FTW95FA002

NTSB accident investigation · Piper PA-28R-200 · Pagosa Springs, CO · October 1, 1994

Accident · Serious injuriesField investigationFinal report
Date
October 1, 1994, 14:20 local (20:20 UTC)
Place
Pagosa Springs, CO
Injuries
3 serious
Damage
Destroyed
Phase of flight
Maneuvering
Aircraft
N1480XPiper PA-28R-200
Weather
Visual (VMC) · Day
Status
Completed · report May 18, 1995
Report
Approved by Office Director
FAA report
19941001032469A
Case key
19188

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 pilot's continued flight into known adverse weather. Factors were the pilot's lack of familiarity with the geographic area, the turbulence and high density altitude.

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.

In flight collision with terrain/waterManeuvering - turn to reverse direction
Terrain condition - blind/box canyon
Lack of familiarity with geographic areaPilot in command(cfi)Factor
Flight into known adverse weather - continuedPilot in commandCause
Weather condition - turbulenceFactor
Weather condition - high density altitudeFactor
In flight collision with terrain/waterDescent - uncontrolled

Analysis

Private pilots, enrolled in a professional pilot course, were building cross country flight time for their commercial certification. On the return flight from California to Texas, routing was planned through Colorado for the instructional portion of the mountain curriculum. Airmets included weather advisories for turbulence. The flight instructor amended the flight route and continued even though flight watch issued the AIRMET for turbulence and that VFR was not recommended. Company personnel reported that the flight instructor had made numerous flights along the regular mountain flying curriculum route (highest elevation 9,927 feet); however, 'this was the instructor's first trip crossing the Continental divide through the canyon at elwood pass' an elevation of 11,875 feet. Density altitude was calculated at 14,000 feet. This was the flight instructor's second demonstration that day for a 180 degree turn- around procedure in a box canyon environment. The instructor stated that 'near the completion of the turn, we experienced a severe unexpected downdraft' with a resulting rate of decent of '6,000 fpm' and the airplane hit the trees.

Factual narrative

History of flight:

On October 1, 1994, at 1420 mountain daylight time, a Piper PA-28R-200, N1480X, was destroyed while maneuvering to reverse flight direction near Pagosa Springs, Colorado. The airline transport rated pilot/flight instructor and the two private pilots received serious injuries. Visual meteorological conditions prevailed for the cross country mountain flying instructional flight.

During interviews and on the enclosed statements the operator and flight instructor reported the information in this paragraph. The flight originally departed the Le Tourneau University Flight School on September 29, 1994, at Longview, Texas, for a cross country flight to Palm Springs, California. The two private pilots were enrolled in Le Tourneau University Title 14 CFR Part 141 professional pilot course and were building cross country flight time toward their commercial certification. On the return flight, routing was planned through Colorado for the mountain portion of the course curriculum.

On October 1, 1994, the flight departed Page, Arizona, for Salida, Colorado. The private pilot and flight instructor evaluated the in flight weather and amended the flight plan for a more southerly route with a destination change to Alamosa, Colorado. The amended route was to follow the road from Pagosa Springs, Colorado, over Wolf Creek Pass, to Alamosa. As the flight continued, they realized a selection of the "wrong road" and the flight instructor made the decision for a turn-around at about 2,500 feet above ground level according to the enclosed statement. This was the flight instructor's second demonstration for the day on how to do a 180 degree turn around procedure in a box canyon environment. The flaps were fully extended prior to turning the airplane. The instructor turned the airplane to the "right side of the canyon (south) and then began the turn back towards the left in a bank of approximately 35 degrees." The flight instructor stated that "near the completion of the turn, we experienced a severe unexpected downdraft" with a resulting rate of descent of "6,000 FPM" and the airplane hit the trees.

Personnel information:

Flight Instructor records from the school and the Federal Aviation Administration (FAA) indicated that he was designated as the chief flight instructor on August 24, 1989. The designation included a standardization flight in the PA-28R-200. On February 13, 1994, the flight instructor satisfactorily completed an AOPA Air Safety Foundation flight instructor refresher clinic and an FAA surveillance on July 21, 1995.

During interviews, school personnel stated that the mountain flying curriculum route, with a departure from Longview, Texas, included Alexander Airport, Salida, Colorado; Buena Vista Airport, Buena Vista, Colorado; and Lake County Airport, Leadville, Colorado, with the highest elevation at 9,927 feet. The school curriculum does not specify a minimum altitude in mountainous terrain. They reported that the flight instructor had made numerous flights along this route; however, "this was the instructor's first trip crossing the continental divide through the canyon at Elwood Pass" an elevation of 11,875 feet.

Meteorological information:

A review of the enclosed weather data revealed the information in this paragraph. Winds aloft throughout the area from 9,000 feet MSL through 18,000 MSL feet were from the southwest at 15 to 24 knots. Temperature aloft was 35 degrees Fahrenheit with a surface temperature at 70 degrees Fahrenheit. The calculated density altitude at the accident elevation of 11,400 feet was 14,000 feet. Airmets for the area included occasional mountain obscurement (clouds, precipitation, and fog) and moderate turbulence throughout Colorado. An airmet for occasional moderate mixed icing in clouds and precipitation between 12,000 feet MSL and FL200 was valid. VFR flight was not recommended.

Communications:

A review of flight service station data (enclosed) revealed the following summary information. All times are converted to mountain daylight time unless otherwise indicated.

1033: The pilot obtained a standard weather briefing and filed a VFR flight plan via telephone with Prescott Flight Service Station (FSS), from Page (PGA), Arizona, to Salida (0V2), Colorado.

1208:34 The pilot contacted Denver Automated Flight Service Station (AFSS) facility via aircraft radio to activate the flight plan and was requested by facility specialists to refile the flight plan. From the location of 24 miles south of Dove Creek, Colorado, at 9,500 feet MSL direct to Salida, Colorado, the estimated time of arrival was 1310.

1211:17 Airmet sierra covered all of Colorado above 10,000 feet and VFR not recommended was issued to the pilot due to occasional moderate turbulence below FL200 and the possibility of occasional moderate mixed icing in the clouds and precipitation from 12,000 feet MSL to FL200.

1239:13 During cruise at 10,500 feet MSL at 9.6 miles north of Durango, Colorado, the pilot contacted Denver AFSS and reported a flight deviation to the south with a change of destination to Alamosa, Colorado.

1249:25 The pilot contacted Denver AFSS, reported a flight location 25 miles east of Durango, Colorado, and extended the arrival time to 1400. Denver issued flight precautions for mountain obscurement along the route, VFR not recommended, occasional moderate turbulence, and the altimeter setting of 30.02.

1450:47 The pilot reported a smooth ride at 10,500 feet and the base of the clouds at 12,000. There were no additional communications.

Search and rescue (enclosed reports) was initiated and the airplane and occupants were located at 0213 on October 2, 1994. The remoteness of the site, rough terrain conditions, and darkness hampered the rescue.

Wreckage and impact information:

The airplane came to rest on a measured magnetic heading of 040 degrees at an elevation of 11,400 feet MSL on the north slope of the canyon with the highest peak along the continental divide at 12,654 feet. Trees, on a measured magnetic heading of 010 degrees, along the 35 degree upslope of the canyon had their upper trunk areas separated and lying on the ground. The cockpit and cabin area remained intact. The outboard section of the left wing separated from the airframe and the leading edge of both wings was crushed aft toward the main spar. Both fuel tanks were compromised and engine mounts separated. One propeller blade was twisted and bent aft. See the enclosed wreckage diagram for additional details.

Flight control continuity was confirmed. Physical evidence of fuel was present at the site, fuel was present on the engine driven output side of the fuel pump, and the fuel selector was "ON" the right fuel tank. Engine continuity was confirmed.

Test and research:

The engine was examined by a NTSB investigator on October 12, 1994, at Greeley, Colorado. There were no pre-impact anomalies.

Additional data:

The airplane was released to the owner.

Aircraft

Registration
N1480X
Reported as
Piper PA-28R-200
Category
Airplane
Serial number
28R-7535288
Airframe hours
3,977
Engine
Lycoming IO-360-C1C, 200 horsepower, reciprocating
Damage
Destroyed
Flight
Instructional · Part 91
Operator
Same As Registered Owner
Registered owner
Le Tourneau University
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · September 13, 1994 · 70 hours before
Departed
PGA · Page, AZ
Destination
ALS · Alamosa, CO
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
42
Certificates
Flight instructor, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Seat
Right
Flight hours
7,400 total · 400 in this make and model · 7,200 as pilot in command · 69 in the last 90 days · 30 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
210° at 15 knots
Visibility
10 statute miles
Lowest ceiling
12,000 ft broken
Temperature
66 °F, dew point 27 °F
Altimeter
29.00 inHg
Observed at
ALS, 40 nm away

FAA reports on this event · 1

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