Accident Details
Probable Cause and Findings
The pilot's failure to set the throttle of his second failed engine to 'Cracked-1/2-Open' as called for in the Engine Failure/Restart checklist, followed by a high-power engine surge. Factors include the pilot's delay in landing for refueling, the pilot becoming lost/disoriented, drug impairment, and fuel exhaustion.
Aircraft Information
Registered Owner (Historical)
Analysis
HISTORY OF FLIGHT
On April 27, 1997, approximately 1245 Pacific daylight time, a Smith Aerostar 601P, N30LL, impacted the surface of Lake of the Woods about 23 miles northwest of Klamath Falls International Airport (Kingsley Field), Oregon. The private pilot, who was the sole occupant, received fatal injuries, and the aircraft sustained substantial damage. The pilot, who departed Bellingham International Airport, Bellingham, Washington, about three hours and twenty minutes earlier, was reportedly conducting a 14 CFR Part 91 flight en route to Midland, Texas, in order to visit a relative. The pilot, who had not filed a flight plan, was operating the aircraft in visual meteorological conditions at the time of the accident.
On the morning of the accident, the pilot went to his aircraft and contacted Aviation Northwest with a request for fuel. When the fueler arrived at the aircraft, the pilot first had him top off the fuselage tank. Then according to the fueler, the pilot pushed the fuselage tank drain valve in order to drain and inspect fuel from the bottom of the tank. When he pushed in the valve, it stuck in the open position, and he had to wiggle it in order to get it to pop out and close. Once it popped out, the fuel stopped flowing and there did not appear to be any leaks. After inspecting the fuel that had been drained from the fuselage tank, the pilot told the fueler to fill both wing tanks to the top because "...he needed every drop he could get." When fueling was completed, the aircraft had taken on 85.9 gallons of aviation fuel, and all tanks had been filled to the top.
About 15 minutes after the aircraft was refueled, the pilot started both engines and began a series of engine run-ups which lasted approximately 35 to 40 minutes. According to a witness, the aircraft remained in its usual parking spot while the pilot ran the engines at various power settings for varying lengths of time. Although one or both engines were occasionally at idle, it appeared to the witness that most of the time was spent with at least one of the engines, and sometimes both, at a high power setting. According to the witness, who said he had observed the run-up from a distance, he did not remember the engines running rough or anything unusual about their operation. At 0912, the pilot terminated the engine runs, and called for a taxi clearance. He was given clearance to runway 16, whereupon he taxied to the runway 16 run-up area and once again performed high-power run-ups on both engines for what was estimated to be about five to six minutes. At 0921, the pilot called Bellingham Tower for takeoff clearance and said that he would be making an eastbound departure. At 0923, the pilot departed Bellingham, made a left turn after takeoff, and was last seen climbing to the east. He did not contact Seattle Approach or Seattle Center during departure, and there is no record of the pilot making contact with any other FAA facility until he contacted Klamath Falls Air Traffic Control Tower at 1225. According to the FAA, the pilot had not filed a flight plan and did not receive an FAA-provided weather briefing prior to departure.
At 1225, the pilot of N30LL contacted Klamath Falls (Kingsley) Tower and said that he was inbound for landing, and estimated that he was 30 miles north-northeast of the airport. The tower told the pilot to report entering a right downwind for runway 32, and then gave him the current altimeter setting. The pilot advised the tower that he had Papa (Automatic Terminal Information Service Information Papa). There was no further contact between the aircraft and the tower until 1235, when the pilot transmitted "Klamath Tower Aero, ah this is ah Aerostar three zero lima, ah we've got ah fuel problem, we're a little low. I am over a lake and I don't know where the city is. I'm headed straight at a mountain with snow on top. Can you help me?" The controller asked the pilot whether he was transponder equipped, and the pilot responded that he was and that he was "...squawking one two zero zero." Then while coordinating with Seattle Center Sector 10 for a discrete transponder code for the aircraft, the controller asked the pilot if the lake he was over was a big lake. The pilot responded with "Yes, a great big lake with a highway on the north end of it." Believing that the pilot was over Klamath Lake (which was later confirmed by recorded time-annotated radar data), the controller told the pilot "Okay, you're over Klamath Lake, which is just northeast of the city. Ah, you can proceed southeast along the ridgeline and ah you'll come right into the city, and then right on ah the southeast side of the city you'll see the airport." The controller further advised the pilot that if he followed the freeway "...it will come right into the city." In addition the controller advised him that once he got over the city of Klamath Falls he would be able to see the airport. The pilot responded to these instructions with "Understand, zero lima lima." About 75 seconds after the pilot had said he was having a fuel problem, the controller told him to squawk a code of 3561, and the pilot repeated the squawk to the controller. The controller asked the pilot what his altitude was, and the pilot advised him he was descending through 7,000 feet. The controller then asked the pilot to confirm that he was low on fuel, but that the engines were still running. The pilot confirmed that was correct, and asked the controller to tell him again what the assigned squawk was. The controller repeated the squawk, and then, because Seattle Center had advised him that the aircraft was continuing to the west and had offered to provide vectors for the pilot, told the pilot he was headed westbound and advised him to contact Seattle Center on 127.6. Soon thereafter, the pilot made radio contact with Seattle Center and was instructed to fly heading one zero zero degrees. At 1239, about one minute after making contact with center, all radar and direct radio contact was lost with the aircraft. About three minutes after losing direct radio contact, the pilot of another aircraft (N116WC) reported he thought he had heard the pilot of N30LL reporting that he was heading toward Klamath Falls, but that one engine had lost power. About one minute after that report, the pilot of a third aircraft (N816JW) reported that he had heard the pilot of N30LL loud and clear, and that the pilot had reported he had lost both engines. There was no further direct or indirect radio contact with the pilot of N30LL.
The next reported sighting of the aircraft occurred at 1242, when it was spotted by individuals who were fishing on Lake of the Woods, which is located about 28 miles northwest of Klamath Falls. According to those individuals, when the aircraft was first observed it had come in low over the lake and had leveled off at about 200 to 300 feet above the surface. As it continued over the lake, which is approximately two and one-half miles long and three-quarter to one mile wide, it began to slow, and its nose began to rise. It reportedly continued to slow, and then suddenly rolled quickly to one side and went "...almost straight down into the lake." Although there were conflicting stories about whether the aircraft's engines were running or not, one pilot-rated witness was adamant that there were absolutely no engine sounds except one very loud engine roar of about two seconds duration that occurred just prior to the aircraft impacting the water. This individual said that he was not looking in the direction where the aircraft went down when it came in over the lake, and that he did not know there was an aircraft in the area until he heard a loud engine roar. Upon hearing the roar, he turned in the direction of the noise just in time to see a plume of water rise from where the aircraft had impacted the lake. He reported that he immediately went to the area where he had seen the plume and found numerous small pieces of debris. He also reported that there was no fuel slick and only a slight smell of aviation gas. He said that although there was no fuel slick, there was a slight oil slick, the source of which led him to the location of one of the engines in about 30 feet of water.
METEOROLOGICAL INFORMATION
The 1155 Aviation Routine Weather Report (METAR) for Klamath Falls reported winds 330 degrees at four knots, 30 statue miles visibility, few clouds at 3,000 feet, temperature 11 degrees Celsius, dew point minus three degrees Celsius, with an altimeter setting of 30.07 inches of Mercury. The Klamath Falls METAR for 1255, about 12 minutes after the accident, was winds 290 degrees at three knots, 30 miles visibility, few clouds at 3,000 feet, few clouds at 25,000 feet, temperature 13 degrees, dew point minus one degree, altimeter 30.06. Also, the pilot of another aircraft flying in the area of the accident at 1241, reported that it was "...severe VFR out there."
WRECKAGE AND IMPACT INFORMATION
The aircraft impacted the surface of the Lake of the Woods about 200 feet west of the Sunset Beach boat ramp, and sank in about 30 to 40 feet of water. The aircraft was recovered from the lake about a day and a half after the accident, and according to local environmental officials, during the time the aircraft remained submerged in the lake, only a very light sheen of fuel was seen on the water's surface. The wreckage was recovered from the lake in two major sections. The largest section included the fuselage from just forward of the instrument panel to just aft of the trailing edge of the wing flaps. This section included the inboard two-thirds of both wings, along the right engine, which was still partially attached to its mount. The second major section was made up of the aft portion of the fuselage and the empennage. Recovered separately were the first four feet of the nosecone, the outboard one-third of both wings, the left engin...
Data Source
Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# SEA97FA094