# NTSB FTW95FA002: Piper PA-28R-200, N1480X, Pagosa Springs, CO, October 1, 1994 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Field investigation · Final report - Date: October 1, 1994, 14:20 local (20:20 UTC) - Place: Pagosa Springs, CO - Coordinates: 37.239246, -107.029052 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=37.2392&lon=-107.0291&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Highest injury: Serious injuries - Injuries: 3 serious - Status: Completed, report May 18, 1995 - Report: Approved by Office Director - NTSB case key (mKey): 19188 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=FTW95FA002 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/19188/pdf - Page: https://openairdocs.org/ntsb/FTW95FA002 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight collision with terrain/water, maneuvering - turn to reverse direction - terrain condition - blind/box canyon - lack of familiarity with geographic area, pilot in command(cfi) (contributing factor) - flight into known adverse weather - continued, pilot in command (cause) - weather condition - turbulence (contributing factor) - weather condition - high density altitude (contributing factor) - In flight collision with terrain/water, descent - 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](https://openairdocs.org/deregistered/N1480X-1997-02-19), registration cancelled 1997-02-19, S/N 28R7535288 (OpenAirDocs) - Reported make and model: PIPER PA-28R-200 - Registry model: [Piper PA-28R-200](https://openairdocs.org/model/piper-pa-28r-200) (registry code 7102811) (OpenAirDocs) - Category: Airplane - Serial number: 28R-7535288 - Airframe hours: 3977 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 42; 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 (OpenAirDocs). - [Accident 19941001032469A](https://openairdocs.org/incident/19941001032469A), Oct 1, 1994: Piper PA28R200, Pagosa Springs, CO, Destroyed. Severe downdraft in a canyon while demo of a 180. Unable escape. Down draft hit trees. AIRMET out on turbulence. 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.