Aviation Accident Summaries

Aviation Accident Summary ERA11FA182

Allagash, ME, USA

Aircraft #1

CGPDO

DIAMOND DA-40

Analysis

On the day of the flight, the pilot called the London International Airport (YXU), London, Canada, Flight Service Station (FSS) to file a flight plan. When asked by the FSS if he wanted a weather briefing or Notices to Airmen (NOTAMs) the pilot declined. According to the FSS personnel, the pilot did not receive the vital weather information that called for icing along the route of flight. Two pilot reports were documented before the accident time with moderate icing conditions reported. According to the pilot-in-command (PIC), he and the pilot-rated passenger had reviewed the weather from computer sources. The PIC determined that an en route area of low pressure would have prevented them from reaching their final destination that day. The PIC noted that the low pressure area would be moving into their current area, Halifax, the following day, so he and the passenger decided to depart Halifax for Saint John, New Brunswick, where they would stay until the weather associated with the front had passed. The flight departed and reached a cruising altitude of 6,000 feet. During the flight, the passenger advised the PIC that ice had formed on the left wing, and the PIC observed the same on the right wing. The PIC described the accumulation as no thicker than a nickel at that point. The PIC requested a lower altitude, and a Montreal air traffic controller authorized a descent to 5,200 feet. The PIC told the controller that they were still experiencing icing and needed to descend to a lower altitude. During the descent, the PIC recalled that the airplane experienced the most ice he had ever seen in his life and that the canopy had completely frozen over. He described the ice as being as large as a house brick on the leading edge, extending back on the wing for 1 foot, and about 1 or 2 inches thick on the wing. The pilot observed that the airspeed was 84 knots and the airplane was buffeting in straight and level flight with full power. Ice continued to accumulate on the airplane, and the PIC advised the passenger to start looking for somewhere to land. The pilot estimated that they were about 1,000 feet above ground level while the airplane continued buffeting. The next thing that the PIC remembered was waking up in the airplane, next to the pilot-rated passenger, with no recollection of how long he was unconscious. Examination of the airplane revealed no evidence of a preimpact mechanical malfunction. Based on weather conditions, the airplane encountered severe icing conditions.

Factual Information

HISTORY OF FLIGHT On March 7, 2011, about 1345 eastern standard time, a Diamond DA-40, Canadian registration CGPDO, was substantially damaged when it impacted a wooded area in the vicinity of Allagash, Maine. The certificated commercial pilot received serious injuries and the private pilot-rated passenger was fatally injured. Instrument meteorological conditions prevailed, and an instrument flight rules flight plan (IFR) was filed for the flight from Halifax International Airport (CYHZ), Halifax, Nova Scotia, Canada, to Quebec Jean Lesage International Airport (CYQB), Quebec, Canada. The personal flight was conducted under the provisions of Part 6 Canadian Aviation Regulation (CAR) 640. According to the pilot–in–command (PIC), on the morning of the accident, he reviewed the weather with the pilot-rated passenger (PRP). He concluded that an en route area of low pressure prevented them from the flight to their final destination, Toronto Buttonville (CYKZ). The PIC made the decision to wait until noon to re-evaluate their options. By noon, he determined that the low pressure area was moving into the Halifax area the following day. The pilots decided to depart Halifax for Saint John, New Brunswick (CYSJ) where they would wait out the weather associated with the frontal passage. They felt this would expedite the return to CYKZ; versus waiting for the frontal passage through Halifax. The pilot called the London International Airport (YXU), London, Canada, Flight Service Station (FSS) to file his flight plan. When asked by the FSS if he wanted a weather briefing or Notice to Airmen (NOTAMS) the pilot declined. The flight departed IFR and reached a cruising altitude of 6,000 feet. The PIC stated that the weather in Halifax at departure was rainy with crosswinds. He recalled that they were given a clearance direct to Saint John VOR. The PIC stated that they monitored the weather during the flight and the weather radar depiction showed mostly areas of rain. He recalled that the weather was better than forecasted, and that they encountered rain again as they approached the Saint John VOR. The PRP questioned the PIC about continuing on to CYQB, as the Meteorological Aerodrome Report (METAR) and Terminal Area Forecast (TAF) looked good. The PIC reviewed the current METARs and TAFs for the area. Low ceilings and poor visibility in snow were reported. The PIC reported that the weather at CYQB appeared better, so they re-filed their flight plan with the Moncton Center to CYQB at 6,000 feet, using St. Georges, Quebec (CYSG) as their new alternate. While overflying the Saint John VOR, the pilots observed that the temperature was +6 degrees Celsius. The flight continued, within areas depicted on radar as rain. The multi-function display depicted a freezing level area at 6,000 feet agl straight ahead, and a zone further ahead indicating a 4,000 feet agl freezing level. During the flight, the PRP advised the PIC that there was a formation of ice on the left wing, and the PIC observed the same thing on the right wing. The PIC described the accumulation as no higher than a nickel. The PIC asked the PRP for the outside air temperature and was told that it now indicated +1 degree Celsius. They discussed the weather and agreed that the situation was not good, as they were in an area of weather that was not visible on the display and that the temperature had dropped to +1 degree Celsius. They discussed their options, and decided to descend to a lower altitude. The PIC requested a lower altitude, and Montreal air traffic control (ATC) authorized a lower altitude of 5,200 feet. The PIC indicated to ATC that they were experiencing icing and needed to be at a lower altitude. During the descent, the PIC recalled that he experienced the most ice he had ever seen in his life, and that the canopy had completely frozen over. The front of the canopy and the wings were covered in ice. He described the ice as being as large as a house brick on the leading edge, extending back on the wing for 1 foot, and was approximately 1 or 2 inches thick on the wing. As they leveled the aircraft at 4,000 feet, the airspeed immediately decreased. Full power was applied, and the PIC asked the PRP to advise him if the airspeed decreased below 80 knots. The airspeed was observed at 84 knots and buffeting was experienced in straight and level flight. Ice continued to accumulate on the airplane and the PIC advised the PRP to start looking for somewhere to land. The airplane continued buffeting and the pilot estimated that they were approximately 1,000 feet agl. The next thing that the PIC remembered was waking up in the airplane next to the passenger, with no recollection of how long he was unconscious. His feet were in the snow, there was no canopy on the airplane and the engine and panel were missing. He said he knew right away that the PRP was deceased. PERSONNEL INFORMATION The pilot, age 31, held a Canadian flight instructors pilot certificate for airplane single-engine and multi-engine land, and a first class Canadian airman medical certificate issued September 15, 2010, with no limitations. The pilot's logbook was not recovered for examination. According to Canadian authorities, the pilot reported a total of 3,000 hours flight time of which more than 1,500 hours was on the DA40. He flew approximately 20 hours in the last 90 days prior to the accident. He also held a Federal Aviation Administration commercial multi-engine certificate and an instrument rating. The PRP was the owner of the aircraft. He held a Canadian private pilot license with a visual flight rules over the top rating (VFROTT). He had approximately 400 hours total flight time. According to Canadian authorities, the flight was performed as a crew; workload was divided between both pilots similar to professional pilot duties. The PRP managed radio calls and monitored the outside temperature for most of the flight. AIRCRAFT INFORMATION The three-seat, low-wing, fixed-gear airplane, serial number 40.915, was manufactured in 2008. It was powered by a Lycoming IO-360-M1A, 180-horsepower engine and equipped with a MT-Propeller model D-94315, variable pitch wooden propeller. Review of copies of maintenance logbook records showed an annual inspection was completed on January 21, 2011, at a recorded Hobbs reading of 302 hours, and at an airframe total time of 299.7 hours. METEOROLOGICAL INFORMATION The closest unofficial surface observing station was Clayton Lake, Maine, located 17 miles east southeast of the accident site; reported winds were from 010 degrees at 7 knots gusting to 14 knots with a temperature and dew point of -7 degrees Celsius, and an altimeter setting of 29.75 inches of mercury. The closest official surface observing station with ceiling and weather information was Frenchville, Maine, located 72 miles east northeast from the accident site, which reported winds from 020 degrees at 18 knots gusting to 30 knots, 1 mile visibility, moderate freezing precipitation, and a broken ceiling at 900 feet AGL, a temperature of -7 degrees Celsius and a dew point of -9 degrees Celsius, and an altimeter setting of 29.77 inches of mercury. The Terminal Aerodrome Forecast (TAF) for the destination location of CYQB, as well as the closest reporting site to the accident site with a TAF, expected wind from 050° at 6 knots, visibility 1 mile in light snow, vertical visibility of 1,000 feet agl, with a temporary conditions between 1300 EST and 1600 EST of visibility 3 miles in light snow, overcast ceiling at 2,500 feet. The National Weather Service Area Forecast Discussion issued at 1249 EST discussed a band of freezing rain remaining stationary located across north central Maine due to a wedge of warm air aloft. This wedge of warm air aloft was expected to diminish into the afternoon. Snow continued to be expected across northwest Maine with the highest snow totals located across the Maine Highlands. Two pilot reports (PIREP) were documented before the accident time with moderate icing conditions reported across New Hampshire and Maine. Both of the aircraft that reported the moderate icing conditions had deicing/anti icing capability. WRECKAGE AND IMPACT INFORMATION Wreckage debris and broken tree limbs were scattered about 300 feet along an approximate 200-degree magnetic heading from a broken tree. The airplane came to rest in approximately 6 feet of snow. The nose and the engine were broken away from the fuselage and buried in the snow. The cockpit of the airplane was exposed and the canopy was broken away and located along the debris path. The right wing was attached to the fuselage and fragmented. The empennage was broken away from the fuselage and located buried in snow along the debris path. The left wing was broken away from the fuselage at the wing root and fragmented in the snow along the debris path. Examination of the recovered airframe and flight control system components revealed no evidence of preimpact mechanical malfunction. Examination of the engine revealed that it was separated from the fuselage with the firewall, with the engine mount attached. The propeller remained attached to the crankshaft; the spinner was attached to the propeller hub and crushed. All three wooded blades were shattered mid-span on the blades. An examination of the engine revealed that due to the external damage, an engine run could not be performed. During the engine examination, the crankshaft was rotated by hand and valve train continuity and cylinder compression were confirmed. Further examination revealed that the sound of the magneto impulse couplers engaging when the crankshaft was rotated. The spark plug ignition leads were damaged and spark could not be obtained. The top and bottom spark plugs were examined and exhibited normal wear signatures when compared to the Champion spark plug inspection chart. Examination of the recovered engine and system components revealed no evidence of preimpact mechanical malfunction. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was performed on the PRP on March 9, 2011, by the Office of the Chief Medical Examiner, Augusta, Maine, as authorized by the Maine State Police. The autopsy findings included "multiple blunt force injuries," and the report listed the specific injuries. The cause of death was reported as two of the listed injuries. Forensic toxicology was performed on specimens from the PRP by the Federal Aviation Administration Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. The toxicology report stated that no ethanol was detected in the liver or the muscle, and no drugs were detected in the liver. ADDITIONAL INFORMATION According to NAV Canada, the flight transition through the Nashua, New Hampshire Center (ZBW) was an over flight, westbound at 6,000 feet. There had been an Airman's meteorological Information AIRMET issued two hours earlier for light to moderate icing below 14,000 feet. The aircraft was issued vectors around mountainous terrain per the pilot’s request, in order to stay low due to potential icing. Lost communication procedures were issued, which was standard in the area and altitude the aircraft was transiting. The pilot switched to the Montreal Center on his own, in accordance with the lost communication procedures issued earlier. The pilot returned on ZBW frequency, but the ZBW controller was unable to make contact. Montreal Center was issuing vectors to the aircraft when radar and radio contact were lost. The ZBW controller attempted to reach the pilot through other aircraft but was unable to establish communications. A search and rescue was initiated within thirty minutes.

Probable Cause and Findings

The pilot's inadvertent encounter with icing conditions, which resulted in an aerodynamic stall and loss of control. Contributing was the pilots’ inadequate preflight weather planning.

 

Source: NTSB Aviation Accident Database

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