NTSB Factual Report

HISTORY OF FLIGHT

On January 18, 2003, approximately 2010 Pacific standard time, a Piper PA-28-181, N7282C, impacted the waters of President Channel about one-third mile west of Orcas Island, Washington. The private pilot received serious injuries, the passenger in the right front seat received minor injuries, one passenger in the rear seat was uninjured, and the other rear seat passenger was still strapped in the seat when the aircraft sank to the bottom. The aircraft, which was owned and operated by the pilot, was destroyed by the impact sequence and the effects of the salt-water immersion. The 14 CFR Part 91 personal pleasure flight, which departed Sequim, Washington, about 30 minutes prior to the accident, was being operated in an area where fog and low ceilings had been reported. No flight plan had been filed. There was no report of an ELT activation.

According to the pilot, on the day of the accident, he flew his immediate family from Orcas Island to Sequim, landing there between 0900 and 0915. He and his passengers spent the day with extended family members and attended a church activity in the early evening. They arrived back at the Sequim Valley Airport about 1930, and after a normal preflight, during which the pilot found no anomalies or discrepancies, the flight departed for Orcas Island around 1940. According to the pilot, prior to departure, instead of setting his altimeter to the barometric pressure being transmitted from the Fairchild International Airport Automated Surface Observation System (ASOS), which is located approximately 12 miles west of Sequim Valley, he moved the altimeter-setting knob until the needles on the altimeter matched the published field elevation at Sequim Valley. After departure, he turned to the north and contacted Whidbey Approach as the aircraft was approaching an indicated altitude of 2,000 feet. Upon initial contact with the Whidbey controller, the pilot stated he was "…requesting flight following from Sequim Valley, presently 2,000, climbing to five point five, to Orcas Island eastbound." The controller immediately responded by instructing the pilot to squawk 0441 (mode C code), and advising him that the Whidbey altimeter was 30.18. The pilot repeated the mode C code, but did not make the required read-back of the altimeter setting. Thirteen seconds after the pilot stated that he was "presently 2,000," the controller advised him that Approach had radar contact at 2,500 feet, three miles northeast of Sequim. In a telephone conversation with the NTSB Investigator-In-Charge (IIC), the pilot stated that he then immediately set his altimeter so that it would read 2,500 feet. When asked, he said that he did not set in the barometric pressure provided to him by Whidbey Approach, nor did he check to see what the difference was between the barometric pressure setting now showing on his altimeter (after setting it to 2,500 feet) and that given by the controller. After setting 2,500 feet on his altimeter, the pilot climbed to an indicated altitude of 5,500 feet, and continued on toward his destination. Approximately 15 minutes later, the Whidbey controller advised the pilot that he was eight miles east of Eastsound, and that radar service was being terminated. Soon thereafter, as he flew past the town of Orcas, the pilot noticed that there was an area of low-level fog in the vicinity of the airport. He then continued his descent toward the destination, but did not update his altimeter using the barometric pressure setting transmitted by the Friday Harbor, Washington, ASOS or the Bellingham, Washington Automatic Terminal Information Service (ATIS). When he arrived in the area of the airport itself, he determined that the fog covered the airport, the town of Eastsound, the northern portion of Eastsound Inlet, and an area that extended about three miles north to the southern tip of Sucia Island. The pilot therefore overflew the airport from south to north, proceeded to a point just south of Sucia Island, and then made a left turn back to a point west of Eastsound over President Channel (between Orcas Island and Waldron Island). From there he turned back north again with the intention of looking for a place where he could descend below the fog in order to attempt to proceed to the airport (see pilot's diagrams with 6120.1/2). As he proceeded north, the pilot continued to descend over the water until he reached a point where his altimeter read approximately 600 feet indicated. He then turned on the landing light because he could not see the surface of the water. According to the pilot, just after he leveled at 500 feet indicated, his wife remarked that the water looked close, and then almost immediately thereafter, the left wing of the aircraft impacted the surface of the water. The pilot then immediately pulled up and rapidly added full power. Although he attempted to climb away from the water, he had a hard time determining the attitude of the aircraft because the wing's impact with the water had splashed a considerable amount of salt water on the windshield. Although the engine momentarily sputtered during the rapid throttle increase, according to the pilot, it seemed to quickly accelerate to full power. The pilot then attempted to keep the wings level, but was having trouble doing so. He was not sure if that was because of a lack of visual references on the dark night or because damage to the wing was making the aircraft hard to control. He therefore checked his attitude indicator, which showed that the aircraft was in a left wing-low attitude. Just as he was starting to make an input to roll the aircraft to the right, the left wing again impacted the surface of the water and the aircraft cartwheeled nose first into the channel.

At that point, because the cabin entry door had come off, the front windscreen had broken out, and one wing had separated, the aircraft rapidly filled with water. As the aircraft filled with water and began to sink, both front occupants and one person in the rear were able to get out and come to the surface. Although the pilot dove down and attempted to retrieve the other back seat passenger, he was unable to do so before the fuselage sank to the bottom. Individuals on the shore, who heard the impact and yells for help, rescued the survivors in small boats.

PERSONNELL INFORMATION

The pilot holds a private pilot certificate with a single engine land rating. He does not hold an instrument rating. Of his total 292 hours of pilot time, 162 were in this make and model aircraft, and 28 hours were logged as night time. In a telephone conversation with the IIC, the pilot, who keeps his aircraft at the Orcas Island Airport, said that he had landed at the subject airport at night a number of times in the past. He said that a few times he found it necessary to maneuver under low clouds in order to land there, and that once he diverted to Friday Harbor because the clouds were too low. In the 90 days prior to the accident, he had logged 10 hours of night time.

METEOROLOGICAL INFORMATION

The 1953 aviation surface observation (METAR) at Friday Harbor, which is located about 12 miles south of the accident site, reported winds of 360 degrees at three knots, clear, seven statute miles visibility, temperature three degrees Celsius, dew point three degrees Celsius, and a barometric pressure of 30.17.

The 2053 METAR at Bellingham, which is located about 15 miles northeast of the accident site, indicated winds from ten degrees at three knots, few clouds at 9,000 feet, mist, and a visibility of six miles. Both the temperature and the dew point were one degree, and the barometric pressure was 30.18.

The 2022 METAR at Victoria Airport, Victoria, Canada, which is located about 18 miles southwest of the impact area, reported calm winds, one statute mile visibility, mist, few clouds at 100 feet, and a broken ceiling at 400 feet. Approximately one hour and twenty minutes earlier, the visibility at this station had been 20 miles, with few clouds at 18,000 feet and a broken ceiling at 22,000 feet.

According to a local witness at the airport, the fog moved in around 1830, and seemed to be about 200 feet above the ground and getting lower throughout the evening. A pilot who landed at the airport just as the fog was moving over the northern end of the runway said that the top of the fog layer was about 400 feet above the ground. This same pilot said he had seen the fog move in from the north, and that portions of the fog bank were spread throughout the area north of Orcas Island.

According to the pilot of N7282C and his wife, the visibility en route from Sequim had been very good, with the terrain illuminated by the moon. But once they got down near the water it seemed darker and much harder to see.

According to the individuals who rescued the survivors, at the time the aircraft hit the water the fog was very low over their position (near the shore about one-third mile from the accident site). They said that by the time they got out to where the survivors were, the fog was low and thick in that area as well.

According to the pilot, because he could see the San Juan Islands from his location in Sequim (about 35 miles away), and since it had been clear all day, he chose not to get a weather briefing or to check with someone in the Eastsound area prior to departure.

WRECKAGE AND IMPACT INFORMATION

Although witnesses reported that the aircraft initially touched the surface of the water between Freeman Island and Point Doughty, it is believed that the final impact with the water was very near Point Doughty (see attached map). The wreckage was ultimately located in 205 feet of water about 500 yards north of Point Doughty. After retrieval and removal of the remaining passenger from the right rear seat, the aircraft was taken to a hangar at Sanderson Field, Shelton, Washington, where a teardown inspection of the airframe and engine where conducted. It was determined that the right wing had been torn from the fuselage at the spar attach fittings. The majority of the front windshield was missing, and the engine and engine mount remained attached to the fuselage only by the battery cable, throttle wire, and by a number of other small wires. The instrument panel, which was relatively undamaged, also remained attached to the fuselage only by wires and cables. The left main gear, including the wheel fairing, was still intact on the left wing, but the nose gear tube had sheared near where it connects to the nose wheel fork. There was clear evidence of hydraulic crushing or other impact damage to the skin area under the engine, and also to the spinner attach plate, oil cooler, and parts of the exhaust system. Both lobes of the carburetor float were imploded over most of their surfaces, and a good clear sample of blue-colored fuel was found in the fuel line to the gasculator/fuel strainer.

There was no internal damage to the dry vacuum pump. The airspeed indicator read 158 mph. The turn and bank indicator showed a slight left wing down attitude (one wing width), and the ball was free to move. The attitude indicator was too damaged to read, and the altimeter, which was later determined to have an impact damaged aneroid, read 3,765 feet and approximately 30.49 inches.

The teardown inspection revealed no evidence of pre-impact malfunctions or anomalies associated with the airframe or engine

ADDITIONAL DATA AND INFORMATION

In November of 2001, the pilot took his aircraft to American Avionics, Inc., of Seattle, Washington (Boeing Field), because he had noticed the altimeter occasionally sticking during a climb. According to the relevant work order at American Avionics (invoice #99924), the altimeter was removed from the aircraft and bench-tested. The technicians found that it was "sticking excessively," causing it to be out of tolerance at "most altitudes." The altimeter was then disassembled and inspected, and the mechanical parts were cleaned. The hairspring was adjusted to the proper tension, and dial and gear assembly (part #5934-1-85A) was replaced. In addition, for cosmetic reasons, the dial (20,000 foot) and all three pointers were replaced. According to the documentation, all work was done in accordance with United Maintenance Manual TM-5934, Addendum 1. As required by FAR Part 91.413, after the repair/cleaning was complete, the instrument was tested to 20,000 feet in accordance with FAR Part 43, Appendix E (to include both hysteresis and friction vibration tests). The altimeter was then reinstalled in the aircraft, and an integrated systems check and ATC transponder check were performed. In addition, the static system leak test required by FAR Part 91.411 was performed in accordance with FAR Part 43, Appendix E.

After the accident, the altimeter was subjected to a teardown inspection at Airtech Instrument Company, Inc. (FAA Repair Station IQ6R622N). Although there was no obvious indication of pre-impact anomalies, testing was not possible because of damage to the aneroid and the effects of the salt water immersion. When the aircraft was recovered from the water the barometric window appeared to read 30.49 inches of mercury. During the inspection it was determined to read 30.50 inches, which corresponds to 513 feet when referenced to a barometric pressure of 29.92 (the base line reference for the encoder). This setting (30.50) represents an altitude differential of about 330 feet from the setting reported at the nearest station (30.17 at Friday Harbor) about 15 minutes prior to the accident.

In a telephone conversation with the IIC, the pilot said that although having the altimeter stick in the climb had become fairly common prior to taking the instrument in for repair, he had seen no indication of sticking during any of the flights conducted after the repairs had been made.

The aircraft was released to Jim Stiger of PAC Northwest, Inc., on 1/30/03. At the time of the release, the aircraft was located at Sanderson Field, Shelton, Washington.

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NTSB Probable Cause

The pilot's failure to maintain clearance from the water and his failure to reset the altimeter to the local barometric pressure. Contributing factors were fog and night conditions.