they claimed that they were instructed by the FBI not to speak with anyone about the accident. The other two females and the male did speak to the pilot-interviewer. The NTSB was not made aware of this plan or those interviews until after they had occurred, and no FAA representative was present for the interviews. According to the pilot-interviewer's written report, the two female passengers reported that the accident pilot appeared to manipulate a cabin door after the first takeoff.
However, the FAA representative's notes about the SMA pilot-interviewer's recount of the interviews indicated that one of those female passengers "really couldn't tell" whether the accident pilot touched the door, and that the other female passenger did not recall the pilot adjusting or latching the door after the landing. In addition, whereas the pilot-interviewer's notes did not contain any information regarding his interview of the male passenger, the FAA representative's notes indicated that the pilot-interviewer did interview the male passenger, and that the male passenger did not notice the accident pilot either using his telephone or manipulating the cabin door.
The investigation could not determine why the door recollections were not provided in the FBI interviews, whether the two female passengers had communicated with one another between the accident and the airline-led interviews, or why there were so many discrepancies between the various interview results and summaries.
Other Eyewitness Account
An SMA pilot was on the airline's ramp awaiting his passengers and witnessed a portion of the accident flight. He observed the stationary airplane on taxiway B with "what appeared to be a high engine rpm" for a period of about 45 seconds. He stated that the airplane then reduced power and taxied to runway 7 for an intersection departure. The airplane began a takeoff roll and began climbing, but "A few seconds later, it sounded that the engine was losing power and rpm was fluctuating." The witness observed the airplane level off and begin a "shallow left turn, which quickly steepened with an increasing nose down attitude." The airplane descended behind the terrain and trees, and the witness then heard the sound of impact. During the runup, the airplane was situated about 1,200 feet from the witness. The impact location was situated about 4,000 feet from the witness.
Pilot's Telephone Records
The investigation was able to obtain partial message and call records for the two mobile telephones known to be registered to the pilot. Review of the most complete set of records revealed that that telephone was being used by the pilot's girlfriend on the morning of the accident, and that she was using that telephone to communicate with the pilot at the second telephone number.
The records indicated that 26 text messages were exchanged between the two telephones between 0421:27 and 0600:15; the last message was from the pilot to the girlfriend. Three more messages were sent by the girlfriend between 0652:20 and 0655:28, but no replies from the telephone being used by the pilot were received.
A date/time error in a subpoena, that was not detected until very late in the investigation, precluded a complete record of the activity on the telephone which was in use by the pilot on the morning of the accident.
Airplane Performance Information
According to the airline-provided load manifest, the airplane weight at the time of the accident was about 3,270 pounds, and both the weight and center of gravity were within the allowable limits. The investigation was unable to independently determine the actual flap setting(s) for any portion of the flight.
Although all OH data was presented for the zero-wind case, the actual takeoff would have had an approximate 10 knot headwind. Local temperature, humidity and elevation conditions at the time of the accident resulted in a density altitude of about 2,000 feet.
The manufacturer's OH provided some takeoff, climb, glide, and landing performance data. Two takeoff performance charts, one each for 10 and 25 degrees flaps, presented data for takeoff weights of 2,900 and 3,400 pounds. According to the charts, at the takeoff weight, the distances to clear a 50 foot obstacle would have been about 1,900 and 1,800 feet for 10 and 25 degree flaps, respectively.
Climb data, provided only for 10 degrees flaps, indicated that the initial climb rate would have been about 930 feet per minute (fpm), decreasing to about 870 fpm at 1,000 feet agl. The investigation was unable to determine the maximum altitude reached by the airplane, but the pilot stated that the engine lost power when the airplane was 400 to 500 feet above the ground. Glide data indicated that the airplane would have a zero-flaps glide range of about 1 mile from an altitude of 500 feet. That range would decrease with headwind, off-nominal speed, extended flaps, and/or turning flight.
The OH-indicated landing distance over a 50-foot obstacle, using 40 degrees (full) flaps, "maximum braking," and "short field effort" would have been about 1,050 feet.
Calculations using the ambient conditions and the OH-provided data indicated that for the accident takeoff, presuming normal power output, the airplane would have lifted off about 20 seconds after the start of the takeoff roll, and cleared a 50-foot obstacle in another 4 seconds. At the prescribed climb speed, the airplane would have reached 250 feet agl and 500 feet agl after another 16 and 33 seconds respectively, or about 40 and 57 seconds (respectively) after the start of the takeoff roll. At 250 feet agl, the airplane would have traversed about 4,700 feet from the beginning of the takeoff roll. At that point, there would have been about 850 feet of runway remaining ahead of the airplane, compared to about 4,000 feet if the full runway length had been used. At 500 feet agl, the airplane would have traversed about 7,700 feet from the beginning of the takeoff roll. At that point, the airplane would have been about 1,250 feet beyond the end of the runway, compared to having about 1,000 feet remaining if the full runway length had been used.
FAA Airplane Flying Handbook (AFH) Information
Chapter 5 (Takeoffs) of the AFH (FAA publication 8083-3) stated that in the event of an engine failure on initial climbout, the pilot "should establish a controlled glide toward a plausible landing area (preferably straight ahead on the remaining runway)."
AFH Chapter 16 (Emergency Procedures) provided a lengthy discussion of procedures following engine failure on takeoff in a single engine airplane. The AFH noted that the altitude available is "the controlling factor" in the successful accomplishment of an emergency landing, and cautioned that if an engine failure should occur before a safe altitude is attained, it is "usually inadvisable to attempt to turn back" to the departure airport.
Problems associated with a post-takeoff turnback included a downwind turn, increased groundspeed, increased altitude loss due to the turn, and lateral offset from the runway after the turn. The AFH advised pilots to experiment at safe altitudes to determine realistic altitude values that would enable a safe turnback to the airport. Although such altitudes were not provided by SMA or the airplane manufacturer, multiple studies indicate that 500 feet above ground level should be considered the minimum acceptable altitude for single engine general aviation airplanes attempting a turnback to the departure airport.
http://registry.faa.gov/N4267R
NTSB Identification: WPR13LA045
Nonscheduled 14 CFR Part 135: Air Taxi & Commuter
Accident occurred Monday, November 19, 2012 in Obyan, GU
Aircraft: PIPER PA-32, registration: N4267R
Injuries: 1 Fatal, 5 Serious, 1 Minor.
This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.
On November 19, 2012, about 0618 local time (2018 UTC), a Piper PA-32-300, N4267R, was substantially damaged when it impacted airport terrain immediately after takeoff from Francisco C. Ada/Saipan International Airport (PGSN), Obyan, Saipan, Northern Mariana Islands, a United States territory. One passenger sustained fatal injuries, the pilot and four passengers sustained serious injuries, and one passenger sustained minor injuries. The on-demand charter flight was operated by Star Marianas Air, Inc., under the provisions of Title 14 Code of Federal Regulations Part 135. Dawn visual meteorological conditions prevailed, and no Federal Aviation Administration (FAA) flight plan was filed for the flight.
According to a representative of the operator, they typically carried tourists between Saipan and Tinian, an island about 10 minutes flying time south of Saipan. The passengers on the accident flight included five Chinese nationals and one Philippine national, and the flight was destined for Tinian. According to information obtained from personnel in the PGSN air traffic control tower (ATCT), about 0609 the airplane departed from runway 7, and the pilot then asked to return for landing for an unspecified problem. The airplane landed uneventfully back on runway 7 about 0615. An ATCT controller queried the pilot as to his intentions, and the pilot responded that he wanted to conduct an engine runup. The airplane exited the runway at taxiway Bravo and stopped, and according to several witnesses, the pilot conducted a brief engine runup. The pilot was then cleared for an intersection Bravo departure from runway 7. Witnesses observed the airplane become airborne, drift left, and impact the grass adjoining the north side of the runway. The airplane slid into trees north of the runway, and a fire ensued.
Information obtained by on-scene examination by an FAA inspector revealed that the airplane came to rest about 3,000 feet from the departure end of runway 7, and that the left wing had separated during the ground impact sequence. Initial examination of the airplane established flight control continuity, exclusive of impact-related damage, for the pitch and roll control systems. Initial examination of the engine did not reveal any pre-impact conditions which would have precluded normal operation. The wreckage was transported to a secure location for future detailed examination.
FAA and operator information indicated that the pilot held a commercial pilot certificate, with an instrument airplane rating. The pilot had a total flight experience of about 1,238 hours, including about 674 hours in the accident airplane make and model. His most recent FAA first-class medical certificate was issued in August 2012, and his most recent flight review was completed in January 2012. The airplane was manufactured in 1969, and was equipped with a Lycoming TIO-540 series engine. The airplane had accumulated about 6,805 total hours in service.
The PGSN 0554 automated weather observation included winds from 060 degrees at 10 knots; visibility 10 miles; scattered clouds at 2,000 feet, broken cloud layer at 5,000 feet, overcast cloud layer at 11,000 feet; temperature 27 degrees C; dew point 23 degrees C; altimeter setting of 29.91 inches of mercury.
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District Court for the Northern Mariana Island Chief Judge Ramona V. Manglona yesterday granted a stipulation dismissing Century Tours Inc. from the lawsuit brought by representatives of victims in the 2012 crash at the Francisco C. Ada/Saipan International Airport involving Star Marianas.
The federal court dismissed plaintiffs’ fourth cause of action for negligence against Century Tours Inc. without prejudice, with each party to bear its own fees and costs, court records show.
Attorney Steven P. Pixley, who represents Century Tours, and attorneys John K. Courtney and Mark B. Hanson, representing the plaintiffs, submitted a four-page stipulation in federal court on Monday.
Pixley communicated to Courtney and Hanson that Century Tours Inc. “had absolutely no relationship” with plaintiffs during the relevant time period.
Pixley told the plaintiffs’ counsels that “plaintiffs were not customers of Century Tours at the time of the airplane accident on or about Nov. 19, 2012.”
Pixley further told plaintiffs’ counsels that “Century Tours did not book any of the plaintiffs on the Star Marianas flight which crashed at the Saipan International Airport on Nov. 19, 2012.”
Plaintiffs further agreed to dismiss without prejudice Century Tours as a defendant in the civil action pending in federal court.
Century Tours in turn agreed that if discovery shows potential liability of Century Tours, Century Tours will waive any defense based on the statute of limitations, according to the stipulation.
Weilian Lu, who died in that accident, represented by her child Yixiao Ge, who in turn is represented by guardian Xiaojie Ge, along with co-plaintiffs Xin Hong, Meilin Zhou, Xiaohua Zhou, and Xiuzhong Zhu sued Star Marianas Air Inc., Marianas Air Travel, Tinian Transportation Management Solutions Inc., pilot Jae Choi, Chinese travel agency Tianing, Century Tours, Top Development Inc. and Does 100 in federal court in Nov. 2014 for negligence, wrongful death, negligently inflicted emotional distress, and fraud.
Based on the complaint, defendant Choi — the pilot — crash landed the aircraft Piper PA-32 Cherokee Six operated by defendant SMA, chartered by defendant MAT and maintained by defendant TTMS north of the Saipan airport runway on Nov. 19, 2012.
The crash landing resulted in Lu’s death while four others were severely injured. Lu was dead on arrival at the hospital due to burns.
Hong suffered a thoracolumbar burst fracture and had to undergo surgery.
M. Zhou had a fractured right arm, burned chin, and injured leg and underwent multiple hip surgeries.
X. Zhou suffered third-degree burns on her face, a burnt right arm, fractured left arm and head injuries.
Zhu suffered an injured forehead, dislocated left arm and fractured back. He suffers from a sleep disorder.
Scheduled 14 CFR Part 135: Air Taxi & Commuter
Accident occurred Friday, April 19, 2019 in Saipan, MP
Aircraft: Piper PA32, registration: N4599X
NTSB investigators will use data provided by various entities, including, but not limited to, the Federal Aviation Administration and/or the operator, and will not travel in support of this investigation to prepare this aircraft accident report.
Piper PA-32-300 Cherokee Six B, Star Marianas Air (Marianas Air Transfer Inc.), N4267R: Accident occurred November 19, 2012, near Saipan International Airport (SPN/PGSN) - Northern Mariana Islands
NTSB Identification: WPR13LA045
Nonscheduled 14 CFR Part 135: Air Taxi & Commuter
Accident occurred Sunday, November 18, 2012 in Obyan, MP
Probable Cause Approval Date: 07/07/2015
Aircraft: PIPER PA-32, registration: N4267R
Injuries: 1 Fatal, 5 Serious, 1 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.
The 14 Code of Federal Regulations Part 135 airline operated a fleet of single-engine airplanes that shuttled passengers between two islands located about 10 minutes’ flying time apart. The flight was carrying six passengers and was being conducted in visual meteorological conditions at dawn. After a normal start, taxi-out, and engine run-up, the airplane departed using the full length of the 8,000-ft-long runway. About 4 minutes after takeoff, the pilot radioed the air traffic control tower that he wanted to “come back in for an immediate landing”; the airplane landed uneventfully on the departure runway about 3 minutes later.
The airplane exited the runway at the first taxiway, situated about 3,150 ft past the runway threshold, and the pilot subsequently conducted an engine run-up. The pilot returned to the runway and initiated an intersection takeoff using the 5,550 ft of remaining runway. About 45 seconds after the pilot began the takeoff, the airplane experienced a partial loss of engine power, so he began a second turnback. During the turnback, the airplane stalled at low altitude and impacted airport property near the end of a runway parallel to the departure runway. A postimpact fire ensued; one passenger did not exit the airplane and died.
The pilot did not recall making the first turnback, and the investigation was unable to determine the reason for the first turnback. One passenger reported that the pilot was using his mobile telephone at an inappropriate time during the beginning of the flight, and two other passengers reported that the cabin door became unlatched at some point during the flight. Neither passenger reported that any door problems occurred after the second takeoff. Although there was no evidence to support the passengers’ allegations regarding the telephone or the cabin door events, an airline representative suggested that the first turnback was conducted due to the door coming open and that the subsequent engine run-up was conducted to conceal the actual reason for the turnback. The representative added that the second turnback may have been due to the pilot’s distraction and loss of situational awareness as he attempted to relatch the door that might have become unlatched again.
Postaccident on-site wreckage examination and test runs and examination of the engine did not reveal any preimpact mechanical deficiencies that could be directly linked to the power loss. Although anomalies with the engine-driven fuel pump and one magneto were detected during their respective examinations, the units performed satisfactorily during bench testing. However, there were a sufficient number of undetermined details regarding the preimpact configuration and condition of the airframe and the engine to preclude a determination of the preaccident functionality and airworthiness of the airplane. Those details included the magneto-to-engine timing, the internal timing of the right magneto, the fuel selector valve takeoff setting, and the fuel quantity in the selected tank.
Review of airplane performance data indicated that the 5,550 ft of runway beyond the taxiway intersection was more than sufficient for the takeoff. The performance data showed a rapid roll into a sustained bank angle during the turnback, which did not support the airline’s scenario that the airplane veered off course due to the pilot’s loss of situational awareness. The investigation was unable to determine the initiation altitude of the turnback or whether there was sufficient altitude for the safe execution of such a maneuver. However, deductions of the airplane location, altitude, and heading based on the ground scar information indicated that a safe landing would not have been possible from the point in the flightpath where the airplane stalled. Neither the airline nor the airplane manufacturer provided any specific guidance to pilots regarding minimum safe turnback altitudes.
The pilot’s decision to conduct an intersection takeoff, instead of a full-runway-length takeoff, left 3,150 ft less runway. Although he did not state it explicitly, the apparent reason that the pilot opted for the intersection takeoff was for schedule expediency, by obviating the need for the extra few minutes required to taxi back for a full-runway-length takeoff. Based on the accident flightpath, the additional 3,150 ft of runway likely would have been sufficient to enable a straight-ahead landing after the power loss rather than a turnback. By foregoing the taxi-back, the pilot reduced his margin of safety by decreasing his options in the event of an engine anomaly or power loss. Review of aerial imagery revealed that, beyond the airport’s northeast boundaries, there were very few locations suitable for an emergency landing following a low-altitude power loss, which likely contributed to the pilot’s decision to attempt to return to the airport. Although the airline published the preferred flight tracks between the two airports that it primarily served, it did not provide any guidance regarding preferred flightpaths or emergency landing sites following an engine failure at low altitude.
The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
A partial loss of engine power shortly after takeoff for reasons that could not be determined because postaccident examination did not reveal any anomalies that would have precluded normal operation and the pilot’s failure to maintain airplane control during the unsuccessful attempt to return for landing on the airport. Contributing to the accident was the pilot’s decision to conduct his second takeoff using less than the full runway length available and the airline’s lack of guidance regarding how to respond to engine failures at low altitudes.
HISTORY OF FLIGHT
On November 19, 2012, about 0618 local time (2018 November 18 Universal Coordinated Time), a Piper PA-32-300, N4267R, was destroyed when it impacted airport terrain during an attempted turnback immediately after takeoff from Francisco C. Ada/Saipan International Airport (PGSN), Obyan, Saipan, Northern Mariana Islands, a United States territory. One passenger sustained fatal injuries, the pilot and four passengers sustained serious injuries, and one passenger sustained minor injuries. The on-demand charter flight was operated by Star Marianas Air, Inc. (SMA), under the provisions of Title 14 Code of Federal Regulations Part 135. Dawn visual meteorological conditions prevailed, and no Federal Aviation Administration (FAA) flight plan was filed for the flight.
According to a representative of the airline, the airline typically shuttled tourists between Saipan and Tinian, an island about 10 minutes' flying time south of Saipan. The passengers on the accident flight included five Chinese nationals and one Filipino national, and the flight was destined for Tinian.
According to information from the FAA and Serco, the PGSN air traffic control tower (ATCT) service provider, the pilot first contacted the ATCT at 0604, requesting taxi clearance. The flight was instructed to taxi to the end of runway 7, and was cleared for takeoff about 4 minutes later. About 4 minutes after takeoff, the pilot radioed the ATCT that he wanted to "come back in for an immediate landing if possible." About 3 minutes later, the airplane landed uneventfully on runway 7, and exited the runway at taxiway B. The pilot briefly ran up the engine, and about 3 minutes after landing, informed the ATCT that he was ready for an intersection departure from runway 7. About 45 seconds after that, the airplane was observed turning back to the left, and some garbled radio transmissions were received from the airplane. Shortly thereafter, the airplane impacted airport property near the northeast end of runway 6, a smaller parallel runway situated northwest of runway 7.
The bulk of the airplane came to rest at the treeline northwest of runway 6, and a post-accident fire began. The pilot and most passengers exited or were helped from the airplane, but the female passenger seated in the front right seat remained in the airplane, and was fatally injured.
About 2 days after the accident, the wreckage was examined on scene by personnel from the FAA, and was then recovered to a secure location.
PERSONNEL INFORMATION
Pilot Experience and Medical Information
FAA and airline information indicated that the pilot held a commercial pilot certificate, with an instrument airplane rating. The pilot began flying for SMA in January 2012. The airline initially qualified the pilot for "PIC" (pilot-in-command) authority in the PA-32-300 on January 11, 2012, and for flight instructor/check airman authority in the airplane on February 3, 2012. His most recent flight review was completed in January 2012, and his most recent FAA first-class medical certificate was issued in August 2012.
The pilot had a total flight experience of about 1,238 hours, including about 674 hours in the accident airplane make and model. Airline records indicated that the pilot had flown about 54 hours in October 2012, and about 31 hours in November, the month of the accident. According to the airline's records, the pilot was on duty from 0200 to 0500 on November 15, and did not have another duty period until 1900 on November 17. He was then on duty for 11 hours, had a rest period of 12 hours and 40 minutes, and then went back on duty at 1840 the evening before the accident. At the time of the accident, the pilot had been on duty for almost 12 hours.
The FAA Civil Aeromedical Institute conducted forensic toxicology examinations on "blood, serum" specimens from the pilot, and reported that no carbon monoxide, ethanol, or any screened drugs were detected.
Pilot Flight Recollections
A brief telephone interview was conducted with the accident pilot about 2 weeks after the accident. The pilot remembered most of the accident flight, including events leading up to it, but he had no recollection of the takeoff and return just prior to the accident takeoff.
According to the pilot, the flight/load manifest was satisfactory, and he did not note any defects during his preflight inspection, taxi-out, or engine runup. The initial takeoff and climbout was normal, but when the airplane reached an altitude of about 400 to 500 feet above ground level (agl), he noticed a "significant change" in engine sound and power. He observed that the manifold pressure and rpm gauges did not indicate full takeoff power, but stated that the engine gauges in the airline's fleet are "never accurate." He did not observe any unusual instrument indications, but his sense was that the engine's power and sound was less than that normally experienced for the indicated power settings.
Upon sensing the power loss, the pilot immediately pushed the throttle, propeller, and mixture controls full forward, but the power continued to decrease. The pilot then turned on the electric fuel boost pump, and switched the fuel selector valve from the left to the right tank.
The pilot stated that because he had conducted an intersection takeoff, he did not believe that there was enough runway remaining to land on, and he was therefore faced with the choice of putting the airplane in the ocean ahead, or attempting a turnback for landing on the airport property. He decided to attempt a turnback, and was cognizant of the decreasing power, airspeed, and altitude, as well as the danger of stalling. Initially the pilot intended to land on runway 24, but he overflew that, and then decided to try to land on the ramp. He said that he maintained a bank angle of about 35 to 45 degrees in the turn, but when the airplane was about 15-20 feet above the ground, the airplane suddenly "dropped to the ground." That was the last item he recalled about the accident sequence.
When asked about the air turnback, landing, and runup that he had conducted just prior to the accident takeoff, the pilot recalled such an event, but he could not recall whether that event was the night before, or 2 weeks prior to, the accident flight. Regarding that event, the pilot recalled that on departing Saipan, he experienced a "slight power loss" of about 100 rpm, but was able to climb to 1,500 feet on the right downwind traffic pattern leg, and therefore, elected to return to the departure runway. He "landed long," but otherwise normally. He exited the runway, leaned the mixture to "clean the plugs," conducted an engine runup, and determined that the airplane was "fine." The pilot then departed uneventfully, and landed successfully at Tinian, where he informed maintenance or company personnel about the engine event.
When informed during a telephone interview with NTSB and FAA personnel that the ATCT records indicated that he had conducted a successful air turnback just prior to the accident, again the pilot had no specific recollection of that event. The pilot did not reconcile his lack of recollection of a previous turnback with his recollection that he had conducted an intersection takeoff during the accident flight.
AIRCRAFT INFORMATION
General Information
The airplane was manufactured in 1969, and was equipped with a Lycoming IO-540 series engine. It was an all-metal low-wing monoplane design with fixed, tricycle-style landing gear. The airplane seated seven persons in a 2-3-2 arrangement from front to back. The cabin was equipped with two entrance doors, one on the front right side (for pilot and co-pilot/front seat passenger), and one at the left rear for the other five passengers. The airplane had two baggage compartments, one forward and one aft.
Flap positions include retracted (up/0 degrees), 10, 25, and 40 degrees, and were selected by moving the flap handle to one of the corresponding pre-select notches. The flaps were spring-loaded to the retracted position.
Fuel System and Usage Procedures
The airplane was equipped with four individually-selectable fuel tanks; left tip/aux, left main, right main, and right tip/aux. Total fuel capacity was 84 gallons. The four-position wing flaps were manually actuated via a cockpit handle and torque tube arrangement.
The manufacturer's Owner's Handbook (OH) specified that for takeoff, the fuel selector valve should be set to the "fullest main tank." The OH specified that once in cruise, "in order to keep the airplane in best lateral trim...the fuel should be used alternately from each tip tank" until the tip tank quantities were "nearly exhausted." At that point the OH specified switching to the main tanks.
Maintenance Information
According to the maintenance records, the airplane had accumulated a total time (TT) in service of about 6,805 hours at the time of the accident. An overhauled engine was installed in July 2012, when the airplane had a TT of about 6,290 hours.
The airline maintained the airplane on a progressive, cyclic inspection program which included four elements or segments, designated as "AAIP-1" through "AAIP-4." The most recent completed inspection cycle was the AAIP-1, which was completed on November 17, 2012, at an airframe TT of about 6,799 hours, and an engine time since overhaul of about 516 hours.
METEOROLOGICAL INFORMATION
The PGSN 0554 automated weather observation included winds from 060 degrees at 10 knots, visibility 10 miles, scattered clouds at 2,000 feet, broken cloud layer at 5,000 feet, overcast cloud layer at 11,000 feet, temperature 27 degrees C, dew point 23 degrees C, altimeter setting of 29.91 inches of mercury.
COMMUNICATIONS
PGSN was equipped with an ATCT that was operating at the time of the accident, and was operated and staffed under contract to the FAA by Serco Management Services, Inc. A transcript of the communications between the ATCT and the accident airplane was prepared and provided by Serco.
According to the transcript, the pilot first contacted the ATCT at 0604:32, and advised that he was at the "commuter ramp" with the terminal information, and was ready to taxi. The controller cleared the airplane to taxi to the "end" of runway 7 via taxiway B and runway 6. The pilot acknowledged "full length," and was advised to expect a 2-minute delay for wake turbulence separation. At 0608:27, the flight was cleared for takeoff and an "early right turnout," which the pilot read back correctly. At 0612:08, the pilot radioed "Saipan tower, uh" but did not continue. At 0612:35, the pilot radioed that he wanted to come back for an "immediate landing if possible," and after a brief discussion about his position, was cleared to land on runway 7. When asked if he required emergency assistance, the pilot replied "negative."
After the airplane landed, at 0614:28, the controller instructed the pilot to exit the runway at taxiway B, and remarked that this was the "second time it happened to you in less than two weeks, huh?" to which the pilot responded in the affirmative, and stated that he "just want[ed] to make sure everything's good to go." At 0614:54, the pilot told the controller that he just wanted to do a "quick run-up," and the controller told him to do so on taxiway B, and to advise when ready for departure.
At 0616:17, the pilot advised the controller that he was ready for an intersection departure, and was cleared a few second later. At 0617:17, the pilot radioed "six seven romeo would like" but he did not complete that request. At 0617:27, in response to observing the airplane turning and descending, the controller cleared the airplane to land, and a partial, unintelligible response was received from the airplane. Shortly after that, the controller initiated the accident response procedures.
AIRPORT INFORMATION
PGSN was equipped with two parallel runways, designated as 6/24 and 7/25. Runway 7/25, which was the primary runway and the one used for the two departures, measured 8,700 by 200 feet. Taxiway B, which was perpendicular to the two runways, was located about 3,150 feet beyond the threshold of runway 7. A runway 7 intersection departure from taxiway B would have about 5,550 feet of available runway. The specified traffic pattern direction for runway 7 was left-hand.
Runway 6/24 was a designated portion of the pavement that paralleled the full length of runway 7/25. Runway 6/24 measured 7,000 by 100 feet, and the threshold of runway 24 was directly abeam that of runway 25. The centerline of runway 6/24 was offset about 750 feet northwest of that of runway 7/25.
The shoreline to the northeast of the airport was oriented approximately perpendicular to the runways, and was situated approximately 2,600 feet beyond the end of runway 7. The shoreline to the southwest of the airport was also oriented approximately perpendicular to the runways, and was situated approximately 4,300 feet prior to the runway 7 threshold. The airport elevation was listed as 211 feet above mean sea level.
Review of commercially-available aerial imagery revealed that beyond the northeast airport boundaries, most of the vicinity was either ocean or heavily-vegetated terrain, with very few roads or open fields.
WRECKAGE AND IMPACT INFORMATION
According to information provided by FAA inspectors who responded to the accident site, the main wreckage came to rest at the junction of the grassy area adjoining runway 6 and the parallel treeline situated about 290 feet northwest of the centerline or runway 6/24. The main wreckage was located about 1,050 feet from the runway 7/25 centerline, and about 700 feet before the departure ends of runways 6 and 7.
The main wreckage consisted of the majority of the airplane, excluding the left wing, some cockpit/cabin transparencies, some miscellaneous airplane components, and some luggage. The evidence was consistent with the left wing striking the ground first, while the airplane was in a left turn. The ground scars and debris path were oriented to the northwest, and curved about 15 degrees to the left.
The first ground scar was located in the grass about 35 feet from the northwest side of runway 6. The left wing was located about 108 feet beyond the first impact point; the wing was fracture-separated from the airplane at the root, and was lying inverted. The left main landing gear was fracture-separated from the wing; it was found about 10 feet beyond the left wing. The main wreckage was about 114 feet beyond the left wing, and a passenger suitcase was located between the left wing and main wreckage. The airplane came to rest upright against and parallel to the tree line, oriented on a heading of approximately 240 degrees. The cockpit and cabin contents were fire damaged or consumed by fire, as was the outboard half of the right wing.
The aft fuselage and empennage were essentially intact. Pitch and rudder control continuity was established from the cockpit area to the respective aft control surfaces. The pitch trim tab was set so that its trailing edge was about 1/2 inch below the stabilator trailing edge. The right wing flap was found in the retracted position, but the left flap was fracture-separated from its actuation linkage and therefore not fixed in any position. Photographs taken several hours after the accident, and subsequent to recovery of the front-right seat passenger, depict the cockpit flap handle to appear to be in the flaps-retracted position. The investigation was unable to determine if the flap handle was disturbed during or subsequent to the accident.
The ignition key remained in the ignition and its orientation appeared consistent with it being in the "BOTH" position, but fire damage precluded positive determination. The fuel selector handle appeared to be set to a right side tank, but visual inspection did not permit determination of whether it was set to right main tank, or the right tip tank. The engine control quadrant was fire- and impact-damaged, but the three levers appeared to be near their full-forward positions.
The engine was displaced aft and nose-down, but the engine was relatively undamaged. There was no evidence of any catastrophic internal engine failures. The three propeller blades remained attached to the hub, which remained attached to the engine. Two blades were bent aft, and one exhibited S-bending and chordwise scoring. The propeller did not exhibit any evidence of any pre-impact mechanical failures.
The left tip tank was compromised, and contained no fuel, but some fuel was recovered from the left inboard tank. That fuel was not visually contaminated. The right tip tank was impact and fire damaged, and contained no fuel. The right inboard tank was impact damaged. Attempts to sump it for fuel resulted in only a few drops, possibly due to the post-accident orientation.
MEDICAL AND PATHOLOGICAL INFORMATION
The FAA CAMI conducted forensic toxicology examinations of cavity blood and multiple tissue specimens from the right front seat passenger, and reported that no cyanide, ethanol, or any screened drugs were detected. However, the CAMI reported that a carbon monoxide level of 25 percent was detected in the passenger's femoral blood.
TEST AND RESEARCH
Engine Examination and Test Run
The engine was removed, crated and shipped to the Lycoming Engines facility in Pennsylvania for examination and testing. The engine did not exhibit any significant thermal damage. The propeller blades remained attached to the hub, and the hub remained attached to the engine. The magnetos were discovered to have been removed and loosely reinstalled. Follow-up investigation revealed that the mechanic who removed and crated the engine had to remove the magnetos in order to separate the engine from the airframe. The magneto-to-engine timing was not determined prior to their initial removal, nor were the magnetos marked in order to enable subsequent determination of their timing relative to the engine.
The airplane fuel selector valve was included in the crate. Examination indicated that it was set to the right outboard fuel tank, and that the valve was unable to be repositioned by hand due to damage.
The cooling baffles were removed to facilitate visual examination of the engine, which indicated that the engine appeared to be in sufficient condition to allow it to be run in a test cell. Several components were either removed outright, or replaced with serviceable or test-cell specific ('slave') hardware to facilitate an engine test run. These included, but were not limited to, the propeller (damage), right magneto (damage), and the air inlet housing for the fuel servo (test cell compatibility). The magnetos were set to the specified magneto-to-engine timing values for the test runs.
After mounting in the test cell and filling with warmed oil, an engine start was attempted. After six attempts the start was suspended, and examination revealed that fuel was exiting the engine driven fuel pump drain port. The pump was bypassed, and fuel was provided via the test cell hardware. After four more attempts, the engine started, but the automated test cell safety system shut the engine down due to high oil pressure, which was determined to be a result of the engine's 18-month dormancy.
The engine was restarted and ran for 5 minutes, but would not idle smoothly. The engine was again shut down, and cylinders 2 and 6 were determined by manual touch to be running significantly cooler than the other four cylinders. The fuel injector nozzles for cylinders 2 and 6 were removed, and found to be about 75 and 100 percent occluded, respectively. The age of, and the reasons for, the occlusions were not determined. The nozzles were cleaned and reinstalled.
The engine was restarted, and successfully completed Lycoming's Production Engine test sequence. The engine developed full rpm and manifold pressure, ran normally with only minor anomalies, and no deficiencies or problems that would have precluded continued operation were noted. Complete details are provided in a separate document in the NTSB public docket for this accident.
The magnetos and the engine driven fuel pump were sent to their respective manufacturers for detailed examination.
Magneto Information
Review of the maintenance records revealed that at the time of the accident, the magnetos had accumulated the following times on the airplane:
Left: 28 hours (installed 11/13/2012)
Right: 409 hours (installed 8/16/2012)
No other documentation regarding the previous history of the magnetos was located, and the investigation did not determine how much time the magnetos had accumulated since their overhaul, or on any other aircraft, if any. Therefore, the times cited herein can only be considered as minimum values.
Both magnetos were shipped to their manufacturer, Continental Motors in Mobile, Alabama, for examination and testing.
The left magneto's internal timing was found to be correct by both using a timing light and by visually examining the distributor gear position through the timing port. The magneto was placed on a test bench, and each lead produced a spark across a 7mm gap throughout all operating speeds. The impulse coupling functioned properly. The magneto was disassembled. Examination of the distributor gear while the axle was installed in the distributor block bushing revealed no discernable radial or axial play. There were no anomalies noted with the left magneto's internal components.
The right magneto's internal timing was checked using a timing light and by visually examining the distributor gear position through the timing port. The internal timing was trailing by three distributor gear teeth. The magneto was placed on a test bench and each lead produced a spark across a 7mm gap throughout all operating speeds, in the correct firing order. According to a Continental Motors (CMI) representative, the bench test spark gap was significantly larger than would be expected to be found in service, and that based upon the bench test results, the magneto in its as-tested condition would not have adversely affected engine performance.
The right magneto was disassembled. Examination of the distributor gear while it was still installed on the distributor block axle/shaft revealed that there was a significant angular displacement between the gear and the block. Four of the six fixed electrodes were mechanically damaged. Some of the material had been shaved off the electrodes, and electrode shavings and chips were found on the inside circumference of the distributor block. The distributor gear teeth displayed a worn condition on the carbon-brush-end of the gear. A number of the distributor gear teeth apexes displayed mechanical deformation damage consistent with imprints of the drive gear teeth. Examination of the distributor block revealed that the bushing in which the distributor gear axle rides, and which is normally molded into the block, was loose. Visible gaps were noted between the bushing and the housing, and fragmented block material was noted under the felt strip and felt washer. Representatives of CMI indicated that they had become aware of other similar magneto block failures. In February 2015, CMI issued two related Service Bulletins (SB 15-1 and SB-669) to provide relevant magneto inspection guidance.
The loose bushing permitted the distributor gear axle to tilt enough to disengage the distributor gear from the drive gear, permitting changes to the internal timing. Although the loose bushing and resulting off-plane freeplay of the timing gear was necessary to enable the mis-timing, it was not sufficient. The investigation did not determine the forcing mechanism(s) for the mis-timing. Therefore, the investigation was unable to determine whether any internal timing change was a gradual migration, a random step function, or some combination of the two. As a result, the investigation was unable to determine whether the as-found internal timing was representative of the magneto internal timing, either during the accident flight or any previous flights. Refer to the magneto examination report in the NTSB accident docket for additional details.
In August 1994, Lycoming issued Mandatory Service Bulletin SB516, which specified the inspection, and replacement at overhaul, of certain magnetos. The left magneto on the accident engine was subject to that SB. According to a Lycoming representative, any Lycoming-accomplished/approved overhaul requires compliance with all Lycoming Mandatory SBs. The accident engine was overhauled in 2012 by a commercial maintenance facility, and the accompanying FAA Form 8130-3 stated that the engine was "overhauled, tested, and certified" in accordance with all Lycoming specifications. However, the airplane's maintenance records indicate that a magneto that was subject to the SB was installed at overhaul, which was not in accordance with Lycoming standards. The investigation was unable to determine the reason for this discrepancy.
According to the FAA inspector for this accident, Part 135 operators are not required to comply with manufacturer's Service Bulletins (SBs) unless the SB is either incorporated into an Airworthiness Directive (AD), or is incorporated into any other operator document that is FAA approved. That same inspector reported that in his review of the airline's relevant guidance, he did not locate any requirements for compliance with manufacturer's SBs (excluding manufacturer's recommendations for overhaul of airframes, engines, propellers, and accessories).
Engine-Driven Fuel Pump Information
Review of the maintenance records and other documentation revealed that the pump was manufactured prior to 1992, and that it was installed on the engine on October 8, 2012. At the time of the accident, the pump had accumulated about 345 hours in service on the airplane. No other documentation regarding the history of the pump was located, and the investigation did not determine how much time the pump had accumulated since its overhaul, or on any other aircraft, if any. Therefore, the time cited herein can only be considered as a minimum value.
The fuel pump data plate indicated that it was manufactured by Romec. The pump was shipped to a Crane Aerospace facility in Ohio, of which Romec had become a subsidiary. Examination of the pump revealed that it had been overhauled by a company other than Crane/Romec, and that the overhaul had been accomplished on an unknown date subsequent to March 2010.
The pump was subjected to the Crane acceptance test procedure (ATP) for new pumps. The pump passed the performance portion of the ATP, but failed the static leak portion of the ATP; the pump shaft seal was found to be compromised. There were several anomalies detected with the assembly of the pump, most of which were consistent with being artifacts of the overhaul. These included improperly torqued screws, misidentified components, and lubricant or grease in improper locations. Although some anomalies had the potential to result in pump malfunction or failure, there was no evidence that the detected anomalies were associated with the subject accident.
In addition to those anomalies, areas of wear, and particulate contamination were observed in the pump. The shaft seal had significant rust-colored contaminants, which could have contributed to the shaft seal failure. The possibility that the rust developed or increased during the unpreserved engine's dormant period between the accident and the pump examination could not be excluded. According to a Crane representative, the "shaft seal leak has little impact on pump performance."
The leak was between the interior wetted portion of the pump and the gearbox cavity on the engine, and there was provision for the leaking fluid to be vented overboard or back to the intake. That scenario was consistent with the engine test cell observations. Some additional details can be found in the NTSB accident docket for this accident.
ORGANIZATIONAL AND MANAGEMENT INFORMATION
Airline Background Information
According to information provided by company representatives, SMA was an FAR Part 135 operator based on Tinian. SMA operated primarily as a passenger shuttle between Tinian and Saipan, which was approximately a 10-minute flight. The Tinian offices included SMA's headquarters, maintenance and dispatch facilities and personnel. SMA maintained an outstation on Saipan, which included passenger facilities, station agents, as well as technicians and pilots on an as-needed basis.
SMA operated about 4,500 flights per month, which representatives variously characterized as about 800 hours per month, and as about 125 hours per airplane per month. SMA had completed about 100,000 flights prior to the accident, and SMA representatives reported that SMA had had only two "incidents" (including the subject accident).
At the time of the accident, SMA operated a fleet of seven PA-32-300, two C-172, one C-172RG, and one Piper Navajo airplanes. Not all the airplanes were on the Part 135 certificate, and the Cessnas were used to transport company personnel and goods between Tinian and Saipan
SMA had approximately 22 pilots, each of whom was hired on a 1-year contractual basis. Pilots were typically scheduled for 12-hour shifts that began and ended at 7 am and 7 pm, and the normal schedule cycle was a repeat of 3 days on, 1 day off, 3 days on, and 2 days off. Pilots were released from schedules when traffic loads did not warrant their use/retention.
SMA conducted its own maintenance on its airplanes. SMA had a total of 12 aircraft technicians, including 5 certificated mechanics with airframe and powerplant ratings, and 1 with inspection authorization. The airplanes on the Part 135 certificate, including the accident airplane, were maintained in accordance with an FAA-approved inspection program.
Airline Dispatch, Release, and Loading Procedures
FAR Part 135 did not require SMA to maintain or use FAA-defined dispatch personnel or procedures. According to SMA representatives, SMA did maintain and use personnel in a dispatch-like capacity, but those personnel did not hold FAA dispatch certificates. SMA variously referred to those personnel as "dispatchers" and "flight followers." Those personnel performed weather briefings, airplane releases, and exercised "operational control."
Normal SMA dispatch procedures included assigning pilots to specific airplanes and providing printed weather information to the pilot. The dispatcher would then issue the pilot the airplane "can," which was a metal clipboard and container that held the aircraft flight log (AFL), other related paperwork, and the airplane keys.
SMA station agents, who were direct employees of SMA, would conduct passenger check in and loading. Their responsibilities included weighing of passengers and bags, seat assignments, baggage compartment loading determinations, issuance of boarding passes, and supervision or conduct of baggage and passenger loading. Station agents also presented load manifest to pilots, who verified and signed.
Airline Fuel Procedures
SMA maintained its primary fuel supply on Saipan, with some on Tinian. The "standard" first flight of each day fuel loads were 17 gallons (g) in each tip tank, and 7g in each main (inboard) tank. Although SMA conducted late night and very early morning flights, they did not indicate what their demarcation point for the beginning of each "day" was. Each flight between Tinian and Saipan typically consumed about 3 gallons. After the third or fourth "rotation" (a round trip between the islands), if the airplane was scheduled for additional flights, the dispatcher would advise the fuel truck of the potential need for fuel. Dispatchers arranged for fueling, and fuel truck personnel fueled the airplanes.
The airline's flight manifest records indicated that the airplane had 48 gallons of fuel on board for the flight. The airplane had most recently been fueled with 20.7 gallons on the day of the accident. The provided records did not indicate whether, or how many times, the airplane had flown subsequent to the refueling, or permit an independent determination of the fuel quantity on board for the accident flight. There were no reports of any fuel-related problems with any of the airline's airplanes in the days surrounding the accident.
According to SMA personnel and the General Operations Manual (GOM) checklist, the PA-32 pilots flying between Saipan and Tinian were supposed to adhere to standardized fuel-tank usage procedures, which, per the GOM, required the cockpit fuel tank selector handle to point "East for Enroute," which was towards Hawaii. Tinian was situated south of Saipan, and Hawaii was to the east of both. Therefore, on a southbound flight to Tinian, the selector would be set to the left tank, and on a northbound flight to Saipan, the selector would be set to the right tank.
Airline Airplane Airworthiness
Pilots were responsible for conducting daily 'first flight' checks, pre-flight inspections, and engine run ups. Once the pilot determined that an airplane was in satisfactory condition for flight, s/he would taxi it to the passenger terminal area to receive passengers.
Airplane airworthiness status was indicated in an electronic calendar, as well as on a manual display board in the Tinian dispatch office. SMA procedures prohibited the release of an "unairworthy" airplane to a pilot, and pilots are prohibited from flying an airplane with an "open" (uncorrected) maintenance item, unless it is indicated as acceptable per the applicable Minimum Equipment List (MEL). Pilots communicated airplane anomalies to the maintenance group by physically logging the item on the airplane copy of the AFL.
Airline Maintenance Writeup Procedures
In response to questions from the NTSB, SMA representatives provided the following information regarding maintenance writeup procedures.
Prior to a flight, station ground staff observe the general condition of the airplane, and notify the pilot if they have any concerns. The pilot checks the item in question, to determine whether a maintenance discrepancy exists. If the pilot determines that no maintenance discrepancy exists, s/he accepts the airplane, and conducts the flight. If a maintenance discrepancy does exist, the discrepancy is logged in the AFL, and the airplane is removed from service until the discrepancy is cleared by maintenance.
If a pilot notes a problem after taxiing out or during flight, the pilot decides whether to continue the flight or return. If the airplane returns to the departure airport, but does not return to the station (gate) because the pilot determines that no maintenance discrepancy exists and the situation can be corrected by the pilot, the pilot corrects the item, and departs without notice to dispatch or the station. Examples of such situations included unclosed doors, improperly inserted microphone or headset jacks, and insecure seat belts. If the pilot returns to the departure station (gate), dispatch is notified. If the airplane requires maintenance, dispatch is notified, and coordination with maintenance is required to determine when the airplane can be further utilized. Similarly, if the pilot continues the flight to the destination airport and then reports a mechanical irregularity, dispatch is notified, and coordination with maintenance is required to determine when the airplane can be further utilized.
Maintenance discrepancies are to be entered on the AFL sheets either before or after the discussions with maintenance. Except for MEL items, all maintenance discrepancies must be cleared by maintenance personnel before the airplane can be released back into service. MEL items may be deferred by the pilot in accordance with the MEL. Every MEL item must be carried forward onto each subsequent AFL until the item is cleared by maintenance.
SMA personnel stated that occasionally, "the items of interest that delay or cancel an aircraft from taking a specific flight are not determined to be" maintenance discrepancies that necessitate an AFL entry, citing a flooded engine as an example. They also noted that items detected and corrected by maintenance personnel would not appear on the AFL sheets. Instead, those items would be captured by the maintenance work order system, and appear as "Unscheduled Maintenance"' in the documentation.
Airline Flight Monitoring Procedures
SMA station agents were required to observe and monitor departures and arrivals. Saipan station agents had the capability to monitor PGSN ATCT communications. The station agents were required to then radio each flight departure and arrival to the dispatchers, who would log those departure and arrival times. SMA did not have any specific procedures requiring the capture of information regarding air turnbacks and subsequent departures, such as occurred on the accident flight. Neither the station agent nor the dispatchers noted the first turnback of the accident flight in any official records. The investigation did not locate any evidence to indicate that either the station agent or the dispatchers were aware of the first turnback until after the accident occurred.
Airline GOM Takeoff and Landing Information
The GOM explicitly stated that pilots were prohibited from substituting "personal" procedures for GOM procedures.
The Normal Procedures checklist from the SMA GOM specified a takeoff flap setting of 10 degrees. Although that checklist did not specify a landing flap setting, the GOM did contain guidance that indicated that landings were to be conducted using full flaps.
The GOM contained some guidance regarding pilots' use of full runway length versus intersection takeoffs from Saipan (PGSN). No similar information for departures from Tinian was provided, because those taxiways only accessed the runway at either end. The GOM guidance was consistent with conducting PGSN runway 7 takeoffs from the intersection of taxiway B and runway 7, instead of full length. That intersection was the closest point of runway 7 to the terminal ramp used by SMA. The GOM guidance for departures from PGSN runway 25 stated that pilots could conduct their takeoffs either full-length or from the taxiway D intersection. The terminal was closer to the taxiway D intersection than it was to the runway end.
The GOM runway takeoff guidance was consistent with minimizing taxi distances and times, and also with ensuring that, by the time an airplane reached mid-channel between the two islands, it would have sufficient altitude to be able to glide back to land in the event of an engine power loss.
Previous Airline Turnbacks
The ATCT communications transcript indicated that shortly after the pilot completed the turnback and landing prior to the runup and accident takeoff, the controller radioed that the turnback was the pilot's second one in as many weeks, which the pilot acknowledged. As a result of that exchange, on November 28, 2012, the FAA requested the ATCT records regarding any SMA turnbacks. The ATCT service provider representative responded that their records only dated back through November 12, 2012, and that there was one event in those records. The event occurred on November 13 local date (November 12 UTC), involving SMA PA-32 flight "TN4254R that departed 1842UTC (0442L) and landed 1845 UTC (0445L)." Review of the airline's records revealed that the accident pilot was on duty from 2000 on November 12, 2012, until 0610 on November 13, 2012 (dates and times local), that he was the pilot for a Saipan to Tinian leg in that airplane at the time of the ATC-reported turnback, and that the flight time was about 23 minutes, instead of the usual 10- to 15-minute durations. All this information was consistent with the pilot conducting the air turnback cited in the ATC records.
Despite the pilot's statement that he reported a recent previous turnback event to the airline, no recent anomaly reports or maintenance writeups for any such event associated with the pilot or N4254R were located in the airline's records. The only relevant maintenance record located was for a different airplane and different pilot. According to airline's records, on July 16, 2012, another pilot in another of the airline's PA-32 airplanes (N4599X) made an "immediate return" to the airport when the engine began "missing." That landing was uneventful, and the airplane returned to the gate. That event was subsequently attributed by the airline to water contamination of the fuel.
Airline Turnback Training Information
The airline's flight training manual that was available and in effect at the time of the accident provided the following guidance regarding engine failures on takeoff: "Airborne but not at a safe altitude to maneuver: Land straight ahead on the remaining runway if able, otherwise the best option is to land straight ahead considering the terrain." The flight training manual "Acceptable Performance Guidelines" for engine failure during takeoff stated that in the case of "no runway remaining," the pilot should "maintain straight flight path...and make the best choice of where to land."
According to an airline representative, the airline's PA-32 emergency checklist contained the following guidance regarding an engine power loss during takeoff: "If area ahead is rough... make only a shallow turn if necessary to avoid obstructions." However, review of the emergency procedures checklist revealed that the checklist that was available and in effect at the time of the accident did not contain the cited guidance. A revised version of that checklist, published in December 2014, did contain the cited verbiage.
Airline-Suggested Accident Scenario
A representative of the airline reported that the upper latches of the forward right cabin doors on their PA-32 airplanes have previously become unsecured after takeoff. The representative suggested that the first turnback was to enable the pilot to secure the door, and that the engine runup was intended to conceal the actual reason for the turnback. The representative suggested that the left turn and accident after the second takeoff was possibly due to the door becoming unlatched again, and the pilot's subsequent distraction and loss of situational awareness during his efforts to re-secure the door during the initial climb. Impact and thermal damage precluded a determination of the status (open/closed/locked etc.) of the door at the time of the accident, and the pilot never reported any cabin door problems to investigators. Review of airplane performance data and accident site ground scars indicated that a sustained bank angle of approximately 55 degrees, initiated at an altitude of about 150 to 200 feet agl, would be required to yield the observed ground scar location and heading.
ADDITIONAL INFORMATION
Passenger Accounts
The passengers consisted of five Chinese females and one Filipino male. The one female who reportedly spoke some English did not survive the accident. The male spoke some English. Three female passengers were interviewed shortly after the accident by U.S. Federal Bureau of Investigation (FBI) personnel, and with the knowledge of the NTSB. Two of those passengers were interviewed twice by the FBI; a total of five FBI interviews with the three female passengers were conducted. Those passengers agreed that the pilot did not inform them of the reasons for either the first or second turnback. Those passengers' accounts of the maximum altitude reached after the second takeoff ranged between 20 and 100 meters above ground level. None reported any in-flight smoke or fire. In one of the second interviews, one passenger reported that the pilot used his mobile telephone during boarding and after the first takeoff.
A few days after the accident, at the request of the airline's chairman, an SMA pilot attempted to interview all the surviving passengers. Two female passengers refused to be interviewed, because they claimed that they were instructed by the FBI not to speak with anyone about the accident. The other two females and the male did speak to the pilot-interviewer. The NTSB was not made aware of this plan or those interviews until after they had occurred, and no FAA representative was present for the interviews. According to the pilot-interviewer's written report, the two female passengers reported that the accident pilot appeared to manipulate a cabin door after the first takeoff.
However, the FAA representative's notes about the SMA pilot-interviewer's recount of the interviews indicated that one of those female passengers "really couldn't tell" whether the accident pilot touched the door, and that the other female passenger did not recall the pilot adjusting or latching the door after the landing. In addition, whereas the pilot-interviewer's notes did not contain any information regarding his interview of the male passenger, the FAA representative's notes indicated that the pilot-interviewer did interview the male passenger, and that the male passenger did not notice the accident pilot either using his telephone or manipulating the cabin door.
The investigation could not determine why the door recollections were not provided in the FBI interviews, whether the two female passengers had communicated with one another between the accident and the airline-led interviews, or why there were so many discrepancies between the various interview results and summaries.
Other Eyewitness Account
An SMA pilot was on the airline's ramp awaiting his passengers and witnessed a portion of the accident flight. He observed the stationary airplane on taxiway B with "what appeared to be a high engine rpm" for a period of about 45 seconds. He stated that the airplane then reduced power and taxied to runway 7 for an intersection departure. The airplane began a takeoff roll and began climbing, but "A few seconds later, it sounded that the engine was losing power and rpm was fluctuating." The witness observed the airplane level off and begin a "shallow left turn, which quickly steepened with an increasing nose down attitude." The airplane descended behind the terrain and trees, and the witness then heard the sound of impact. During the runup, the airplane was situated about 1,200 feet from the witness. The impact location was situated about 4,000 feet from the witness.
Pilot's Telephone Records
The investigation was able to obtain partial message and call records for the two mobile telephones known to be registered to the pilot. Review of the most complete set of records revealed that that telephone was being used by the pilot's girlfriend on the morning of the accident, and that she was using that telephone to communicate with the pilot at the second telephone number.
The records indicated that 26 text messages were exchanged between the two telephones between 0421:27 and 0600:15; the last message was from the pilot to the girlfriend. Three more messages were sent by the girlfriend between 0652:20 and 0655:28, but no replies from the telephone being used by the pilot were received.
A date/time error in a subpoena, that was not detected until very late in the investigation, precluded a complete record of the activity on the telephone which was in use by the pilot on the morning of the accident.
Airplane Performance Information
According to the airline-provided load manifest, the airplane weight at the time of the accident was about 3,270 pounds, and both the weight and center of gravity were within the allowable limits. The investigation was unable to independently determine the actual flap setting(s) for any portion of the flight.
Although all OH data was presented for the zero-wind case, the actual takeoff would have had an approximate 10 knot headwind. Local temperature, humidity and elevation conditions at the time of the accident resulted in a density altitude of about 2,000 feet.
The manufacturer's OH provided some takeoff, climb, glide, and landing performance data. Two takeoff performance charts, one each for 10 and 25 degrees flaps, presented data for takeoff weights of 2,900 and 3,400 pounds. According to the charts, at the takeoff weight, the distances to clear a 50 foot obstacle would have been about 1,900 and 1,800 feet for 10 and 25 degree flaps, respectively.
Climb data, provided only for 10 degrees flaps, indicated that the initial climb rate would have been about 930 feet per minute (fpm), decreasing to about 870 fpm at 1,000 feet agl. The investigation was unable to determine the maximum altitude reached by the airplane, but the pilot stated that the engine lost power when the airplane was 400 to 500 feet above the ground. Glide data indicated that the airplane would have a zero-flaps glide range of about 1 mile from an altitude of 500 feet. That range would decrease with headwind, off-nominal speed, extended flaps, and/or turning flight.
The OH-indicated landing distance over a 50-foot obstacle, using 40 degrees (full) flaps, "maximum braking," and "short field effort" would have been about 1,050 feet.
Calculations using the ambient conditions and the OH-provided data indicated that for the accident takeoff, presuming normal power output, the airplane would have lifted off about 20 seconds after the start of the takeoff roll, and cleared a 50-foot obstacle in another 4 seconds. At the prescribed climb speed, the airplane would have reached 250 feet agl and 500 feet agl after another 16 and 33 seconds respectively, or about 40 and 57 seconds (respectively) after the start of the takeoff roll. At 250 feet agl, the airplane would have traversed about 4,700 feet from the beginning of the takeoff roll. At that point, there would have been about 850 feet of runway remaining ahead of the airplane, compared to about 4,000 feet if the full runway length had been used. At 500 feet agl, the airplane would have traversed about 7,700 feet from the beginning of the takeoff roll. At that point, the airplane would have been about 1,250 feet beyond the end of the runway, compared to having about 1,000 feet remaining if the full runway length had been used.
FAA Airplane Flying Handbook (AFH) Information
Chapter 5 (Takeoffs) of the AFH (FAA publication 8083-3) stated that in the event of an engine failure on initial climbout, the pilot "should establish a controlled glide toward a plausible landing area (preferably straight ahead on the remaining runway)."
AFH Chapter 16 (Emergency Procedures) provided a lengthy discussion of procedures following engine failure on takeoff in a single engine airplane. The AFH noted that the altitude available is "the controlling factor" in the successful accomplishment of an emergency landing, and cautioned that if an engine failure should occur before a safe altitude is attained, it is "usually inadvisable to attempt to turn back" to the departure airport.
Problems associated with a post-takeoff turnback included a downwind turn, increased groundspeed, increased altitude loss due to the turn, and lateral offset from the runway after the turn. The AFH advised pilots to experiment at safe altitudes to determine realistic altitude values that would enable a safe turnback to the airport. Although such altitudes were not provided by SMA or the airplane manufacturer, multiple studies indicate that 500 feet above ground level should be considered the minimum acceptable altitude for single engine general aviation airplanes attempting a turnback to the departure airport.
NTSB Identification: WPR13LA045
Nonscheduled 14 CFR Part 135: Air Taxi & Commuter
Accident occurred Monday, November 19, 2012 in Obyan, GU
Aircraft: PIPER PA-32, registration: N4267R
Injuries: 1 Fatal, 5 Serious, 1 Minor.
This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.
On November 19, 2012, about 0618 local time (2018 UTC), a Piper PA-32-300, N4267R, was substantially damaged when it impacted airport terrain immediately after takeoff from Francisco C. Ada/Saipan International Airport (PGSN), Obyan, Saipan, Northern Mariana Islands, a United States territory. One passenger sustained fatal injuries, the pilot and four passengers sustained serious injuries, and one passenger sustained minor injuries. The on-demand charter flight was operated by Star Marianas Air, Inc., under the provisions of Title 14 Code of Federal Regulations Part 135. Dawn visual meteorological conditions prevailed, and no Federal Aviation Administration (FAA) flight plan was filed for the flight.
According to a representative of the operator, they typically carried tourists between Saipan and Tinian, an island about 10 minutes flying time south of Saipan. The passengers on the accident flight included five Chinese nationals and one Philippine national, and the flight was destined for Tinian. According to information obtained from personnel in the PGSN air traffic control tower (ATCT), about 0609 the airplane departed from runway 7, and the pilot then asked to return for landing for an unspecified problem. The airplane landed uneventfully back on runway 7 about 0615. An ATCT controller queried the pilot as to his intentions, and the pilot responded that he wanted to conduct an engine runup. The airplane exited the runway at taxiway Bravo and stopped, and according to several witnesses, the pilot conducted a brief engine runup. The pilot was then cleared for an intersection Bravo departure from runway 7. Witnesses observed the airplane become airborne, drift left, and impact the grass adjoining the north side of the runway. The airplane slid into trees north of the runway, and a fire ensued.
Information obtained by on-scene examination by an FAA inspector revealed that the airplane came to rest about 3,000 feet from the departure end of runway 7, and that the left wing had separated during the ground impact sequence. Initial examination of the airplane established flight control continuity, exclusive of impact-related damage, for the pitch and roll control systems. Initial examination of the engine did not reveal any pre-impact conditions which would have precluded normal operation. The wreckage was transported to a secure location for future detailed examination.
FAA and operator information indicated that the pilot held a commercial pilot certificate, with an instrument airplane rating. The pilot had a total flight experience of about 1,238 hours, including about 674 hours in the accident airplane make and model. His most recent FAA first-class medical certificate was issued in August 2012, and his most recent flight review was completed in January 2012. The airplane was manufactured in 1969, and was equipped with a Lycoming TIO-540 series engine. The airplane had accumulated about 6,805 total hours in service.
The PGSN 0554 automated weather observation included winds from 060 degrees at 10 knots; visibility 10 miles; scattered clouds at 2,000 feet, broken cloud layer at 5,000 feet, overcast cloud layer at 11,000 feet; temperature 27 degrees C; dew point 23 degrees C; altimeter setting of 29.91 inches of mercury.
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District Court for the Northern Mariana Island Chief Judge Ramona V. Manglona yesterday granted a stipulation dismissing Century Tours Inc. from the lawsuit brought by representatives of victims in the 2012 crash at the Francisco C. Ada/Saipan International Airport involving Star Marianas.
The federal court dismissed plaintiffs’ fourth cause of action for negligence against Century Tours Inc. without prejudice, with each party to bear its own fees and costs, court records show.
Attorney Steven P. Pixley, who represents Century Tours, and attorneys John K. Courtney and Mark B. Hanson, representing the plaintiffs, submitted a four-page stipulation in federal court on Monday.
Pixley communicated to Courtney and Hanson that Century Tours Inc. “had absolutely no relationship” with plaintiffs during the relevant time period.
Pixley told the plaintiffs’ counsels that “plaintiffs were not customers of Century Tours at the time of the airplane accident on or about Nov. 19, 2012.”
Pixley further told plaintiffs’ counsels that “Century Tours did not book any of the plaintiffs on the Star Marianas flight which crashed at the Saipan International Airport on Nov. 19, 2012.”
Plaintiffs further agreed to dismiss without prejudice Century Tours as a defendant in the civil action pending in federal court.
Century Tours in turn agreed that if discovery shows potential liability of Century Tours, Century Tours will waive any defense based on the statute of limitations, according to the stipulation.
Weilian Lu, who died in that accident, represented by her child Yixiao Ge, who in turn is represented by guardian Xiaojie Ge, along with co-plaintiffs Xin Hong, Meilin Zhou, Xiaohua Zhou, and Xiuzhong Zhu sued Star Marianas Air Inc., Marianas Air Travel, Tinian Transportation Management Solutions Inc., pilot Jae Choi, Chinese travel agency Tianing, Century Tours, Top Development Inc. and Does 100 in federal court in Nov. 2014 for negligence, wrongful death, negligently inflicted emotional distress, and fraud.
Based on the complaint, defendant Choi — the pilot — crash landed the aircraft Piper PA-32 Cherokee Six operated by defendant SMA, chartered by defendant MAT and maintained by defendant TTMS north of the Saipan airport runway on Nov. 19, 2012.
The crash landing resulted in Lu’s death while four others were severely injured. Lu was dead on arrival at the hospital due to burns.
Hong suffered a thoracolumbar burst fracture and had to undergo surgery.
M. Zhou had a fractured right arm, burned chin, and injured leg and underwent multiple hip surgeries.
X. Zhou suffered third-degree burns on her face, a burnt right arm, fractured left arm and head injuries.
Zhu suffered an injured forehead, dislocated left arm and fractured back. He suffers from a sleep disorder.
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