CEN12FA086

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.

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.

HISTORY OF FLIGHT 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. According to a load manifest form found in the wreckage, dated November 28, 2011, the crew that flew N59773 from the Crawfordsville Municipal Airport (CFJ), near Crawfordsville, Indiana, to the Perry-Houston County Airport (PXE), near Perry, Georgia, and onto the Palm Beach International Airport (PBI), near West Palm Beach, Florida, listed the pilot-rated passenger as the pilot-in-command and listed the pilot and the medical crewmember as “other crew.” This form indicated that this crew started their duty period at 0700 when they flew from CFJ and they ended their duty period at 1430 in PBI. According to another load manifest form, also dated November 28, 2011, the crew that flew N59773 from PBI, to JES, and onto PWK listed the pilot as the pilot-in-command and listed the pilot-rated passenger and the medical crewmember as "other crew." This form indicated that this crew started their duty period at 1430 at PBI. This form indicated that they departed from PBI at 1642 and landed at JES at 1830. Fueling records showed an airplane was fueled at JES with 160 gallons of aviation gasoline (avgas) and an additional 5 gallons of avgas, which totaled a combined servicing of 165 gallons of avgas. This manifest form indicated that they departed from JES at 1900 and were destined for PWK. The duty period ending time was not completed. A review of the recording of the approach controller’s frequency revealed that the pilot representing Lifeguard N59773 requested to fly direct to the outer marker navigation aid named PAMME. The controller indicated that the flight had to be taken on a heading to intercept the approach outside PAMME and the controller denied the request. The flight was given that heading for the instrument approach and the pilot then declared an emergency. The controller inquired if the flight was still landing at PWK. The pilot reported that he was unable, the airplane was out of fuel, and that the airplane was “coasting.” The controller asked if the field was in sight. The pilot reported negative and asked for the cloud tops. The controller indicated that the cloud deck was 1,400 feet overcast. The pilot responded that the flight was coasting down and that the pilot would report visual contact. The pilot further indicated that the flight was flying direct to PWK. The controller advised the flight of a low altitude alert and the flight acknowledged that alert. The controller again asked if the pilot had the field in sight. The pilot reported affirmative. The flight was cleared for the visual approach to runway 16 and the pilot was informed to cancel the flight’s IFR flight plan. The controller further indicated that the change to the airport’s advisory frequency was approved. There was no further recorded radio communication from the Lifeguard EMS flight. A transcript of the air traffic controller’s communications is appended to the docket associated with this investigation. The pilot-rated passenger sat in the front right seat of the airplane. During a postaccident telephone interview, he indicated that the flight from PBI to PWK started out normal. While flying over the lower portion of Lake Michigan, the pilot selected the auxiliary fuel tanks to use up all the fuel in the auxiliary tanks. The last quarter of the main tanks was reportedly consumed “pretty fast” as monitored on the gauges. The right fuel flow warning light came on north of PWK. The pilot selected the crossfeed valve to its ON position. The fuel warning light went out. The pilot asked the air traffic controller to proceed direct to the outer marker and the air traffic control indicated that he was unable to grant that request. The fuel light came on again and the pilot declared an emergency. The pilot-rated passenger said that he had no idea of the amount of fuel that remained in the fuel tanks. The right engine subsequently started to shutter. The flight was cleared direct. The cloud tops were at 3,000 feet above mean sea level (msl). The airplane was turned left and then both engines “died” on a west heading. The airplane “coasted.” The airplane was in clouds during the descent and popped out of the clouds about 1,400 feet msl where there was about 700 feet of altitude left. The pilot rated passenger made some radio calls. The airplane was turned to a southbound heading. The pilot-rated passenger advised the pilot of suitable landing sites but the flight was unable to get to them. The landing gear was up. Flaps were up. The pilot moved the mixture to idle/cutoff and feathered the engines’ propellers. He pointed out a dark spot to the pilot and the pilot turned to it. The airplane scraped the tops of trees. The first tree impacted the pilot’s side and it came through the window. Both the pilot and the pilot-rated passenger were “on the flight controls.” The controls then went limp. The pilot-rated passenger indicated that he tried to keep the airplane away from the houses and both of his yoke handles broke off. A nearby neighbor found him in the wreckage and asked him if he was “ok.” It was about one-half hour before he was placed in an ambulance. During a postaccident telephone interview, the medical crew member indicated that the purpose of the flight was to fly to PBI to pick up a patient and passenger and then fly them to PWK. The patient and passenger were informed that there would be one or maybe two stops for fuel. The airplane appeared to be topped off at JES. The fueling started on the right side of the airplane and continued to the left side. The fuel pump shut off after about 160 gallons were pumped. The pump was restarted and the airplane was fueled with more fuel. The flight was "ok" until it encountered “bad air” and the flight descended to about 7,000 feet. At one point in the flight, the medical crew member saw that a cockpit gauge indicated that there was one-half hour remaining before reaching the destination. The pilot remarked on how fast the airplane was flying and the ground speed was about 250 to 260 mph. The pilot reached down and switched tanks. The pilot also rocked the airplane’s wings. Both the engines shut off at the same time. Trees were observed once the flight descended through the clouds. During the accident sequence, the airplane’s nose pitched up as the airplane impacted trees. The passenger screamed and then the screaming stopped. The pilot-rated passenger sitting in the co-pilot’s seat advised them to brace. He said that the seat belt dug into him and his seat separated from its floor track. He was able to loosen his belt. He felt the door and its bottom half was open. He pushed open the top half. He did not initially see the pilot-rated passenger. He talked to a woman in a nearby house and related that there was an airplane acci