Wednesday, June 24, 2020

Loss of Control in Flight: Let L-23 Super Blanik, N317BA; fatal accident occurred June 09, 2018 in Moose, Teton County, Wyoming

Figure 2: Accident Site

Exemplar photograph of N317BA

Aerial view of the accident site 

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

Additional Participating Entities: 

Federal Aviation Administration / Flight Standards District Office; Salt Lake City, Utah
Air Accidents Investigation Institute; Letnany, FN
Blanik Aircraft CZ s.r.o.; Letnany, FN
Teton Aviation Center; Driggs, Idaho

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


https://registry.faa.gov/N317BA 


Location: Moose, WY
Accident Number: CEN18FA217
Date & Time: 06/09/2018, 1115 MDT
Registration: N317BA
Aircraft: LET L 23 SUPER BLANIK
Aircraft Damage: Destroyed
Defining Event: Loss of control in flight
Injuries: 2 Fatal
Flight Conducted Under:  Part 91: General Aviation - Business - Sightseeing 

On June 9, 2018, about 1115 mountain daylight time, a LET L-23 glider, N317BA, was destroyed when it was involved in an accident near Moose, Wyoming. The pilot and passenger sustained fatal injuries. The glider was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 sightseeing flight.

The glider was operated by Teton Aviation Center (TAC), based at Driggs-Reed Memorial Airport (DIJ), Driggs, Idaho. The accident flight was a sightseeing flight to view the Teton Range . The operator reported that a sightseeing flight was typically about 1 hour in duration; the first 30 minutes was conducted under tow before the glider released and spent the remaining 30 minutes gliding back to DIJ. The tour predominately flew over the Caribou-Targhee National Forest, encompassing both Idaho and Wyoming.

The tow pilot reported that he and the glider pilot discussed the planned route and briefed safe altitudes for the flight, and then completed the preflight duties for the glider together.

After departing from DIJ, the tow airplane and glider proceeded south and climbed to 11,000 ft mean sea level (msl) and turned west toward Darby Canyon. The aircraft arrived at the foothills of Darby Canyon at 11,500 ft msl and the tow pilot reported that "there wasn't much lift." They then flew east toward the boundary of Grand Teton National Park, gaining "a little lift" off the various ridgelines. The tow pilot reported that, prior to reaching the park boundary, they flew north, paralleling the Teton Range, and were "slowly climbing." About 3 miles west of the South Teton peak, at an altitude of 13,800 ft msl, the glider pilot released from tow at 1037. The tow pilot visually confirmed the release in his rearview mirror and returned to DIJ, where he landed about 1045.

The tow pilot reported that he maintained radio communication with the glider pilot throughout the tow and that they worked together to find lift to gain sufficient altitude for release. The tow pilot did not report any anomalies with the glider during the tow.

The passenger's cell phone was recovered from the accident site and a video recording of the accident flight was retrieved. The recording, taken from the front seat by the passenger, began when the glider was near the Teton Range during the flight, flying over Grand Teton National Park. After about 2 minutes, the footage showed Middle Teton in front of the glider and off to the left; the glider was nearly level with the top of Middle Teton. The pilot stated "this is not good.". The glider then banked slightly right parallel to the ridgeline of Middle Teton.

The last frame where the airspeed indicator was visible showed an indicated airspeed of about 42 kts. The top of the ridgeline was above the altitude of the glider. The glider then appeared to enter a steep descent. The pilot again stated "this is not good." The glider appeared to exit the steep descent as it passed by a cliff marking the end of the ridgeline. The glider then appeared to enter another steep descent. The pilot stated, "I'm in trouble." The glider returned to a neutral pitch attitude but appeared to be descending. The glider was traveling along the ridgeline between Middle Teton and South Teton. As the glider descended, it began a right turn pointing toward the ridgeline. In the last frame before the recording ended, the yaw string mounted in front of the passenger's windshield was hanging about 45° to the right.

When the flight did not return as expected, TAC personnel attempted to reach the glider pilot via radio. At 1220, the glider was reported overdue to the Federal Aviation Administration (FAA), and an alert notice was subsequently issued.

A National Park Service (NPS) search and rescue team consisting of NPS rangers from Jenny Lake Rescue, working in conjunction with Teton County (Wyoming) Search and Rescue, used cell phone data to determine the last known coordinates of the glider. The owner of TAC departed from DIJ about 1435 in a private helicopter and flew to the area of the last known coordinates, where he located the wreckage in steep mountainous terrain about 11,000 ft msl, between Middle Teton peak (12,809 ft msl) and South Teton peak (12,519 ft msl) near the frozen Icefloe Lake in Grand Teton National Park, as shown in Figure 1.

Figure 1: Accident Site Location 


Pilot Information


Certificate: Flight Instructor; Commercial
Age: 65, Female
Airplane Rating(s): Single-engine Land
Seat Occupied: Rear
Other Aircraft Rating(s): Glider
Restraint Used:
Instrument Rating(s): None
Second Pilot Present: No
Instructor Rating(s): Glider
Toxicology Performed: Yes
Medical Certification: Class 2 With Waivers/Limitations
Last FAA Medical Exam: 06/03/2014
Occupational Pilot:No 
Last Flight Review or Equivalent: 04/30/2017
Flight Time: (Estimated) 1200 hours (Total, all aircraft) 

The pilot previously held an FAA second class medical certificate, which expired on June 20, 2016. Glider operations under 14 CFR Part 91, including personal flights, flight instruction, and sightseeing tour flights, do not require the pilot to hold an FAA medical certificate.

TAC reported the pilot was hired in March 2001. Since the date of hire, she flew 650 hours of instruction in the glider and flew 559 sightseeing tour flights in the glider. The pilot's most recent recurrency flight was conducted on April 27, 2018.

In postaccident interviews, TAC personnel described the pilot as, "very safety conscious," "very by the book," "very cautious," and "always thorough." The pilot's husband reported that she never expressed any concerns about working at TAC and she "enjoyed taking passengers on flights and working with her coworkers." 

Aircraft and Owner/Operator Information


Aircraft Make: LET
Registration: N317BA
Model/Series: L 23 SUPER BLANIK NO SERIES
Aircraft Category: Glider
Year of Manufacture:1997 
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 978406
Landing Gear Type: Retractable - Tandem
Seats: 2
Date/Type of Last Inspection: 02/23/2018, Annual
Certified Max Gross Wt.: 1124 lbs
Time Since Last Inspection:
Engines:
Airframe Total Time: 3782.9 Hours as of last inspection
Engine Manufacturer:
ELT: Not installed
Engine Model/Series:
Registered Owner: Teton AvJet, LLC
Rated Power:
Operator: Teton AvJet, LLC
Operating Certificate(s) Held: None 

The LET L-23 Super Blaník Sailplane Flight Manual stated:


The LET L-23 Super Blaník sailplane is a cantilever, high-wing, two-seat glider of all-metal structure with fabric covered control surfaces. Both flight compartments are covered by a single-section canopy which may be emergency jettisoned in flight. Both cockpits are equipped with all sailplane flight control including flight and navigation instrument panels.

The operator kept the glider fully assembled. Review of weight and balance information revealed that, with the pilot and passenger onboard, the glider was within weight and balance limitations for the flight. Review of the glider's maintenance records revealed no evidence of uncorrected mechanical discrepancies. 

Meteorological Information and Flight Plan


Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KJAC, 6419 ft msl
Distance from Accident Site: 8 Nautical Miles
Observation Time: 1656 UTC
Direction from Accident Site: 153°
Lowest Cloud Condition: Clear
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: Calm /
Turbulence Type Forecast/Actual: Terrain-Induced / Terrain-Induced
Wind Direction:
Turbulence Severity Forecast/Actual: Moderate / Moderate
Altimeter Setting: 30.04 inches Hg
Temperature/Dew Point: 18°C / 7°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: DRIGGS, ID (DIJ)
Type of Flight Plan Filed: None
Destination: DRIGGS, ID (DIJ)
Type of Clearance: None
Departure Time: 0950 MDT
Type of Airspace: Class G

The National Weather Service (NWS) Storm Prediction Center's forecast upper air constant pressure charts for 0600 showed the conditions at about 10,000 ft and 18,000 ft msl.

The charts depicted a long wave trough over the western United States with southwesterly winds over Idaho and Wyoming; wind speeds increased with height with little change in direction. The front side of an upper level trough implies upper-level divergence and general rising motion of the area and the development of clouds and precipitation if adequate moisture is available. Upper level troughs also support surface fronts.

AIRMET Tango was current for moderate turbulence below 16,000 ft over a large portion of the central and southwestern United States. The accident site was located within the boundary of the advisory area.

High-Resolution Rapid Refresh numerical model data was plotted and indicated a lifted condensation level (LCL) about 3,200 ft agl. The profile below 10,000 ft was characterized as conditional unstable with a Lifted Index of -1. The sounding thermal structure did not support any strong thermal activity. The sounding profile indicated that the glider likely encountered southerly winds from 185° at 25 to 27 knots, with the potential for light turbulence at 12,700 ft msl. With this wind direction, no significant orographic lift would be generated on the western slopes of the Teton Mountain Range.

There was no record that the pilot obtained a preflight weather briefing from the FAA contract Automated Flight Service Station (AFSS) provider, Leidos, or from a third-party provider. It could not be determined what weather information the pilot may have reviewed before departure.

Wreckage and Impact Information


Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: 1 Fatal
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 2 Fatal
Latitude, Longitude: 43.724722, -110.819167 (est)

Photos provided by the NPS showed both wings and an impact crater located on a west-facing, snow and ice-covered saddle, which originated at South Teton Peak and extended to the northeast, culminating at Middle Teton peak. The photos showed the fuselage, empennage, and miscellaneous debris located near the base of the saddle by Icefloe Lake.

The wreckage was extracted via external load with an NPS-contracted helicopter to a secure location for a wreckage layout and examination. All major structural components of the glider were accounted for. Flight control continuity was established throughout the airframe, and no preimpact mechanical malfunctions or failures with the glider were noted.

Medical And Pathological Information


Teton Pathology, Jackson, Wyoming, conducted an autopsy of the pilot. The cause of the death was attributed to multiple blunt force injuries. The autopsy revealed no significant natural disease that could pose a hazard to flight safety.

The FAA's Forensic Sciences Laboratory performed toxicology tests on specimens from the pilot; testing was negative for ethanol and drugs. A test for carbon monoxide and cyanide was not performed. 

Organizational And Management Information


The 14 CFR Part 91 Letter of Authorization for Teton Aviation Center was managed by the FAA Salt Lake City Flight Standards District Office, Salt Lake City, Utah. FAA Letters of Authorization for sightseeing tour flights only include powered aircraft (such as airplanes and helicopters). Non-powered aircraft, such as gliders or balloons, are not included.

The TAC Standard Operating Procedures (SOP) discussed sightseeing tour flights and stated in part:

Teton Aviation Center scenic flights are operated under §119.1(e)(2) and a Letter of Authorization under 91.147, which authorize us to conduct non-stop scenic air tours within a 25 nautical mile radius of the Driggs airport (KDIJ). We do not have authorization to overfly Grand Teton National Park, and are required to remain at least ½ mile outside Park boundaries. Minimum altitude is 2000' AGL [above ground level] over mountainous terrain.

No TAC aircraft may be flown below 500' above ground (AGL) unless it is taking off or landing. Maneuvers require at least 2000'AGL unless otherwise specified on TAC maneuver summary sheets, or the FAA Practical Test Standard (PTS). Glider pilots are required to adhere to the minimum station altitudes.

Additional Information

Previous Flight


The day before the accident, the pilot flew with another passenger and provided a sightseeing tour flight. The passenger reported that the flight consisted of four passes on the backside of the Teton mountain range in the Grand Teton National Park, and provided various photos he took during the flight showing the proximity to terrain, as shown in Figure 3.


Figure 3: Aerial View of Terrain, captured the day before the accident flight 

During the flight, the pilot talked with the passenger about his lack of interest in roller coasters. The pilot asked the passenger what kind of tour flight he would like to receive. He reported that she jokingly asked if he wanted a "rock and roll flight." The passenger responded that he wanted the relaxing version of the tour flight. The passenger described the pilot as a "very competent" pilot who had "smooth flying skills." He reported the overall flight was "peaceful and enjoyable."


Kristine Ciesinski poses for a portrait for the Teton Valley Magazine at the Driggs Airport. Ciesinski, an international opera star, teacher and pilot, died June 9th, 2018 while piloting a glider that crashed over the Tetons. A passenger with her also died. He was David Ross, 65, of Salt Lake City.

David J. Ross

The son of a man who died in a 2018 scenic glider accident in Grand Teton National Park is suing Teton Aviation for wrongful death.

The complaint, filed in Teton County District Court on June 8th, claims Teton Aviation Center failed to properly service the glider David J. Ross was in when he died and claims the company hired and retained “careless and dangerous pilots.”

Ross, 65, of Salt Lake City, was on a scenic trip with pilot Kristine Ciesinski, 65, of Victor, Idaho, on June 9th, 2018, when the glider crashed between the Middle Teton and South Teton, above Icefloe Lake.

The pair left that day from Teton Aviation Center in Driggs, Idaho. Around noon they were reported overdue to the Teton Interagency Dispatch center.

The wreckage was found at 10,800 feet in rocky and steep terrain.

Ciesinski, a soprano opera singer and a commercial pilot, also died in the crash.

Ciesinski’s estate is also listed on the lawsuit as a defendant.

“Defendant Kristine F. Ciesinski had a duty to exercise reasonable care and obligation not to fly the glider in a negligent, unsafe, dangerous, reckless or careless manner,” the complaint states. “The acts and omissions of defendant Kristine F. Ciesinski, including but not limited to flying a glider in an unsafe, careless, or dangerous manner, including but not limited to being towed and released at an altitude that exceeded the certification and rating of the glider by the manufacturer, flying too close to the mountainous terrain, exercising poor judgment while operating the glider, and failing to operate the glider in a safe and prudent manner.”

The complaint claims negligence on the part of Teton Aviation, or Teton Avjet, caused the crash, the death of Ross and the “extreme fear, pain, and suffering in Mr. Ross prior to his death.”

In an accident report the National Transportation Safety Board states that it reviewed cellphone video on Ross’s phone that was recovered from the wreckage.

“After about two minutes the footage showed Middle Teton in front of the glider and off to the left; the flier was nearly level with the top of Middle Teton,” the report states. “The pilot stated, “this is not good.” The glider then banked slightly right parallel to the ridgeline of Middle Teton.”

In the recording Ciesinski be heard saying “I’m in trouble” shortly before the recording ends, according to the report.

In interviews after the accident Teton Aviation Center employees described Ciesinski as “very safety conscious, very by the book, very cautious and always thorough.”

Ciesinski was hired at Teton Aviation Center in 2001 and flew 650 hours and 559 sightseeing tours, the report stated.

The glider information was listed as a 1997 LET L 23 Super Blanik.

“The operator kept the glider fully assembled,” the report stated. “Review of weight and balance information revealed that, with the pilot and passenger onboard, the glider was within weight and balance limitations for the flight. Review of the glider’s maintenance records revealed no evidence of uncorrected mechanical discrepancies.”

Teton Aviation suspended glider flights after the accident and they have not been resumed, employees there confirmed on Tuesday. Efforts to reach manager Peter Kline were unsuccessful.

The amount in controversy listed on the complaint is $3 million.

https://www.jhnewsandguide.com



Kristine Ciesinski

2 comments:

  1. Flew 559 sightseeing tour flights in the glider, finding enough rising air to fly the intended profile. Then one time, it wasn't enough.

    ReplyDelete
  2. I would characterize this as a forced landing; not a "loss of control." Earlier comment is spot on. She didn't encounter enough rising air at just the wrong time and ran out of options.

    ReplyDelete