DEN03FA038

NTSB accident investigation · Piper PA-28R-200 · La Sal, UT · January 24, 2003

Accident · FatalField investigationFinal report
Date
January 23, 2003, 20:37 local (Jan 24, 2003, 03:37 UTC)
Place
La Sal, UT
Injuries
4 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N106AWPiper PA-28R-200
Weather
Visual (VMC) · Night
Status
Completed · report March 30, 2004
Report
Approved by Office Director
Parties
New Piper Aircraft Company, FAA FSDO, Textron Lycoming
FAA report
20030123000989A
Case key
56415

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

the loss of engine power (total) due to fuel starvation, the pilot not following procedures/directives (fuel management procedures), and the pilot's inadequate preflight planning/preparation for the flight. Contributing factors were the pilot's inadequately equipping the airplane (lack of supplemental oxygen), the pilot's hypoxic physical impairment, and the pilot's total lack of experience in type of operation.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of engine power(total) - nonmechanicalCruise
Inadequate transition/upgrade trainingPilot in command
Procedures/directives - not followedPilot in commandCause
Fluid,fuel - starvationCause
Preflight planning/preparation - inadequatePilot in commandCause
Aircraft/equipment inadequatePilot in commandFactor
Physical impairment(anoxia/hypoxia)Pilot in commandFactor
Lack of total experience in type operationPilot in commandFactor
Forced landingEmergency descent/landing
In flight collision with terrain/waterEmergency descent/landing
Terrain condition - mountainous/hilly
Light condition - dark nightFactor

Analysis

The non-instrument rated private pilot (approximately 140 hours of flight experience) filed a night VFR flight plan [in a complex airplane] for 15,500 feet, a cruising airspeed of 140 knots, a time en route of 4 hours, and 8 hours of fuel onboard. The pilot did not have a complex airplane endorsement. The airplane was non pressurized, and no supplemental oxygen was onboard. The airplane manufacturer’s representative calculated the flight to require 5 hour, 25 minutes (with no wind), which was 25 minutes longer than the maximum estimated capability of the airplane. Radar data indicates that the pilot flew above 12,500 feet for 2 hours, 17 minutes, above 14,000 feet for 1 hours, 49 minutes, and at approximately 16,000 feet for an estimated 45 minutes. At approximately 3 hours and 40 minutes (352 nm) into the flight, the pilot declared a "Mayday." Radar data indicates that the airplane departed 14,800 feet, and descended through 9,800 feet at approximately 1,077 feet per minute. The radar data showed the airplane in a straight flight track until it descended below radar coverage; the airplane's impact ground scar of approximately 280 degrees was aligned with this flight track. The engine fuel burn calculations suggest that 10 to 15 gallons of fuel were in the airplane at the time of the accident. An examination of the wreckage showed the left wing attached to the fuselage and resting up hill. The cockpit area, forward fuselage, and right wing were broken, charred, and consumed by fire. The extent of thermal damage to the fuselage suggested that fuel assisted in the conflagration. An examination of the engine and other airplane systems revealed no anomalies.

Factual narrative

History of flight

On January 23, 2003, at 2037 mountain standard time, a PA-28R-200, N106AW, was destroyed when it impacted terrain during a night forced landing attempt near La Sal, Utah. A postimpact fire ensued. The non-instrument rated private pilot and her three passengers were fatally injured. Air West Flight Center Inc., Longmont, Colorado, was operating the airplane under Title 14 CFR Part 91. Visual meteorological conditions prevailed for the personal, night, cross-country flight that originated from Longmont, Colorado, at 1657. The pilot had filed and opened a VFR flight plan with a destination of Las Vegas, Nevada (VGT).

The operator of the airplane said the pilot had originally requested the airplane be available for departure at 1100. The pilot had flown a Cessna 172 from Jeffco Airport, Broomfield, Colorado, on January 21, 2003, to Albuquerque, New Mexico, and was delayed getting back to Jeffco Airport on January 23, 2003, due to early morning inclement weather in Albuquerque. The pilot landed the Cessna 172, at Jeffco Airport, at approximately 1430.

At 1624, the pilot called Denver Automated Flight Service Station (AFSS), to file a flight plan and get a weather briefing. She originally filed for Longmont, direct Grand Junction, and direct Las Vegas. The AFSS specialist reported that the weather over Corona Pass (elevation 12,000 feet plus) was: wind 270 degrees at 27 gusting to 33 knots; visibility 3 statue miles; broken clouds at 700 feet; temperature 27 degrees Fahrenheit; dew point 18 degrees Fahrenheit. The pilot changed her flight plan to Pueblo, Durango, St. George, to Las Vegas; an estimated 650 nautical mile flight. The pilot requested an altitude of 15,500 feet, a cruising airspeed of 140 knots, a time en route of 4 hours, and 8 hours of fuel onboard.

Witnesses reported that the airplane began to taxi for takeoff, between 1645 and 1650; the first radar return was recorded at 1658. At 1702, the pilot contacted Denver Radio to open her VFR flight plan. Denver Air Route Traffic Control Center (ARTCC) radar data indicates that the airplane flew south to Walsenburg, Colorado, and at approximately 1810 turned west towards Alamosa, Colorado. Radar data indicates that the pilot flew above 12,500 feet for 2 hours, 17 minutes, above 14,000 feet for 1 hour, 49 minutes, and at approximately 16,000 feet for an estimated 45 minutes.

While flying above 14,000 feet, from 1842 to 2031, the pilot received numerous heading corrections from ARTCC, some of them by as much as 70 degrees. On one occasion, the pilot reported that she was over Montrose, Colorado, and the ARTCC informed her that she was over Telluride, Colorado. The pilot responded with "roger that, I appreciate it, can't see a darn thing out here." The radio communication between the pilot and ARTCC became increasing difficult and erratic. Many other aircraft assisted in relaying information between the two.

The ARTCC radar data indicates that the airplane departed 14,800 feet at 2030. The rate of descent increased, and a maximum descent was calculated to be 1,077 feet per minute. At 2035, the pilot transmitted the following: "Denver radio, mayday, mayday, I've got myself in (unintelligible)." At 2037:42, a Federal Express flight 1290, flying in the area, said "yeah, we just picked up a strong Emergency Locator Transmitter (ELT) signal on 121.5, it's gone now." The ELT signal was not received again. On the morning of January 25, 2003, at approximately 0930, a rancher observed a column of smoke on his land. Upon investigation, he discovered the downed airplane.

Personnel information

The pilot held a private pilot certificate with a single engine airplane rating that was issued on December 23, 2001. She was issued a third class airman's medical certificate and student pilot certificate on March 19, 2001. The certificate contained no limitations. The pilot's flight logbook was not recovered. The pilot filled in an application (pilot information sheet) at Air West Flying Club (Wings of Denver Flying Club), Broomfield, Colorado, on January 8, 2003 [the pilot had miss-dated the application, January 8, 2002]. At that time, she reported having 128 hours total flight time, 40 hours of which were in a high performance, complex airplane.

The pilot flew with a flight instructor from Air West Flying Club, Broomfield, Colorado, on three occasions (between November 1, 2002 and January 13, 2003) for a total of 3.7 hours; he had a ground training lesson with her for 1.5 hours on January 8, 2003. The flight instructor was an FAA Safety Counselor, and he commented that the pilot "always seemed to be in a hurry." He said she would " run in the door, ready to go." All the flight time at Air West Flying Club was in a Cessna 172.

On January 20, 2003, the pilot rented a Cessna 172 and flew to Albuquerque, New Mexico, with one passenger. They were scheduled to fly back to Jeffco Airport (BJC), Broomfield, Colorado, on the morning of January 23, 2003. Due to inclement weather at Albuquerque, she departed late and landed at Jeffco Airport at approximately 1430. The pilot reported a total flight time for the trip of 7.6 hours. The pilot's total flight experience was estimated to be 140 hours.

The pilot had received some training in a high performance, complex airplane (the accident airplane), on May 5, 2002, and on May 30, 2002, but the flight instructor from Air West Flight Center, Longmont, Colorado, who flew with her said that he would not endorse her flight logbook for complex aircraft. He said that "she was a little behind the airplane in the traffic pattern." Subsequently, he never signed the flight schools' rental agreement card for the pilot, authorizing her to operate the schools PA-28R-200. On January 27, 2003, 5 days after the accident, the flight instructor noted that the flight schools rental agreement card had still not been initialed, by an instructor, to fly the accident airplane. Several days after that, the Investigator-In-Charge looked at the rental agreement card, and observed an "OK" in the PA-28R-200 space. When the staff was queried about the sign-off, no one knew where it came from. The pilot had flown, as a passenger, with one of her friends on several trips in a Piper Navajo, a high performance, complex airplane, but no documentation could be found that she had ever received the complex endorsement in her flight logbook.

According to Title 14 CFR (Code of Federal Regulations) Part 61, Chapter 31 (e) "no person may act as pilot in command of a complex airplane (an airplane that has a retractable landing gear, flaps and a controllable pitch propeller) unless that person has (i) received a onetime endorsement in the pilot's logbook from an authorized instructor who certifies the person is proficient to operate a complex airplane."

Aircraft information

The airplane was a single engine, propeller-driven, four seat airplane, which was manufactured by Piper Aircraft Company, in 1975. The airplane had a maximum takeoff gross weight of 2,650 pounds. It was powered by a Lycoming IO-360-C1C, four cylinder, reciprocating, horizontally opposed, direct drive, air cooled, fuel injected engine, which had a maximum takeoff rating of 200 horsepower at sea level. Maintenance records indicate a 100-hour inspection had been performed on the airplane on January 20, 2003. At the time of the last inspection, the airframe had 6,544.2 hours, and the engine had approximately 51 hours since it had been overhauled.

The airplane was not equipped with a supplemental oxygen system, and it was not pressurized. The operator reported that the pilot did not take a portable supplemental oxygen unit with her; no supplemental oxygen equipment was found at the accident site. According to FAR Part 91, Section 211 (a) "no person may operate a civ

Aircraft

Registration
N106AW
Reported as
Piper PA-28R-200
Category
Airplane
Serial number
28R-7535202
Airframe hours
6,544.2
Engine
Lycoming IO-360-C1C, 200 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Registered owner
Air West Flight Center Inc.
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · January 20, 2003 · 5 hours before
Departed
2V2 · Longmont, CO
Destination
VGT · Las Vegas, NV
Flight plan
VFR

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
38
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Valid Medical--no waivers/lim.
Last flight review
December 1, 2001
Seat
Left
Toxicology
Performed
Flight hours
144 total · 6 in this make and model · 100 as pilot in command · 7 in the last 90 days · 6 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Night
Wind
220° at 3 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
36 °F, dew point 19 °F
Altimeter
30.20 inHg
Observed at
CNY, 36 nm away

Docket · 24

The files NTSB released with the investigation on February 19, 2004, on NTSB’s docket system: statements, records, photos and specialists’ reports. 10.9 MB in all.

Supplement SItem 1 · .PDF · 23 KBWitness StatementsItem 2 · .PDF · 76 KBMaps, Charts, Radar Data and Flight PlanningItem 3 · .PDF · 3.4 MBWeather Reports and RecordsItem 4 · .PDF · 192 KBTranscript of Radio CommunicationsItem 5 · .PDF · 737 KBOther Pertinent Forms and ReportsItem 6 · .PDF · 419 KBStatement of Party Representatives to NTSB InvestigationItem 7 · .PDF · 53 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 8 · .PDF · 39 KBToxicological ReportItem 9 · .PDF · 55 KBPhoto #1 - Piper N106AW, forward looking aftItem 10 · .PDF · 67 KBPhoto #2 - Right side of fuselage. The right wing is in the lower left of pictureItem 11 · .PDF · 71 KBPhoto #3 - The fuselage of N106AW. Note left wing in the back and the cockpit areaItem 12 · .PDF · 82 KBPhoto #4 - Right side of the empennageItem 13 · .PDF · 66 KBPhoto #5 - The left side of N106AW's empennageItem 14 · .PDF · 73 KBPhoto #6 - The left wing of N106AWItem 15 · .PDF · 52 KBPhoto #7 - Propeller blade AItem 16 · .PDF · 414 KBPhoto #8 - Propeller blade BItem 17 · .PDF · 408 KBPhoto #9 - The crankshaft's bent flangeItem 18 · .PDF · 411 KBPhoto #10 - The AC's empennage and right wing looking fwdItem 19 · .PDF · 712 KBPhoto #11 - The left wing's leading edge damageItem 20 · .PDF · 643 KBPhoto #12 - The left side of the engineItem 21 · .PDF · 704 KBPhoto #13 - The front of the engine looking aftItem 22 · .PDF · 702 KBPhoto #14 - The left side of the empennageItem 23 · .PDF · 708 KBPhoto #15 - The left wing inboard 4 feet with landing gear wheelItem 24 · .PDF · 715 KB

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.