Accident Details
Probable Cause and Findings
The pilot's failure to extend the landing gear, his improper aborted landing procedure, and inadvertent stall/mush. Factors in the accident were an improper adjustment of the landing gear warning horn system by company maintenance personnel, and the failure of the pilot to utilize the prelanding checklist.
Aircraft Information
Registered Owner (Historical)
Analysis
HISTORY OF FLIGHT
On September 18, 2000, about 1510 Alaska daylight time, a Piper PA-31T3 airplane, N220CS, was destroyed by impact and postimpact fire after colliding with tundra-covered terrain, about 300 yards south of the Nuiqsut Airport, Nuiqsut, Alaska. The airplane was being operated as a visual flight rules (VFR) scheduled domestic commuter flight under Title 14, CFR Part 135, when the accident occurred. The airplane was operated as Flight 181 by Cape Smythe Air Service Inc., Barrow, Alaska. The airline transport certificated pilot and four passengers received fatal injuries; the remaining five passengers received serious injuries. Visual meteorological conditions prevailed, and a VFR flight plan was filed. The flight originated at the Deadhorse Airport, Deadhorse, Alaska, at 1445.
Ground witnesses at the Nuiqsut Airport saw the airplane touch down on runway 22 with the landing gear retracted. The airplane was equipped with a fuselage-mounted belly cargo pod. The belly pod lightly scraped the runway for about 40 feet, but the airplane transitioned to a climb. As the airplane began climbing away from the runway, the ground witnesses saw the landing gear extend. The airplane climbed to about 100 to 150 feet above the ground, and then began a descending left turn. The airplane collided with the ground on a 095 degree heading. The ground witnesses did not describe observing any smoke or flames emanating from the airplane before the crash.
According to surviving passenger statements and interviews, the accident flight and approach to the Nuiqsut Airport was unremarkable. During the landing phase, the passengers said the airplane scraped the runway. A warning horn was not heard before runway contact. The airplane then pulled upward from a level attitude into a climb that several passengers described as a 30 to 45 degree nose high angle. Several of the passengers felt the airplane "shudder" or "shimmy", roll to the right and left, and then heard a warning horn as the airplane banked to the left. The airplane then descended to the ground in a left-wing-low attitude.
The wreckage path extended for about 300 feet, during which the landing gear, belly pod, left wing, and the left engine separated from the airplane. A postcrash fire destroyed the fuselage, right wing, and the right engine.
PERSONNEL INFORMATION
Pilot Information
The pilot held an airline transport pilot certificate with a multiengine land rating, commercial pilot privileges with an airplane single-engine land rating, and private pilot privileges with a single-engine sea rating. The most recent first-class medical certificate was issued to the pilot on August 24, 2000, and contained no limitations.
According to the operator, the pilot was hired by the company on September 27, 1998, and at that time, his total flight experience was 573 hours, with 72 hours of multiengine. The pilot was assigned to the company base at Barrow. He completed his initial company training, including Cessna 207 ground training, on September 30. He then completed Beech BE-99 ground training on October 2, and Beech BE-99 second-in-command pilot flight training on October 6. The pilot was assigned to Beech BE-99 airplanes, eventually accruing 924 hours in the BE-99 as second-in-command.
Company records show that the pilot completed a VFR company check ride in a Cessna 207 on November 13, 1998, and began accruing initial operating experience (IOE) in Cessna 207 airplanes on November 23. He eventually accrued 825 hours in Cessna 207 airplanes.
The pilot received two hours of initial ground training on May 8, 1999, on general subjects for Cessna 185 airplanes. He did not receive any flight training in the airplane.
Company records show that the pilot was unassigned to all aircraft on February 3, 2000, after undergoing minor surgery, and reassigned to all aircraft on February 29. He was unassigned to Cessna 207 airplanes on March 1, pending completion of a company line check. He was reassigned to Cessna 207 airplanes on March 23, after completion of a line check.
According to the company's PA-31-T3 ground/flight training manual, transition training to the airplane requires 16 hours of ground training, 6 hours, or to proficiency, of flight training, a company proficiency flight check, 20 hours of IOE, and then a company line check.
Company records indicate that on May 28, 2000, the pilot began receiving flight training in the accident airplane. He received 16 hours of transition ground training in the Piper PA-31-T3 on October 3rd and 4th, 1999. According to the pilots logbook, the pilot first logged flight time in the accident airplane make and model on April 22, 2000, with 1.2 hours of dual instruction while on an extra section mail flight. On May 28, he logged 2.6 hours of dual instruction in the Barrow area, and on June 25, he logged 2.9 hours as pilot-in-command in the Barrow area. From July 10 to July 11, the pilot logged 6.1 hours in the Nome area as dual instruction. On July 12, the pilot logged 1.9 hours as dual instruction during an aircraft check ride as an on-demand pilot. During the check ride, the pilot received an unsatisfactory rating from the director of operations for his conduct of nonprecision approaches. Following retraining, the company removed all instrument approach restrictions on the pilot.
The pilot began on-demand charter flights in the accident airplane, logging 1.7 hours as pilot-in-command between Barrow and Atqasuk, Alaska, on July 21, 2000, after passing a company proficiency flight at Barrow. On July 25, the pilot began logging IOE on commuter flights, accompanied by a check airman on most, but not all flights. The pilot continued to conduct single-pilot, on-demand flights before completing his commuter IOE requirements. On August 10, after accruing 51 hours of IOE, the pilot logged his first flight as a commuter captain while flying without a co-pilot, or a company check airman.
On September 1, 2000, the pilot accrued 100 hours in the accident airplane, and was authorized to use the autopilot in lieu of a second pilot for IFR operations. He eventually accrued a total of 165 hours in the accident airplane make and model.
On the day of the accident, the pilot had completed one flight (Flight 115) from Barrow, to Atqasuk, to Wainwright, Alaska, to Barrow, for a total of 1.25 flight hours. The day before the accident, the pilot accrued 4.15 flight hours. Two days before the accident, the pilot accrued 1.35 hours.
All of the pilot's ground and flight training, check rides, and line checks, were conducted by company check airman.
A review of the FAA's Program Tracking and Reporting Subsystem (PTRS) data pertaining to the pilot, revealed two en route surveillance flights by FSDO operations inspectors with the pilot in Cessna 207 airplanes. The pilot had two ramp inspections by FSDO maintenance inspectors, one in a Cessna 207, and one in a Beech BE-99. The pilot had one en route surveillance flight by a FSDO avionics inspector in a Cessna 207.
During a flight in the accident airplane on August 4, 2000, the pilot reported a landing gear problem in which the nose gear would not extend. The chief pilot was also on board the airplane. At that time, the pilot had logged 61.3 hours in the accident airplane make and model.
Company Information
The operator is a Federal Aviation Regulations (FAR) Part 135 Air Carrier, and holds commuter and on-demand operations specifications. Company facilities are located at Barrow, Alaska, Nome, Alaska, Kotzebue, Alaska, and Deadhorse, Alaska. The president, chief pilot, and the director of maintenance reside in Barrow. The director of operations, and the chief maintenance inspector/manager of stations, reside in Nome.
A review of the company's operations manual revealed that the president, director of maintenance, director of operations, chief pilot, and the manager of stations, are designated as having the authority of exercising operational control over company aircraft, and/or flight crews.
The company's operations specification, issued by the FAA, indicate that flights shall only be initiated, diverted, or terminated under the authority of the director of operations, who may delegate his authority, but retains responsibility.
On June 17, 1999, the company requested and received approval from the FAA for a change in the chief pilot position. On August 18, 2000, the FAA withdrew the check airman approval for the company's chief pilot because of his numerous accidents during the previous year.
AIRCRAFT INFORMATION
The airplane is a nonpressurized, twin-engine turboprop equipped with Pratt & Whitney PT6A-11 engines that produce 500 horsepower each. The maximum takeoff and landing weight is 9,000 pounds. The maximum zero fuel weight is 7,600 pounds. The airplane is not required to have a cockpit voice recorder, a flight data recorder, nor a ground proximity warning system. The airplane is equipped for instrument flight into known icing conditions, and may be operated by a single pilot.
The airplane was maintained on an approved aircraft inspection program (AAIP). The AAIP is divided into phase inspections, each consisting of four event cycles, each 150 hours apart.
Examination of the maintenance records revealed that an event number four inspection was accomplished on September 15, 2000, 7.7 hours before the accident. The airplane had accumulated a total time in service of 10,156.7 hours. The left engine had accrued a total time of 11,666.40 hours, 6,017.2 hours since overhaul. The right engine had accrued a total time of 10,622.90 hours, 4,444.1 hours since overhaul. Both propellers had accrued 364.1 hours.
The accident airplane pilot had a nose gear extension problem with the accident airplane on August 4, 2000. The maintenance log notes that the pilot cycled the gear several times, pulled the nose gear bottle (emergency blow-down syst...
Data Source
Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# ANC00MA125