Aviation Accident Summaries

Aviation Accident Summary ANC17FA018

Nome, AK, USA

Aircraft #1

N736AS

CESSNA R172K

Analysis

The private pilot was conducting a cross-county flight from Wasilla to Nome, Alaska, at night. According to GPS data, the airplane departed at 1710 and crashed at 2223. The pilot's third-class medical certificate had the limitation "not valid for night flying," but meteorological information for Nome indicated that the end of civil twilight occurred at 2022. Thus, the pilot's operation of the flight after 2022 was not in compliance with his medical certification. The pilot was also not in compliance with the requirement in Title 14 Code of Federal Regulations 91.409(a) for airplanes operating under Part 91 to have annual inspections.   The pilot dispensed 35 gallons of fuel into the airplane and fuel containers before the flight. The fuel quantity in the fuel tanks before the flight is unknown. According to the airplane manufacturer's performance charts, if the airplane was filled to the maximum capacity of 52 gallons, it would have had a no-wind range of 505 to 545 nm with 5 gallons of reserve fuel, depending on the engine and propeller settings. The GPS data indicated that the airplane flew a total distance of 518 nm from the taxi to the accident time, which was above the minimum range. The destination weather forecast product that was available before the flight indicated ceilings as low as 1,500 ft and visibility 4 miles in light snow and mist. The updated forecast that was published during the flight and was valid at the time of the accident indicated a ceiling of 500 ft and visibility of 1 ½ miles. No evidence indicated that the pilot obtained weather forecast information before or during the flight. About 45 minutes before the pilot's expected arrival, a friend at the destination told the pilot that the ceiling was 600 ft in fog, which was below visual flight rules weather. The pilot's text messages revealed that he would continue to the destination because he thought that he could "sneak in." However, the pilot did not have an instrument rating. Witness statements and an automated weather recording revealed a low ceiling in fog at the time that the airplane arrived in the terminal area. The pilot attempted to land four times but was unable to see the unlit runway through the fog, so the pilot departed the terminal area. A larger, plowed, and well-lit airport was 1 mile away and would have been an appropriate destination for a night flight in a wheel-equipped airplane. Although the specific reasons why the pilot was determined to land at the small, dark, snow-covered destination airport are not known, it is possible that the pilot wanted to avoid detection because of the packaged marijuana that was found in the airplane wreckage. GPS data indicated that, 8 minutes after departing the terminal area, the airplane slowed to a groundspeed of 35 knots (well below the 54-knot stall speed) at an altitude of 373 ft, and the airplane crashed about 1 minute later. An examination of the wreckage revealed that the airplane impacted sea ice in a nose-down spin, resulting in extensive wing leading edge crush damage, which was consistent with an aerodynamic stall at a low altitude and a loss of control. The fuel tanks had no quantifiable fuel, and the propeller blades lacked chordwise scratches or torsional deformation, which were consistent with an impact due to a loss of engine power after fuel exhaustion. A forced emergency landing on the sea ice would have been possible had the pilot maintained glide speed after the loss of engine power. Also, a suitable airport with good weather conditions was located 60 nm northeast of the destination. Had the pilot elected to divert to that airport before attempting visual approaches in instrument meteorological conditions, the airplane might have had enough fuel to land at that airport.

Factual Information

HISTORY OF FLIGHTOn March 5, 2017, about 2223 Alaska standard time, a Cessna R172K airplane, N736AS, impacted sea ice in Norton Sound, about 10 miles east of Nome, Alaska. The private pilot sustained fatal injuries, and the airplane was substantially damaged. The airplane was registered to and operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91 as a visual flight rules (VFR) personal flight, and instrument meteorological condition (IMC) prevailed at the time of the accident. No flight plan was filed. The flight departed Wasilla Airport (IYS), Wasilla, Alaska, at 1710 destined for Nome City Field Airport (94Z), Nome, Alaska. The pilot's fiancée stated that the pilot had not flown his airplane since late summer 2016 and that he had listed the airplane for sale in January 2017 because he flew the airplane infrequently. She said that the pilot had flown to Nome often but usually during the summer. On the day of the accident, the pilot's fiancée observed him fueling the airplane from a self-service commercial fuel tank and filling 5-gallon fuel containers before departure. A fuel receipt indicated that the pilot purchased 35.3 gallons of fuel. The distance from IYS to 94Z is about 470 nautical miles (nm). The pilot's fiancée reported that she received a text message from the pilot about 2100 indicating that he was about 45 minutes from 94Z but would not be able to land there due to weather. The pilot also sent a text message to a friend in Nome, asking about the weather. The friend reported that she sent a text message at 2141 to the pilot indicating a visibility of 10 miles and a ceiling of 600 ft overcast. The pilot responded, "Ok I think I can sneak in." He sent text messages to his friend indicating "one more try" and "one more ok" before texting "not happening" at 2214. A review of Garmin GPSmap 296 data showed an airplane track that included four approaches to runway 21 at 94Z, some maneuvering in the area, and a departure from the area to the east. Witnesses observed the airplane in fog. They stated that the airplane engine sounded normal and that the airplane lights were on. One witness called the Nome flight service station to ensure that the runway lights were on at Nome Airport (PAOM), which was a larger airport located 1 mile west of 94Z. This witness stated that he was surprised that someone would attempt to land at 94Z given the weather conditions (reported by a witness who lived near 94Z to be "very foggy" with a ceiling of about 300 ft) and the unlit snow-covered runway. That witness observed the airplane making multiple approaches in fog and then departing to the east. He also heard, on the common traffic advisory frequency, a transmission that sounded as if someone were stating "no, no, no!" sometime after the airplane departed the area. This witness then listened to another frequency for an emergency locator transmitter signal but did not hear one. The Garmin GPSmap 296 data showed that the airplane made no en route stops after departure from IYS and that the airplane was at an altitude of about 9,000 ft while in cruise flight. The total GPS distance flown was 518 nm; the total GPS movement time was about 5 hours 15 minutes. The last GPS data point, which was 9 minutes after the last landing attempt, was at 2223 and indicated that the airplane's groundspeed was 36 knots at an altitude of 373 ft. Figure 1 shows the GPS track data in the Nome area. A GPS report is in the public docket for this accident. Figure 1. Garmin GPSmap 296 flight data and airport and wreckage locations. The pilot's fiancée reported the airplane overdue about 0530 on March 6. The Federal Aviation Administration (FAA) issued an alert notice at 0606, and an area-wide airport and radio search was conducted. About 0959, a Nome search and rescue crew located the airplane wreckage on sea ice about 10 miles east of Nome, in Norton Sound near Hastings Creek. PERSONNEL INFORMATIONThe pilot, age 28, held a private pilot certificate with an airplane single-engine land rating. He held a third-class medical certificate issued on January 22, 2013, with the limitation "not valid for night flying or by color signal control." A review of FAA aeromedical certification documentation revealed that the pilot failed the color vision test during his 2013 and 2006 aeromedical physicals. According to a statement by the pilot's fiancée, the pilot was well rested and had worked until 1300 on the day of the accident. The pilot's logbook was not located. His most recent FAA medical application, dated January 22, 2013, stated that he had 62 hours total flight experience with no accumulated time in the previous 6 months. The flight time that the pilot accumulated in the 4 years after the examination could not be determined. AIRCRAFT INFORMATIONThe four-seat, high-wing, fixed-gear Cessna R172K Hawk XP airplane, serial number R1722378, was manufactured in 1977. The airplane was equipped with a 210-horsepower Continental Motors IO-360-K engine, serial number 355372, and a constant-speed two-blade McCauley 2A34C203-C propeller. The airplane was configured with wheels. A review of the airframe and engine logbooks revealed that the airplane's most recent annual inspection was completed on February 5, 2015, with a tachometer time of 1,380.4 hours, an airframe total time of 2,102.5 hours, and an engine time since major overhaul of 131.4 hours. The airplane had not been inspected for more than 2 years before the accident and thus was not in compliance with 14 CFR 91.409(a), which states that airplanes operating under Part 91 are required to undergo annual inspections. METEOROLOGICAL INFORMATIONThe closest weather reporting facility was PAOM, which was about 11 miles west of the accident site. At 2204, an automated special weather observation report indicated the following conditions: wind calm, sky overcast 400 ft, visibility 10 miles, temperature -21°C, dew point 22°C, and altimeter 30.49 inches of mercury. The PAOM terminal aerodrome forecast (TAF) that was published at 1422 on the day of the accident, which would have been available to the pilot before the flight, stated the following conditions from 1600 onward: wind 330° at 3 knots, visibility 4 miles in light snow and mist, and ceiling broken at 1,500 ft. The next TAF was published at 2020, which was after the flight departed, and was valid starting at 2100. The TAF forecasted wind from 280° at 4 knots, visibility 1 ½ miles in light snow and mist, and ceiling overcast at 500 ft. No evidence indicated that the pilot obtained a weather brief before or during the flight. The nearest public airport outside of Nome is White Mountain Airport (PAWM), White Mountain, Alaska, which is 60 miles northeast of Nome. The 2158 and 2258 automated observations at PAWM both reported a visibility of 10 miles and a clear ceiling. The US Naval Observatory listed sunset in Nome on March 5, 2017, at 1933 and the end of evening civil twilight at 2022. The FAA defines night at "the time between the end of evening civil twilight and the beginning of morning civil twilight." AIRPORT INFORMATIONThe four-seat, high-wing, fixed-gear Cessna R172K Hawk XP airplane, serial number R1722378, was manufactured in 1977. The airplane was equipped with a 210-horsepower Continental Motors IO-360-K engine, serial number 355372, and a constant-speed two-blade McCauley 2A34C203-C propeller. The airplane was configured with wheels. A review of the airframe and engine logbooks revealed that the airplane's most recent annual inspection was completed on February 5, 2015, with a tachometer time of 1,380.4 hours, an airframe total time of 2,102.5 hours, and an engine time since major overhaul of 131.4 hours. The airplane had not been inspected for more than 2 years before the accident and thus was not in compliance with 14 CFR 91.409(a), which states that airplanes operating under Part 91 are required to undergo annual inspections. WRECKAGE AND IMPACT INFORMATIONThe airplane came to rest in an open area of sea ice and snow in a steep nose-low attitude on a 110° heading, as shown in figure 2. All major components were located in the wreckage field. The engine, forward fuselage, and cabin were significantly crushed, and the wing leading edges exhibited fore-to-aft accordion crush damage. The empennage and rear fuselage were intact with a spanwise fracture and torsional displacement of the rear fuselage behind the wing. All flight control surfaces remained attached to the airplane, and continuity to the cockpit controls was established. The flaps were in the up position. Figure 2. N736AS wreckage on the Norton Sound sea ice. The propeller remained attached to the crankshaft, and the propeller blades were bent slightly aft with no chordwise abrasions or torsional deformation. The engine exhibited impact damage, and the crank case and cylinders remained intact with no evidence of a catastrophic failure. The left and right fuel tank caps were secure, and no measurable fuel was observed in either wing fuel tank, which appeared intact. The fuel selector knob indicated "both." Six plastic 5-gallon containers were located in the aft cabin area. Two of the cans were intact and full of fuel, two were ruptured and smelled of fuel, and two were intact and empty. A large cooler with packaged marijuana was discovered in the rear seat. ADDITIONAL INFORMATIONPerformance Fuel Planning The Cessna 172 Hawk XP pilot operating handbook (POH) indicated that the airplane had a total fuel capacity of 52 gallons and a usable fuel quantity of 49 gallons. A range profile chart in section 5, figure 5-8, indicated that, with standard temperature conditions, at an altitude of 9,000 ft, and with no wind, a 545-nm range can be planned at 60% brake horsepower (BHP), and a 505-nm range can be planned at 70% BHP, with a 5-gallon fuel reserve for each range. The engine power settings and the total fuel quantity at the start of the flight are unknown. Engine Failure Section 3 of the POH states the following: After an engine failure in flight, the best glide speed should be established as quickly as possible. While gliding toward a suitable landing area, an effort should be made to identify the cause of the failure. If the engine cannot be restarted, a forced landing without power must be completed. The POH also stated that the first procedure for an engine failure during flight is to attain 75 knots (indicated airspeed). Stalls Section 2, figure 2-2 of the POH indicated that the stall speed at maximum gross weight with the flaps retracted was 54 knots. The FAA's Airplane Flying Handbook (FAA-H-8083-3A), chapter 4, states the following concerning stalls: A stall is an aerodynamic condition which occurs when smooth airflow over the airplane's wings is disrupted resulting in loss of lift. Specifically, a stall occurs when the AOA [angle-of-attack]—the angle between the chord line of the wing and the relative wind—exceeds the wing's critical AOA. It is possible to exceed the critical AOA at any airspeed, at any attitude, and at any power setting…. A pilot must recognize the flight conditions that are conductive to stalls and know how to apply the necessary corrective action. This level of proficiency requires learning to recognize an impending stall by sight, sound, and feel. MEDICAL AND PATHOLOGICAL INFORMATIONThe Alaska State Medical Examiner, Anchorage, Alaska, performed an autopsy of the pilot. The autopsy report attributed the pilot's cause of death to multiple blunt force injuries. The FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed forensic toxicology on specimens from the pilot with negative results for carbon monoxide, ethanol, and drugs.

Probable Cause and Findings

The pilot's improper decision to conduct multiple visual approaches to the destination airport despite the night instrument meteorological conditions; the airplane's low fuel state at that time, which resulted in a total loss of engine power due to fuel exhaustion; and the pilot's subsequent failure to maintain adequate airspeed, which led to an aerodynamic stall and a loss of control. Contributing to the accident was the pilot's operation of the flight with a medical certification limitation that precluded him from night flying.

 

Source: NTSB Aviation Accident Database

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