ASN Wikibase Occurrence # 140133
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| Date: | Monday 28 November 2011 |
| Time: | 22:50 |
| Type: |  Piper PA-31-350 Navajo Chieftain |
| Owner/operator: | Trans North Aviation Ltd |
| Registration: | N59773 |
| MSN: | 31-7652044 |
| Year of manufacture: | 1975 |
| Total airframe hrs: | 17630 hours |
| Engine model: | Lycoming LTIO-540-J2BD |
| Fatalities: | Fatalities: 3 / Occupants: 5 |
| Aircraft damage: | Substantial |
| Category: | Accident |
| Location: | Riverwoods, IL -
 United States of America
|
| Phase: | Approach |
| Nature: | Ambulance |
| Departure airport: | Jesup Wayne County Airport, GA (KJES) |
| Chicago-Executive Airport, IL (PWK/KPWK) | |
| Investigating agency: | NTSB |
| Confidence Rating: |  Accident investigation report completed and information captured |
On November 28, 2011, about 2250 central standard time, the pilot of Lifeguard N59773, a Piper PA-31-350 Chieftain airplane, declared an emergency, reporting that the airplane was out of fuel, and indicating that the flight was gliding without engine power direct to the destination airport, Chicago Executive Airport (PWK), near Wheeling, Illinois. The emergency medical services (EMS) airplane subsequently sustained substantial damage when it impacted trees and terrain near Riverwoods, Illinois. The airline transport pilot and two passengers on board sustained fatal injuries. A pilot-rated passenger received serious injuries and the medical crew member received minor injuries. The airplane was registered to and operated by Trans North Aviation Ltd. under the provisions of 14 Code of Federal Regulations Part 135 as a non-scheduled, domestic, on-demand, EMS passenger flight. Night visual meteorological conditions prevailed at the time of the accident for the flight, which operated on an activated instrument flight rules (IFR) flight plan. The flight departed from the Jesup-Wayne County Airport (JES), near Jesup, Georgia, about 1900.
The airplane was dispatched on an emergency medical services flight. While being vectored for an instrument approach, the pilot declared an emergency and reported that the airplane was out of fuel. He said the airplane lost engine power and that he was heading toward the destination airport. The airplane descended through clouds and impacted trees and terrain short of its destination.
No preimpact anomalies were found during a postaccident examination. The postaccident examination revealed about 1.5 ounces of a liquid consistent with avgas within the airplane fuel system. Based on the three previous flight legs and refueling receipts, postaccident calculations indicated that the airplane was consuming fuel at a higher rate than referenced in the airplane flight manual. Based on this consumption rate, the airplane did not have enough fuel to reach the destination airport; however, a 20-knot tailwind was predicted, so it is likely that the pilot was relying on this to help the airplane reach the airport. Regardless, he would have been flying with less than the 45-minute fuel reserve that is required for an instrument flight rules flight. The pilot failed to recognize and compensate for the airplane’s high fuel consumption rate during the accident flight. It is likely that had the pilot monitored the gauges and the consumption rate for the flight he would have determined that he did not have adequate fuel to complete the flight.
Toxicology tests showed the pilot had tetrahydrocannabinol and tetrahydrocannabinol carboxylic acid (marijuana) in his system; however, the level of impairment could not be determined based on the information available. However, marijuana use can impair the ability to concentrate and maintain vigilance and can distort the perception of time and distance. As a professional pilot, the use of marijuana prior to the flight raises questions about the pilot’s decision-making.
The investigation also identified several issues that were not causal to the accident but nevertheless raised concerns about the company’s operational control of the flight. The operator had instituted a fuel log, but it was not regularly monitored. The recovered load manifest showed the pilot had been on duty for more than 15 hours, which exceeded the maximum of 14 hours for a regularly assigned duty period per 14 Code of Federal Regulations Part 135. The operator stated that it was aware of the pilot’s two driving while under the influence of alcohol convictions, but the operator did not request a background report on the pilot before he was hired. Further, the operator did not list the pilot-rated passenger as a member of the flight crew, yet he had flown previous positioning legs on the dispatched EMS mission as the pilot-in-command.
Probable Cause: The pilot's inadequate preflight planning and in-flight decision-making, which resulted in a loss of engine power due to fuel exhaustion during approach. Contributing to the accident was the pilot's decision to operate an airplane after using illicit drugs.
Accident investigation:
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Sources:
NTSB
FAA register: 2. FAA: http://registry.faa.gov/aircraftinquiry/NNum_Results.aspx?omni=Home-N-Number&nNumberTxt=59773
6. https://flightaware.com/live/flight/N59773/history/20111128/2308Z/KJES/KPWK
Location
Images:
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 29-Nov-2011 00:29 | harro | Added |
| 29-Nov-2011 00:39 | harro | Updated [Aircraft type, Registration, Cn, Operator, Phase, Nature, Departure airport, Source] |
| 29-Nov-2011 01:04 | RobertMB | Updated [Time, Aircraft type, Operator, Other fatalities, Phase, Nature, Departure airport, Destination airport, Source, Narrative] |
| 29-Nov-2011 08:50 | Anon. | Updated [Total fatalities, Narrative] |
| 30-Nov-2011 13:29 | inspector | Updated [Embed code] |
| 30-Nov-2011 22:01 | inspector | Updated [Embed code] |
| 30-Nov-2011 22:04 | Anon. | Updated [Embed code] |
| 01-Dec-2011 12:11 | fishman5599 | Updated [Embed code] |
| 01-Dec-2011 12:12 | Anon. | Updated [Embed code] |
| 12-Dec-2011 13:34 | Geno | Updated [Source, Narrative] |
| 21-Dec-2016 19:26 | ASN Update Bot | Updated [Time, Damage, Category, Investigating agency] |
| 21-Oct-2017 20:28 | Dr. John Smith | Updated [Time, Location, Departure airport, Destination airport, Source, Narrative] |
| 21-Oct-2017 20:30 | Dr. John Smith | Updated [Location] |
| 21-Oct-2017 20:32 | Dr. John Smith | Updated [Source, Damage] |
| 27-Nov-2017 17:25 | ASN Update Bot | Updated [Time, Operator, Other fatalities, Departure airport, Destination airport, Source, Damage, Narrative] |
| 02-Jul-2023 21:50 | Captain Adam | Updated [[Time, Operator, Other fatalities, Departure airport, Destination airport, Source, Damage, Narrative]] |
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