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ASN Wikibase Occurrence # 178404
Last updated: 21 December 2019
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Date:07-AUG-2015
Time:17:50
Type:Silhouette image of generic P46T model; specific model in this crash may look slightly different
Piper PA-46-500TP Malibu Meridian
Owner/operator:Raymond Shortino
Registration: N819TB
C/n / msn: 4697117
Fatalities:Fatalities: 4 / Occupants: 4
Aircraft damage: Written off (damaged beyond repair)
Location:NW of Adirondack Regional Airport (KSLK), Saranac Lake, NY -   United States of America
Phase: Initial climb
Nature:Private
Departure airport:Saranac Lake, NY (SLK)
Destination airport:Rochester, NY (ROC)
Narrative:
The private pilot, who was experienced flying the accident airplane, was conducting a personal flight with three passengers on board the single-engine turboprop airplane. Earlier that day, the pilot flew uneventfully from his home airport to an airport about 1 hour away. During takeoff for the return flight, the airplane impacted wooded terrain about 0.5 mile northwest of the departure end of the runway. There were no witnesses to the accident, but the pilotís radio communications with flight service and on the common traffic advisory frequency were routine, and no distress calls were received. A postcrash fire consumed a majority of the wreckage, but no preimpact mechanical malfunctions were observed in the remaining wreckage.
Examination of the propeller revealed that the propeller reversing lever guide pin had been installed backward. Without the guide pin installed correctly, the reversing lever and carbon block could dislodge from the beta ring and result in the propeller blades traveling to an uncommanded feathered position. However, examination of the propeller components indicated that the carbon block was in place and that the propeller was in the normal operating range at the time of impact. Additionally, the airplane had been operated for about 9 months and 100 flight hours since the most recent annual inspection had been completed, which was the last time the propeller was removed from and reinstalled on the engine. Therefore, the improper installation of the propeller reversing lever guide pin likely did not cause the accident.
Review of the pilotís autopsy report revealed that he had severe coronary artery disease with 70 to 80†percent stenosis of the right coronary artery, 80 percent stenosis of the left anterior descending artery, and mitral annular calcification. The severe coronary artery disease combined with the mitral annular calcification placed the pilot at high risk for an acute cardiac event such as angina, a heart attack, or an arrhythmia. Such an event would have caused sudden symptoms such as chest pain, shortness of breath, palpitations, or fainting/loss of consciousness and would not have left any specific evidence to be found during the autopsy. It is likely that the pilot was acutely impaired or incapacitated at the time of the accident due to an acute cardiac event, which resulted in his loss of airplane control.

Probable Cause: The pilotís loss of airplane control during takeoff, which resulted from his impairment or incapacitation due to an acute cardiac event.

Sources:

NTSB: https://www.ntsb.gov/_layouts/ntsb.aviation/brief.aspx?ev_id=20150807X03037&key=1
https://flightaware.com/live/flight/N819TB/history/20150807/2100Z/KSLK/KROC
http://aerossurance.com/safety-management/ntsb-pt6a-beta-arm-hf-hcd/
FAA register: http://registry.faa.gov/aircraftinquiry/NNum_Results.aspx?NNumbertxt=819TB


Revision history:

Date/timeContributorUpdates
08-Aug-2015 05:24 Geno Added
08-Aug-2015 06:46 Geno Updated [Time, Total fatalities, Total occupants, Location, Source, Damage, Narrative]
08-Aug-2015 16:10 Geno Updated [Aircraft type, Registration, Cn, Operator, Departure airport, Destination airport, Source, Narrative]
08-Aug-2015 16:47 Geno Updated [Aircraft type, Registration, Cn, Operator, Departure airport, Destination airport, Source, Narrative]
10-Aug-2015 08:05 Chieftain Updated [Phase]
12-Aug-2015 13:56 Aerossurance Updated [Time, Registration, Nature, Source, Narrative]
17-Aug-2016 15:22 Iceman 29 Updated [Source, Embed code, Narrative]
21-Dec-2016 19:30 ASN Update Bot Updated [Time, Damage, Category, Investigating agency]
01-Dec-2017 15:08 ASN Update Bot Updated [Operator, Other fatalities, Departure airport, Destination airport, Source, Embed code, Narrative]
10-Jan-2018 19:16 Aerossurance Updated [Source, Embed code]

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