N59773

Substantial
Fatal

PIPER PA-31-350S/N: 31-7652044

Accident Details

Date
Tuesday, November 29, 2011
NTSB Number
CEN12FA086
Location
Riverwoods, IL
Event ID
20111129X93953
Coordinates
42.164443, -87.898056
Aircraft Damage
Substantial
Highest Injury
Fatal
Fatalities
3
Serious Injuries
1
Minor Injuries
1
Uninjured
0
Total Aboard
5

Probable Cause and Findings

The pilot's inadequate preflight planning and in-flight decision-making, which resulted in a loss of engine power due to fuel exhaustion during approach. Contributing to the accident was the pilot's decision to operate an airplane after using illicit drugs.

Aircraft Information

Registration
N59773
Make
PIPER
Serial Number
31-7652044
Engine Type
Reciprocating
Year Built
1975
Model / ICAO
PA-31-350PA31
Aircraft Type
Fixed Wing Multi Engine
No. of Engines
2

Registered Owner (Historical)

Name
TRANS NORTH AVIATION LTD
Address
PO BOX 1445
Status
Deregistered
City
EAGLE RIVER
State / Zip Code
WI 54521-1445
Country
United States

Analysis

HISTORY OF FLIGHT

On November 28, 2011, about 2250 central standard time, the pilot of Lifeguard N59773, a Piper PA-31-350 Chieftain airplane, declared an emergency, reporting that the airplane was out of fuel, and indicating that the flight was gliding without engine power direct to the destination airport, Chicago Executive Airport (PWK), near Wheeling, Illinois. The emergency medical services (EMS) airplane subsequently sustained substantial damage when it impacted trees and terrain near Riverwoods, Illinois. The airline transport pilot and two passengers on board sustained fatal injuries. A pilot-rated passenger received serious injuries and the medical crew member received minor injuries. The airplane was registered to and operated by Trans North Aviation Ltd. under the provisions of 14 Code of Federal Regulations Part 135 as a non-scheduled, domestic, on-demand, EMS passenger flight. Night visual meteorological conditions prevailed at the time of the accident for the flight, which operated on an activated instrument flight rules (IFR) flight plan. The flight departed from the Jesup-Wayne County Airport (JES), near Jesup, Georgia, about 1900.

According to a load manifest form found in the wreckage, dated November 28, 2011, the crew that flew N59773 from the Crawfordsville Municipal Airport (CFJ), near Crawfordsville, Indiana, to the Perry-Houston County Airport (PXE), near Perry, Georgia, and onto the Palm Beach International Airport (PBI), near West Palm Beach, Florida, listed the pilot-rated passenger as the pilot-in-command and listed the pilot and the medical crewmember as “other crew.” This form indicated that this crew started their duty period at 0700 when they flew from CFJ and they ended their duty period at 1430 in PBI.

According to another load manifest form, also dated November 28, 2011, the crew that flew N59773 from PBI, to JES, and onto PWK listed the pilot as the pilot-in-command and listed the pilot-rated passenger and the medical crewmember as "other crew." This form indicated that this crew started their duty period at 1430 at PBI. This form indicated that they departed from PBI at 1642 and landed at JES at 1830. Fueling records showed an airplane was fueled at JES with 160 gallons of aviation gasoline (avgas) and an additional 5 gallons of avgas, which totaled a combined servicing of 165 gallons of avgas. This manifest form indicated that they departed from JES at 1900 and were destined for PWK. The duty period ending time was not completed.

A review of the recording of the approach controller’s frequency revealed that the pilot representing Lifeguard N59773 requested to fly direct to the outer marker navigation aid named PAMME. The controller indicated that the flight had to be taken on a heading to intercept the approach outside PAMME and the controller denied the request. The flight was given that heading for the instrument approach and the pilot then declared an emergency. The controller inquired if the flight was still landing at PWK. The pilot reported that he was unable, the airplane was out of fuel, and that the airplane was “coasting.” The controller asked if the field was in sight. The pilot reported negative and asked for the cloud tops. The controller indicated that the cloud deck was 1,400 feet overcast. The pilot responded that the flight was coasting down and that the pilot would report visual contact. The pilot further indicated that the flight was flying direct to PWK. The controller advised the flight of a low altitude alert and the flight acknowledged that alert. The controller again asked if the pilot had the field in sight. The pilot reported affirmative. The flight was cleared for the visual approach to runway 16 and the pilot was informed to cancel the flight’s IFR flight plan. The controller further indicated that the change to the airport’s advisory frequency was approved. There was no further recorded radio communication from the Lifeguard EMS flight. A transcript of the air traffic controller’s communications is appended to the docket associated with this investigation.

The pilot-rated passenger sat in the front right seat of the airplane. During a postaccident telephone interview, he indicated that the flight from PBI to PWK started out normal. While flying over the lower portion of Lake Michigan, the pilot selected the auxiliary fuel tanks to use up all the fuel in the auxiliary tanks. The last quarter of the main tanks was reportedly consumed “pretty fast” as monitored on the gauges. The right fuel flow warning light came on north of PWK. The pilot selected the crossfeed valve to its ON position. The fuel warning light went out. The pilot asked the air traffic controller to proceed direct to the outer marker and the air traffic control indicated that he was unable to grant that request. The fuel light came on again and the pilot declared an emergency. The pilot-rated passenger said that he had no idea of the amount of fuel that remained in the fuel tanks. The right engine subsequently started to shutter. The flight was cleared direct. The cloud tops were at 3,000 feet above mean sea level (msl). The airplane was turned left and then both engines “died” on a west heading. The airplane “coasted.” The airplane was in clouds during the descent and popped out of the clouds about 1,400 feet msl where there was about 700 feet of altitude left. The pilot rated passenger made some radio calls. The airplane was turned to a southbound heading. The pilot-rated passenger advised the pilot of suitable landing sites but the flight was unable to get to them. The landing gear was up. Flaps were up. The pilot moved the mixture to idle/cutoff and feathered the engines’ propellers. He pointed out a dark spot to the pilot and the pilot turned to it. The airplane scraped the tops of trees. The first tree impacted the pilot’s side and it came through the window. Both the pilot and the pilot-rated passenger were “on the flight controls.” The controls then went limp. The pilot-rated passenger indicated that he tried to keep the airplane away from the houses and both of his yoke handles broke off. A nearby neighbor found him in the wreckage and asked him if he was “ok.” It was about one-half hour before he was placed in an ambulance.

During a postaccident telephone interview, the medical crew member indicated that the purpose of the flight was to fly to PBI to pick up a patient and passenger and then fly them to PWK. The patient and passenger were informed that there would be one or maybe two stops for fuel. The airplane appeared to be topped off at JES. The fueling started on the right side of the airplane and continued to the left side. The fuel pump shut off after about 160 gallons were pumped. The pump was restarted and the airplane was fueled with more fuel. The flight was "ok" until it encountered “bad air” and the flight descended to about 7,000 feet. At one point in the flight, the medical crew member saw that a cockpit gauge indicated that there was one-half hour remaining before reaching the destination. The pilot remarked on how fast the airplane was flying and the ground speed was about 250 to 260 mph. The pilot reached down and switched tanks. The pilot also rocked the airplane’s wings. Both the engines shut off at the same time. Trees were observed once the flight descended through the clouds. During the accident sequence, the airplane’s nose pitched up as the airplane impacted trees. The passenger screamed and then the screaming stopped. The pilot-rated passenger sitting in the co-pilot’s seat advised them to brace. He said that the seat belt dug into him and his seat separated from its floor track. He was able to loosen his belt. He felt the door and its bottom half was open. He pushed open the top half. He did not initially see the pilot-rated passenger. He talked to a woman in a nearby house and related that there was an airplane accident. He heard people by the airplane and went to the airplane. He observed a small fire and told responders of the fire extinguisher location. The medical crew member reported that the pilot was in the front left seat, the pilot-rated passenger was in the front right seat, the patient’s wife was in the rear-facing seat behind the pilot, the patient was belted on the gurney, and he was in the forward-facing seat just in front of the rear cabin door.

The Riverwoods Police Department received an initial 911 phone call about 2250. The first responders found the wreckage near a residence northwest of the intersection or Portwine and Orange Brace roads.

PERSONNEL INFORMATION

Pilot

The 58-year-old pilot held an airline transport certificate with an airplane multi-engine land rating and he held commercial pilot privileges for single engine land airplanes. He held a flight instructor certificate with single engine, multi-engine, and instrument airplane ratings. He also held a type rating in SA-227 airplanes. A Federal Aviation Administration (FAA) 8410-3 Airman Competency/Proficiency Check Form showed that he passed a 1-hour checkride in the PA-31-350 with the operator’s Chief Pilot on June 7, 2011. The operator reported that the pilot had accumulated 6,607 hours of total flight time, 120 hours of total flight time in the PA-31-350, 171 hours of flight time in the 90 days prior to the accident, 61 hours of flight time in the 60 days prior to the accident, 5 hours of flight time in the 24 hours prior to the accident, and 12 hours of flight time in the Chieftain in the 90 days prior to the accident.

He held a first-class medical certificate, dated February 15, 2011, with limitations for hearing amplification and corrective lenses. The pilot reported on his application for that medical certificate that he had accumulated 6,350 hours of total flight time and 20 hours of flight time in the six months prior to that application. The pilot previously reported that he had a history of convictions for driving under the influence on both Ma...

Data Source

Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# CEN12FA086