LAX06FA258
LAX06FA258

HISTORY OF FLIGHT

On August 11, 2006, about 0215 Saipan standard time (about 1615, August 10, 2006, Coordinated Universal Time (UTC)), a Piper PA-32-300, N4509T, experienced a total loss of engine power during initial climb from the Saipan International Airport, Saipan, Northern Mariana Islands. The pilot made a forced landing into high, vegetation-covered terrain about 1/2-mile southeast of the departure end of runway 07. The airplane was substantially damaged during the impact sequence and thereafter was consumed by post impact fire. The single engine airplane, known as a Cherokee Six, had a total of seven installed seats. The commercial pilot and six passengers received serious injuries. The inter-island passenger transportation flight was operated and performed by Taga Air Charter Services, Inc., Tinian, NM, the airplane's registered owner. Taga Air holds a 14 Code of Federal Regulations Part 135 air carrier operating certificate. Taga Air reported that the flight was performed under the provisions of 14 Code of Federal Regulations Part 91 on behalf of the Tinian Dynasty Hotel & Casino (TDHC). Visual meteorological conditions prevailed during the dark nighttime flight. Taga Air dispatched the flight and followed its progress under a company visual flight rules flight plan. The flight originated from Saipan about 0213.

The pilot reported that he arrived at the Saipan International Airport about 1900, to commence his nighttime 12-hour-long flight shift, which was to end at 0700 the following morning. The pilot was wearing his customary uniform, which included captain's epaulettes on his shoulders.

According to the pilot, he flew the first round trip between the islands of Saipan and Tinian in the accident airplane using fuel from the right main fuel tank. The second trip was begun using fuel from the left main fuel tank. The flight time between the islands is about 10 minutes.

The pilot stated that when the passengers arrived at the Saipan Airport for their flight to Tinian, Taga Air's ground crew loaded them along with their tagged luggage into the airplane. Because each bag had been weighed and marked, the ground crew knew where to position their luggage in the airplane.

The pilot performed a "walk-around" of the airplane and checked the fuel. All of the airplane's systems were working fine. The ground crew gave the passengers a safety briefing and provided the pilot with the weight and balance document, which the ground crew had completed.

The pilot stated that he made an on time departure. He took off from the intersection of taxiway Bravo on runway 07. Departure from this intersection provided him with about 2/3 of the runway's full length. According to the pilot, it was a customary practice to take off from intersection Bravo.

The pilot reported that the airplane's acceleration down the runway was normal. The engine was not backfiring, missing, or making any atypical sound. The climb was uneventful until reaching between 200 and 350 feet above ground level at which time the airplane began descending. The pilot stated that he could not recall whether or not the airplane lost all engine power, but he deployed full wing flaps in preparation for a forced landing onto terrain next to the airport.

Saipan air traffic control tower personnel reported that seconds after the pilot became airborne, he broadcast "09T going down." No further communications were received by the control tower personnel.

The airplane crashed into jungle-like terrain on the right side of the departure runway. Within minutes, it was consumed by a post impact ground fire.

PERSONNEL INFORMATION

The TDHC employed the pilot, age 25, for several purposes including the transportation of passengers on daily flights between the islands of Saipan and Tinian. The pilot held a commercial pilot certificate with the following ratings: airplane single and multiengine land, airplane single engine sea, and instrument airplane. In addition, he held a certified flight instructor certificate for airplane single and multiengine, and instrument airplane.

In March, 2006, the pilot was issued a First Class airman medical certificate without limitations.

On an April, 2006, new employment resume, the pilot indicated that his total flight time was 410 hours and his total nighttime flying experience was 35 hours. On April 10, 2006, the pilot commenced Cherokee Six flight training at Taga Air.

By the accident date, the pilot's total flight time was 560 hours, and his total nighttime flying experience was 105 hours. He had flown about 106 hours during the preceding 90-days, and he had made about 100 round trip flights with passengers between Saipan and Tinian.

AIRCRAFT INFORMATION

Maintenance Records

By the accident date, the 1972 Piper airplane, model PA-32-300, serial number 32-7240083, had a total airframe time of about 5,325 hours. The engine's approximate total time was 4,941 hours. Taga Air maintained the airplane on an annual and 100-hour inspection basis.

Maintenance records indicated that the last annual inspection was performed on July 12, 2006, at a total airplane time of 5,282.2 hours. On this date, the engine's time since new was 4,898.2 hours, and its time since last overhaul was about 1,234.8 hours.

A review of maintenance records and pilot squawks recorded on Taga Air's "Aircraft Flight Log" was performed. The review period was from the date of the last annual inspection through August 9, 2006. Records were not available/recovered for August 10 and 11.

The records review revealed that in each instance where discrepancies had been recorded on the "Flight Discrepancies" portion of the airplane's log sheets, the listed discrepancies were addressed by close out actions on the "Corrective Actions" portion of the log sheets.

No discrepancies were listed on the log sheet dated August 9, 2006. The accident pilot did not report experiencing any maintenance discrepancies during his preflight inspection in preparation for the accident flight.

Seat Installation

After manufacture, the "6-seat" airplane had been equipped with an optional 7th seat. The seating configuration was, accordingly, 2 seats in the first (front) row, 3 seats in the middle row, and 2 seats in the third (rear) row.

METEOROLOGICAL INFORMATION

About 19 minutes prior to the accident Saipan Airport reported its surface wind was from 230 degrees at 3 knots, 10 miles visibility, few clouds at 2,000 feet and scattered clouds at 9,000 feet. The temperature and dew point were, respectively, 26 and 24 degrees Fahrenheit. When the accident airplane was cleared for takeoff, the wind was reported as calm.

AIRPORT AND GROUND FACILITIES

Saipan International Airport's elevation is 215 feet mean sea level (msl). The Federal Aviation Administration (FAA) reported that, at the time of the accident, all airport equipment, lights and services were operating normally at the airport.

Runway 07 was dry at the time of N4509T's takeoff. The runway has an asphalt/grooved surface and is 8,700 feet long by 200 feet wide. The distance between runway 07's threshold and intersection Bravo, the location from which N4509T initiated its departure, is about 3,100 feet. From intersection Bravo to the runway's end is about 5,600 feet.

WRECKAGE AND IMPACT INFORMATION

The wreckage was located about 2,500 feet southeast of runway 07's departure end. (For a perspective showing the relationship between the runway and the location of the accident site, see the picture included in the Safety Board's docket for this accident.)

The on-scene portion of the Safety Board's investigation was performed by FAA Honolulu, Hawaii, Flight Standards District Office personnel and the Safety Board investigator's authorized Piper Aircraft participant. The participants reported that their physical examination of the airplane's structure and ground scar were consistent with the airplane impacting the high, native vegetation-covered, rough terrain in a near level flight upright attitude. The airplane was found oriented on an approximate 77-degree magnetic heading, and at an approximate elevation of 220 feet msl. All major structural components and flight control surfaces were accounted for at the accident site.

The propeller blades were observed bent in an aft direction. There was an absence of blade s-bending and torsional deformation.

The majority of the airframe was observed consumed by fire. The entire cockpit, instrument panel and fuselage were destroyed. A few gallons of fuel were observed in the left wing's main fuel tank. The other tanks were breached and/or destroyed by fire. Fuel caps were found secured to the 4 fuel tanks.

No evidence of preimpact disconnection of any flight control surface or control system was observed. The fuel selector valve was located attached to the floor of the fire-damaged fuselage. The Piper participant reported that, upon examination, the valve was observed oriented to provide fuel from the left tip tank to the engine.

SURVIVAL ASPECTS

Taga Air's Director of Operations (DO) reported that no shoulder harness was available for the pilot's use. During the wreckage examination, no evidence of shoulder harnesses was observed at any of the passenger seat locations. A total of 7 seats were observed installed in the airplane.

TESTS AND RESEARCH

Engine Examination

The Lycoming engine was disassembled and examined under Safety Board supervision at Textron Lycoming's Williamsport, Pennsylvania, manufacturing factory. The engine was observed impact and fire damaged. Portions of its case were melted. In pertinent part, all of the connecting rods were found attached to the crankshaft, which along with the camshaft was intact. The accessories, including magneto wiring harnesses, were destroyed. All accessory gear teeth were found intact. No evidence of preimpact mechanical anomalies was noted.

Taga Air's Fueling Policy and Procedures

Taga Air's DO reported that it was company policy to only place fuel into the airplane's two main (inboard) wing tanks. The auxiliary (outboard) tip tanks are typically kept empty or nearly empty.

The pilot reported that at the beginning of his work shift in the accident airplane the main fuel tanks had been topped off. He stated that during his flights he had not used fuel from the tip tanks, and it was company policy not to use the wing tip tanks. The pilot stated that the tip tanks mostly are kept empty or nearly empty. He also stated the company does not use the wing tip fuel tanks anymore.

FAA Type Certificate and Piper Aircraft Fuel Usage Requirements

The FAA's Type Certificate Data Sheet (TCDS) prescribes the conditions and limitations under which the airplane meets FAA airworthiness requirements. According to the TCDS, the airplane must be operated pursuant to its FAA approved Airplane Flight Manual (AFM), Piper report number VB-393.

The Limitation Section of the airplane's AFM states that the limitations to "Fill tip tanks first; use main tanks first" must be observed in the operation of this airplane.

Additionally, the AFM requires placement of a placard on the fuel selector valve cover that states: "FILL TIP TANKS FIRST. USE MAIN TANKS FIRST."

Service Bulletin (SB) Compliance, 7th Seat Installation

On November 28, 1988, Piper issued mandatory SB #896, on the subject "Shoulder Harness Installation & Usage." By serial number reference, the SB was pertinent to the accident airplane. The SB stated that the purpose was to inform its customers of the availability of shoulder harness kits, and the SB indicated that, in the interest of safety, Piper "strongly urges you to install and use the complete restraint system of both seat belts and shoulder harnesses for all crew and passengers each time your aircraft is operated."

However, the SB included a note regarding shoulder harness usage when a 7th seat was installed in the Cherokee Six. The SB stated the following: "For customers with optional seventh seat installation, Piper recommends that this seat not be used. An adequate shoulder restraint is not available."

Taga Air Maintenance Records Examination

A review of maintenance records for the applicability of SBs indicated that Taga Air determined compliance with SB #896 was required. Also, its records indicated that the provisions of the SB had been complied with. The FAA requires compliance with manufacturer's mandatory SBs during operation under Part 135.

Taga Air Weight and Balance Procedures

Prior to departure for the accident flight, ground crew prepared a load manifest document for the flight. The Taga Air manifest indicated, in part, that a total of 6 passengers and baggage were to be flown from Saipan to Tinian. The total weight of all occupants, including baggage, was 1,152 pounds. The airplane's basic empty weight was 2,001 pounds. The total weight of the airplane, occupants and baggage was, accordingly, 3,153 pounds. Including fuel, the airplane's total weight was 3,387 pounds.

The load manifest incorporates preprinted data including various captions where subsequent data is to be entered during the flight planning process. As indicated on the manifest, the preprinted arm for use in the balance computations for the middle row of seats is 120.1 inches.

FAA Requirements, Weight and Balance

According to the FAA's TCDS, the airplane's maximum certificated gross weight is 3,400 pounds.

For weight and balance computational purposes, the 2 or 3 seats located in the center row of the fuselage have an arm of 118.1 inches. This is 2 inches forward of the arm used by Taga Air in its load manifest form.

The TCDS states when loading the airplane, "All weight in excess of 3112 lb. must be fuel weight only."

An examination of the Limitation Section in the AFM indicates a requirement that a placard be displayed on the fuel selector valve cover stating the following: "ALL WEIGHT IN EXCESS OF 3112 POUNDS MUST BE FUEL WEIGHT ONLY."

Taga Air personnel reported that the accident airplane was loaded pursuant to the aforementioned manifest form, and no baggage (weight) was removed to reduce the load to the requisite 3,112 pounds.

The Safety Board investigator calculates that, based upon the Taga Air provided passenger, baggage, and fuel quantity weight, the airplane was about 41 pounds over its allowable operating weight upon departure for the accident flight (3,153 lbs - 3,112 lbs = 41 lbs).

ADDITIONAL INFORMATION

Operating Requirements and Airplane Usage

Taga Air was issued Air Carrier Certificate number Z8TA in 2003, which authorized commencement of single pilot on-demand air taxi Part 135 operations. In 2005, the FAA modified the certificate to authorize Basic Part 135 operations. One of the Basic Air Taxi operational requirements was that Taga Air could not utilize more than 5 air taxi pilots. A review of FAA records indicated that as of March, 2006, Taga Air had 5 pilots (captains) in the company. Taga Air had received FAA approval to operate the following Piper PA-32-300 airplanes on its Air Carrier Certificate: N4089W, N4127R, N4254R, and N4509T (accident airplane).

Taga Air's Director of Maintenance (DM) had requested that the FAA Principal Maintenance Inspector assigned to their company add N4509T to Taga Air's Air Carrier Certificate. The DM stated that Taga Air had "inspected the aircraft [N4509T] and its equipment and determined that the aircraft conforms to the requirements of FAR 135.25(a), including...current airworthiness condition."

The FAA added N4509T to Taga's Air Carrier Certificate, with an effective date of August 3, 2006. According to Section A008 of Taga Air's revised FAA Operations Specifications entitled "Operational Control," on August 3, the company became responsible for operational control and had full authority for directing all aspects of the operation, including flight locating procedures.

Daily Flights and Operational Control

Taga Air management reported that its airplanes were used to transport TDHC passengers on a daily basis between Saipan and Tinian. The TDHC provided Taga Air with its passenger transportation requirements, which included a passenger list. Taga Air would fulfill the transportation order.

On June 8, 2006, a lease was effected between Taga Air Charter Services, Inc., a Saipan-based corporation (lessee), and the Hong Kong Entertainment (Overseas) Investments, Ltd., known as the Tinian Dynasty Hotel & Casino, a Tinian-based corporation (lessor).

Under the lease, the TDHC acquired access to Taga Air's 4 PA-32-300 airplanes, which were listed on Taga Air's air carrier certificate. The TDHC additionally leased from Taga Air a Cessna 172N and a Cessna 172RG. In total, this provided the TDHC with about 30 passenger seats for its use.

Lease provisions included requirements that all airplanes were airworthy, fully insured, and were to be utilized for FAR Part 91 operations by pilots that the TDHC hired.

Taga Air's Director of Operations (DO) reported to the Safety Board investigator that no insurance existed on the accident airplane, and that event was an oversight by company personnel.

Taga Air management personnel reported that ownership of Taga Air was, principally, by the same personnel who owned and/or operated the TDHC. The accident pilot reported that the two companies were "all one unit." Flight operations were overseen by Taga Air, and Taga Air's DO completed the Safety Board's "Pilot/Operator Aircraft Accident/Incident Report" form #6120.1 for the accident flight.

Insurance Requirements & FAA Oversight

The FAA's Honolulu-based Flight Standards District Office (FSDO) authorized inclusion of the accident airplane on Taga Air's FAA approved 14 CFR Part 135 Air Carrier Operations Specifications. The FSDO utilizes a document entitled "Office File Checklist Part 135 Air Carrier Operations" for monitoring and recording Part 135 operators' compliance with various requirements. One of the requirements involves providing the FAA with evidence of liability insurance for airplanes operated under FAR Part 135.

Specifically, the Department of Transportation (DOT) requires air taxi operators to provide the FAA with the aircraft make, model, and the registration number of the aircraft that the operator proposes to utilize in air taxi service. The DOT requires submission of a certificate of insurance evidencing required liability coverage for the requested aircraft.

The Safety Board investigator's examination of the FAA's "Office File Checklist" revealed it did not bear any entries for 2006. Specifically, the log sheet entry for documenting the receipt of the DOT's OST Form 4507 was blank. However, the form did exist in the FAA's files. Upon the Safety Board investigator's further examination of the certificate of insurance document associated with this form, it was noted that the accident airplane was not listed.

Purpose and Conduct of the Flight

According to Taga Air management personnel, the purpose of the accident flight was not local area sightseeing, but rather it was to transport internationally-arriving passengers and an off duty Taga Air pilot from Saipan to a hotel on the neighboring island of Tinian.

The accident pilot was flying a Taga Air-owned airplane and was wearing a captain's uniform. The accident pilot indicated that Taga Air provided him with specific guidance and instructions regarding operation of the airplane.

Taga Air requested that the airplane be placed on its FAR Part 135 certificate. The FAA amended Taga Air's Part 135 Operation Specifications to include the airplane about 1 week before the accident.

Taga Air personnel had provided flight training to the pilot. Their personnel checked him out in the model of airplane. On August 11, the pilot was not approved by Taga Air to fly under its Part 135 certificate.

The TDHC employed the pilot and leased the accident airplane from Taga Air, its registered owner. During the days following the accident, FAA personnel from the Honolulu Flight Standards District office advised Taga Air's management that this type of flight could not be performed under Part 91 and "must be stopped."

According to FAA personnel, it was their understanding that the purpose of the passenger-carrying accident flight was to transport the five passengers and a Taga Air off duty company pilot (non-revenue passenger) to the neighboring island of Tinian, about 11 nautical miles from Saipan. The flight should have been performed under the provisions of 14 CFR Part 135. The flight was performed at the request of the TDHC, which benefited from the flight. The TDHC does not hold an air carrier certificate. The FAA reported that the accident flight was considered to be a "revenue flight by rule."

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