# NTSB DEN93FA043: Piper PA-28-181, N38481, Elbert, CO, April 17, 1993 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: April 16, 1993, 21:00 local (Apr 17, 1993, 03:00 UTC) - Place: Elbert, CO - Coordinates: 39.21928, -104.530288 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=39.2193&lon=-104.5303&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report June 17, 1994 - Report: Approved by Office Director - NTSB case key (mKey): 11074 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=DEN93FA043 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/11074/pdf - Page: https://openairdocs.org/ntsb/DEN93FA043 ## Probable cause THE PILOT'S INADVERTENT VFR FLIGHT INTO IMC. FACTORS WERE HIS LACK OF INSTRUMENT TRAINING/EXPERIENCE, EXISTING WEATHER, AND DARK NIGHT CONDITIONS. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight encounter with weather, cruise - normal - light condition - dark night (contributing factor) - weather condition - obscuration (contributing factor) - weather condition - rain (contributing factor) - weather condition - snow (contributing factor) - vfr flight into imc - inadvertent, pilot in command (cause) - lack of total instrument time, pilot in command (contributing factor) - Loss of control - in flight, cruise - normal - In flight collision with terrain/water, descent - uncontrolled - terrain condition - mountainous/hilly ## Analysis WHILE ON A CROSS COUNTRY FLIGHT IN DARK NIGHT CONDITIONS, THE NON INSTRUMENT RATED PILOT INADVERTENTLY ENCOUNTERED INSTRUMENT METEOROLOGICAL CONDITIONS WHILE IN CRUISE FLIGHT. THE AIRCRAFT COLLIDED WITH THE GROUND ON A HEADING OPPOSITE THE INTENDED DIRECTION OF TRAVEL. ALTHOUGH VMC PREVAILED AT THE DESTINATION AIRPORT 28 MILES SOUTH OF THE SITE, LOCAL RESIDENTS REPORTED REDUCED VISIBILITY WITH RAIN AND SNOW SHOWERS IN THE VICINITY. ## Factual narrative HISTORY OF FLIGHT On Friday, April 16, 1993, at approximately 2100 mountain daylight time, (all times are adjusted to mountain daylight time unless otherwise noted), a Piper PA-28-181, N38481, impacted the ground approximately five miles east of Elbert, Colorado. The private, non instrument rated pilot and passenger received fatal injuries and the aircraft was destroyed. Instrument meteorological conditions prevailed at the accident site and no flight plan was filed for this personal cross country flight to Colorado Springs, Colorado, which originated from Waterloo, Iowa. On April 15, 1993, at 2137, the pilot of N38481, received an outlook briefing from Fort Dodge, Iowa, Automated Flight Service Station (AFSS) for a flight from Waterloo, Iowa, (ALO),to Grand Island, Nebraska, (GRI), direct to Colorado Springs,(COS). On April 16th, at 0909, the same person received a full brief for the flight. On the same date, at 1127, an updated briefing was given. At 1636 on April 16, the pilot of N38481 called Columbus, Nebraska, AFSS by telephone, and obtained a pre flight brief for a VFR flight from GRI to COS. According to the attached fueling order, N38481, stopped for fuel at Central Nebraska Regional Airport, Grand Island, Nebraska, where 29.4 gallons of 100LL aviation grade fuel was purchased. The time stamp on the fuel ticket was 1743. According to persons at the fueling facility, the aircraft departed 10 to 15 minutes after fueling was completed. At 1812, N38481 made initial contact with Minneapolis, Minnesota, Air Route Traffic Control Center, (ARTCC), and requested VFR flight following to Colorado Springs, at 6,500 feet above mean sea level, (msl). The controller issued the aircraft a discreet transponder beacon code of 2625, and at 1818 Denver ARTCC accepted handoff of N38481 from Minneapolis. At 1940, N38481 was issued a frequency change to another Denver ARTCC transmitter. The pilot reported on the new frequency and was given the Goodland, Kansas, altimeter setting. During this interchange, the pilot of N38481 reported a "little bit choppy ride and a little precipitation." This interchange was followed by Denver ARTCC advising N38481 that there were no current weather reports between the aircraft's position and Colorado Springs. At 1951, Denver ARTCC advised N38481 of poor radar coverage for a portion of the flight. Denver ARTCC terminated radar coverage and suggested contact with Denver ARTCC on frequency 134.92 in the vicinity of Hugo, Colorado. At 2031, N38481 reported on Denver ARTCC frequency VFR, three miles west of Limon, Colorado, at 8,000 feet msl. Denver ARTCC issued the Limon altimeter and advised the aircraft that it would be a little longer before radar contact could be established. No evidence of further radio contact between N38481 and any facility was found. PERSONNEL INFORMATION According to the pilot's log and license, he received his student pilot certificate on February 6, 1989, and his private pilot certificate on April 14, 1989. According to a "shared time" log found in the aircraft, this pilot last flew the aircraft, prior to the accident flight, on January 1, 1993, for 3.1 hours on a flight from Waterloo, Iowa, to Saint Louis, Missouri, and return. METEOROLOGICAL INFORMATION Four observations by the Colorado Springs Automated Weather Observation System (AWOS) are detailed below. 1858 - ceiling clear below 12,000 feet, visibility greater than 10 miles, temperature 37 degrees Fahrenheit, dew point 31 degrees Fahrenheit, wind 360 degrees at 6 knots, altimeter 30.04. 1956 - Measured clouds at 7,000 feet broken and 9,000 feet overcast, visibility 10 miles plus, temperature 47, dew point 34, wind 360 degrees at 9 knots, altimeter 29.93. 2056 - Measured clouds at 3,400 feet broken and 4,900 feet overcast, visibility 10 miles in rain, temperature 41, dew point 35, wind 010 degrees at 9 knots with gusts to 16 knots, altimeter 30.00. Remarks - Rain began at 05 minutes past the hour and the pressure rising. 2156 - Measured clouds at 4,400 feet overcast, visibility 10 miles plus, temperature 41, dew point 34, wind 360 degrees at 9 knots, altimeter 30.03. Remarks - Rain ended at 59 past the hour. Another aircraft accident occurred at approximately 2217, eleven miles south of this accident the same evening. A witness in the area of that accident stated that the visibility at the time was 10 to 20 feet with snow showers and fog. The National Weather Service observations taken at 2056 were similar to the 2058 AWOS but contained the remarks, "lower clouds obscuring mountain tops southwest through northwest with VIRGA present in all quadrants." Attached is information provided by a witness who was proceeding south on Interstate Highway 25 from Denver to Colorado Springs on the evening the accident occurred. This witness has a background in meteorology, as evidenced by his cover letter, and his observations provide information concerning weather in the accident area which is north of a east/west ridge line known as Palmer Divide. This ridge line separates the Colorado Springs area from the accident area. The observations provide evidence of rain and snow showers in the accident area. Several local residents were interviewed during the investigation and provided observations of low clouds, reduced visibility with rain and snow showers during the evening when the accident occurred. At 2025, Limon, Colorado, radar, which is approximately 50 miles east of the accident site, had a level four thunderstorm in progress containing snow showers. At 2125, the Limon radar indicated a thunder storm was occurring over Limon and was moving to the northeast at 15 knots, and at 2225, the radar was showing a level four thunderstorm containing snow showers. COMMUNICATIONS All known radio communications with the accident aircraft were conducted on Minneapolis Flight Watch and Denver Flight Watch radio frequencies. Communications with AFSS facilities were primarily via telephone. WRECKAGE AND IMPACT INFORMATION The aircraft impacted the ground on a northerly track with initial impact on the south bank of a stream oriented east and west. (See attached wreckage diagram.) The initial impact point contained fragments of red glass and wing tip material. Approximately 15 feet along the impact track, a deep gouge was present on the downward slope of the creek bank. This impact point contained pieces of the forward portion of the engine and propeller spinner. At a point 70 feet from the initial impact point, the pr ## Aircraft - Registration: [N38481](https://openairdocs.org/deregistered/N38481-2012-11-14), registration cancelled 2012-11-14, S/N 28-7790555, built 1977 (OpenAirDocs) - Reported make and model: PIPER PA-28-181 - Registry model: [Piper PA-28-181](https://openairdocs.org/model/piper-pa-28-181) (registry code 7102807) (OpenAirDocs) - Registry engine: [Lycoming O&VO-360 series](https://openairdocs.org/engine/lycoming-o-vo-360-series) (registry code 41514, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-7790555 - Airframe hours: 1801 - Engines: LYCOMING IO-360-B1E 180 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Registered owner: Educational Consultants, Inc. - Airworthiness certificate: Standard, Normal - Last inspection: Annual, May 7, 1992 - Departed: GRI, GRAND ISLAND, NE - Destination: COS, CO SPRINGS, CO ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 48; private; airplane ratings: single-engine land; medical: class 3, valid medical--w/ waivers/lim; seat: left; toxicology performed; flight hours: 561 total, 552 in this make and model, 548 as pilot in command ## Weather - Conditions: Instrument (IMC), Night/dark - Visibility: -99 statute miles - Lowest ceiling: 200 ft - Altimeter: 30.00 inHg ## 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 19930416009569A](https://openairdocs.org/incident/19930416009569A), Apr 16, 1993: Piper PA28181, Elbert, CO, Destroyed. Lost control in area of snow showers and rain. Dark night. Limited ground lights in area. ## Other investigations on N38481 (1) 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. - [NTSB OAK78DXQ05](https://openairdocs.org/ntsb/OAK78DXQ05), Nov 30, 1977: Piper PA-28 (N38481), Lund, NV, substantial damage 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.