Friday, January 18, 2019

Loss of Control in Flight: Piper PA-23-250 Aztec E, N14372; fatal accident occurred January 17, 2019 near Bowers Field Airport (KELN), Ellensburg, Kittitas County, Washington



Aviation Accident Final Report - National Transportation Safety Board 

The National Transportation Safety Board did not travel to the scene of this accident.

Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Spokane, Washington
Lycoming Engines
Piper Aircraft Inc

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


Location: Ellensburg, Washington 
Accident Number: WPR19LA066
Date & Time: January 16, 2019, 16:45 Local 
Registration: N14372
Aircraft: Piper PA23 
Aircraft Damage: Destroyed
Defining Event: Loss of control in flight 
Injuries: 1 Fatal
Flight Conducted Under: Part 91: General aviation - Personal

Analysis

The instrument rated pilot departed into marginal visual flight rules conditions between sunset and the end of civil twilight. Shortly after takeoff, he contacted air traffic control and stated that he was in the clouds at 5,000 ft mean sea level (msl) and requested an instrument landing system approach at the destination airport. The controller issued the airplane a discrete transponder code and asked the pilot if he wanted an IFR clearance; however, the pilot did not respond, and no further communications were received from the airplane. Radar data showed that the airplane entered a descending left turn before radar contact was lost about 3,050 ft msl. Witnesses and surveillance video indicated that the airplane descended out of the clouds in a steep, nose-low attitude and impacted terrain. The extensive fragmentation of the wreckage precluded a thorough examination of the airplane's flight controls, instruments, and other systems; however, no anomalies were noted during examination of the engines.

AIRMETs for instrument flight rules (IFR), mountain obscuration, turbulence, and icing conditions were all valid for the area of the accident site at the time of the accident. Both the departure and destination airports reported overcast ceilings below 2,000 ft above ground level about the time of the accident, with surface temperatures just above freezing. An atmospheric sounding indicated a high potential for light rime icing and moderate turbulence at 5,000 ft in the vicinity of the accident site, and radar imagery suggested clouds and potential light icing conditions. There was no evidence that the pilot obtained a weather briefing before departure.

Although impact damage precluded a thorough examination of the airplane's flight instruments, the restricted visibility and lighting conditions present at the time were conducive to the development of spatial disorientation, and the airplane's descending turn and high-energy impact are consistent with the known effects of spatial disorientation.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The instrument rated pilot’s loss of control due to spatial disorientation.

Findings

Personnel issues Spatial disorientation - Pilot
Environmental issues Below VFR minima - Effect on operation
Personnel issues Aircraft control - Pilot

Factual Information

HISTORY OF FLIGHT

On January 17, 2019, at 1645 Pacific standard time, a Piper PA23-250 airplane, N14372, was destroyed when it was involved in an accident near Ellensburg, Washington. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight. The flight originated from Bowers Field Airport (ELN), Ellensburg, Washington, about 1639, and was destined for McAllister Field Airport (YKM), Yakima, Washington, located about 28 nautical miles south. Radar data showed the airplane depart ELN to the northwest, make an approximate 180° left turn to the southeast, and then make a turn southwest before flying south. (See Figure 1). At 1644, the airplane had reached an altitude of 4,750 ft mean sea level (msl); shortly thereafter, it entered a descending left turn before radar data ended at 16:45:18 and 3,050 ft msl.

The instrument rated pilot contacted air traffic control after departure and stated that he was in the clouds at 5,000 ft, and he requested the instrument landing system RWY27 approach at YKM. The controller issued the pilot a discrete transponder code and asked the pilot if he was requesting an IFR clearance, but the pilot did not respond, and no further communications were received from the airplane. 

One witness at ELN reported that he helped the pilot clear snow from his airplane. The accident pilot indicated to him that he had hoped to conduct the flight in visual flight rules (VFR) conditions. The witness looked to the south and indicated that he could see the ridge to the south in some places but not in others and stated that the whole valley was covered by clouds "here and there." The accident pilot indicated that he would be contacting air traffic control for vectors around the weather.

A witness near the accident scene heard the airplane flying low and looked up to see it "diving down sideways." A second witness stated that he heard the engines "gunning" and he looked up and saw a two-engine airplane descending nose-low before it impacted the ground.

Video of the accident, which was taken from about 3 miles southeast of the accident site, was consistent with the witness observations. The video showed the airplane exiting clouds and remaining in an approximate 30° nose-low attitude and at a significant bank angle until it impacted the ground.

METEOROLOGICAL INFORMATION 

AIRMETs for instrument flight rules (IFR), mountain obscuration, turbulence, and icing conditions were all valid for the area of the accident site at the time of the accident. The station models on the surface analysis chart surrounding the accident site depicted calm to light winds of 5 knots or less, overcast clouds, temperatures in the low-to-mid 30s °F, and dew point temperatures in the low 30s to high 20s °F, or temperature-dew spreads of 4°F or less. Several stations west, northeast, and east of the accident site reported snow showers, and a station south of the accident site report visibility restricted in mist or fog.

The National Composite Radar Image depicted several areas of echoes associated with rain and snow showers extending over and north of the Ellensburg area and another area immediately south of the accident site. Very light intensity echoes were identified within 5 miles east and south of the accident site. The 1653 observation at YKM included 10 miles visibility, an overcast ceiling at 1,300 ft agl, temperature 3°C, and dew point 1°C.

The end of civil twilight occurred at 1717 on the day of the accident.

There was no evidence that the pilot obtained a weather briefing from an official, access-controlled source before departing on the flight.

WRECKAGE AND IMPACT INFORMATION

The wreckage debris path was orientated on a 213° magnetic heading and extended about 350 ft. Ground signatures and the orientation of the wreckage indicated that the airplane impacted the ground in a noselow, left-wing-low attitude. The wreckage was highly fragmented; impact damage precluded determination of flight control continuity and examination of the flight instruments.

Both engines were examined, and no anomalies were noted that would have precluded normal operation. The propellers were found separated from both engines. Both propeller assemblies displayed symmetry of impact damage. Chordwise scratches and leading-edge gouges were present on all blades.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was conducted on the pilot by the King County Medical Examiner, Seattle, Washington, and the cause of death was attributed to multiple blunt force injuries. Toxicology testing performed by the FAA Forensic Sciences Laboratory was negative for ethanol. Tamsulosin was detected in liver and muscle specimens. Tamsulosin, brand name Flomax, is a urinary retention medication used to treat an enlarged prostrate. The pilot had reported the use of Tamsulosin on his most recent flight physical and no restrictions to flight were issued because of it.

ADDITIONAL INFORMATION

The FAA Civil Aeromedical Institute publication, "Introduction to Aviation Physiology," defines spatial disorientation as a “loss of proper bearings; state of mental confusion as to position, location, or movement relative to the position of the earth.” Factors contributing to spatial disorientation include changes in acceleration, flight in IFR conditions, frequent transfer between visual flight rules and IFR conditions, and unperceived changes in aircraft attitude. 

The FAA’s Airplane Flying Handbook (FAA-H-8083-3B) describes some hazards associated with flying when the ground or horizon are obscured. The handbook states, in part, the following:

The vestibular sense (motion sensing by the inner ear) in particular can and will confuse the pilot.

Because of inertia, the sensory areas of the inner ear cannot detect slight changes in airplane attitude, nor can they accurately sense attitude changes that occur at a uniform rate over a period of time. On the other hand, false sensations are often generated, leading the pilot to believe the attitude of the airplane has changed when, in fact, it has not. These false sensations result in the pilot experiencing spatial disorientation.

History of Flight

Enroute-cruise Loss of control in flight (Defining event)
Uncontrolled descent Collision with terr/obj (non-CFIT)

Pilot Information

Certificate: Commercial 
Age: 75,Male
Airplane Rating(s): Single-engine land; Multi-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 2 With waivers/limitations 
Last FAA Medical Exam: February 20, 2017
Occupational Pilot: No 
Last Flight Review or Equivalent:
Flight Time: 1935 hours (Total, all aircraft), 4 hours (Last 90 days, all aircraft)

Aircraft and Owner/Operator Information

Aircraft Make: Piper
Registration: N14372
Model/Series: PA23 250
Aircraft Category: Airplane
Year of Manufacture: 1972 
Amateur Built: No
Airworthiness Certificate: Normal 
Serial Number: 27-7304961
Landing Gear Type: Retractable - Tricycle
Seats: 6
Date/Type of Last Inspection: November 6, 2018 
Annual Certified Max Gross Wt.:
Time Since Last Inspection: 
Engines: 2 Reciprocating
Airframe Total Time: 4795.5 Hrs as of last inspection
Engine Manufacturer: Lycoming
ELT: 
Engine Model/Series: TIO-540
Registered Owner: 
Rated Power:
Operator: On file 
Operating Certificate(s) Held: None

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual (VMC)
Condition of Light: Dusk
Observation Facility, Elevation: KELN 
Distance from Accident Site:
Observation Time: 00:53 Local 
Direction from Accident Site:
Lowest Cloud Condition: 
Visibility: 4 miles
Lowest Ceiling: Overcast / 1500 ft AGL 
Visibility (RVR):
Wind Speed/Gusts: 4 knots / 
Turbulence Type Forecast/Actual:  /
Wind Direction: 140° 
Turbulence Severity Forecast/Actual:  /
Altimeter Setting: 29.7 inches Hg 
Temperature/Dew Point: 2°C / 0°C
Precipitation and Obscuration: Moderate - None - Mist
Departure Point: Ellensburg, WA (KELN)
Type of Flight Plan Filed: None
Destination: Yakima, WA (YKM) 
Type of Clearance: None
Departure Time: 16:31 Local
Type of Airspace: Class G

Airport

Runway Surface Type:
Airport Elevation: 
Runway Surface Condition:
Runway Used: 
IFR Approach: None
Runway Length/Width:
VFR Approach/Landing: None

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries:
Aircraft Fire: None
Ground Injuries: Aircraft
Explosion: None
Total Injuries: 1 Fatal
Latitude, Longitude: 46.947223,-120.512779(est)

Location: Ellensburg, WA
Accident Number: WPR19LA066
Date & Time: 01/17/2019, 1645 PST
Registration: N14372
Aircraft: Piper PA23
Injuries: 1 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal 

On January 17, 2019, about 1645 Pacific standard time, a Piper PA23-250 airplane, N14372, impacted the ground near Ellensburg, Washington. The commercial pilot was fatally injured, and the airplane was destroyed. The airplane was registered to and operated by the pilot as a Title 14 Code of Federal Regulations Part 91 personal flight. Visual meteorological conditions existed at the accident site about the time of the accident, and no flight plan had been filed. The flight originated from Bowers Field Airport (ELN), Ellensburg, Washington about 1631 and was destined for McAllister Field Airport (YKM), Yakima, Washington.

One witness who was about 2,300 ft northwest of the accident site reported that, he heard a low flying airplane which caused him to look up. He observed the airplane about 200-300 ft above the ground, "diving down sideways." He heard a loud bang and drove towards the wreckage.

Another witness located about 200 ft southeast of the accident site reported seeing the airplane about 300 ft above the ground and heard the engines "gunning." He observed the airplane impact the ground about 45° angle, right wing low.

The airplane impacted flat terrain. The wreckage debris path was orientated on a magnetic heading about 213° and was about 350 ft from the first piece of identified wreckage to the last piece of identified wreckage.

The wreckage was recovered and transported to a secure facility for further examination. 

Aircraft and Owner/Operator Information

Aircraft Make: Piper
Registration: N14372
Model/Series: PA23 250
Aircraft Category: Airplane
Amateur Built: No
Operator: On file
Operating Certificate(s) Held: None

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Dusk
Observation Facility, Elevation: KELN
Observation Time: 0053 UTC
Distance from Accident Site:
Temperature/Dew Point: 2°C / 0°C
Lowest Cloud Condition:
Wind Speed/Gusts, Direction: 4 knots / , 140°
Lowest Ceiling: Overcast / 1500 ft agl
Visibility:  4 Miles
Altimeter Setting: 29.71 inches Hg
Type of Flight Plan Filed: None
Departure Point: Ellensburg, WA (KELN)
Destination: Yakima, WA (YKM)

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Fatal
Latitude, Longitude:  46.947222, -120.512778 (est)

Dr. Frank Smith 

A pilot who died in a small plane crash two miles south of Ellensburg on Thursday was a surgeon at Kittitas Valley Healthcare who lived in the lower Yakima Valley.

Dr. Frank L. Smith, 75, of Wapato was the only person on board the Piper PA-23-250 Aztec E when it crashed.

Smith grew up in the San Fernando Valley in California and moved to Toppenish in 2001 to work at the Yakima Valley Farm Workers Clinic, and bought a home and orchard in Wapato, according to a biography on Kittitas Valley Healthcare website. He went to work at KVH in Ellensburg in 2010.

“Frank was a gifted surgeon, but moreover a gracious and gentle man,” Dr. Kevin Martin, KVH Chief Medical Officer, said in a statement. “Over and over I’ve heard people say that you always knew where you stood with Frank, and that he ended every conversation with ‘I love you.’ We all felt we stood in that warm heart. He leaves us better for that and we can only hope he knew he was just as loved.”

Smith was a graduate of Harvard Medical School and did his residency at the Peter Bent Brigham Hospital (now Brigham and Women’s Hospital) in Boston. He was a civil rights activist in college, participated in the march from Selma and the March on Washington in 1963, and served in the U.S. Air Force, according to the biography.

Investigators believe Smith was on his way to Yakima when the plane crashed, according to a news release from the sheriff’s office.

A farmer reported the downed aircraft in his field at 5 p.m. Thursday. The cause of the crash is under investigation.

The Sheriff’s Office said Smith appropriately communicated his take-off and direction from Bowers Field in Ellensburg a few minutes before the crash.

Original article can be found here ➤ https://www.yakimaherald.com

2 comments:

  1. 1972 PIPER PA-23-250, Fixed wing multi engine, (6 seats / 2 engines), Airworthiness Class Standard/Normal, Serial Number27-7304961, Engines LYCOMING TI0-540 (Reciprocating)
    Weight Less than 12,500 lbs.

    When operating these types of aircraft, one must know:

    https://www.youtube.com/watch?v=L_KGu2CFUU4

    Thank you!

    ReplyDelete