N509FN

HISTORY OF FLIGHT

On January 5, 2008, about 1343 Alaska standard time, a twin-engine Piper PA-31-350 airplane, N509FN, received substantial damage when it collided with ocean water following a loss of control shortly after takeoff from Runway 36 at the Kodiak Airport, Kodiak, Alaska. The airplane was being operated by Servant Air, Inc., Kodiak, as a visual flight rules (VFR) on-demand charter flight under the provisions of Title 14 Code of Federal Regulations (CFR) Part 135, when the accident occurred. Of the 10 people aboard, the airline transport pilot and 5 passengers died at the scene, 3 passengers sustained serious injuries, and 1 passenger sustained minor injuries. Visual meteorological conditions prevailed, and company flight following procedures were in effect. The flight was en route to Homer, Alaska.

During an initial hospital room interview with the National Transportation Safety Board (NTSB) investigator-in-charge (IIC), on January 5, about 2200, a passenger related that the purpose of the flight was to transport a group of commercial fishermen from Kodiak to Homer for Russian Christmas. He added that many of the passengers were family members that lived in the same community near Homer.

The passenger stated that he was seated in the third row on the right side of the airplane. He said that shortly after becoming airborne, he saw the airplane's nose baggage door open slightly, which he said initially startled the pilot. He said that while the airplane was still over the departure end of Runway 36, the pilot initiated a shallow right turn, presumably to return to the airport. He said that as soon as the pilot started the right turn, the baggage door swung open to the full open position, and it remained in that position. The passenger said that as the airplane continued the right turn, it rolled sharply to the right, and began a rapid, nose and right wing low descent. It collided with the water adjacent to the departure end of Runway 36. The passenger said that during the collision the fuselage fragmented, and the airplane sank shortly after impact. He said that he was able to free himself from the sinking wreckage by swimming though a large void in the airplane's fuselage.

According to the contract Air Traffic Control Tower (ATCT) specialist that was on duty at the time of the accident, the accident airplane departed from runway 36, and became airborne about midway along the 5,013-foot long runway. The ATCT specialist said that as the airplane continued to climb approaching the departure end of the runway, the pilot calmly stated that he needed to return to the airport, but gave no reason for his need to return. The ATCT specialist reported that as the airplane began a right turn, it began a steep roll to the right, and descended nose-low into the water. He said that immediately after witnessing the accident, he alerted airport fire rescue crew of the accident, and contacted the U.S. Coast Guard's Air Station Kodiak, which is located adjacent to the Kodiak airport.

The ATCT specialist noted that just after the accident, another Kodiak-based operator in a float-equipped de Havilland DHC-2 Beaver airplane contacted him on the tower radio frequency and said, in part: "[Kodiak] tower, Beaver five forty five's by the Crash Harbor, um can I help there?" The ATCT specialist responded by saying: "Beaver five forty five, yeah, you may be able to uh, you may be the first one that can get to those people that are in the water, they are right off the approach end of runway one eight, just off Buskin Beach, and uh you can transition into the airspace at your discretion." The ATCT specialist said that the pilot of the float-equipped de Havilland DHC-2 went directly to the accident site, then landed near the partially submerged wreckage.

During an interview with the NTSB IIC, on January 8, the pilot of the de Havilland DHC-2 Beaver airplane reported that at the time of the accident he was doing a postmaintenance engine run following a 100-hour inspection of his airplane. He said that while parked in a bay locally known as "Crash Harbor" adjacent to the Kodiak Airport, he initially overheard the radio conversation between the accident pilot and ATCT specialist, followed by the conversations between the ATCT specialist and the fire rescue crews, so he offered his assistance.

The pilot said that once he found the partially submerged wreckage, he landed, and then taxied close as he could to the sinking wreckage. He said he discovered two passengers swimming in the water next to the submerged wreckage, and two other passengers clinging to the airplane's exposed vertical stabilizer. He said that wind conditions at the time of the rescue made it very difficult to maneuver his airplane next to the wreckage. Once he had the four severely hypothermic passengers aboard, he departed to the north, and flew directly to the Kodiak boat harbor where an ambulance was waiting. The pilot noted that when he departed the accident site, no other passengers were visible on the surface of the water.

Pilot Preflight

During an interview with the NTSB IIC on January 8, an employee of Servant Air reported that the accident pilot loaded the airplane himself, while his passengers waited in the operator's lounge. The employee noted that he watched the pilot load various items into the forward baggage area, closed and latched the baggage door, then continued loading the remaining items in the aft baggage area, and wing lockers. He said that when the pilot was done loading the airplane, he saw him do a "walk around" the entire airplane. He said that when the pilot approached the forward baggage area, the pilot slide his open left hand across the closed door, then while making a loose fist, he lightly tapped the door, just above the door's handle and lock assembly, then continued around the airplane's right wing.

PERSONNEL INFORMATION

Pilot Information

The pilot held an airline transport pilot certificate with airplane multiengine land and sea, and helicopter ratings. He also held a flight instructor certificate with airplane single-engine land, multiengine land, instrument airplane, and helicopter ratings. His most recent first-class medical certificate was issued August 7, 2007, and contained no limitations.

According to the NTSB Pilot/Operator Aircraft Accident Report (NTSB Form 6120.1) submitted by Servant Air, dated January 18, 2008, the pilot's total flight time was 9,437 hours, of which 400 were in the accident airplane make and model, and 1,108 in multiengine airplanes.

His most recent airman competency/proficiency check (CFR Part 135.293) check ride was on September 1, 2007, the company president, who was a company check airman, administered the check ride in the accident airplane.

A review of the flight and duty records for the pilot revealed in the 30 days before the accident, he flew about 47.5 hours. His flight time in the previous 90 days was about 179.6 hours.

According to the operator, the company hired the pilot on June 1, 2004, and at that time, his total combined (helicopter and airplane) flight experience was about 6,555 flight hours, with 36 hours in multiengine airplanes.

Before being hired by Servant Air, the pilot was a full-time helicopter pilot for the United States Coast Guard. During his time in service with the Coast Guard, he was stationed in various theaters around the world, including Alaska. While in the Coast Guard, he accumulated about 6,000 flight hours in helicopters, and about 465 hours in airplanes.

Company Information

The operator is a Federal Aviation Regulations (FAR) Part 135 Air Carrier, and holds scheduled commuter and on-demand operations specifications. Company facilities are in Kodiak and Anchorage, Alaska. The president/director of maintenance and chief pilot reside in Kodiak. The vice president/director of operations resides in Anchorage. A review of 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. At the time of the accident, the company president was out of town, and the vice president/director of operations was in Kodiak in his absence.

A review of Servant Air's FAA approved training program revealed no specific training requirements concerning the proper operation of the nose baggage door. In addition, there were no emergency procedures training concerning an inadvertent opening of the nose baggage door.

AIRCRAFT INFORMATION

The airplane was equipped with two Lycoming TIO-540-J2B engines that were each rated at 350 horsepower.

The airplane's original maximum gross weight was 7,000 pounds, but it had been modified to 7,368 pounds in accordance with an FAA-approved supplemental type certificate (STC).

According to the load manifest computed by the pilot just before departure, the airplane's gross weight was 7,221 pounds, or 147 pounds below its maximum gross weight.

The airplane was not equipped with a cockpit voice recorder, or a flight data recorder.

Maintenance records revealed that the last recorded inspection event of the engine and airframe was a 100-hour inspection, completed on December 18, 2007, 18 days and 27 service hours before the accident. At that time, the airplane had a total of 13,102 service hours. The left engine had about 615 service hours since the last major overhaul, and the right engine had about 1,151 service hours since the last major overhaul.

The most recent annual inspection of the engines and airframe was on August 15, 2007, at which the airplane had 12,914 service hours. The left engine had about 427 service hours since a major overhaul, and the right engine had about 1,363 service hours since major overhaul.

The left engine overhaul was done by Aero Recip Alaska, on June 14, 2006. ...