Saturday, November 9, 2019

Controlled Flight into Terrain: Piper PA-28-140, N9549W; fatal accident occurred September 29, 2017 in Brinnon, Jefferson County, Washington

Lance T. Aikins
Lance first worked as a pilot in the United States Navy and then as a Captain with United Airlines for 34 years, before retiring in 2013.
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The National Transportation Safety Board traveled to the scene of this accident.

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; Renton, Washington
Lycoming Engines; Williamsport, Pennsylvania
Piper Aircraft; Vero Beach, Florida
NTSB-Editor; Federal Way, Washington
 
Aviation Accident Factual Report - National Transportation Safety Board: https://app.ntsb.gov/pdf


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

https://registry.faa.gov/N9549W

Location: Brinnon, WA
Accident Number: WPR17FA215
Date & Time: 09/29/2017, 2213 PDT
Registration: N9549W
Aircraft: PIPER PA 28-140
Aircraft Damage: Destroyed
Defining Event: Controlled flight into terr/obj (CFIT)
Injuries:1 Fatal, 1 Serious 
Flight Conducted Under: Part 91: General Aviation - Instructional 

On September 29, 2017, about 2213 Pacific daylight time, a Piper PA-28-140, N9549W, was destroyed when it impacted trees and terrain near Brinnon, Washington (WA) during a night cross-country flight. The student pilot was seriously injured, and the flight instructor was fatally injured. The airplane was owned and operated by the Shelton Flight flying club as a Title 14 Code of Federal Regulations Part 91 instructional flight. Night visual meteorological conditions prevailed in the vicinity of the accident site about the time of the accident. The airplane had departed Jefferson County International Airport (0S9), Port Townsend, Washington, and was destined for its base and origination point of Sanderson Field Airport (SHN), Shelton, Washington when the accident occurred.

The pilot who flew the airplane immediately prior to the accident pilots stated that he flew the airplane for about an hour, and that the airplane operated normally, with no irregularities or problems. That pilot topped off the fuel tanks, and then turned the airplane over to the accident pilots about 2015.

The flight was the student pilot's first night flight, and was to consist of three legs, with full-stop landings at each of the two intermediate airports. The accident pilots did not file a flight plan for any of the legs but were in radio communication with air traffic control (ATC) for the first leg and the first part of the second leg.

The trip originated when the airplane departed SHN about 2050. The pilots requested and received visual flight rules (VFR) flight following services by ATC, with a stated destination of Snohomish County Airport (Paine Field, PAE), Everett, Washington. The airplane conducted a full stop landing at PAE about 2130, and then departed PAE for 0S9. About 2135, the pilot acknowledged a communications facility switch from PAE ATCT, but did not establish contact with the next facility; no further ATC communications to or from the airplane were recorded.

The airplane landed at 0S9 about 2156, and then departed on a direct course towards SHN. Although the pilots were not in communication with ATC during this leg, the flight was captured by Federal Aviation Administration (FAA) ground-based radar. The last radar return from the airplane was obtained at 2212:23 and depicted the airplane as slightly north of the accident location, and at an indicated radar altitude of 3,250 ft. About 2238, the student pilot telephoned 911 to summon help; this was the first notification that the airplane was missing or had crashed.

First responders reached the wreckage about 0500 the next morning, and the student pilot was airlifted from the scene by a US Navy helicopter a few hours later. Investigation and recovery personnel accessed the accident site 2 days after the accident. The wreckage was situated on a heavily wooded slope in the Olympic National Forest at an elevation about 3,075 ft mean sea level (msl).

Student Pilot Information

Certificate: Student
Age: 35, Male
Airplane Rating(s): None
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used:
Instrument Rating(s): None
Second Pilot Present: Yes
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 3 Without Waivers/Limitations
Last FAA Medical Exam: 09/01/2015
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time: 44 hours (Total, all aircraft), 43 hours (Total, this make and model)

Flight Instructor Information

Certificate: Airline Transport; Flight Instructor
Age: 69, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Right
Other Aircraft Rating(s):
Restraint Used:
Instrument Rating(s): Airplane
Second Pilot Present: Yes
Instructor Rating(s): Airplane Single-engine
Toxicology Performed: Yes
Medical Certification: Class 2 With Waivers/Limitations
Last FAA Medical Exam: 12/08/2016
Occupational Pilot: Yes
Last Flight Review or Equivalent:
Flight Time: (Estimated) 27000 hours (Total, all aircraft) 

Flight Instructor

The flight instructor was a retired airline pilot with multiple type ratings. Insurance application information indicated that he had a total flight experience of over 27,000 hours, including more than 2,000 hours in fixed-gear, single-engine airplanes. His most recent FAA second-class medical certificate was issued in December 2016. No records of either his flight instruction or PA-28 experience could be determined. No information was located to indicate that the flight instructor instructed at any flight training schools.

Student Pilot

The student pilot obtained his FAA third-class medical certificate in September 2015. He had logged 44.5 hours of flight time, not including the accident flight, in his personal logbook. His first flight was in December 2016, and all his flights except one were conducted in the accident airplane.

Aircraft and Owner/Operator Information

Aircraft Make: PIPER
Registration: N9549W
Model/Series: PA 28-140 140
Aircraft Category: Airplane
Year of Manufacture: 1967
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 28-22981
Landing Gear Type: Tricycle
Seats: 4
Date/Type of Last Inspection: 09/17/2017, Annual
Certified Max Gross Wt.:
Time Since Last Inspection: 34 Hours
Engines: 1 Reciprocating
Airframe Total Time: 5495 Hours at time of accident
Engine Manufacturer: LYCOMING
ELT: Installed
Engine Model/Series: O-320 SERIES
Registered Owner: On file
Rated Power: 0 hp
Operator: On file
Operating Certificate(s) Held: None

FAA information indicated that the airplane was manufactured in 1967, and was purchased by Shelton Flight in August 2015. Maintenance records indicated that the airplane was equipped with a Lycoming O-320-E2A series engine. The engine was overhauled and installed in the accident airplane in October 1994, at which time the airplane tachometer registered 4,791.0 hours. The most recent annual inspection was completed in September 2017, at which time the airplane tachometer registered 5,461.9 hours.

Meteorological Information and Flight Plan

Conditions at Accident Site: Unknown
Condition of Light: Night
Observation Facility, Elevation: 0S9, 110 ft msl
Distance from Accident Site: 18 Nautical Miles
Observation Time: 2155 PDT
Direction from Accident Site: 360°
Lowest Cloud Condition: Few / 3600 ft agl
Visibility:  9 Miles
Lowest Ceiling: Overcast / 4200 ft agl
Visibility (RVR):
Wind Speed/Gusts: 5 knots /
Turbulence Type Forecast/Actual: Unknown / Unknown
Wind Direction: 140°
Turbulence Severity Forecast/Actual: Unknown / Unknown
Altimeter Setting: 30.05 inches Hg
Temperature/Dew Point: 13°C / 11°C
Precipitation and Obscuration: Unknown Obscuration; Unknown Precipitation
Departure Point: Port Townsend, WA (0S9)
Type of Flight Plan Filed: None
Destination: Shelton, WA (SHN)
Type of Clearance: None
Departure Time: 2159 PDT
Type of Airspace: 

The SHN 2053 automated weather observation included winds from 250° at 6 knots, visibility 10 miles, clear skies, temperature 13° C, dew point 11° C, and an altimeter setting of 30.02 inches of mercury. At 2300, the approximate time that the flight would have returned to SHN, the skies remained clear, the wind speed had increased, and temperatures had decreased slightly.

Bremerton National Airport (PWT), Bremerton, Washington was located slightly east of the direct route between SHN and PAE. The PWT 2056 automated weather observation included calm winds, visibility 10 miles, clear skies, temperature 8° C, dew point 7° C, and an altimeter setting of 30.05 inches of mercury. The 2239 observation indicated scattered clouds at 1,800 ft and a broken ceiling at 6,000 ft.

The PAE 2053 automated weather observation included winds from 010° at 6 knots, visibility 10 miles, broken ceiling at 3,600 ft, overcast ceiling at 4,600 ft, temperature 13° C, dew point 8° C, and an altimeter setting of 30.05 inches of mercury. At 2153 the ceiling was overcast at 3,700 ft, and at 2253 the ceiling was overcast at 4,400 ft.

The 0S9 2035 automated weather observation included calm winds, visibility 10 miles, overcast ceiling at 4,000 ft, temperature 13° C, dew point 10° C, and an altimeter setting of 30.03 inches of mercury. By 2055 the ceiling had lowered to 3,800 ft, and by 2115 was at 3,600 ft. The 2135 observation included a broken ceiling at 3,600 ft and overcast ceiling at 4,100 ft. At 2155, which was about the time that the airplane was at 0S9, the observation included few clouds at 3,600 ft, and an overcast ceiling at 4,200 ft.

Wreckage and Impact Information

Crew Injuries: 1 Fatal, 1 Serious
Aircraft Damage: Destroyed
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Fatal, 1 Serious
Latitude, Longitude: 47.761111, -122.936389 

On-Scene

The accident location was about 1/4 mile south of the last radar return, and coincident with a direct track from 0S9 to SHN. Site elevation was about 3,075 ft. A partial swath of topped or damaged trees, presumed to have been made by the airplane, was observed. The swath had an approximate alignment of 110°, and a descent angle of about 30°. Most trees appeared to be Douglas Fir, with trunks up to about 18 inches in diameter, and heights of 75 ft or more.

The fuselage came to rest upright, on an approximate heading of 180°, at about a 30° airplane nose down angle; the aft end was supported by vegetation. The engine remained attached to the fuselage, and the propeller remained attached to the engine. The propeller and engine were partially embedded in the soil. The cockpit volume was compromised by crushing in the aft direction. Both fuel tanks were breached, and no fuel was observed at the time of the site examination. Both wings and the left horizontal stabilizer were fracture-separated from the fuselage. All aerodynamic and flight control surfaces appeared to be present at the accident site. The key remained in the ignition switch, which was set to the "BOTH" position. The cockpit fuel selector valve handle was found set to the right fuel tank. The tachometer registered 5,495.38 hours. The 121.5 Mhz emergency locator transmitter (ELT) was found still attached to its antenna cable, and the switch was found in the "AUTO" (armed) position. The wreckage was recovered to a secure facility for subsequent detailed examination.

Post-Recovery

All major portions of the airplane and all flight control surfaces were identified in the recovered wreckage. Flight control continuity was confirmed to the extent possible, given the condition of the wreckage. The flaps were in the retracted position at impact. The pitch trim components suggested that the stabilator was set to neutral to slightly airplane nose up at impact, but damage precluded positive determination. No pre-impact anomalies or mechanical deficiencies of the airframe were observed that would have precluded continued normal operation.

The engine was partially damaged by impact. No evidence of any pre-impact internal failures of the engine was observed. Both magnetos were intact and produced sparks at all towers when rotated by hand. All spark plugs displayed normal in-service appearance and condition. Engine valve and drive train continuity was confirmed by hand rotation of the engine. All cylinders appeared normal during borescope examination.

The carburetor was partially fractured but remained attached to the engine. Both the throttle and mixture controls remained attached to the carburetor. The carburetor was disassembled, and the metal floats exhibited hydraulic crushing on their outboard sides. The carburetor fuel inlet screen was found free of debris. The engine driven fuel pump produced pressure when operated by hand. The vacuum pump was disassembled, and the rotor and vanes were found intact. No pre-impact anomalies or mechanical deficiencies of the engine that would have precluded continued normal operation and flight were observed.

Additional Information

Student Pilot's Background and Schedule

The student pilot became interested in flying when he was teaching at the aforementioned skydiving school and asked the accident flight instructor to be his primary flight instructor. It was not determined what curriculum or program guidance, if any, the flight instructor used to instruct the student pilot. According to one of the skydiving school owners, the accident flight instructor and pilot frequently used tables at the skydiving facility to conduct their lessons and flight planning. According to the FAA Aviation Instructor Handbook, low-noise level, distraction-free rooms or spaces, particularly those equipped with instructional aids, positively contribute to learning quality.

The student was a service member in the U.S. Army at the time of the accident. He stated that he worked his regular Army shift of 0430 to 1200 each day from Tuesday, September 26 through Friday September 29 (the day of the accident). On Tuesday, he worked at the skydiving school from 1300 to 1700. On Wednesday, he met with the accident flight instructor to review the planned flight from 1300 to 1400, and then worked at the skydiving school from 1400 to 1700. On Thursday, he worked at the skydiving school from 1300 to 1700, and then played baseball from 1930 to 2230.

On the day of the accident, he worked his normal Army shift, and then napped at home from about 1300 to 1700. He arrived at SHN about 1950, and he and the flight instructor took possession of the airplane about 2015. One account by the student pilot stated that they reviewed the flight plan again in the airplane, but another account stated that he did not remember much before the accident.

Hemispheric Rule

Title 14 CFR paragraph 91.159 specifies the cruising altitudes to be used as a function of direction of flight, and this guidance is typically referred to as the "hemispheric rule." Hemispheric rule flight altitudes are predicated on magnetic course (MC), which is the true course adjusted for magnetic variation. For MC values from 0° (360°) to 179°, odd thousand-foot altitudes are to be used, and for MC values from 180° to 359°, even thousand-foot altitudes are to be used. For VFR flights, such as the accident flight, 500 ft are to be added to each altitude. The hemispheric rule only applies to flights at altitudes greater than 3,000 ft above ground level (agl).

Sectional Chart Maximum Elevation Figures

Sectional Aeronautical charts are divided into quadrants, which are areas bounded by ticked lines of 30 minutes of latitude and longitude. Each quadrant contains a Maximum Elevation Figure (MEF). According to the FAA's Aeronautical Chart User's Guide, the MEF represents the highest elevation within a quadrant, including terrain and other obstacles (towers, trees, etc.). MEF figures are rounded up to the nearest 100 ft value, and the last two digits of the number are not shown. Thus, a quadrant with an obstacle of 4,437 ft would have an MEF of 45.

Student Pilot's Flight Planning

Both the student and flight instructor owned multiple personal electronic devices (PEDs) that could be used for flight planning and as navigation aids during flight; these included three tablets (such as iPads with the Foreflight software), and one Appareo Stratus GPS device. The student stated that the flight instructor did not let him use any PEDs during flight; the flight instructor's intent was to prevent the student pilot from becoming reliant on those devices until he was proficient using more traditional, non-electronic means such as paper flight plan sheets, paper charts, ground reference points (landmarks), and ground tracks. The flight instructor would typically use his PEDs to monitor or augment the flight while they were airborne.

According to the student, he and the flight instructor had spoken a few weeks prior to the accident regarding the night flight. The originally discussed route of flight was SHN to PLU (Pierce County Airport - Thun Field, Puyallup, Washington) to PAE to 0S9 to SHN. The two met 2 days before the accident flight, in order to review the student's flight plan. That plan was for the route SHN-PAE-0S9-SHN; the student pilot forgot to include PLU in his flight planning. The flight plan was complete except for winds aloft information. The flight instructor reportedly told the student that the student pilot's proffered plan looked good. The investigation did not determine the medium (PED, paper, or both) that was used for this review, and did not determine what, if any, altitude discussions took place.

The student reported that he was familiar with the planned flight and had flown it or similar routes previously. According to his logbook, the student had flown to 0S9 three other times, including once from 0S9 to SHN, a week before the accident. The student pilot's specific route(s) for that airport pair were not known, but he stated that he "always" used an altitude of 5,500 ft so that the flight "would clear the mountains."

PEDs on Accident Flight

According to the student, as part of their preflight preparations at SHN that evening, the flight instructor used the student mobile phone as a 'hot-spot' for his Stratus device to enable them to access the most current weather information. For the flight itself, the flight instructor used his iPad mini with Foreflight to monitor the flight's progress. The Appareo Stratus communicates wirelessly with the iPad/Foreflight unit to present altitude, navigation, weather, and traffic information. "Geo-referencing" the term used to describe when such information is graphically depicted in relation to a map or aerial photo image was the primary display mode for the iPad/Foreflight combination and included terrain display and warning capability. Neither the iPad's specific operating/display mode nor any accident fight or flight track information was recorded by the iPad, but the Stratus did retain flight and flight track information, and that data was successfully recovered for the investigation.

Student Pilot's Accident Flight Plan

During a post-accident examination, a paper Seattle Sectional Aeronautical chart and a commercial preprinted tabular flight plan form with handwritten entries were found in the cockpit. Their condition (open/unfolded, torn, scuffed, and stained) was consistent with them being used by the pilot at the time of the accident. According to these documents, the student pilot had planned a flight for the route SHN-PAE-0S9-SHN.

The chart contained penciled lines depicting the direct track routes for the three flight legs. The tabular flight plan contained handwritten entries for the same route, but with three enroute landmarks inserted between SHN and PAE, and one landmark ("PWT") inserted between 0S9 and SHN. The entries included altitude, wind, track/course, distance, and time information for each of the trip legs. The form did not have a column for magnetic course.

Review of the checkpoint locations on the Sectional chart revealed that the checkpoints generally were abeam of, instead of directly on, the track lines between the origin and destination airports. Although most checkpoints were offset from the direct airport-to-airport tracks, the student-entered track/course information on the tabular form were of a constant value for each origin-destination airport pair. In other words, the student's tabular planned flight was a series of direct airport-to-airport legs (SHN-PAE-0S9-SHN) that were the same as the tracks drawn on the Sectional chart, and did not include any track/course information to or from any of the checkpoints.

The elevation of 0S9 was 110 ft, and the elevation of SHN was 272 ft. The track line for the last planned (and accident) leg direct from 0S9 to SHN that the student pilot had drawn on the Sectional chart crossed a region of mountainous terrain. A charted peak of 3,440 ft was directly on that track line, and charted peaks of over 4,000 ft were about 5 miles to the west of that track line. The Maximum Elevation Figure (MEF) for that quadrant was 4,800 ft. The accident location was on the track line from 0S9 to SHN, less than 1 mile before the 3,440 ft peak.

Student Pilot's Planned Flight Altitudes

As part of the effort to determine the student pilot's altitude selection methodology, some of his entries into his flight-planning form were compared to NTSB-generated values for the same trip legs.( See Table located in Docket)

During a post-accident interview, the student pilot did not recall when he entered the altitudes on his flight plan form. Most of the underlying terrain on the student pilot's planned legs had elevations less than 500 ft, meaning that generally, the 3,500 ft altitude would have put the airplane above 3,000 ft agl, and that the flight would be required to comply with the hemispheric rule.

Aside from circumnavigating the globe, it is geometrically impossible to conduct any flight at a constant altitude above 3,000 ft agl that returns to the airport of origin and also complies with the hemispheric rule. The student pilot had entered the same 3,500 ft altitude for all three of the trip legs.

Recovered Stratus Data

An Appareo Stratus PRX V2 device that belonged to the flight instructor was found in the wreckage. The device is a self-contained battery-powered unit with an internal Attitude and Heading Reference System (AHRS), GPS/WAAS receiver and Automatic Dependent Surveillance - Broadcast (ADS-B) receiver. The device communicates wirelessly with compatible devices, such as the flight instructor's iPad, to display all acquired information. In addition, the device records GPS position and AHRS information internally in its non-volatile memory at approximately 5 data records per second (5 Hz). The device was sent to the NTSB Vehicle Recorders Laboratory in Washington D.C, for a successful download of data from all three legs of the accident flight.

The following flight event timeline was developed from the recovered Stratus data.

2035:43 Status powered ON
2044:04 Begin taxi SHN
2045:31 Arrive run up area SHN
2050:10 Exit run up area SHN
2050:55 Start T/O roll SHN 23. ATC flight following for this leg
2128:20 Touchdown PAE runway 34L
2129:56 Stop PAE
2133:29 Start T/O roll PAE runway 34L. No ATC flight following this leg
2153:17 Touchdown 0S9 runway 9
2154:39 Stop 0S9
2158:25 Take 0S9 runway 27
2158:46 Start T/O roll 0S9 runway 27. No ATC contact for this leg
2212:48 Last data point. Accident

The data indicated that for the last leg of the flight, the airplane departed from 0S9 via runway 27 about 2159, began a left turn of about 160° to the southeast, then turned to a southerly course directly toward SHN. About 6 minutes after takeoff, the airplane stopped its climb at about 3,500 ft, but exhibited several altitude excursions of about 500 ft over the next 3 minutes. The airplane leveled off about 2208 at an altitude about 3,300 ft, still proceeding approximately directly towards SHN.

The last minute of recorded data consisted of two altitude excursions, with a net overall altitude decrease of about 200 ft. The final data point had a time tag of 2212:48, and a GPS altitude of 3,094 ft.

Stratus-derived groundspeeds recovered from the device were consistent with the published performance of the airplane. Refer to the public docket for this accident for detailed information.

Flight Instructor Responsibilities

Title 14 CFR paragraph 91.3 states that the pilot-in-command (PIC) of an aircraft is directly responsible for, and is the final authority as to, the operation of that aircraft." Title 14 CFR paragraph 91.103 states that "Each pilot in command shall, before beginning a flight, become familiar with all available information concerning that flight."

Controlled Flight into Terrain (CFIT) Accidents

The FAA states that controlled flight into terrain (CFIT) "occurs when an airworthy aircraft is flown, under the control of a qualified pilot, into terrain … with inadequate awareness on the part of the pilot of the impending collision." In April 2003, the FAA published Advisory Circular (AC) 61-134, "General Aviation Controlled Flight Into Terrain Awareness." The AC highlights the inherent risk that CFIT poses for general aviation pilots.

The AC defined "situational awareness" as the pilot's knowledge "of what is happening around the aircraft at all times in both the vertical and horizontal planes. This includes the ability to project the near-term status and position of the aircraft in relation to other aircraft, terrain, and other potential hazards."

The AC stated that, "in visual meteorological conditions, the pilot in command (PIC) is responsible for terrain and obstacle clearance (See and Avoid)…" and identified several CFIT risks, including:

Loss of situational awareness
Breakdown in good aeronautical decision making
Failure to comply with appropriate regulations
Failure to comply with minimum safe altitudes
The AC also cited excerpts from the FAA Aeronautical Information Manual (AIM), which listed frequent pilot-involved causal factors for general aviation accidents, and stated that many of those same factors applied to CFIT accidents. These factors included:

Inadequate preflight preparation and/or planning
Failure to see and avoid objects or obstructions
Improper in-flight decisions or planning
The AC further stated that:

"VFR flight operations may be conducted at night in mountainous terrain with the application of sound judgment and common sense. Proper pre-flight planning, giving ample consideration to winds and weather, knowledge of the terrain and pilot experience in mountain flying are prerequisites for safety of flight. Continuous visual contact with the surface and obstructions is a major concern and flight operations under an overcast or in the vicinity of clouds should be approached with extreme caution."

2 comments:

Anonymous said...

RIP to the instructor. I'm at a loss for words...

Anonymous said...

Instructor rule #1: The student is always and unintentionally trying to kill you. Rule #2, never forget rule #1.