# NTSB CEN22FA069: Piper PA46-500TP, N744Z, Steamboat Springs, CO, December 11, 2021 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: December 10, 2021, 18:09 local (Dec 11, 2021, 01:09 UTC) - Place: Steamboat Springs, CO · Mountain side - Coordinates: 40.459893, -106.85728 - Nearby events: https://openairdocs.org/map.md?lat=40.4599&lon=-106.8573&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-IFR missed approach: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: Piper Aircraft, Hartzell, FAA - FSDO - NTSB case key (mKey): 104385 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN22FA069 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104385/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=104385 - Page: https://openairdocs.org/ntsb/CEN22FA069 ## Probable cause The pilot’s failure to adhere to the published instrument approach procedure, which resulted in controlled flight into terrain. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA46-500TP, 4 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=7104622), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Info processing/decision: identification/recognition](https://openairdocs.org/ntsb-findings/02041510): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA46-500TP, 2 cases](https://openairdocs.org/ntsb-findings/02041510/cases.md?model=7104622), [All aircraft, 559 cases](https://openairdocs.org/ntsb-findings/02041510/cases.md) - [Ceiling/visibility/precip: below approach minima](https://openairdocs.org/ntsb-findings/03035070): Environmental issues › Conditions/weather/phenomena · Decision related to condition (probable cause); cases with it: [Piper PA46-500TP, 1 case](https://openairdocs.org/ntsb-findings/03035070/cases.md?model=7104622), [All aircraft, 11 cases](https://openairdocs.org/ntsb-findings/03035070/cases.md) - [Air traffic/operating proc: missed approach procedure](https://openairdocs.org/ntsb-findings/03014045): Environmental issues › Operating environment · Compliance w/ procedure (probable cause); cases with it: [Piper PA46-500TP, 1 case](https://openairdocs.org/ntsb-findings/03014045/cases.md?model=7104622), [All aircraft, 2 cases](https://openairdocs.org/ntsb-findings/03014045/cases.md) - [Air traffic/operating proc: instrument approach procedure](https://openairdocs.org/ntsb-findings/03014035): Environmental issues › Operating environment · Compliance w/ procedure (probable cause); cases with it: [Piper PA46-500TP, 1 case](https://openairdocs.org/ntsb-findings/03014035/cases.md?model=7104622), [All aircraft, 1 case](https://openairdocs.org/ntsb-findings/03014035/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach-IFR missed approach: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120) (defining event); cases with it: [Piper PA46-500TP, 3 cases](https://openairdocs.org/ntsb-events/120/sequence.md?model=7104622), [All aircraft, 1,074 cases](https://openairdocs.org/ntsb-events/120/sequence.md) ## Analysis The pilot was conducting a solo night cross-country flight in low visibility through mountainous terrain. The pilot was then cleared by an air traffic controller to conduct a RNAV (GPS)-E instrument approach into the destination airport. After passing the final approach fix and before the missed approach point, the pilot, for an unknown reason, executed a left turn, consistent with the missed approach procedure. During the turn toward the holding waypoint, the airplane did not climb. Shortly thereafter, the airplane impacted steep rising terrain The local weather at the time of the accident indicated a cloud ceiling of 1,200 ft above ground level and 1 statute mile visibility, which was below the weather minimums for the approach. Data retrieved from the onboard avionics revealed that although the pilot flew the published route in accordance with the instrument approach procedure, the minimum required altitudes were not adhered to. A review of the ForeFlight weather briefing data indicated that a route weather briefing had been generated by the pilot with the filing of the instrument flight rules (IFR) flight plan. While no weather imagery was reviewed during the period, the pilot had checked METARs for the destination and another nearby airport before departure and viewed the RNAV (GPS)-E approach procedure at the destination airport. A review of the data that was presented to the pilot indicated that visual flight rules conditions prevailed at the destination with light snow in the vicinity at the time it was generated. Based on the preflight weather briefing the pilot obtained, he was likely unaware of the IFR conditions and below minimum weather conditions at the destination until he descended into the area and obtained the current local weather during the flight. It is probable that, based upon the weather and flight track information, as the pilot was on the instrument approach, he became aware of the below minimum weather conditions and elected to initiate the missed approach, as evident by the turn away from the airport similar to the missed approach procedure and the flaps and landing gear being in transition. This investigation was unable to determine why the missed approach procedure was prematurely initiated and why the airplane failed to climb. Additionally, there were no preimpact mechanical malfunctions or anomalies found during a postaccident examination that would have precluded normal operation. ## Factual narrative Data recovered from the Garmin GPS revealed that the airspeed varied between 89 and 110 knots during the instrument approach. 14 CFR 97.3 states that approach category is determined by either the reference landing speed (VREF), if specified, or if VREF is not specified, 1.3 VSO at the maximum certificated landing weight. The Piper PA46-500TP Pilot’s Operating Handbook did not specify a VREF but did state that VSO at maximum certificated landing weight was 69 knots. When multiplied by a factor of 1.3, the resultant value was 89.7. 14 CFR 97.3 further stated that if the speed was less than 91 knots, the airplane would fall into a Category A approach category and if it was between 91 knots, but less than 121 knots, it would fall into a Category B approach category. The instrument approach procedure for a Category A aircraft required 1¼ sm flight visibility for landing and a Category B aircraft required 1 ½ sm flight visibility for landing. It could not be determined if the pilot decided his approach category based upon 1.3 VSO or the actual approach speed flown. On December 10, 2021, about 1809 mountain standard time, a Piper PA46-500TP, N744Z, was substantially damaged when it was involved in an accident near Steamboat Springs, Colorado. The pilot and sole occupant was fatally injured. The airplane was operated under Title 14 Code of Federal Regulations (CFR) Part 91 as a personal flight. A review of archived Federal Aviation Administration (FAA) automatic dependent surveillance-broadcast (ADS-B) data revealed that the airplane departed Cody, Wyoming (COD), about 1705 and was en route to Steamboat Springs/Bob Adams Field (SBS). FAA air traffic control data showed that the pilot was operating on an instrument flight rules flight plan and at 1757 was cleared by an air traffic controller to conduct the RNAV (GPS)-E instrument approach procedure at SBS (see figure 1). Figure 1: Published Instrument Approach Procedure For terrain clearance, the procedure required the airplane to cross the final approach fix PEXSA at or above 9,700 ft mean sea level (msl) and WAKOR, the next waypoint located 2.2 nm from runway 32 threshold, at or above 8,740 ft msl. The ADS-B data showed that the accident airplane crossed PEXSA about 9,100 ft msl and WAKOR about 8,200 ft msl respectively. The procedure allowed for a descent to the minimum descent altitude of 8,140 ft msl or 1,258 ft above ground level after passing WAKOR. The missed approach point for the procedure was the runway 32 approach end, and then required a climbing left turn to 11,300 ft msl and indicated the pilot should proceed direct to the HABRO waypoint to enter a holding pattern. Immediately after passing WAKOR, the airplane made a left turn as shown in figure 2 and descended to an altitude of about 7,850 ft msl. The airplane subsequently began to climb, and the last ADS-B data point recorded at 1808:49 indicated an altitude of about 8,125 ft msl and was located about 3.5 miles north of the accidentsite. Figure 2: A Google Earth plot showing the accident aiplane’s ground track in the vicinity of the KSBS terminal area. An FAA published approach plate for the RNAV (GPS)-E approach has been overlaid with a 50% opacity. A yellow pin has been added indicating the position of the wreckage. A search of the FAA contract automated flight service station Leidos indicated that they had no contact with the pilot nor did any third-party vendors utilizing the Leidos Flight Service system on December 10 or 11, 2021. A search of ForeFlight indicated that they had an account with the pilot who filed an IFR flight plan through their system for the flight between COD to SBS. Before the accident flight the pilot did not view any weather imagery but did enter the flight route into the system, which generated a general route briefing. As a part of that briefing, the pilot was provided the current METAR for SBS, which indicated a broken cloud ceiling of 4,500 ft and 7 sm visibility. The airplane first impacted Emerald Mountain about 8,172 ft msl on a heading of about 164° as evidenced by broken and cut tree branches. After the initial impact, the airplane bounced and came to rest about 8,216 ft msl, and sustained substantial damage to the fuselage, tail and both wings. A postaccident examination of the airframe, engine, and propeller revealed no pre-accident mechanical malfunctions or anomalies that would have precluded normal operation. The positions of the landing gear and flap actuator were consistent with both being in transit at the time of impact. ## Aircraft - Registration: [N744Z](https://openairdocs.org/deregistered/N744Z-2024-01-07), registration cancelled 2024-01-07, S/N 4697134 (OpenAirDocs) - Reported make and model: PIPER PA46-500TP - Registry model: [Piper PA46-500TP](https://openairdocs.org/model/piper-pa46-500tp) (registry code 7104622) (OpenAirDocs) - Registry engine: [Pratt & Whitney Canada PT6A-42](https://openairdocs.org/engine/pratt-whitney-canada-pt6a-42) (registry code 52062, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: 4697134 - Engines: Pratt and Whitney Canada PT6A-42A turbo prop - Damage: Substantial damage - Flight: Personal, Part 91 - Registered owner: Cowboy Air LLC - Airworthiness certificate: Standard, Normal - Departed: COD, Cody, WY - Destination: SBS, Steamboat Springs, CO - Flight plan: IFR - Airport: SBS, Steamboat Springs/Bob Adams Fld - Equipment: Auto-pilot, Electronic primary flight display, Onboard weather, Data recorder, Stall warning system, ADS-B, Electronic multifunction display ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 43; injuries: fatal; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; seat: left; restraint: 4-point; toxicology performed; flight hours: 581 total ## Weather - Conditions: Instrument (IMC), Night - Wind: 260° at 5 knots - Visibility: 1 statute miles - Lowest ceiling: 1,200 ft overcast - Temperature: 16 °F, dew point 16 °F - Altimeter: 29.95 inHg - Observed at: KSBS, 7 nm away - METAR: KSBS 110055Z AUTO 26005KT 1SM OVC012 M09/M09 A2995 RMK AO1 T10921092 ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20211210020969A](https://openairdocs.org/incident/20211210020969A), Dec 10, 2021: Piper PA46-500TP, Steamboat Sprin, CO, Substantial damage, 1 fatal. On December 10, 2021, about 1809 mountain standard time, a Piper PA46-500TP, N744Z, was substantially damaged when it was involved in an accident near… ## Docket (19 files) The files NTSB released with the investigation on June 8, 2023, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=104385. 62.8 MB in all. - Examination summary (item 1, PDF, 4 pages, 241 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14911999&FileExtension=pdf&FileName=Examination%20Summary-Rel.pdf - Electronic devices - specialist's factual report (item 2, PDF, 30 pages, 4.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15438474&FileExtension=pdf&FileName=CEN22FA069_Electronic%20Devices%20Factual_FINAL2-Rel.pdf - Attachment 1 to electronic devices - specialist's factual report (item 3, CSV, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14282007&FileExtension=csv&FileName=Attachment1_CEN22FA069-Rel.csv - Autopilot and MFD - email report (item 4, PDF, 1 page, 586 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15727849&FileExtension=pdf&FileName=CEN22FA069%20-%20(Steamboat%20Springs,%20CO)%20-%20Autopilot%20and%20MFD%20-%20Email%20Report-Rel.pdf - Meggitt magic displays - email report (item 5, PDF, 1 page, 6.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15438348&FileExtension=pdf&FileName=CEN22FA069%20-%20(Steamboat%20Springs,%20CO)%20-%20Meggitt%20Magic%20Displays%20-%20Email%20Report-Rel.pdf - Meggitt dau - specialist's factual report (item 6, PDF, 6 pages, 239 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14511851&FileExtension=pdf&FileName=CEN22FA069%20Meggitt%20DAU%20Factual_FINAL1-Rel.pdf - Meteorology factual report (item 7, PDF, 29 pages, 3.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14845759&FileExtension=pdf&FileName=CEN22FA069%20-%20Steamboat%20Springs,%20CO%20WX%20Factual-Rel.pdf - Meteorology attachment 1 - foreflight weather briefing data (item 8, PDF, 27 pages, 4.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14846097&FileExtension=pdf&FileName=Attachment%201%20-%20CEN22FA069%20ForeFlight%20Route%20Briefing-Rel.pdf - ADS-B plot (item 9, KMZ, 251 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14931319&FileExtension=kmz&FileName=20211211_AA03A5_471635855_ADSB-Rel.kmz - ADS-B data file (item 10, CSV, 4.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14930895&FileExtension=csv&FileName=20211211_AA03A5_471635855_ADSB-Rel.csv - Air traffic control (item 11, PDF, 1 page, 62 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14931714&FileExtension=pdf&FileName=ATC%20Memo-Rel.pdf - Instrument approach procedure (item 12, PDF, 1 page, 267 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14909119&FileExtension=pdf&FileName=Instrument%20Approach-Rel.pdf - Pilot logbook excerpts (item 13, PDF, 4 pages, 22.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14909992&FileExtension=pdf&FileName=Logbook%20Photos_Redacted-Rel.pdf - Maintenance records (item 14, PDF, 3 pages, 9.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14910388&FileExtension=pdf&FileName=Recent%20Maintenance_Redacted-Rel.pdf - Photos (item 15, PDF, 2 pages, 770 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14912910&FileExtension=pdf&FileName=Photo%20Array-Rel.pdf - Lightbulb examination (item 16, PDF, 1 page, 457 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14931952&FileExtension=pdf&FileName=Lightbulb%20Analysis-Rel.pdf - Autopsy memo (item 17, PDF, 1 page, 127 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14910086&FileExtension=pdf&FileName=Autopsy%20Memo-Rel.pdf - Toxicological report (item 18, PDF, 1 page, 162 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14910497&FileExtension=pdf&FileName=Toxicology_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 19, PDF, 1 page, 2.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15427566&FileExtension=pdf&FileName=74962%20Signed%20NTSB%20Wreckage%20Release_Redacted-Rel.pdf From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.