Pilot Debrief

Piper PA32R near Anchorage, AK — 2019-02-13

Final reportANC19TA014
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Date
2019-02-13
Location
Anchorage, AK, USA
Aircraft
Piper PA32R
Registration
N40449
Category
Airplane
Highest injury
Serious
Fatalities
0
Phase of flight
Descent

Probable cause

The pilot’s failure to ensure that the passenger’s lap belt was appropriately fastened for the forecast turbulent conditions, and the passenger’s failure to tighten her lap belt appropriately, which resulted in the passenger’s serious injury during an encounter with turbulence.

NTSB narrative

The pilot reported that the airplane encountered momentary severe turbulence while descending toward the destination airport. A passenger in the second row hit her head on the cabin ceiling and sustained a serious injury to her neck. The passenger stated that she was familiar with the operation of the seat belt and flew in the airplane about once or twice a month for many years, but on this flight, she did not tighten the lap belt sufficiently. Weather forecasts indicated that occasional to constant moderate turbulence was expected in the area; however, the pilot did not ensure that the passenger’s lap belt was appropriately fastened.

Analysis

Primary failure mode
Human factors
First missed decision gate
Passenger did not tighten her lap belt enough despite familiarity with its use.

NTSB coding

Evidence available

  • Photos
  • 4 docket documents
View NTSB final reportView NTSB docket

Docket documents4

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