1 fatality

30 Sep 2017: PIPER PA 28-140 140 (N9549W) — Brinnon, WA

Brinnon, WA, United States

On 30 Sep 2017, a PIPER PA 28-140 140 (registration N9549W) was involved in an aviation accident near Brinnon, WA. One person was killed. Investigators recorded the probable cause as: The flight instructor's failure to completely and properly evaluate the student pilot's incorrectly- planned flight, and his failure to use all available resources to maintain situation awareness during the flight, which resulted in controlled flight into… This summary draws on records from NTSB; 12 related events involving the same aircraft type or operator are linked below.

SourcesNTSBPrimary reportUpdated 1778583330Data APIEditorial standards

On September 29, 2017, a Piper PA-28-140 (N9549W) destroyed during a night instructional flight near Brinnon, Washington. The student pilot was seriously injured; the flight instructor was fatally injured.

History of Flight

On September 29, 2017, about 2213 Pacific daylight time, a Piper PA-28-140, N9549W, was destroyed when it impacted trees and terrain near Brinnon, Washington, during a night cross-country flight. The student pilot was seriously injured, and the flight instructor was fatally injured. The airplane was owned and operated by the Shelton Flight flying club as a Title 14 Code of Federal Regulations Part 91 instructional flight. Night visual meteorological conditions prevailed. The airplane had departed Jefferson County International Airport (0S9), Port Townsend, Washington, and was destined for its base at Sanderson Field Airport (SHN), Shelton, Washington.

The pilot who flew the airplane immediately prior stated that he flew for about an hour with no irregularities, topped off the fuel tanks, and turned the airplane over to the accident pilots about 2015.

The flight was the student pilot's first night flight, consisting of three legs with full-stop landings at two intermediate airports. No flight plan was filed, but radio communication with ATC occurred for the first leg and part of the second.

The trip originated when the airplane departed SHN about 2050. The pilots requested VFR flight following with a destination of Snohomish County Airport (PAE), Everett, Washington. A full stop landing at PAE occurred about 2130, then departure for 0S9. About 2135, the pilot acknowledged a communications facility switch from PAE ATCT but did not establish contact with the next facility; no further ATC communications were recorded.

The airplane landed at 0S9 about 2156, then departed on a direct course towards SHN. The flight was captured by FAA ground-based radar, with the last return at 2212:23 indicating an altitude of 3,250 ft. About 2238, the student pilot telephoned 911 to summon help; this was the first notification of the accident.

First responders reached the wreckage about 0500 the next morning, and the student pilot was airlifted by a US Navy helicopter. Investigation and recovery personnel accessed the site 2 days after the accident. The wreckage was on a heavily wooded slope in the Olympic National Forest at an elevation about 3,075 ft msl.

Personnel Information

Flight Instructor: The flight instructor was a retired airline pilot with multiple type ratings. Insurance application information indicated a total flight experience of over 27,000 hours, including more than 2,000 hours in fixed-gear, single-engine airplanes. His most recent FAA second-class medical certificate was issued in December 2016. No records of his flight instruction or PA-28 experience could be determined. No information indicated that he instructed at flight training schools.

Student Pilot: The student pilot obtained his FAA third-class medical certificate in September 2015. He had logged 44.5 hours of flight time (excluding the accident flight) in his personal logbook. His first flight was in December 2016, and all but one flight were conducted in the accident airplane.

Aircraft Information

FAA information indicated the airplane was manufactured in 1967 and purchased by Shelton Flight in August 2015. Maintenance records indicated it was equipped with a Lycoming O-320-E2A engine, overhauled and installed in October 1994 (tachometer 4,791.0 hours). The most recent annual inspection was completed in September 2017 (tachometer 5,461.9 hours).

Meteorological Information

At SHN, the 2053 automated weather observation included winds from 250° at 6 knots, visibility 10 miles, clear skies, temperature 13°C, dew point 11°C, altimeter 30.02 inHg. At 2300, skies remained clear, wind speed increased, and temperatures decreased.

At PWT, the 2056 observation included calm winds, visibility 10 miles, clear skies, temperature 8°C, dew point 7°C, altimeter 30.05 inHg. The 2239 observation indicated scattered clouds at 1,800 ft and a broken ceiling at 6,000 ft.

At PAE, the 2053 observation included winds from 010° at 6 knots, visibility 10 miles, broken ceiling at 3,600 ft, overcast at 4,600 ft, temperature 13°C, dew point 8°C, altimeter 30.05 inHg. At 2153, ceiling overcast at 3,700 ft; at 2253, overcast at 4,400 ft.

At 0S9, the 2035 observation included calm winds, visibility 10 miles, overcast at 4,000 ft, temperature 13°C, dew point 10°C, altimeter 30.03 inHg. By 2055, ceiling lowered to 3,800 ft; by 2115, 3,600 ft. At 2135, broken at 3,600 ft and overcast at 4,100 ft. At 2155 (about the time at 0S9), few clouds at 3,600 ft and overcast at 4,200 ft.

Wreckage and Impact Information

The accident location was about 1/4 mile south of the last radar return, coincident with a direct track from 0S9 to SHN. Site elevation about 3,075 ft. A partial swath of topped or damaged trees, presumed made by the airplane, was observed with an approximate alignment of 110° and descent angle of about 30°. Most trees appeared to be Douglas Fir, trunks up to about 18 inches in diameter, heights of 75 ft or more.

The fuselage came to rest upright on an approximate heading of 180° at about a 30° nose-down angle; the aft end supported by vegetation. The engine remained attached, propeller attached and partially embedded in soil. The cockpit volume was compromised by crushing. Both fuel tanks were breached; no fuel observed. Both wings and left horizontal stabilizer were fracture-separated. All aerodynamic and flight control surfaces appeared present. The key remained in the ignition switch set to "BOTH". The cockpit fuel selector valve handle was found set to the right fuel tank. The tachometer registered 5,495.38 hours. The ELT was found attached with switch in "AUTO" (armed). The wreckage was recovered for detailed examination.

Post-recovery, all major portions and flight control surfaces were identified. Flight control continuity was confirmed to the extent possible. The flaps were retracted at impact. Pitch trim components suggested stabilator set to neutral to slightly nose up, but damage precluded positive determination. No pre-impact airframe anomalies were observed that would have precluded continued normal operation.

The engine was partially damaged. No evidence of pre-impact internal failures. Both magnetos produced sparks when rotated. Spark plugs displayed normal appearance. Engine valve and drive train continuity confirmed. All cylinders appeared normal during borescope. The carburetor was partially fractured but attached; throttle and mixture controls attached. Carburetor disassembled showed metal floats with hydraulic crushing on outboard sides. Fuel inlet screen free of debris. Engine-driven fuel pump produced pressure when operated by hand. Vacuum pump rotor and vanes intact. No pre-impact engine anomalies observed.

Additional Information

The student pilot became interested in flying while teaching at a skydiving school and asked the accident flight instructor to be his primary instructor. It was not determined what curriculum or program guidance the instructor used. The student was a U.S. Army service member. He worked a regular Army shift of 0430 to 1200 each day from Tuesday, September 26 through Friday, September 29. On Tuesday, he worked at the skydiving school from 1300 to 1700. On Wednesday, he met with the instructor to review the planned flight from 1300 to 1400, then worked at the skydiving school from 1400 to 1700. On Thursday, he worked at the school from 1300 to 1700, then played baseball from 1930 to 2230. On the accident day, he worked his normal shift, napped from about 1300 to 1700, arrived at SHN about 1950, and took possession of the airplane about 2015. One account stated they reviewed the flight plan again in the airplane; another stated he did not remember much before the accident.

Both pilots owned multiple personal electronic devices (PEDs) including tablets and a Stratus GPS device. The student stated the instructor did not let him use PEDs during flight to prevent reliance on them. The instructor used his iPad mini with Foreflight to monitor the flight. The Stratus recorded flight data that was recovered.

A paper Seattle Sectional chart and a tabular flight plan form with handwritten entries were found in the cockpit. The chart contained penciled lines for direct tracks for the three legs. The tabular form had handwritten entries for the same route but with enroute landmarks. The student pilot had entered 3,500 ft altitude for all three legs. The track line for the last leg (0S9 to SHN) crossed mountainous terrain, with a charted peak of 3,440 ft directly on the track line and peaks over 4,000 ft about 5 miles west. The Maximum Elevation Figure for that quadrant was 4,800 ft. The accident location was on the track line less than 1 mile before the 3,440 ft peak.

Recovered Stratus data provided a timeline: departure from 0S9 via runway 27 about 2159, left turn to southeast, then southerly course toward SHN. About 6 minutes after takeoff, climb stopped at about 3,500 ft, with altitude excursions of about 500 ft over the next 3 minutes. The airplane leveled off about 2208 at about 3,300 ft, still proceeding toward SHN. The last minute showed two altitude excursions with a net decrease of about 200 ft. The final data point at 2212:48 indicated GPS altitude of 3,094 ft. Groundspeeds were consistent with published performance.

The source discussed Controlled Flight into Terrain (CFIT) accidents and referenced FAA Advisory Circular 61-134, which highlights risks such as loss of situational awareness, inadequate preflight planning, and failure to see and avoid.

Probable Cause

Not specified in the source.

Contributing factors

Causes

Instructor/check pilotEffect on operation

Other contributing factors

Student/instructed pilot