Saturday, October 27, 2018

Piper PA-31-310 Navajo C, registered to and operated by Strait Air (2000) Ltd, C-GQAM4: Fatal accident occurred May 03, 2017 in Colton, St. Lawrence County, New York

Éric Carrier


The National Transportation Safety Board traveled to the scene of this accident.

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; Albany, New York
Piper Aircraft; Vero Beach, Florida
Lycoming; Williamsport, Pennsylvania
Transportation Safety Board of Canada

Aviation Accident Factual Report - National Transportation Safety Board: https://app.ntsb.gov/pdf

Investigation Docket- National Transportation Safety Board: https://dms.ntsb.gov/pubdms 

 
http://wwwapps.tc.gc.ca  




Location: Colton, NY
Accident Number: ERA17FA172
Date & Time: 05/03/2017, 2030 EDT
Registration: C-GQAM
Aircraft: PIPER PA31
Aircraft Damage: Destroyed
Defining Event: Miscellaneous/other
Injuries: 1 Fatal
Flight Conducted Under: Non-U.S., Commercial 

On May 3, 2017, about 2030 eastern daylight time, a Piper PA-31, Canadian registration C-GQAM, impacted trees and terrain near Colton, New York. The Canadian commercial pilot was fatally injured, and the airplane was destroyed. The airplane was registered to and operated by Strait Air (2000) Ltd. as an air taxi flight under the provisions of Canadian Aviation Regulation 703. Visual meteorological conditions prevailed, and the flight was operated on a visual flight rules flight plan. The flight originated from Quebec/Jean Lesage International Airport (CYQB), Quebec, Quebec, Canada, at 1916, and was destined for Montreal Saint-Hubert Longueuil Airport (CYHU), Saint Hubert, Quebec, Canada.

According to the operator, the flight's estimated duration was 1 hour, and the airplane departed with 720 pounds (120 gallons) of fuel on board. According to CYQB Terminal Control air traffic control data, at 1919, the pilot was cleared to fly direct to CYHU at 2,000 ft mean sea level (msl). The pilot acknowledged the clearance, and there were no further radio transmissions from the pilot. The airplane continued flying a straight course, at 2,100 ft msl, overflew CYHU, and impacted terrain about 100 miles beyond the destination airport.

One witness heard the airplane flying over her house and reported that the engine sounded like it was "spitting and sputtering." The sound lasted for about 5 to 10 seconds and then stopped. Shortly thereafter, the witness heard "a loud bang." Another witness was inside his home when he heard a "low whining noise" that was followed by "a loud thud." A third witness reported that he heard the airplane flying low over his house and went outside to watch it. He watched the airplane head southwest at an "extremely low" altitude, and then he heard three "pops" coming from the airplane. A few seconds after that, the airplane banked to the left and began to "gradually lose altitude." The airplane continued in the descending left turn until he lost sight of it as it dropped below the horizon.

Pilot Information

Certificate: Commercial; Foreign
Age: 35, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Unknown
Other Aircraft Rating(s): None
Restraint Used: Unknown
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 1 With Waivers/Limitations
Last FAA Medical Exam: 05/17/2016
Occupational Pilot: Yes
Last Flight Review or Equivalent:
Flight Time:   5250 hours (Total, all aircraft), 1187 hours (Total, this make and model), 2 hours (Last 24 hours, all aircraft)

According to Transport Canada records, the pilot held a commercial pilot certificate with ratings for airplane single-engine land, airplane multi-engine land, and instrument airplane. The pilot was issued a category 1 medical certificate on May 17, 2016. According to the operator, the pilot had about 5,250 total hours of flight experience and 1,187 hours in the accident airplane make and model.

According to the pilot's family, he would typically fly from Quebec City to Montreal every weekday evening, stay in Montreal and sleep until about 0330, go back to the airport, and fly back to Quebec City in the morning. He would usually take a nap during the day before the next evening flight.

Aircraft and Owner/Operator Information

Aircraft Make: PIPER
Registration: C-GQAM
Model/Series: PA31 310
Aircraft Category: Airplane
Year of Manufacture: 1979
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 31-7912093
Landing Gear Type: Retractable - Tricycle
Date/Type of Last Inspection: 10/31/2016, Annual
Certified Max Gross Wt.: 6840 lbs
Time Since Last Inspection:
Engines: 2 Reciprocating
Airframe Total Time:
Engine Manufacturer: Lycoming
ELT:
Engine Model/Series: TIO-540-A2C
Registered Owner: Strait Air (2000) Ltd
Rated Power: 310 hp
Operator: Strait Air (2000) Ltd
Operating Certificate(s) Held: None 

According to Transport Canada records, the airplane was manufactured in 1979 and was registered to the operator in 2003. It was equipped with two 310-horsepower Lycoming TIO-540-A2C engines that drove two Hartzell constant-speed propellers. The airplane's most recent annual or 100-hour inspection was performed on October 31, 2016.

Right and left fuel flow warning lights illuminated to warn the pilot of an impending fuel flow interruption. The lights were activated by a sensing probe mounted near each inboard fuel tank outlet. No audible warning was associated with the illumination of the lights.

Section 4, "Normal Procedures" in the POH recommended that when the airplane is loaded to a rearward center of gravity, fuel from the outboard tanks be used first during cruise flight.

The airplane was equipped with a KFC 200 autopilot. According to the pilot operating handbook (POH), when the autopilot was disengaged, the autopilot light on the annunciator panel would flash at least four times and then remain off to indicate that the autopilot was disengaged. Also, a 2-second audible warning tone would sound when the autopilot disconnected.

According to the cruise checklist found in the POH, the following items should be completed:

Fuel Selectors – OUTBOARD OR INBOARD
Power – Set
Cowl Flaps – As required
Mixture – Leaned

According to the POH, the airplane was equipped with four flexible fuel cells, two in each wing. The outboard fuel cells had a capacity of 40 gallons each, and the inboard cells had a capacity of 56 gallons each, providing a total fuel capacity of 192 gallons, 187.3 gallons of which were usable. According to the POH, the inboard fuel tanks were to be used for taxi, takeoff, climb, and descent. The outboard tanks were only to be used in level flight while en route.

According to the engine manufacturer's operating manual, using the most conservative fuel consumption in economy cruise, the airplane consumed about 13.5 gallons per hour of fuel per engine. Assuming that the en route phases of flight were performed on the outboard fuel tanks, with the engines' power at economy cruise, the airplane would have an estimated 2.9 hours of fuel endurance in the outboard tanks with the tanks full.

Interpolation of performance charts revealed that, assuming the airplane typically flew at 2,000 ft msl en route, it would take about 3 minutes to climb and 3 minutes to descend, totaling 6 minutes, or 0.1 hour.

On May 2, 2017, the airplane flight records indicated that the airplane departed from CYQB for CYHU with full fuel tanks, which was 1,123 lbs of fuel, and accumulated 0.9 hours of flight time. On the morning of May 3, 2017, the records indicated that the airplane flew from CYHU for CYQB with a total flight time of 1.0 hours. Finally, the airplane departed on the accident flight and accumulated about 1.25 hours of flight time. There was no evidence the airplane had been refueled between these flights.


Figure 1. Estimated Outboard Tank Fuel Consumption.


Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Dusk
Observation Facility, Elevation: MSS, 214 ft msl
Distance from Accident Site: 24 Nautical Miles
Observation Time: 2053 EDT
Direction from Accident Site: 5°
Lowest Cloud Condition: Clear
Visibility: 10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 5 knots /
Turbulence Type Forecast/Actual: / None
Wind Direction: 220°
Turbulence Severity Forecast/Actual: /
Altimeter Setting: 30.1 inches Hg
Temperature/Dew Point: 7°C / 1°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Quebec, QC (CYQB)
Type of Flight Plan Filed: VFR
Destination: Saint Hubert, QC (CYHU)
Type of Clearance: VFR
Departure Time: 1916 EDT
Type of Airspace:

The 2053 recorded weather observation at Massena International Airport – Richards Field (MSS), Massena, New York, located about 24 nautical miles north of the accident location, included wind from 220° at 5 knots, visibility 10 miles, sky clear, temperature 7°C, dew point 1°C, and an altimeter setting of 30.10 inches of mercury. 



Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: N/A
Aircraft Fire: On-Ground
Ground Injuries: N/A
Aircraft Explosion: On-Ground
Total Injuries: 1 Fatal
Latitude, Longitude: 44.531111, -74.891111 (est)

Examination of the accident site revealed damage to trees consistent with a 45° left bank and level pitch attitude at impact. The airplane impacted terrain about 1,200 ft msl, and a postimpact fire ensued. A ground scar was located about 40 ft past the initial tree strike and about 100 ft before the main wreckage. The initial impact crater was about 2 ft deep. All components of the airplane were located in the vicinity of the main wreckage, and the debris field was about 240 ft long on about a 300° heading. There were several branches located along the debris path with 45° cuts in the wood.

Flight control continuity was confirmed from the cockpit to all the flight control surfaces. The cockpit and cabin were partially consumed by fire. Both wings were impact-separated, fragmented, and located along the debris path. The left wing tip light's lens cap was located in the initial impact crater, and the right wing tip light's lens cap was located in the vicinity of the first tree strike. All fuel tanks were breached, and the fuel selector valves were found in the outboard tank positions. The empennage remained attached to the fuselage and was partially consumed by fire. The vertical stabilizer and rudder remained attached to the empennage. The lower forward section of the vertical stabilizer was partially consumed by fire. The top approximate 2 ft of the rudder were impact-damaged. The left and right horizontal stabilizers and the left elevator were impact-damaged, and the outboard sections were separated and located along the debris path. The right elevator remained attached to the empennage and was impact-damaged and bent aft.

The left engine was examined, and crankshaft continuity was confirmed. Holes were drilled into the engine case to allow for examination of the internal components of the engine, and there was no evidence of heat distress or mechanical disconnects. The No. 2 top and bottom and the No. 6 bottom spark plugs were not located. The No. 5 top spark plug exhibited corrosion. All other spark plugs exhibited "worn out-normal" wear when compared to the Champion Check-a-plug Chart. The cylinders were examined with a borescope, and carbon deposits were noted on the tops of the pistons. The turbocharger was impact-separated from the engine. No scoring was noted on the housing; however, the compressor blades were bent opposite the direction of rotation. Both magnetos would not rotate by hand due to thermal damage. No anomalies were noted with the left engine that would have precluded normal operation before the accident.

The left propeller hub remained attached to the crankshaft flange. The three propeller blades of the left engine were impact-separated and located along the debris path. The blades were lettered A, B, and C, for descriptive purposes. Blade A was bent aft in a smooth arc, exhibited torsional twisting, leading edge gouging, and blade tip deformation and curling. Blade B was bent forward midspan, exhibited leading edge gouging, and torsional twisting. Blade C was bent and curled aft, exhibited trailing edge S-bending, torsional twisting, leading edge damage, and about 8 inches of the blade was torn from the tip.

The right engine was examined, and the crankshaft would not rotate when trying to move the propeller by hand. Holes were drilled in the top section of the case, and a borescope was used to examine the internal components of the engine. Crankshaft continuity was confirmed, and there were no anomalies noted inside the engine. The spark plugs exhibited normal wear when compared to the Champion Check-a-plug Chart. The cylinders were examined with a borescope, and carbon deposits were noted on the tops of the pistons. The Nos. 1, 2, and 4 cylinders were impact-damaged. No evidence of foreign object ingestion or detonation was noted in the engine. The valves were intact. The left and right magnetos of the right engine were consumed by postimpact fire. The turbocharger compressor housing exhibited rotational scoring. The turbocharger exhaust clamps were all secure. The turbocharger waste gate was impact-separated, and the butterfly could be operated by hand. No anomalies were noted with the right engine that would have precluded normal operation before the accident.

The right propeller remained attached to the crankshaft flange, and the blades remained attached to the propeller hub. They were lettered for descriptive purposes. All blades rotated in the hub socket. Blade A exhibited leading edge damage and was bent aft about 80°. Blade B exhibited trailing edge S-bending, torsional twisting, and leading edge damage. About 6 inches of the tip of blade B was separated and not located. Blade C was bent slightly, and no other damage was noted.

Medical And Pathological Information

The St. Lawrence County Coroner's Office, Canton, New York, performed the autopsy on the pilot. The autopsy report indicated that the pilot's cause of death was exsanguination (loss of a substantial proportion of blood). No significant natural disease was identified, but the examination was limited by the severity of damage to the body.

The FAA's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological testing of the pilot. Fluid and tissue specimens from the pilot tested negative for carbon monoxide and ethanol. The testing identified 1.9 ng/ml of tetrahydrocannabinol (THC) and 19.6 ng/ml of 11-carboxytetrahydrocannabinol (THC-COOH) in cavity blood. THC and THC-COOH were also identified in liver and lung.

THC is the principal psychoactive constituent of marijuana. Marijuana is a psychoactive drug with therapeutic levels as low as 1 ng/ml. According to the National Highway Traffic Safety Administration's Drugs and Human Performance Fact Sheet on marijuana, "it is difficult to establish a relationship between a person's marijuana blood or plasma concentration and performance impairing effects. Concentrations of parent drug and metabolite are very dependent on pattern of use as well as dose. THC concentrations typically peak during the act of smoking, while peak [THC-COOH] concentrations occur approximately 9-23 minutes after the start of smoking. Concentrations of both analytes decline rapidly and are often < 5 ng/ml at 3 hours."

Additional Information

Pilot's Work Schedule

According to the operator, the pilot's home base was CYQB. On Monday mornings, he drove from CYQB to CYHU, which was about a 2.5-hour drive. 

Monday to Friday, the pilot had the following schedule:

Begin at CYHU at 0300
Take off for CYQB at 0400
Arrive at CYQB at 0500

Begin at CYQB at 1800
Takeoff for CYHU at 1900
Arrive at CYHU at 2000

There was a crew rest area at the fixed based operator in CYQB, where the pilot would rest between the flights. On Friday evenings, the pilot drove from CYHU to CYQB and had the rest of the weekend off.

NTSB Identification: ERA17FA172
Nonscheduled 14 CFR Non-U.S., Commercial operation of Strait Air (2000) Ltd
Accident occurred Wednesday, May 03, 2017 in Colton, NY
Aircraft: PIPER PA31, registration: C-GQAM
Injuries: 1 Fatal.

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 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.

On May 3, 2017, about 2030 eastern daylight time, a Piper PA-31, Canadian registration C-GQAM, impacted trees and terrain near Colton, New York. The Canadian commercial pilot, and sole occupant, was fatally injured. The airplane was destroyed. The airplane was registered to and operated by Strait Air (2000) Ltd. as a Canadian Aviation Regulation 703 air taxi flight. Visual meteorological conditions prevailed at the accident site and along the route of flight about the time of the accident, and the flight was operated on a visual flight rules flight plan. The flight originated from Quebec/Jean Lesage International Airport (CYQB), Quebec, Quebec, Canada, at 1916, and was destined for Montreal Saint-Hubert Longueuil Airport (CYHU), Saint Hubert, Quebec, Canada.

According to the operator, the accident flight was supposed to be a 45-minute flight. According to CYQB Terminal Control air traffic control data, at 1919, the pilot was cleared to fly direct to CYHU at 2,000 ft mean sea level (msl). After that, there were no further radio transmissions from the airplane. The airplane continued flying a straight course, while at 2,100 ft msl, overflew CYHU, and impacted terrain about 100 miles beyond the destination airport.

According to witnesses, they heard the airplane "sputter" and heard an "engine whining" prior to an explosion. One witness reported that he heard the airplane flying low over his house and went outside to watch it. He watched the airplane head southwest "extremely low," and then he heard three "pops" coming from the airplane. A few seconds after that, the airplane banked to the left and began to "gradually lose altitude." He did not see any type of course correction of the airplane prior to losing sight of it beyond the horizon.

According to Transport Canada records, the pilot held a commercial pilot certificate with ratings for airplane single-engine land, multiengine land, and instrument airplane. The pilot was issued a category 1 medical certificate on May 17, 2016. According to the operator, the pilot had about 5,250 total hours of flight experience and 1,187 hours in the accident make and model.

According to Transport Canada records, the airplane was manufactured in 1979 and was registered to the corporation in 2003. In addition, it was equipped with two Lycoming TIO-540-A2C, 310-horsepower engines that drove two Hartzell constant speed propellers. The airplane's most recent annual or 100-hour inspection was performed on October 31, 2016.

The airplane entered the trees in about a left 45° bank angle, impacted several trees prior to impacting the ground, and then came to rest in a heavily wooded area. The airplane impacted terrain about 1,200 ft mean sea level and a postimpact fire ensued. There was a ground scar located about 40 feet past the initial tree strike and about 100 feet prior to the main wreckage. The initial impact crater was about 2 feet deep. All components of the airplane were located in the vicinity of the wreckage and the debris field was about 240 feet long on about a 300° heading. There were several branches located along the debris path with 45° cuts in the wood.

Flight control continuity was confirmed from the cockpit to all the respective flight control surfaces. The cockpit and cabin were partially consumed by fire. Both wings were impact-separated, fragmented, and located along the debris path. The red wing tip light lens cap was located in the initial impact crater and the right wing tip lens cap was located in the vicinity of the first tree strike. The empennage remained attached to the fuselage and was partially consumed by fire. It was cut by recovery personnel. The vertical stabilizer and rudder remained attached to the empennage. The lower forward section of the vertical stabilizer was partially consumed by fire. The top approximate 2 feet of the rudder was impact-damaged. Both left and right horizontal stabilizers and left elevator were impact-damaged and the outboard sections were separated and located along the debris path. The right elevator remained attached to the empennage, was impact-damaged, and bent aft.

The left engine was examined and crankshaft continuity was confirmed. Holes were drilled into the engine case and there was no evidence of heat distress or mechanical disconnects. The No. 2 top and bottom, and No. 6 bottom spark plugs were not located. The No. 5 top spark plug exhibited corrosion. All other spark plugs exhibited "worn out-normal" wear when compared to the Champion Check-a-plug Chart. The cylinders were examined with a borescope, and carbon deposits were noted on the tops of the pistons. The turbocharger was impact-separated from the engine and the compressor shroud was removed. No scoring was noted on the housing; however, the compressor blades were bent opposite the direction of rotation. Both magnetos would not rotate by hand as a result of thermal damage.

The left propeller hub remained attached to the crankshaft flange. The three propeller blades of the left engine were impact-separated and located along the debris path. The blades were lettered A, B, and C, for descriptive purposes. Blade A was bent aft in a smooth arc, exhibited torsional twisting, leading edge gouging, and blade tip deformation and curling. Blade B was bent forward midspan, exhibited leading edge gouging, and torsional twisting. Blade C was bent and curled aft, exhibited trailing edge s-bending, torsional twisting, leading edge damage, and about 8 inches of the blade was torn from the tip.

The right engine was examined and the crankshaft would not rotate when trying to move the propeller by hand. Holes were drilled in the top section of the case, inline with the rotation plane of the connecting rods. A borescope was used to examine the internal section of the engine. Crankshaft continuity was confirmed and there were no anomalies noted inside the engine. The right engine spark plugs were removed and exhibited normal wear when compared to the Champion Check-a-plug Chart. The cylinders were examined with a borescope and carbon deposits were noted on the tops of the pistons. The Nos. 1, 2, and 4 cylinders were impact-damaged. No evidence of foreign object injestion or detonation was noted in the engine. The valves were intact. The left and right magneto of the right engine was consumed by postimpact fire. The turbocharger compressor housing exhibited rotational scoring. The turbocharger exhaust clamps were all secure. The turbocharger waste gate was impact-separated and the butterfly could be operated by hand. No anomalies were noted with the right engine that would have precluded normal operation prior to the accident.

The right propeller remained attached to the crankshaft flange. The blades remained secure in the propeller hub. They were lettered for descriptive purposes. Blade A was free to rotated in the hub socket. It exhibited leading edge damage and was bent aft about 80°. Blade B rotated within the hub socket. The blade exhibited trailing edge S-bending, torsional twisting, and leading edge damage. About 6 inches of the tip of blade B was separated and not located. Blade C rotated within the hub socket. The blade was bent slightly and no other damage was noted.

Two cabin heaters that were located in the wreckage were retained for further examination.

No comments: