# NTSB SEA08LA095: Piper PA-28-181, N432RM, Bridger, MT, March 26, 2008 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: March 25, 2008, 21:24 local (Mar 26, 2008, 03:24 UTC) - Place: Bridger, MT - Coordinates: 45.190555, -108.593055 - Nearby events: https://openairdocs.org/map.md?lat=45.1906&lon=-108.5931&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120) - Highest injury: Minor injuries - Injuries: 1 minor - Status: Completed, report May 6, 2009 - Report: Approved by Office Director - Parties: Piper Company, Rocky Mountain College, Federal Aviation Administration - NTSB case key (mKey): 67720 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=SEA08LA095 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/67720/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=67720 - Page: https://openairdocs.org/ntsb/SEA08LA095 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Perception/orientation/illusion: situational awareness](https://openairdocs.org/ntsb-findings/02022035): Personnel issues › Psychological · Pilot (probable cause); cases with it: [New Piper PA-28-181, 1 case](https://openairdocs.org/ntsb-findings/02022035/cases.md?model=7103201), [All aircraft, 111 cases](https://openairdocs.org/ntsb-findings/02022035/cases.md) - [Action: incorrect action performance](https://openairdocs.org/ntsb-findings/02041015): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [New Piper PA-28-181, 1 case](https://openairdocs.org/ntsb-findings/02041015/cases.md?model=7103201), [All aircraft, 1,386 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md) - [Navigation system: global positioning sys (GPS)](https://openairdocs.org/ntsb-findings/01023457): Aircraft › Aircraft systems · Incorrect use/operation (probable cause); cases with it: [New Piper PA-28-181, 1 case](https://openairdocs.org/ntsb-findings/01023457/cases.md?model=7103201), [All aircraft, 3 cases](https://openairdocs.org/ntsb-findings/01023457/cases.md) - [Personality/attitude: confidence/reliance on equip](https://openairdocs.org/ntsb-findings/02021015): Personnel issues › Psychological · Pilot (probable cause); cases with it: [New Piper PA-28-181, 1 case](https://openairdocs.org/ntsb-findings/02021015/cases.md?model=7103201), [All aircraft, 11 cases](https://openairdocs.org/ntsb-findings/02021015/cases.md) - [Light condition: dark](https://openairdocs.org/ntsb-findings/03036020): Environmental issues › Conditions/weather/phenomena · Not specified (probable cause); cases with it: [New Piper PA-28-181, 1 case](https://openairdocs.org/ntsb-findings/03036020/cases.md?model=7103201), [All aircraft, 448 cases](https://openairdocs.org/ntsb-findings/03036020/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: VFR encounter with IMC](https://openairdocs.org/ntsb-events/401); cases with it: [New Piper PA-28-181, 1 case](https://openairdocs.org/ntsb-events/401/sequence.md?model=7103201), [All aircraft, 392 cases](https://openairdocs.org/ntsb-events/401/sequence.md) - [Enroute-cruise: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120) (defining event); cases with it: [New Piper PA-28-181, 1 case](https://openairdocs.org/ntsb-events/120/sequence.md?model=7103201), [All aircraft, 1,074 cases](https://openairdocs.org/ntsb-events/120/sequence.md) ## 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](https://openairdocs.org/deregistered/N432RM-2008-06-23), registration cancelled 2008-06-23, S/N 2843623, built 2006 (OpenAirDocs) - Reported make and model: PIPER PA-28-181 - Registry model: [New Piper PA-28-181](https://openairdocs.org/model/new-piper-pa-28-181) (registry code 7103201) (OpenAirDocs) - Registry engine: [Lycoming O-360 series](https://openairdocs.org/engine/lycoming-o-360-series) (registry code 41575, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 2843623 - Airframe hours: 1278 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 18; injuries: minor; 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 ## 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 20080325013969A](https://openairdocs.org/incident/20080325013969A), Mar 25, 2008: Piper PA28181, Destroyed. (-23) On March 25, 2008 about 2150 mountain daylight time, a Piper PA28-181, N432RM, was destroyed when the aircraft impacted the ground during a training… ## Docket (22 files) The files NTSB released with the investigation on May 25, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=67720. 10.1 MB in all. - Cockpit displays recorded flight data factual report (item 1, PDF, 8 pages, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13907855&FileExtension=pdf&FileName=Cockpit%20Displays%20Recorded%20Flight%20Data%20Factual%20Report-Master-Rel.pdf - Cockpit displays recorded flight data factual report attachment I-1 tabular data (item 2, CSV, 489 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=7493253&FileExtension=csv&FileName=Cockpit%20Displays%20Recorded%20Flight%20Data%20Factual%20Report%20Attachment%20I-1%20Tabular%20Data-Master-Rel.csv - Cockpit displays recorded flight data factual report attachment I-2 tabular data (item 3, CSV, 224 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=7493255&FileExtension=csv&FileName=Cockpit%20Displays%20Recorded%20Flight%20Data%20Factual%20Report%20Attachment%20I-2%20Tabular%20Data-Master-Rel.csv - Materials laboratory 15-factual report 08-052 (item 4, PDF, 6 pages, 617 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13907858&FileExtension=pdf&FileName=Materials%20Laboratory%2015-Factual%20Report%2008-052-Master-Rel.pdf - Pilot-operator aircraft accident report NTSB form 61201 (item 5, PDF, 9 pages, 529 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=230628&FileExtension=pdf&FileName=Pilot-Operator%20Aircraft%20Accident%20Report%20NTSB%20Form%2061201-Rel.pdf - Plots of flight track (item 6, PDF, 3 pages, 292 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13907970&FileExtension=pdf&FileName=Plots%20of%20Flight%20Track-Master-Rel.pdf - Rmc GPS training (item 7, PDF, 2 pages, 38 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13908496&FileExtension=pdf&FileName=RMC%20GPS%20Training-Master-Rel.pdf - Pilot written statement (item 8, PDF, 3 pages, 218 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=230635&FileExtension=pdf&FileName=Pilot%20Written%20Statement-Rel.pdf - Record of conversation-pilot (item 9, PDF, 2 pages, 16 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13907768&FileExtension=pdf&FileName=Record%20of%20Conversation-Pilot-Master-Rel.pdf - Record of conversation-cfi (item 10, PDF, 2 pages, 15 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13908279&FileExtension=pdf&FileName=Record%20of%20Conversation-CFI-Master-Rel.pdf - Record of conversation-training (item 11, PDF, 1 page, 13 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13908563&FileExtension=pdf&FileName=Record%20of%20Conversation-Training-Master-Rel.pdf - Inflight slc flight watch (item 12, PDF, 1 page, 12 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13908103&FileExtension=pdf&FileName=Inflight%20SLC%20Flight%20Watch-Master-Rel.pdf - Rocky party submission (item 13, PDF, 1 page, 39 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=230673&FileExtension=pdf&FileName=Rocky%20Party%20Submission-Master.pdf - Statement of party representatives to NTSB investigation (item 14, PDF, 3 pages, 235 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=230642&FileExtension=pdf&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Rel.pdf - Release of aircraft wreckage NTSB form 612015 (item 15, PDF, 1 page, 62 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=230645&FileExtension=pdf&FileName=Release%20of%20Aircraft%20Wreckage%20NTSB%20Form%20612015-Rel.pdf - Photo 1 accident site provided by recovery crew (item 16, PDF, 1 page, 4.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13926525&FileExtension=pdf&FileName=Photo%201%20Accident%20Site%20Provided%20by%20Recovery%20Crew-Master-Rel.pdf - Photo 2 on scene cabin provided by recovery crew (item 17, PDF, 1 page, 100 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13926275&FileExtension=pdf&FileName=Photo%202%20On%20Scene%20Cabin%20Provided%20by%20Recovery%20Crew-Master-Rel.pdf - Photo 3 accident site looking downhill provided by recovery crew (item 18, PDF, 1 page, 92 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13926102&FileExtension=pdf&FileName=Photo%203%20Accident%20Site%20Looking%20Downhill%20Provided%20by%20Recovery%20Crew-Master-Rel.pdf - Photo 4 flying to site provided by recovery crew (item 19, PDF, 1 page, 66 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13926278&FileExtension=pdf&FileName=Photo%204%20Flying%20to%20Site%20Provided%20by%20Recovery%20Crew-Master-Rel.pdf - Photo 5 area of accident site provided by recovery crew (item 20, PDF, 1 page, 91 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13926105&FileExtension=pdf&FileName=Photo%205%20Area%20of%20Accident%20Site%20Provided%20by%20Recovery%20Crew-Master-Rel.pdf - Photo 6 fuselage provided by recovery crew (item 21, PDF, 1 page, 88 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13926367&FileExtension=pdf&FileName=Photo%206%20Fuselage%20Provided%20by%20Recovery%20Crew-Master-Rel.pdf - Photo 7 engine and propeller provided by recovery crew (item 22, PDF, 1 page, 65 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13926521&FileExtension=pdf&FileName=Photo%207%20Engine%20and%20Propeller%20Provided%20by%20Recovery%20Crew-Master-Rel.pdf From the NTSB's public API. 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