SEA08LA095

NTSB accident investigation · Piper PA-28-181 · Bridger, MT · March 26, 2008

Accident · Minor injuriesLimited investigationFinal report
Date
March 25, 2008, 21:24 local (Mar 26, 2008, 03:24 UTC)
Place
Bridger, MT
Injuries
1 minor
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N432RMPiper PA-28-181
Defining event
Enroute-cruise: Controlled flight into terr/obj (CFIT)
Weather
Visual (VMC) · Night
Status
Completed · report May 6, 2009
Report
Approved by Office Director
Parties
Piper Company, Rocky Mountain College, Federal Aviation Administration
FAA report
20080325013969A
Case key
67720

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 failed to maintain situational awareness during the flight. Contributing to the accident were the dark night, the pilot's failure to follow approved navigational procedures for the flight, and the pilot's over reliance on the avionics in the airplane.

Findings · 5

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Action: incorrect action performancePersonnel issues › Action/decision · PilotNew Piper PA-28-181: 1 caseAll aircraft: 1,386 casesProbable cause
Navigation system: global positioning sys (GPS)Aircraft › Aircraft systems · Incorrect use/operationNew Piper PA-28-181: 1 caseAll aircraft: 3 casesProbable cause
Light condition: darkEnvironmental issues › Conditions/weather/phenomena · Not specifiedNew Piper PA-28-181: 1 caseAll aircraft: 448 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The pilot departed on a night, solo cross-country flight to fulfill a training requirement for his commercial pilot certificate. Although the pilot was aware that the flight was to be flown using dead reckoning and pilotage, he did not verify the ground checkpoints during the flight, which resulted in his loss of situational awareness. Following departure, the air traffic controller had the pilot fly southeast of the airport. After the pilot cleared the airspace, in an action inconsistent with established visual flight rules (VFR) procedures set by his school, the pilot incorrectly entered a true course rather than a magnetic course into the global positioning system (GPS) onboard the airplane. In the process of programming the GPS unit, he used a GPS course entry procedure that was only to be used during instrument flight procedures rather than VFR flight navigation. The pilot then activated the autopilot to fly the entered course. During the flight, the airplane entered instrument flight rules conditions and the pilot disconnected the autopilot. The pilot then received a warning on the GPS that the airplane was close to terrain. He began a left turn to return to visual flight rules. During the turn, the airplane impacted the terrain. The pilot did not report any mechanical or navigational anomalies with the airplane and none were identified during the postaccident examination of the wreckage and instrumentation.

Factual narrative

History of flight

On March 25, 2008, about 2124 mountain daylight time, a Piper PA-28-181, N432RM, collided with terrain approximately 17 miles southeast of Bridger, Montana. Rocky Mountain College was operating the flight under the provisions of 14 Code of Federal Regulations Part 91. The private pilot, the sole occupant, sustained minor injuries. The airplane sustained substantial damage. Night visual meteorological conditions prevailed along the planned route for the cross-country flight, and a visual flight rules (VFR) flight plan was filed for the roundtrip flight. The pilot departed Billings Logan International Airport, Billings, Montana.

According to the operator, the pilot was conducting a night cross-country flight in preparation for obtaining a commercial pilot certificate. The pilot was scheduled to return later that night. An emergency locater transmitter (ELT) was recorded in the area at 2152. When the pilot did not return to Rocky Mountain College's facility, an Alert Notice (ALNOT) was issued at 0157 AM on March 26.

A ground and aerial search was initiated. The pilot was located the following morning and rescued by a search and rescue helicopter in the Pryor Mountains, Custer National Forest. The elevation of the accident site was about 7,400 feet mean sea level (msl) and the highest point of the mountains rose to 8,646 feet msl.

According to personnel at the college, the pilot was to fly from Billings to Powell using visual flight rules navigational procedures. His planned route of flight would have taken him west of the Billings airport, and then south over a highway to his destination. The Pryor Mountains are located approximately 12 miles east of the pilot's planned route of flight.

Personnel information

The 18 year old pilot is a student at Rocky Mountain College. Several weeks prior to the accident, he had completed an instrument rating and was currently working on obtaining the required training for a commercial certificate. As part of the curriculum for the commercial certificate, the pilot was required to perform a solo, night, cross-country flight.

In an interview with the Safety Board investigator, the pilot reported that upon takeoff, he was given a heading of 130 degrees. Once he was out of the Billings airspace, he was told to maintain VFR. He opened his VFR flight plan and entered in a global positioning system (GPS) direct course to Powell Municipal Airport, Powell, Wyoming. He manually entered a course of approximately 192 degrees for the GPS course, which he recalled as his calculated true course for the flight. The pilot had also calculated his magnetic course using a magnetic variation between 13 to 14 degrees east prior to the flight, but did not enter it into the GPS. He did not recall verifying the ground checkpoints as indicated on the VFR flight plan. During the flight, the pilot encountered a storm consisting of rain and snow. The pilot could not see lights on the ground and decided to turn around.

To determine his location, he looked at his sectional chart. He believed that the terrain he was over was about 6,500 to 6,800 feet msl. The airplane was at 7,500 feet msl. The pilot entered a standard rate turn to the left and the two Garmin 430 GPS units in the airplane flashed a warning. The pilot pushed "enter" to look at a message and then saw that the airplane was close to terrain. The pilot pulled up, added power, and then he lost consciousness. The pilot stated that until he entered the instrument conditions he was using the autopilot.

Once the pilot woke up, he unbuckled his restraint system, turned the electrical system off, and turned on the Emergency Transmitter (ELT). He started to climb up the hill in the snow, but sank up to his neck in the snow. He then went back to the airplane, put on his hat and gloves, and did an inventory of his survival kit, which included flares. He used the space blankets to stay warm and curled up in the cockpit. During the night he relocated to the tail section of the airplane. Also during the night, the pilot shot off flares.

The pilot could hear search aircraft in the morning, so he hiked to the top of the hill. He tried his cell phone and was able to contact his certified flight instructor (CFI) to tell her what happened. He then used an orange tarp to increase his visibility to the over flying aircraft. A rescue helicopter used hand signals to show him where to go, and the pilot followed them to a clearing where they were able to land and pick him up.

The airplane was equipped with Avidyne Entegra Multi-Function Display (MFD) and Primary Flight Display (PFD) units, and two Garmin 430 GPS units. During the flight, the pilot had set the MFD to the engine page so it was not displaying terrain information. The pilot stated that the airplane and navigation systems operated normally during the flight.

The pilot said that he began his flight training in the state of Washington where he obtained his private pilot certificate. He started Rocky Mountain College in September of 2007 where he obtained his instrument rating several weeks prior to the accident. The majority of the pilot's flight time in Montana had been instrument work. The pilot most recently flew to Seattle, Washington area, and filed an instrument flight rules flight plan, but flew under visual meteorological conditions.

According to the pilot's CFI, the pilot had flown four flights since obtaining his instrument rating. The first flight was to get the pilot back into performing maneuvers and looking outside. The pilot had been on a VFR, day, dual cross-country flight to Gallatin Field Airport, Bozeman, Montana. For this flight, his CFI reviewed his flight plan but the actual flight was completed with another instructor. The pilot also completed a dual, local, night flight with the CFI, in addition to a local, night, solo flight of 2.1 hours.

The pilot had originally planned his flight for Monday, but due to weather it was moved to Tuesday. The CFI was debating on joining the pilot for the flight but elected to send him solo because she had classes the following day (a dual, night, cross-country flight is required but can commence after the solo, night, cross-country flight). She met the pilot at the airport where they discussed his flight plan and reviewed the weather. The pilot had planned checkpoints to use during the flight, and the CFI verified that he would be able to see the checkpoints at night. The pilot knew that the flight was to be completed using pilotage and "ded" reckoning, not using VHF (very high frequency) omni-directional range (VOR) or the autopilot, and limited use of the GPS.

He planned to fly to Powell and then return to Billings. Once he arrived at Powell, he would close his flight plan, and then open the return flight plan to Billings. After arriving at Billings, he would close his flight plan and then perform touch-and-go landings before terminating his flight. His total planned flight time was 2.9 hours. The instructor asked the pilot to call her once he arrived back to Billings. The CFI indicated that the pilot was a good student and enjoyed flying.

Meteorological information

The pilot obtained a weather briefing and filed his flight plan via telephone through the Lockheed Martin Denver Automated Flight Service Station (AFSS) prior to the accident flight. He was advised that VFR conditions were present along the route of flight. The AFSS specialist indicated that the Montana portion of the flight did not show any weather, and the Wyoming forecast showed isolated showers as well as airman's meteorological information (AIRMETS) for icing and mountain obscuration.

Communications

Communication between the Billings Airport Traffic Control Tower and Lockheed Martin Prescott AFSS Hub (Salt Lake City Flight Watch) were reviewed. When the pilot departed, he was given a departure heading of 130 degrees. He the

Aircraft

Registration
N432RM
Reported as
Piper PA-28-181
Category
Airplane
Serial number
2843623
Airframe hours
1,278
Engine
Textron Lycoming O-360-A4M, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
Rocky Mountain College
Registered owner
Rocky Mountain College
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · February 4, 2008 · 86 hours before
Departed
BIL · Billings, MT
Destination
POY · Powell, WY
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
18
Injuries
Minor
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Without waivers/limitations
Last flight review
February 29, 2008
Seat
Left
Flight hours
150 total · 60 in this make and model · 75 as pilot in command · 36 in the last 90 days · 21 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Night
Wind
210° at 4 knots
Visibility
10 statute miles
Lowest ceiling
9,500 ft broken
Temperature
34 °F, dew point 16 °F
Altimeter
29.97 inHg
Observed at
BIL, 37 nm away

Docket · 22

The files NTSB released with the investigation on May 25, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 10.1 MB in all.

Cockpit displays recorded flight data factual reportItem 1 · PDF · 8 pages · 2.1 MBCockpit displays recorded flight data factual report attachment I-1 tabular dataItem 2 · CSV · 489 KBCockpit displays recorded flight data factual report attachment I-2 tabular dataItem 3 · CSV · 224 KBMaterials laboratory 15-factual report 08-052Item 4 · PDF · 6 pages · 617 KBPilot-operator aircraft accident report NTSB form 61201Item 5 · PDF · 9 pages · 529 KBPlots of flight trackItem 6 · PDF · 3 pages · 292 KBRmc GPS trainingItem 7 · PDF · 2 pages · 38 KBPilot written statementItem 8 · PDF · 3 pages · 218 KBRecord of conversation-pilotItem 9 · PDF · 2 pages · 16 KBRecord of conversation-cfiItem 10 · PDF · 2 pages · 15 KBRecord of conversation-trainingItem 11 · PDF · 1 page · 13 KBInflight slc flight watchItem 12 · PDF · 1 page · 12 KBRocky party submissionItem 13 · PDF · 1 page · 39 KBStatement of party representatives to NTSB investigationItem 14 · PDF · 3 pages · 235 KBRelease of aircraft wreckage NTSB form 612015Item 15 · PDF · 1 page · 62 KBPhoto 1 accident site provided by recovery crewItem 16 · PDF · 1 page · 4.7 MBPhoto 2 on scene cabin provided by recovery crewItem 17 · PDF · 1 page · 100 KBPhoto 3 accident site looking downhill provided by recovery crewItem 18 · PDF · 1 page · 92 KBPhoto 4 flying to site provided by recovery crewItem 19 · PDF · 1 page · 66 KBPhoto 5 area of accident site provided by recovery crewItem 20 · PDF · 1 page · 91 KBPhoto 6 fuselage provided by recovery crewItem 21 · PDF · 1 page · 88 KBPhoto 7 engine and propeller provided by recovery crewItem 22 · PDF · 1 page · 65 KB

FAA reports on this event · 1

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