Saturday, July 10, 2021

Loss of Control in Flight: Piper PA-24-180 Comanche, N5840P; fatal accident occurred July 11, 2019 near Ketchikan International Airport (PAKT), Alaska

Michael Patrick Nash

Michael Patrick Nash

Aviation Accident Final Report - National Transportation Safety Board

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

Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Juneau, Alaska
Piper Aircraft
Lycoming Engines

Investigation Docket - National Transportation Safety Board:

Law Offices Of Michael P. Nash, P.C.

Location: Ketchikan, Alaska 
Accident Number: ANC19FA033
Date & Time: July 11, 2019, 14:19 Local
Registration: N5840P
Aircraft: Piper PA 24-180 
Aircraft Damage: Substantial
Defining Event: Loss of control in flight
Injuries: 1 Fatal
Flight Conducted Under: Part 91: General aviation - Personal

On July 11, 2019, about 1419 Alaska daylight time, a Piper PA-24-180 airplane, N5840P, sustained substantial damage when it was involved in an accident near Ketchikan, Alaska. The airline transport pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight.

The pilot departed Friday Harbor Airport (FHR), Friday Harbor, Washington, about 1010 and was destined for Wrangell Airport (WRG), Wrangell, Alaska. The pilot flew this route often and intended to stop at Ketchikan International Airport (KTN) to purchase fuel before continuing on to WRG. On the morning of the flight, the pilot told his spouse that the forecast weather for KTN was, "not so good," and he intended to fly around KTN and continue to WRG if the weather did not improve.

GPS data revealed that the airplane flew a direct route to the KTN terminal area. According to Federal Aviation Administration (FAA) Ketchikan Flight Service Station (FSS) radio transmissions, about 1412, the pilot called KTN FSS 10 miles southeast of KTN with the current weather information for runway 11. About 5 minutes later, the flight crew of an inbound Boeing 737 contacted KTN FSS with intentions to enter a left downwind for KTN runway 11. The accident pilot then reported that he "was hung up" and could not enter a right downwind but would wait for traffic to clear prior to entering a left downwind. There were no further communications from the pilot. Immediately after the pilot’s last radio transmission, the airplane turned left from a heading of about 320° to the southwest. It descended from 775 ft mean sea level (msl), about 500 ft above ground level (agl), to 447 ft msl within 10 seconds (about 1,970 ft/min descent rate) while accelerating from 99 knots to over 111 knots. The last data point was at 1418:18 about 100 ft agl. (see Figures 1 and 2.) 

Pilot Information

Certificate: Airline transport; Commercial; Flight instructor
Age: 68, Male
Airplane Rating(s): Single-engine land; Single-engine sea; Multi-engine land
Seat Occupied: Left
Other Aircraft Rating(s): None 
Restraint Used: 4-point
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): Airplane single-engine; Instrument airplane
Toxicology Performed: Yes
Medical Certification: None 
Last FAA Medical Exam: June 4, 2019
Occupational Pilot: No 
Last Flight Review or Equivalent:
Flight Time: (Estimated) 12580 hours (Total, all aircraft), 400 hours (Total, this make and model)

The pilot’s logbook was not located. The pilot’s spouse stated that he used to fly commercially for various operators. She also stated that he flew his airplane often as part of his law business, but rarely in instrument conditions. She stated that she had not witnessed him conducting an actual instrument flight in many years.

Aircraft and Owner/Operator Information

Aircraft Make: Piper
Registration: N5840P
Model/Series: PA 24-180 Undesignated
Aircraft Category: Airplane
Year of Manufacture: 1959
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 24-921
Landing Gear Type: Tricycle
Seats: 4
Date/Type of Last Inspection: July 10, 2019 Annual
Certified Max Gross Wt.: 2550 lbs
Time Since Last Inspection: 4.1 Hrs 
Engines: 1 Reciprocating
Airframe Total Time: 4724.3 Hrs at time of accident
Engine Manufacturer: Lycoming
ELT: C91 installed, not activated
Engine Model/Series: O-360-A1A
Registered Owner: 
Rated Power: 180 Horsepower
Operator: On file
Operating Certificate(s) Held: None

Meteorological Information and Flight Plan

Conditions at Accident Site: Unknown
Condition of Light: Day
Observation Facility, Elevation: PAKT,96 ft msl
Distance from Accident Site: 4 Nautical Miles
Observation Time: 21:53 Local
Direction from Accident Site: 322°
Lowest Cloud Condition: Scattered / 900 ft AGL
Visibility: 10 miles
Lowest Ceiling: Broken / 1400 ft AGL
Visibility (RVR):
Wind Speed/Gusts: 13 knots / 
Turbulence Type Forecast/Actual:  /
Wind Direction: 110° 
Turbulence Severity Forecast/Actual:  /
Altimeter Setting: 30.09 inches Hg
Temperature/Dew Point: 17°C / 16°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Friday Harbor, WA (FHR)
Type of Flight Plan Filed: VFR
Destination: Ketchikan, AK (KTN)
Type of Clearance: None
Departure Time: 10:10 Local 
Type of Airspace: Class E

The terminal forecast for PAKT issued at 0923 and current at the time of departure, expected marginal visual flight rules (MVFR) conditions to prevail with visibility greater than 6 miles, rain showers in the vicinity, and cloud ceiling overcast at 2,500 ft agl. An amended forecast was issued two hours into the flight and predicted temporary instrument flight rules (IFR) conditions from 1200 through 1600 of 1.5 statute miles (sm) visibility in light rain showers and mist, with a ceiling broken at 1,000 ft agl, and overcast clouds at 2,000 ft agl.

The Area Forecast for southeast Alaska was issued at 0914 and was available before departure. The forecast indicated that southeast Alaska from PAKT and south expected occasional ceilings below 1,000 ft agl with isolated visibilities below 3 miles in mist and included an AIRMET for IFR conditions and mountain obscuration over the region.

The PAKT automated flight information that the pilot received before the approach indicated marginal VFR weather with 10 sm visibility, scattered clouds at 900 ft agl, broken ceiling at 1,400 ft agl, and an overcast layer at 3,500 ft agl.

FAA weather cameras at PAKT captured images of the accident area around the time of the accident. The southeast camera view at 1410 and 1420 (1 minute after the accident) revealed that the visibility in that sector was less than 2.5 sm and low clouds obscured the hillside accident site. The south camera images from 1412 and 1422 also showed diminished visibility and obscuration of terrain. (see Figures 3 and 4.)

A search of the FAA Automated Flight Service Station (AFSS) contract provider, Leidos, indicated that the pilot filed a VFR flight plan at 0940. The estimated time of departure was 1000 with an estimated time enroute of 4 hours 30, total fuel on board 6:30, and a planned cruising altitude of 3,500 ft. When asked if the pilot wanted an update of the adverse conditions, the pilot indicated “I think we’re good to go” and the call terminated. The pilot did not request a weather briefing.

Third-party weather vendor ForeFlight indicated that the pilot did have an account but did not request any specific weather briefings or review any static weather imagery prior to the flight. The pilot viewed route airports prior to the flight, which could have included airport weather information, but ForeFlight did not have a record of what the pilot viewed on each airport’s page. It is therefore unknown what weather information the pilot viewed prior to the flight. 

Airport Information

Airport: Ketchikan Intl KTN
Runway Surface Type: Asphalt
Airport Elevation: 92 ft msl 
Runway Surface Condition: Dry
Runway Used: 11
IFR Approach: None
Runway Length/Width: 7500 ft / 150 ft 
VFR Approach/Landing: Traffic pattern

14 CFR Part 93 special air traffic rules for KTN were in effect at the time of the accident. The procedures required that VFR aircraft establish two-way communication with KTN FSS for the purpose of receiving traffic advisories.

Wreckage and Impact Information

Crew Injuries: 1 Fatal 
Aircraft Damage: Substantial
Passenger Injuries:
Aircraft Fire: None
Ground Injuries: 
Aircraft Explosion: None
Total Injuries: 1 Fatal
Latitude, Longitude: 55.30107,-131.65202(est)

The wreckage came to rest on the northwest side of Judy Hill at an average elevation of 380 ft in lightly forested terrain. All major components were located at the accident site. The debris path extended about 300 ft on a heading of 193°. The debris field consisted of long, deep ground scars, wing and empennage sections, and terminated at the inverted main fuselage, engine, and inboard portions of the wings. The wing and empennage separations exhibited rearward deformation and some corresponding tree impact indentations. Propeller cuts were observed on two broken tree sections.

Flight control continuity was established from the cockpit control cable ends to the stabilator, rudder and left and right ailerons, with the exception of the right rudder cable end at the rudder horn attachment, which was not located. The flaps were in the retracted position and the control cables and bellcrank were continuous. Various fractures in the control rod ends and bellcranks exhibited dull, dimpled surfaces and deformation consistent with overload failure. Numerous control cable skin tears were evident in the empennage, indicative of flight control connectivity at the time of impact.

The fuel selector was observed in the “Right Tank” and “To Engine” position. The right fuel tank cap was secure in place and the right fuel tank contained 15 gallons. The left fuel tank was breached due to wing crush damage. 

The primary attitude indicator/gyro unit was removed and disassembled. The instrument components were intact with no evidence of gyro rotor or case scoring.

Engine crankshaft and valvetrain continuity was established. The magnetos produced spark at each terminal and spark plugs indicated normal wear. The carburetor sustained impact damage. No fuel system contamination was observed. The engine-driven vacuum pump drive vanes were intact with no foreign matter present.

Additional Information

Spatial Disorientation

The FAA Civil Aerospace Medical Institute's publication, "Introduction to Aviation Physiology," defines spatial disorientation as a loss of proper bearings or a 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 IMC, frequent transfer between VMC and IMC, and unperceived changes in aircraft attitude.

The FAA Airplane Flying Handbook describes some hazards associated with flying when the ground or horizon are obscured. The handbook states, in part:

The vestibular sense (motion sensing by the inner ear) in particular tends to confuse the pilot. Because of inertia, the sensory areas of the inner ear cannot detect slight changes in the attitude of the airplane, 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.

Medical and Pathological Information

The Alaska State Medical Examiner's Office, Anchorage, Alaska, performed an autopsy of the pilot and determined the cause of death to be multiple blunt force injuries. A focus of calcified atherosclerotic stenosis of no more than 30% was observed in the left main coronary artery.

The FAA Forensic Sciences Laboratory performed forensic toxicology that detected chlorpheniramine in a urine sample and 4 ng/mL in heart blood. Hemoglobin A1C was measured at 7.2% in heart blood. Vitreous and urine glucose test were normal.

Chlorpheniramine is a sedating antihistamine medication that is available over-the-counter in a variety of cold, allergy and sleep aid products. Its intended effects generally occur at blood levels ranging from 10 to 40 ng/mL.

The pilot reported high blood pressure and diabetes on his most recent medical certificate application. He was taking multiple medications to treat the conditions and none of those was considered impairing. He had previously been granted special issuance medical certification because of his diabetes. At his last medical examination the month before the accident, the pilot reported no changes in his medication or health concerns. The aviation medical examiner identified no issues and deferred issuance of a third-class medical certificate to the FAA. The prior special issuance expired June 30, 2019. The pilot did not have a valid medical certificate at the time of the accident.

Information from the pilot’s glucometer indicated that his blood sugar was tested multiple times during the flight, including 5 minutes before the accident. The measurements ranged from 107 to 157 mg/dL, which were in a normal range.

 N5840P flight track (red) and wreckage location.

Photograph of the main wreckage area.



  1. If you haven't seen Ketchikan airport, look at the whole picture and the setting. It's surrounded by hills and anything other than straight up the channel is going to be risky. Situational awareness was lost here and scud running wasn't an option with the overcast and ceiling. We lost a C170 this year that was doing the opposite run and put it into the Straits near Victoria BC after running out of fuel. Its a XC that demands respect and caution due to the relative lack of alternatives.

  2. No one is immune from complacency, no matter ratings or hours. When you don't fly to professional standards, you accept all the risks of PPL-only flying as well.