In the early morning hours of July 29, 2016, a Piper PA-31T Cheyenne airplane broke apart midair over a mountainside near McKinleyville, California. The medical flight, operated by Cal-Ore Life Flight (a subsidiary of Santa Rosa-based REACH Air Medical Service) was transporting a patient (April Rodriguez) when it claimed her life and the lives of the pilot (Larry Mills), flight nurse (Deborah Kroon) and certified flight paramedic (Michelle Tarwater). It left a quarter-mile debris trail across the mountainside, according to The Press Democrat.

The National Transportation Safety Board (NTSB) began investigating the crash immediately. Federal investigators found evidence of a problem with the airplane’s wiring, which started a fire in the cockpit during the flight and ultimately led to the flight’s demise. The finding prompted the NTSB to urge the Federal Aviation Administration (FAA) to issue an emergency airworthiness directive (AD) prior to the end of the investigation.

The NTSB only recommends issuing an emergency AD before an investigation is final when it finds evidence that “an imminent threat to life and safety exists.” As with other emergency ADs, this one required “mandatory action and a shorter timeline for addressing the issue” than was outlined in the special airworthiness information bulletin (SAIB) the FAA issued just weeks earlier with guidance from the NTSB.

A Jan. 9, 2017, NTSB press release confirmed evidence of thermal damage near the airplane’s main electrical bus circuit breaker panel, which is mounted in the floor of PA-31T airplanes. The enclosed space is in a confined area, so it is difficult to assess adequately through current maintenance procedures requiring only general visual inspection. The area includes hydraulic lines that run below or adjacent to the wiring and panel.

A closer inspection, however, revealed wiring in this area “showed evidence of electrical arcing” and sections of hydraulic lines “were consumed by in-flight fire.” Electrical arcing occurs when an electrical current is released and moves through an opening of a circuit, which suggests chaffing and that could cause a fire. Federal investigators found similar damage when they used a borescope and camera to inspect six other Piper PA-31T airplanes.

After calling on the FAA to issue an emergency AD, NTSB spokesman Eric Weiss told the Associated Press (AP) that the agency “thinks it’s a dangerous situation having electrical lines next to hydraulic line.”

Piper Aircraft confirmed to the AP that it has been working with both the NTSB and the FAA to address the problems since the SAIB was issued in December including issuing its own “mandatory service bulletin” for operators. The AP reports there are more than 300 31T-series airplanes registered with the FAA.

Four months following the Cal-Ore Life Flight crash, another medial air transport crashed into the parking lot near a gold mine in Elko, Nevada, on Nov. 19, 2016. The crash claimed the lives of all four passengers including three medial crew and a patient. While the airplane was also a PA-31T, the NTSB has not released any details about the cause of the crash. American Medflight operated the airplane. This was at least the third fatal air ambulance crash of 2016 and comes at a time when the FAA is working to improve the safety of air ambulances as we discussed in a recent issue of this Report.

If you need more information on this subject contact Mike Andrews at 800-898-2034 or by email at As stated above, Mike handles aviation litigation for the firm.

Sources: The Press Democrat, Righting Injustice, and National Transportation Safety Board

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