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National Transportation Safety Board Aviation Accident Final Report

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National Transportation Safety Board Aviation Accident Final Report National Transportation Safety Board Aviation Accident Final Report Location: Goodnews Bay, AK Accident Number: ANC16LA032 Date & Time: 06/17/2016, 1200 AKD Registration: N91170 Aircraft: CESSNA 207 Aircraft Damage: Substantial Controlled flight into terr/obj Defining Event: Injuries: 1 Serious (CFIT) Flight Conducted Under: Part 91: General Aviation - Positioning Analysis During cruise flight through an area of mountainous terrain, the commercial pilot became geographically disoriented and selected the incorrect route through the mountains. Upon realizing it was the incorrect route, he initiated a steep climb while executing a 180° turn. During the steep climbing turn, the airplane inadvertently entered instrument meteorological conditions, and the airplane subsequently impacted an area of rocky, rising terrain. The pilot reported there were no mechanical malfunctions or anomalies that would have precluded normal operation of the airplane. Probable Cause and Findings The National Transportation Safety Board determines the probable cause(s) of this accident to be: The pilot's failure to select the correct route through the mountains as a result of geographic disorientation, and his subsequent visual flight into instrument meteorological conditions, which resulted in collision with terrain. Findings Personnel issues Decision making/judgment - Pilot (Cause) Environmental issues Mountainous/hilly terrain - Ability to respond/compensate (Cause) Clouds - Decision related to condition (Cause) Page 1 of 5 Factual Information On June 17, 2016, about 1200 Alaska daylight time, a Cessna 207 airplane, N91170, sustained substantial damage after impacting steep, rising terrain about 8 miles northwest of the Goodnews Airport, Goodnews Bay, Alaska. The airplane was registered to DIO Air, LLC, and operated by Renfro's Alaskan Adventures, Inc., Bethel, Alaska, as a visual flight rules (VFR) repositioning flight under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The commercial pilot, the sole occupant, sustained serious injuries. Instrument meteorological conditions (IMC) prevailed at the accident location, and company flight following procedures were in effect. The flight departed about 1020 from the Quinhagak Airport (AQH), Quinhagak, Alaska, destined for Goodnews Airport (GNU). During an interview with the National Transportation Safety Board (NTSB) investigator-in- charge on June 19, in Anchorage, Alaska, the pilot stated that after departing AQH, and as the flight progressed into an area of mountainous terrain, low clouds inhibited his ability to distinguish the correct route through the mountains from the incorrect route. When he discovered he had chosen the incorrect route, he was in an area that was too narrow and steep to safely turn around. In an effort to reduce his turning radius and avoid the rising terrain ahead, he initiated a steep climb while turning the airplane 180 degrees. During the steep climbing turn, the airplane entered IMC, and the airplane subsequently impacted an area of rock-covered rising terrain. He estimated the cloud ceilings to be about 800 feet mean sea level (msl) and his cruise altitude was about 700 feet msl before initiating the climbing turn. The closest weather reporting facility is Platinum Airport, about 14 southwest of the accident site. At 1156, an aviation routine weather report (METAR) from the Platinum Airport was reporting in part: wind from 210 degrees at 12 knots; visibility 10 statute miles; temperature 48 degrees F, dewpoint 45 degrees F; altimeter 29.85 inHg. The pilot reported no mechanical malfunctions of anomalies that would have precluded normal operation. History of Flight Enroute VFR encounter with IMC Controlled flight into terr/obj (CFIT) (Defining event) Page 2 of 5 ANC16LA032 Pilot Information Certificate: Commercial Age: 27, Male Airplane Rating(s): Multi-engine Land; Single-engine Seat Occupied: Left Land; Single-engine Sea Other Aircraft Rating(s): None Restraint Used: 3-point Instrument Rating(s): Airplane Second Pilot Present: No Instructor Rating(s): Airplane Single-engine Toxicology Performed: No Medical Certification: Class 1 With Waivers/Limitations Last FAA Medical Exam: 09/18/2015 Occupational Pilot: Yes Last Flight Review or Equivalent: 04/16/2016 Flight Time: (Estimated) 1150 hours (Total, all aircraft), 78 hours (Total, this make and model), 943 hours (Pilot In Command, all aircraft), 141 hours (Last 90 days, all aircraft), 64 hours (Last 30 days, all aircraft) Aircraft and Owner/Operator Information Aircraft Make: CESSNA Registration: N91170 Model/Series: 207 Aircraft Category: Airplane Year of Manufacture: 1969 Amateur Built: No Airworthiness Certificate: Normal Serial Number: 20700101 Landing Gear Type: Tricycle Seats: 7 Date/Type of Last Inspection: 05/23/2016, 100 Hour Certified Max Gross Wt.: 3803 lbs Time Since Last Inspection: 35 Hours Engines: 1 Reciprocating Airframe Total Time: 15089.1 Hours as of last Engine Manufacturer: CONT MOTOR inspection ELT: C126 installed, not activated Engine Model/Series: IO 520 SERIES Registered Owner: DIO AIR LLC Rated Power: 300 hp Operator: RENFROS ALASKAN Operating Certificate(s) On-demand Air Taxi (135) ADVENTURES INC Held: Page 3 of 5 ANC16LA032 Meteorological Information and Flight Plan Conditions at Accident Site: Instrument Conditions Condition of Light: Day Observation Facility, Elevation: PAPM, 15 ft msl Distance from Accident Site: 14 Nautical Miles Observation Time: 1956 UTC Direction from Accident Site: 193° Lowest Cloud Condition: Unknown Visibility 10 Miles Lowest Ceiling: Unknown Visibility (RVR): Wind Speed/Gusts: 12 knots / Turbulence Type / Forecast/Actual: Wind Direction: 210° Turbulence Severity / Forecast/Actual: Altimeter Setting: 29.85 inches Hg Temperature/Dew Point: 9°C / 7°C Precipitation and Obscuration: No Obscuration; No Precipitation Departure Point: QUINHAGAK, AK (AQH) Type of Flight Plan Filed: Company VFR Destination: Goodnews Bay, AK (GNU) Type of Clearance: None Departure Time: Type of Airspace: Class G Airport Information Airport: GOODNEWS (GNU) Runway Surface Type: N/A Airport Elevation: 18 ft Runway Surface Condition: Unknown Runway Used: N/A IFR Approach: None Runway Length/Width: VFR Approach/Landing: None Wreckage and Impact Information Crew Injuries: 1 Serious Aircraft Damage: Substantial Passenger Injuries: N/A Aircraft Fire: None Ground Injuries: N/A Aircraft Explosion: None Total Injuries: 1 Serious Latitude, Longitude: 59.236111, -161.716944 Administrative Information Investigator In Charge (IIC): David S Williams Adopted Date: 08/28/2017 Additional Participating Persons: ROY REDIFER; FAA; ANCHORAGE, AK MIKE COUNCIL; CONTINENTAL MOTORS; MOBILE, AL PAUL YOOS; TEXTRON AVIATION; WICHITA, KS Publish Date: 08/28/2017 Note: The NTSB did not travel to the scene of this accident. Investigation Docket: http://dms.ntsb.gov/pubdms/search/dockList.cfm?mKey=93416 Page 4 of 5 ANC16LA032 The National Transportation Safety Board (NTSB), established in 1967, is an independent federal agency mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The NTSB makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of any part of an NTSB report related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report. Page 5 of 5 ANC16LA032.
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