CEN12FA097
CEN12FA097

HISTORY OF FLIGHT

On December 3, 2011, about 2010 eastern standard time, a Piper PA-32-260, N33315, operated by Great Lakes Air (GLA) collided with trees and the terrain in St. Ignace, Michigan. The commercial rated pilot and a private-rated pilot passenger were fatally injured. The airplane was substantially damaged from impact forces. The non-scheduled domestic passenger flight was operated under the provisions of 14 Code of Federal Regulations (CFR) Part 135. Instrument meteorological conditions prevailed and no flight plan was filed. The airplane departed from the Mackinac County Airport (83D), St. Ignace, Michigan, at an estimated time of around 1950 with an intended destination of the Mackinac Island Airport (MCD), Mackinac Island, Michigan.

The passenger contacted another company pilot on the night prior to the accident stating that he was traveling to St. Ignace the following day and he was going to need air transportation to Mackinac Island. The passenger also stated that he needed to be in Gaylord, Michigan on December 4th for a morning meeting. This pilot instructed the passenger to call the airport to schedule the flight.

The other company pilot stated that around noon on the day of the accident, he looked at the flight schedule and noticed that there were no flights scheduled for the day. He stated that he knew they would not be flying that day because of the poor weather, and that the accident pilot seemed relieved that he was not going to have to fly to the island that evening. This pilot stated that he then called the passenger and left a voice message stating that the weather was not very good, but that it should improve later in the day so the passenger should take his time getting to St. Ignace. The passenger returned the call stating that he would take his time.

The accident pilot was the only person on duty at the airport on the night of the accident. The other company pilot spoke with the accident pilot around 1800 and the accident pilot stated that the weather was improving and that he could see the bluff on the island. This pilot stated he checked the Automated Weather Observing System (AWOS) and it was reporting overcast clouds at 800 feet. He stated he told the accident pilot “don’t do anything dumb.” He then called the passenger and left a message stating that the weather now looked alright to get to the island.

The office manager for GLA, who lives near the airport, stated that she heard the airplane depart to the west around 2000 and that the airplane sounded “normal.”

The President of Great Lakes Air, who was also the Director of Operations, stated he arrived at the airport around 2030 and noticed that the door to the building was open, the airplane was gone, and the pilot’s car was in the parking lot. He stated he checked the reservation book and noticed a flight scheduled to the island at 2015. He stated his first thought was that the pilot had diverted to Pellston because of the weather.

When the pilot did not return his family became concerned and began making telephone calls to locate him. The President of Great Lakes Air stated that while he was at the airport, he received a call from the pilot's wife regarding the pilot’s whereabouts.

A search was initiated which involved local pilots, private citizens, the Coast Guard, sheriff’s department, Michigan State Police, Boarder Patrol, and the Sault Tribe Police. An airplane that was involved in the search picked up an emergency locator transmitter signal. A Coast Guard helicopter then hovered over the area and personnel on the ground located the wreckage using a hand held radio to pick up the signal. The wreckage was located approximately 1210 on December 4, 2011.

An witness who lived near the accident site stated that he heard the airplane engine around 1945 and it sounded like “a plane engine getting lower and lower”, followed by a crash. He stated it sounded like a typical “movie” airplane crash sound. The witness went outside to look in the woods around his house, but did not see anything.

PERSONNEL INFORMATION

The pilot held a commercial pilot certificate with airplane single-engine land, airplane multi-engine land, and instrument ratings issued on July 2, 2007. The pilot also held a flight instructor certificate with airplane single-engine land, airplane multi-engine land, and instrument ratings issued on September 19, 2011. The pilot was issued a first-class airman medical certificate, with no restrictions, on February 5, 2011.

A pilot’s logbook was provided by his family for review during the investigation. The first entry in the logbook was dated July 21, 2006, and the last entry was dated October 31, 2011. The logbook contained a total of approximately 2,197 hours of flight time, of which 317 were in PA-32-260 airplanes. The pilot had logged about 95 hours of actual instrument flight time, 99 hours of simulated instrument flight time, and 200 hours of night flight time. The pilot’s time and duty logs indicated that he flew an additional 13 hours in the month of November.

The pilot’s received a Part 135 proficiency check on February 19, 2011. In accordance with 14 CFR Part 61.56 (d) the proficiency check met the requirement for a flight review. The remarks on the Federal Aviation Administration (FAA) Form 8410-3 Airman Competency Proficiency Check which was completed for the pilot’s proficiency check stated “Initial Check This Operator ASEL Type VFR Only.”

FAA airman records indicate the pilot’s certification history as follows:

October 24, 2006
Private pilot certificate issued with airplane single-engine land rating.

February 13, 2007
Instrument rating was added to the private pilot certificate.

June 3, 2007
Commercial pilot certificate issued with airplane multi-engine landing rating. Private pilot privileges for airplane single-engine land.

July 2, 2007
Commercial pilot certificate issued with airplane single-engine land, airplane multi-engine land and instrument ratings.

October 12, 2007
Flight instructor certificate issued with airplane single-engine land rating.

January 19, 2008
Failed practical test for an instrument rating add-on to his flight instructor certificate. Area to be re-examined stated “Entire practical test.”

February 4, 2008
Failed practical test for an instrument rating add-on to his flight instructor certificate. Area to be re-examined stated “Non-precision instrument approach” and “Loss of gyro attitude and heading indicators.”

February 17, 2008
Flight instructor certificate issued with airplane single-engine land and instrument ratings.

September 3, 2009
Flight instructor certificate issued with airplane single-engine land, airplane multi-engine land, and instrument ratings.

September 19, 2011
Flight instructor certificate was renewed.

The pilot was employed by Great Lakes Air in February 2011, and he began his ground training on February 12, 2011. Time and duty records showed the pilot had flown a total of 506.9 hours as an employee of Great Lakes Air. His last flight prior to the accident flight was on November 30, 2011. The pilot had accepted a job flying DC-9’s for a charter company and was scheduled to begin training with his new employer on December 12, 2011.

The passenger held a private pilot certificate with an airplane single-engine land rating issued on September 22, 2010. The passenger was issued a second-class airman medical certificate, issued May 26, 2011, with the limitation “Must wear corrective lenses, possess glasses for near/intermediate vision.” At the time of the medical examination, the pilot reported having 160 hours of flight time, 50 hours of which were accumulated within the preceding 6 months.

One of the pilots who flew for Great Lakes Air stated that he had provided instruction for the passenger in the past and that the passenger was currently working on obtaining his instrument rating. He stated that the passenger typically flew an airplane that belonged to a flying club at MCD.

The passenger was known by some of the employees at Great Lakes Air. They stated he was in an out of the area frequently in the summer and they had frequently provided air transportation for him to the island.

AIRCRAFT INFORMATION

The accident airplane was a Piper model PA-32-260, serial number 32-7500017. It was a six-place, low-wing, single engine airplane, with a tricycle landing gear configuration. The airplane was purchased by GLA in February 1997. The airplane was issued an FAA standard category standard airworthiness certificate on February 10, 1975.

The tachometer time at the time of the accident was 2,686.0. According to the airframe logbook, the last annual inspection was conducted on October 21, 2011, at a tachometer time of 2,665.2. The aircraft total time was calculated to be 11,327 hours.

There was no engine data plate observed attached to the engine. Two data plates were located in the engine logbook folder. One data plate was marked O-540-B1A5 serial number L-5769-40. The other data plate was marked O-540-E4B5, serial number L-5796-40 and contained letter Penn Yan Aero R.S. Y2GR396Y. The engine logbook contained an entry dated February 22, 2010, stating that the engine had been altered from an O-540-B1A5 to an O-540-E4B5. According to the engine logbook, the last annual inspection was conducted on October 21, 2011, at an engine total time of 4,551.9 hours and a tachometer time of 2,665.2 hours. The total time since overhaul listed at the last annual inspection was 749.8 hours.

The airplane was flown about 1 hour after having been fueled with 37.8 gallons of fuel on December 1, 2011.

The airplane was equipped with two navigation (NAV)/communication (COM) radios, an automatic directional finder (ADF), distance measuring equipment, and global positing system (GPS). The Navs were found set on 111.xx and 111.80. The frequency for the Pellston very high frequency omnidirectional range (VOR) is 111.80. The COMs were set at 118.27 and 112.62. The common traffic advisory frequency for both 83D and MCD was 122.7. The automated weather observing system (AWOS) at MCD was 118.275. The GPS was selected on.

METEOROLOGICAL CONDITIONS

Weather conditions recorded by the MCD AWOS, located about 6 miles southeast of the accident site were:

At 2033: wind 170 degrees at 4 knots, visibility 5 miles with mist, scattered clouds at 300 feet, broken clouds at 1,100 feet, overcast clouds at 2,400 feet, temperature 5 degrees Celsius, dew point 4 degrees Celsius, and altimeter 30.02 inches of mercury.

At 2013: wind 170 degrees at 3 knots, visibility 7 miles, scattered clouds at 300 feet, overcast clouds at 900 feet, temperature 5 degrees Celsius, dew point 5 degrees Celsius, and altimeter 30.02 inches of mercury.

At 1959: wind calm, visibility 7 miles, broken clouds at 300 feet, overcast clouds at 700 feet, temperature 5 degrees Celsius, dew point 5 degrees Celsius, and altimeter 30.02 inches of mercury.

At 1953: wind 140 degrees at 3 knots, visibility 5 miles with mist, broken clouds at 300 feet, overcast clouds at 700 feet, temperature 5 degrees Celsius, dew point 4 degrees Celsius, and altimeter 30.02 inches of mercury.

14 CFR Part 135.205(a) states that “No person may operate an airplane under VFR in uncontrolled airspace when the ceiling is less than 1,000 feet unless flight visibility is at least 2 miles.”

One of the pilot’s from Great Lakes Air stated that as a general guideline they look to have a ceiling of at least 1,500 feet to make a night flight to the island. He stated that two days prior to the accident they had a group discussion with one of their new pilots regarding personal minimums, comfort levels, and not doing anything “stupid.” This discussion included the accident pilot.

One of the GLA pilots stated that the weather at St. Ignace was foggy and rainy on the day of the accident. The President of Great Lakes Air stated he arrived at MCD around 2030 on the night of the accident and he was able to see the island, but the ceilings were about 300 feet and fog was rolling in. He stated that the pilots were constantly checking the AWOS at MCD, but the best indicator of the weather was for them to look out the window because they could see the island from their location. He stated that the accident airplane was strictly a VFR airplane.

AIRPORT INFORMATION

The approach end of runway 25 at 83D is approximately 0.2 of a mile from the shore of Lake Huron. The distance between 83D and MCD is about 5 miles over the water of Lake Huron. The approach end of runway 08 at MDC is less than 0.4 of a mile from the shore of Lake Huron.

Both 83D and MCD were equipped with pilot controlled lighting. Both airports are equipped with medium intensity runway lights, precision approach path indicator lights, and runway end identifier lights. One of the GLA pilots stated that you need to be close to the airport to be able to activate the light at 83D.

MCD was equipped with a global positioning system (GPS) approach to runway 26 and a circling VOR/distance measuring equipment (DME) approach.

83D was equipped with an area navigation (RNAV)/GPS approaches to runways 7 and 25.

The accident site was about 1.2 miles south of a well-light casino/hotel complex. One of the GLA pilots stated that the casino is easier to see at night than the airport. He stated that the pilot may have seen the casino lights and was trying to follow the lakeshore back to the airport.

COMMUNICATIONS AND RADAR

There were no known communications between the airplane and any air traffic control facilities.

National Track Analysis Program (NTAP) data provided by the Minneapolis Air Route Traffic Control Center showed four unidentified radar targets near MCD between 1958:35 (hhmm:ss) and 1959:11. The first target was north of MCD. The second target is north of the first one and the third target was to the east. The fourth target which was over the water, indicated the airplane had turned back to the north.

WRECKAGE AND IMPACT INFORMATION

The wreckage was located about 1.6 miles north of 83D. The wreckage path was approximately 250 feet long and on a magnetic heading of 208 degrees. The area consisted of a clearing surrounded by a heavily wooded area. The clearing as about 25 feet wide at the widest point. The wooded area consisted of trees which varied in size, the largest being about 60 feet tall and 10 inches in diameter. The clearing consisted primarily of bog and knee deep water.

The first visible impact was with a tree that was about 8 feet in height. Approximately 25 feet from this tree, a ground impact was visible. The earth was pushed back and the impact hole had filed with water. About 50 feet from this impact area freshly broken tree branches and trunks were visible. The height of these tree breaks varied from close to the ground up to about 20 feet above the ground. Two pieces of the right wing were located approximately 175 feet from the initial tree impact and on the east side of the clearing. The right wing tip was located about 30 feet beyond the other sections of the right wing. Sections of the left wing were located about 230 feet from the initial tree impact and along the west side of the clearing. The main wreckage (fuselage, empennage, and cockpit) was located on the western edge of the clearing with the cockpit area embedded up against a group of trees. The propeller and engine were attached to the firewall and embedded up against the same group of trees. An odor of fuel was present in the area.

The wreckage was removed from the accident site for further examination. The fuselage sustained substantial impact damage. Most of the roof and right side of the fuselage were separated from the remaining wreckage and unrecognizable. The floor of the cockpit area was crushed. The left side of the fuselage was separated into several sections which were separated from the floor structure.

The aft fuselage sustained impact damage and was separated from both the forward fuselage and empennage. The right side of the aft fuselage was destroyed. The left side of the aft fuselage was separated into several pieces. The empennage was separated from the aft fuselage at the rear bulkhead.

The rudder, vertical stabilizer, and horizontal stabilator remained attached to each other. The top portion of the vertical stabilizer was crushed rearward. The top of the rudder sustained minor impact damage. The inboard section of the left side of the horizontal stabilator sustained minor aft crush damage and the trim tab was intact. The right side of the horizontal stabilator was crushed aft. The trim tab sustained impact damage and the outboard end of the tab was pulled from its attachment. The stabilator trim drum jack screw exhibited four threads which correlated to a slight nose down trim setting.

The left wing sustained substantial crush damage and it was separated from the fuselage at the wing root. The wing was separated into two sections outboard of the flap surface. The flap remained attached to the wing. The flap push/pull rod was separated with both ends attached to their respective surfaces. The outboard section of the wing sustained extensive aft crushing. The aileron remained attached to the wing at the outboard hinge. The aileron counterweight was separated from the aileron and it was not located. The leading edge skin outboard of the fuel tank was separated from the wing. The leading edge of the inboard fuel tank was crushed aft. The wing tip tank sustained impact damage and it was separated from the wing. The left main landing gear assembly was separated from the wing.

The right wing which had sustained extensive crush damage was separated from the fuselage at the wing root. The wing was separated in two outboard of the flap surface. The leading edge skin was separated from the inboard section of the wing. The flap remained attached to the wing at its inboard hinge. The flap push/pull rod was separated from the flap surface. The outboard section of the wing sustained impact damage. The aileron remained attached to the wing by the outboard hinge and the aileron counterweight remained attached to the aileron. The inboard fuel tank sustained minor damage. The wing tip tank was separated from the wing and it was destroyed.

Flight control continuity was established to all of the flight controls. The flight control cables were compromised in numerous locations and the separations exhibited signatures indicative of overload separations.

The propeller and mixture controls were in the full forward position. The throttle lever was retarded about 1-inch aft of full forward.

The position of the fuel selector could not be determined due to the amount of impact damage.

An examination of the engine revealed that it had sustained impact damage. The oil sump was fractured and oil was observed dripping from the engine. All filters and screens located were clean of debris. An examination of the vacuum pump revealed that it remained attached to the engine and no anomalies were noted. The No. 1 cylinder exhaust pushrod was separated from the engine.

The carburetor was fractured near the throttle plate. The mixture control arm was separated from the engine and the throttle control arm remained attached to the carburetor. The engine driven fuel pump was fractured and could not be tested. A small amount of fuel drained from the pump when the fuel lines were disconnected from it. No anomalies were noted with the carburetor floats, needle, and seat assembly. There was no fuel present in the fuel bowl.

The cylinder head covers were removed from the engine. The propeller was rotated by hand and continuity was established throughout the engine. Thumb compression and suction was observed on all cylinders. A boroscope inspection of the cylinders and valves revealed the presence of soil in the No. 1 and No. 2 cylinders near the valve heads.

The left magneto was separated from the engine. The right magneto remained attached to the engine. Both magnetos produced a spark on all of the electrodes when rotated by hand. The sparkplugs contained light gray combustion deposits and the electrode conditions appeared normal. Both the top and bottom spark plugs on the No. 2 and No. 6 cylinders were oily.

The propeller was attached to the engine and both blades remained attached in the hub. One blade curved aft and twisted with trailing edge impact damage. The other blade was free to rotate in the hub. This blade was bent aft about 80 degrees beginning approximately 12 inches outboard of the propeller hub. Approximately 12 inches of the blade tip was separated from the remainder of the blade. The separated portion was located near the main wreckage and it contained a gouge in the leading edge.

MEDICAL AND PATHOLOGICAL INFORMATION

Autopsies on both the pilot and passenger were ordered by the Mackinac County Chief Medical Examiner and conducted at Spetrum Health, Grand Rapids, Michigan, on December 5, 2011. The deaths of the pilot and pilot-rated passenger were attributed to injuries received in the accident.

Toxicology testing for both the pilot and passenger was performed by the FAA Civil Aerospace Medical Institute. The test results were negative for all substances in the screening profile.

ADDITIONAL INFORMATION

Great Lakes Air – Flight Dispatch

The management structure for Great Lakes Air consisted of a President, who was also the General Manager and Director of Operations, a Director of Maintenance, and a Chief Pilot.

One of the duties of the Director of Operations as outlined in the GLA General Operations Manual is to schedule and dispatch flights. The Director of Operations stated that he had delegated this authority to the pilots.

The General Operations Manual for GLA stated, “If for any reason an FAA flight plan cannot be filed, the PIC will call the GLA principle business office and talk to the D.O. or D.M. (these are the only two people who can perform this function.) The PIC will provide the same information as required on an FAA flight plan. The person taking the telephone call will record the information and become personally responsible for the information by remaining at the principle business office until the flight arrives at its destination and the PIC notifies the responsible person of the fights arrival.”

“If notice of arrival is not received within 30 minutes after the estimated time of arrival, the responsible person will notify ATC that the aircraft is overdue.”

In the case of the accident flight, the pilot’s brother, who was a Great Lakes Air pilot in training was notified that the flight was going out.

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