Strawberry, AZ, USA
N4188E
PIPER PA-28-181
The student pilot was enrolled in a European flight training academy, which, in conjunction with a US-based operator, provided training services in accordance with European Joint Aviation Authorities standards. The US operator provided aircraft, training facilities, and flight instructors as part of a service agreement with the European academy. The purpose of the flight was to conduct a phase check on the student pilot. The syllabus included a cross-country flight with a subsequent in-flight diversion to a location unknown to the student pilot. The student pilot was located in the forward left seat, a flight instructor was in the forward right seat, and an evaluator was in an aft seat. The evaluator had considerable aviation experience in Europe; however, he only held a Federal Aviation Administration (FAA) private pilot license. Therefore, the flight instructor was used on the flight as a "safety pilot," acting as pilot-in-command, to meet FAA regulatory requirements. The flight instructor had recently joined the US operator, but he was not incorporated into the European flight academy's flight training program; therefore, he had no prior experience as a safety pilot with the academy. The day before the accident, the evaluator provided the student pilot with instructions for the cross-country portion of the phase check, which included flight to a destination airport located in mountainous terrain with a directive to fly at an altitude of 1,000 feet above ground level (agl) throughout the flight. The student pilot was also asked to plan an en route 40-minute target arrival waypoint and to be ready to prepare for an in-flight diversion. The majority of the route planned by the student passed through a series of FAA-designated special conservation areas. Although the FAA did not prohibit flight through such areas, it did discourage it. Further, although the academy and operator did not explicitly prohibit flights to be performed along the chosen route, cross-country check flights were typically accomplished in areas south of the departure airport where terrain was lower. According to radar data, the student pilot successfully manipulated the airplane in precise coordination with his flight plan for about the first 35 minutes following departure. Shortly thereafter, the airplane approached and passed the 40-minute waypoint and then continued along the planned route while in a shallow climb. Examination of the student's flight plan revealed that, to maintain 1,000 feet agl clearance as the airplane approached the waypoint, he would have needed to fly the airplane level and then below rising canyon walls on either side of the route. Avoiding terrain just beyond the waypoint would have required a prompt climb or diversion because the rapidly rising terrain would have required the airplane to climb at a rate that exceeded its climb capabilities. Further, downdrafts and high-density altitude conditions were present in the canyon, which likely further degraded the airplane's available climb performance. Thus, the airplane entered a steep canyon (still along the planned route) that it could neither climb out of nor turn around in. Shortly after, with the airplane flying straight and level, it struck a cliff face at the end of the canyon, 1,000 feet below the canyon's rim. The majority of the airplane's structure was consumed by postimpact fire; postaccident examination revealed no anomalies with the engine or airframe that would have precluded normal operation. Radar data indicated that the airplane was climbing about 4 minutes before impact and that the accident location was at the same elevation as the last radar target. Therefore, the engine was likely producing power during the final stages of the flight. Although no indications of in-flight fire were observed, toxicological tests for the evaluator revealed that he had been exposed to the products of combustion (carbon monoxide and cyanide); however, this likely occurred during the postcrash fire. None of the occupants had ever flown with each other, and no records were recovered indicating that the flight instructor or student pilot had ever flown to the presumed diversion airport. The evaluator arrived late for the flight, so the original flight instructor, who had flight commitments later in the day, asked the accident flight instructor to join the flight at the last minute, which did not allow him sufficient time to participate in the preflight oral briefing and limited the time he had to evaluate the flight plan. From a regulatory standpoint, the flight instructor was the pilot-in-command and, thus, was responsible for the safety of the flight. However, given his relatively junior status within the organization and the young student pilot's lack of experience, it is likely that both pilots deferred responsibility for the flight to the evaluator and trusted that the route was appropriate. It is possible that the unsuitable route was discussed and understood by all of the occupants; however, the reason for not performing the diversion at an appropriate time could not be determined. The Dutch Safety Board (DSB) was a party to the investigation and appointed an accredited representative in accordance with the provisions of Annex 13 to the Convention on International Civil Aviation. The DSB submitted comments regarding the factual report, brief, and probable cause, and they are included in the public docket for this accident.
HISTORY OF FLIGHT On September 13, 2012, about 1453 mountain standard time, a Piper PA-28-181, N4188E, collided with steep terrain within a canyon near Strawberry, Arizona. CAE Global Academy Phoenix (CAE) was operating the airplane under the terms of a training services agreement with KLM Flight Academy, under the provisions of 14 Code of Federal Regulations Part 91, as an instructional/evaluation flight. The student pilot, certified flight instructor (CFI), and private pilot-rated passenger acting as an evaluator, sustained fatal injuries. The airplane sustained substantial damage during the accident sequence, and was subsequently consumed by post impact fire. The cross-country flight departed Falcon Field, Mesa, Arizona, at 1412, with a presumed destination of Payson, Arizona. Visual meteorological conditions prevailed, and a company flight plan had been filed. The student pilot was enrolled in the KLM Flight Academy (KLS) Flight Training Program. The ground portion of the training was provided by KLS in the Netherlands, with the flight portion performed at the facilities of CAE in Mesa. The flight training was provided by CAE in accordance with the European Joint Aviation Authorities (JAA) standards JAR-FCL 1.055, as a European Joint Aviation Requirements (JAR) approved, integrated Airline Transport Pilot License (ATPL) program. CAE provided aircraft, flight instructors, and training facilities as part of the agreement. Progress/phase checks were administered by evaluator pilots employed by KLS, who held JAA examiner authorizations. CAE operated as a flight school under Federal Aviation Administration (FAA) 14 CFR Part 61. The pilot rated passenger held a current European examiner authorization certificate, and was acting in the capacity of an evaluator for KLS. He held an FAA Private Pilot license, and the CFI who was employed by CAE, was utilized in the capacity of a "safety pilot," acting as pilot-in-command, so that the general limitations within 14 CFR Part 61.89 could be met. The student pilot was located in the forward left seat, the CFI in the forward right seat, and the evaluator in an aft seat. Both the student and evaluator were citizens of the Netherlands, and the CFI was a United States citizen. The purpose of the flight was to conduct a phase check for the student as part of his training towards JAA certification. Prior to departure, the evaluator reported to a CAE senior instructor that his intention was to have the student plan for a VFR flight to Winslow, Arizona, with a subsequent emergency practice diversion to Payson. In compliance with both the FAA and JAR practical test standards, the location of the diversion was unknown to the student pilot. The airplane did not return at the expected time, and became the subject of an Alert Notice (ALNOT) about 2130. A search was conducted by the Civil Air Patrol and Gila County Sheriff's Office utilizing radar data and network-based cell phone signal analysis, and the airplane was located about 2100 the following day. The airplane wreckage was located at an elevation of about 5,800 feet within a densely forested area of the Fossil Creek Wilderness, at the northeast end of Calf Pen Canyon. The general area fell within the slopes of the Mogollon Rim Escarpment, 4 miles northeast of the last radar target. The site was surrounded to the north, east, and south by steep canyon walls, rising to an elevation of about 6,800 feet. PERSONNEL INFORMATION All three occupants had never flown with each other either independently, or as a group, and no flight records were recovered indicating that the CFI or student pilot had flown to Payson Airport. CAE did not keep formal records of the KLS evaluator's flight time; as such, it could not be definitively determined if he had flown to Payson before. CFI The 25-year-old pilot held a commercial pilot certificate for airplane single-engine land, multiengine land, and instrument airplane. In July 2011, he was issued a flight instructor certificate with a rating for airplane single-engine land. He held a first-class medical certificate issued on March 16, 2012, with the limitation that he must wear corrective lenses. Documentation provided by CAE revealed a total flight experience of 806 hours. His employment at CAE began on April 2, 2012, and he accumulated 226.8 hours of flight time between that date and the accident. About 205 flight hours took place in the Diamond DA20 airplane, with the remaining 21 hours occurring in the accident airplane make and model, which comprised his total flight experience in that type. According to the CAE Manager of Safety, the DA20 airplane, unlike the PA-28-181, was prohibited from being operated in the mountainous terrain north of Mesa. His time at CAE was spent primarily training Vietnamese students under the CAE FAA-based training program, and he was not incorporated as an approved instructor as part of the KLS program. On the day of the accident, another CFI who was a KLS-approved instructor was due to be the safety pilot for the accident flight. She stated that the evaluator arrived over an hour late, and therefore, she approached the CFI about swapping with her so she would not need to cancel the lesson she had scheduled following. The CFI accepted, but did not participate in the pre-flight briefing or oral portion of the examination with the student and evaluator. Student Pilot The student pilot, aged 19, held an FAA combined student pilot and first-class aviation medical certificate issued on August 1, 2011. The medical certificate had no limitations. KLS records indicated his first training flight took place on August 2, 2012, and between that time and the accident he had accumulated 79 total flight hours, 29 of which were as pilot-in-command. All of his documented flight experience was in the accident airplane make and model. The student pilot's father was employed as a pilot for KLM. His father had known the evaluator since 1983, during which time he had received both flight training, and taken multiple checkrides with him at the Dutch State Flying Academy in Holland (later to become KLM Flight Academy (KLS). The student pilot's grandfather was also an instructor and examiner, and was a colleague with the evaluator while they were both at the Rijksluchtvaartschool (Dutch State Flight Academy). Evaluator The 68-year-old evaluator was the US single-engine flight training manager for the KLS division in Mesa. He held a JAA-issued airline transport pilot certificate with flight examiner and class examiner rating authorization. His FAA private pilot's license had a rating for airplane single-engine land, and was issued initially in December 2005, and then re-issued on January 27, 2010, following its expiration. He held a JAA Airline Transport Pilot certificate, issued in February 1980, with flight instructor, single-engine piston, and instrument airplane ratings, as well as flight examiner and class-rating examiner authorizations valid until June 22, 2013. His most recent JAA examination occurred on May 25, 2012, and was for his flight instructor currency. The FAA license was issued on the basis of his JAA flight crew license. His flight history included time as a fighter pilot for the Netherlands Armed Forces, a Captain for Air Holland, and according to representatives from KLS, a pilot for KLM Exel. He was issued a first-class medical certificate on August 31, 2012, by the Civil Aviation Authority of the Netherlands. The certificate had the limitation that he wear multifocal lenses. AIRCRAFT INFORMATION The airplane was manufactured in 1999, and equipped with a normally aspirated Lycoming O-360-A4M engine and a Sensenich fixed-pitch propeller. A review of the airplane's maintenance logbooks revealed a total airframe time of 14,975 hours at the last progressive inspection, which was completed the morning of the accident. At that time, the engine had accrued 14,309 total flight hours, 2,566 since its most recent overhaul in November 2009. METEOROLOGICAL INFORMATION An automated surface weather observation at Payson Airport (KPAN), Payson, (elevation 5,157 feet msl, 16 miles southeast of accident site) was issued at 1455. It indicated wind from 040 degrees at 14 knots gusting to 17, 10 miles with clear skies, temperature at 27 degrees C, dew point 06 degrees C, and an altimeter setting at 30.25 inches of mercury. The NWS Surface Analysis Chart for 2100Z depicted a high pressure system over Kansas at 1030- hectopascals with a ridge extending southwestward into New Mexico. Thermal low pressure systems were noted over the Arizona and Utah border north of the accident site at 1019-hPa and to the west over the California-Arizona border at 1010-hPa. The station models depicted east-northeasterly winds at 10 to 20 knots over the region with scattered clouds, and no significant weather. Temperatures varied from near 38 degrees C over the southern portion of Arizona to the lower 30's in the northern portion of the state. Geostationary Operational Environmental Satellite (GOES)-13 visible imagery from 1900Z through 2200Z depicted few to scattered cloud cover over the area. The accident site remained clear of clouds with some signs of orographic wind flow or downslope conditions on the leeward side of the Mogollon Plateau, with subsequent rising air and developing cumulus clouds further from the rim. No AIRMETs for turbulence, icing, or IFR conditions were expected over Arizona. A Convective SIGMET was current at the time for developing thunderstorms, which did not impact the route of flight of the accident airplane. Pilot Reports (PIREPS) indicated moderate clear air turbulence for the area during the period of the accident; with pilots at Prescott Airport (KPRC), located approximately 42 miles west of the accident site, reporting several encounters with low level wind shear on approach. Utilizing the weather observation at Payson, the density altitude at the airplane's last known radar position would have been about 8,221 feet. WRECKAGE AND IMPACT INFORMATION The airplane came to rest at the base of a rock abutment, and was surrounded by pine trees ranging in height from 50 to 100 feet. Scaring was present on the bark of a tree adjacent to the wreckage, and fresh rock damage was noted to the abutment at the 50-foot level. About 150 feet west, freshly cut tree limbs were noted to a tree at the 75-foot level. No other trees were damaged. The cabin structure, right wing, vertical stabilizer, and right stabilator were consumed by fire. The engine sustained thermal damage to its accessory case, but was otherwise intact and still attached to the firewall. The remnants of the empennage were located underneath the fuselage debris. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was conducted on all three occupants at the Forensic Science Center, Tucson, Arizona, on behalf of the Gila County Sheriff's Office. The cause of death was reported as the effect of blunt force and thermal injuries to the evaluator and CFI, and blunt force injuries to the student pilot. Additional findings for the evaluator included, arteriosclerotic cardiovascular disease, coronary artery atherosclerosis - mild to moderate, cortical cyst of the right kidney, surgical replacement of the left hip, and surgical repair of the atria of the heart. Toxicological tests on specimens recovered from the three occupants were performed by the FAA Civil Aerospace Medical Institute (CAMI). The results were negative for all screened drug substances and ingested alcohol for the CFI and student pilot. Their recovered specimens were not suitable for carbon monoxide or cyanide analysis. For the evaluator, the results were negative for ingested alcohol, with the following positive findings: >> 16 (%) CARBON MONOXIDE detected in Blood (Heart) >> 0.36 (ug/ml) CYANIDE detected in Blood (Heart) >> Flecainide detected in Liver >> Flecainide detected in Blood (Heart) >> Metoprolol detected in Liver >> Metoprolol detected in Blood (Heart) Refer to the toxicology report included in the public docket for specific test parameters and results. According to CAMI, Flecainide is an antiarrhythmic drug used in the treatment of ventricular tachycardia and premature ventricular contractions; and Metoprolol is a beta-adrenergic receptor antagonist, "beta blocker," used in the treatment of hypertension and certain arrhythmias. TESTS AND RESEARCH Engine and Airframe Examination The airplane's cabin area from the firewall through to the aft section of the tailcone was consumed by fire, with only steel remnants, flight control cables and fittings, and seat frames remaining. The left wing sustained thermal damage and was consumed from the root through to the aileron seam. The right wing was consumed by fire, with only fragmented remnants of skin and spar material remaining. The engine remained attached to the firewall by its mounts, and had sustained thermal damage to its aft section, with the magnetos, engine driven and electrical fuel pump, carburetor and associated fuel lines partially consumed by fire. Cylinders 1, 2, and 4 sustained minimal damage, with cylinder 3 sustaining crush damage to the rocker cover. The top spark plugs for cylinders 1, 2, and 4, as well as the bottom plug for cylinder 3 were removed; no mechanical damage was noted, and the center and fine-wire electrodes exhibited light grey deposits, with wear signatures corresponding to normal operation when compared with the Champion Aviation Check-A-Plug AV-27 Chart (Photo 3). Visual inspection of the combustion chambers was accomplished through the spark plug bores utilizing a borescope; there was no evidence of foreign object damage or detonation, and all combustion surfaces exhibited light grey deposits consistent with normal operation. The propeller remained attached at the crankshaft flange. One blade was bent about 35 degrees aft at the root; the second blade exhibited a 90-degree aft bend midspan. The tip was bent a further 90-degrees inboard. The outboard 2-inch-long section of the tip had separated and was not located. The separation exhibited tearing features, with lengthwise scratches and red-colored rock fragments smeared along the forward blade surface. Examination did not reveal any anomalies with the airframe or engine that would have precluded normal operation. Refer to the engine and airframe report included in the public docket for further details. Radar Data and Flight Planning Data from the airport surveillance radar sensor located at Phoenix Sky Harbor International Airport (PHX) was provided by the FAA. The first target corresponding to the accident airplane was recorded at 1412:36, and indicated a target departing Falcon Field Runway 22L, and initiating a climbing right turn to the north, where it followed the Verde River at an altitude of 3,300 feet mean sea level (msl). About 50 miles north of Falcon Field, the target changed heading to the north-northeast, where over the next 10 minutes it began a climb to 5,600 feet. It then made a 35-degree right turn, entering a northeast oriented canyon. For the next 2 1/2 minutes the target continued at 5,700 feet msl approximately level with the canyon rim. Prior to entering the canyon, the airplane had maintained a continuous ground clearance of between 500 and 1,500 feet. The last minute of radar data (which ended at 1450:43) indicated that the target climbed to an altitude of 5,800 feet as it entered the Calf Pen Canyon, 17 miles northwest of Payson. The canyon was about 7,000 feet wide at the airplane's entry altitude, reducing to 3,800 feet over the next 4 miles of the presumed flight path. Additionally during this period, the terrain rose from 4,800 feet to about 6,800 feet at the canyon's end. The target's ground speed averaged about 85 knots during the last 4 miles of recorded data. A comparison between the radar data and the flight plan (located on the student pilot's laptop) revealed that the student's planned route would have taken them directly over the accident site. The accident occurred about midway between the fifth and six waypoints, which were located about 15 nautical miles apart. The terrain elevation at the fifth waypoint was ab
The flight instructor's and the evaluator's failure to divert at an appropriate time during cruise flight, which resulted in the airplane's inability to maintain a sufficient altitude to clear rising terrain. Contributing to the accident was the flight evaluator's decision to allow the student pilot to plan for and execute a hazardous flight at an inappropriate altitude considering the terrain in high-density altitude conditions.
Source: NTSB Aviation Accident Database
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