Vaughn, NM, USA
N2558M
PIPER PA 28-181
The operator reported that the noninstrument-rated pilot departed on a cross-country flight in the airplane after topping off the fuel tanks. Radar data and fuel records revealed that, about 3 hours later, the airplane stopped at an airport and was fueled. The airplane subsequently departed and flew toward the pilot's destination airport for about 30 miles, but it then returned to the same airport to be fueled again. The airplane subsequently departed again and flew toward the destination airport. Radar data showed that the airplane then climbed to 10,500 ft mean sea level but that it subsequently began to descend; the last radar return showed the airplane at 7,100 ft msl. The airplane was reported missing when it did not arrive at the destination. A subsequent search was conducted, and the airplane's emergency locator transmitter signal was used to find the wreckage. The airplane had impacted rising terrain in a level flight attitude. An examination of the wreckage did not reveal any preimpact anomalies that would have precluded normal operation. Witness marks and bending found on the propeller were consistent with the engine producing power at the time of impact. Multiple weather sources showed that instrument meteorological conditions existed along the route of flight and that these were reported before the accident airplane departed. Additionally, the freezing level was at the surface, and moderate turbulence was expected from the surface through 24,000 ft. Pilots flying in the area around the time of the accident confirmed the presence of turbulence and/or mountain-wave conditions, and they indicated the presence of icing in the clouds with cloud tops near 9,000 ft. Further, no moonlight was present during the flight. No record was found indicating that the pilot received a formal preflight weather briefing; if the pilot had received a formal weather briefing, he would have been made aware of the weather conditions along the route of flight. Although the investigation could not determine what weather information the pilot might have reviewed before departure, his decision to conduct the flight in poor weather conditions was indicative of poor decision-making. The evidence is consistent with the noninstrument-rated pilot flying at night in instrument conditions while likely attempting to fly under the clouds when the airplane hit rising terrain. Toxicological testing of the pilot detected tetrahydrocannabinol (THC). However, the investigation could not determine if the pilot was impaired from the THC before or during the accident flight.
HISTORY OF FLIGHTOn December 30, 2014, about 0330 mountain standard time, a Piper PA-28-181 airplane, N2558M, impacted terrain during a descent near Vaughn, New Mexico. The private pilot and one passenger were fatally injured. The airplane sustained substantial damage. The airplane was registered to the pilot and operated by Pilot's Choice Aviation, Inc., under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Night instrument flight rules (IFR) conditions prevailed in the area for the flight, which did not operate on a flight plan. The flight originated from the Lamesa Municipal Airport (2F5), near Lamesa, Texas, about 0140, and was destined for Albuquerque, New Mexico. According to the operator, a renter flew the accident airplane cross country from the Georgetown Municipal Airport (GTU), near Georgetown, Texas, to the Boerne Stage Field Airport (5C1), near San Antonio, Texas. Radar data showed the flight departed GTU about 0859 mountain standard time, on December 29, 2014, and arrived at 5C1 about 0937, on December 29, 2014. Radar data showed the airplane departed from 5C1 about 1310, on December 29, 2014, and returned to GTU about 1345. The operator reported that the owner subsequently flew the airplane on December 29, 2014, after this cross country flight. The pilot indicated to the operator that he intended to fly to Albuquerque, New Mexico. Prior to the accident flight, the operator serviced the airplane with one quart of oil, made sure additional quarts of oil were in the airplane for the flight, and topped off the fuel tanks with fuel. Airplane dispatch paperwork for the flight indicated the current tachometer time was 5,925.87 hours. Aircraft radar data showed that the airplane departed from GTU about 2150 mountain standard time, on December 29, 2014, and landed at 2F5 about 0019 mountain standard time, on December 30, 2014. Fueling records from the fixed base operator at 2F5 showed that 27.5 gallons of aviation gasoline (avgas) was pumped at 0018. Radar data showed that the airplane departed from 2F5 about 0034 flew northwest for about 30 miles and returned to 2F5 about 0110. Fueling records showed 6.8 gallons of avgas was pumped at 0125. Radar data showed that the airplane departed from 2F5 about 0140, and flew northwest bound. The radar data showed that the airplane climbed to 10,500 feet above mean sea level (msl) during the accident flight. It descended from 9,000 feet about 0323. About 38 seconds later the airplane altitude was about 8,100 feet. The last radar returned showed the airplane was at 7,100 feet about 0324. A friend of the passenger reported that the flight did not arrive. A search for the airplane was conducted and the airplane's emergency locator transmitter signal was detected south of Vaughn, New Mexico, and the airplane was subsequently found about 0200 mountain standard time, on January 1, 2015. The wreckage was found about one-half mile and about 30 degrees from the last radar return. PERSONNEL INFORMATIONThe non-instrument rated pilot, age 46 and seated in the left seat, held a Federal Aviation Administration (FAA) private pilot certificate with an airplane single-engine land and sea rating. The pilot held a FAA third-class medical certificate with no limitations. The pilot recorded in his logbook that he had accumulated 905.9 hours of total flight time, 30.8 hours of flight time in simulated instrument weather conditions, 161.8 hours of flight in night conditions, and 11.6 hours of flight time in the prior 30 and 90 days. His last flight review was conducted on September 11, 2014. AIRCRAFT INFORMATIONN2558M, a 1977-model Piper PA-28-181, was a single-engine, low-wing, fixed tricycle landing gear, semi-monocoque design airplane, with serial number 28-7890256. The airplane was powered by a 180-horsepower, normally aspirated, direct drive, air-cooled, horizontally opposed, carburetor equipped, four-cylinder Lycoming O-360-A4M engine, with serial number L-34549-36A. The engine drove a two-blade fixed pitch McCauley propeller. The airplane was configured to carry a maximum of four occupants. The airplane was equipped for flight in instrument meteorological conditions. The airplane's fuel system consisted of two 25-gallon tanks, with a useable capacity of 24 gallons in each tank. According to an airplane logbook endorsement, the airplane's last inspection was a 100-hour inspection dated December 11, 2014. At that time, the airplane had accumulated 5,903.33 hours of total time in service. METEOROLOGICAL INFORMATIONA National Transportation Safety Board (NTSB) senior meteorologist collected and reviewed weather documents and produced a factual report. The meteorologist's report is appended to the docket associated with this investigation. The report, in part, showed that a dissipating cold front along the route of flight and in the vicinity of the planned destination airport was depicted on a National Weather Service (NWS) Surface Analysis Chart. Forecast IFR conditions, over the route of the route of flight to immediately east of the destination, was shown on a NWS Weather Depiction Chart. A forecast of a stationary front over western New Mexico, a strong pressure gradient over the area, and scattered snow showers over the region were depicted on a NWS 12-hour Low-Level Significant Weather Prognostic Chart. The chart also depicted an extensive area of IFR conditions from Texas, into eastern New Mexico northward into Colorado. The freezing level was depicted on the prognostic chart at the surface and it also showed that moderate turbulence was expected from the surface through 24,000 feet. At 0335, the recorded weather about 110 miles and 90 degrees from the accident site at the Clovis Municipal Airport, near Clovis, New Mexico, was: Wind 020 degrees at 22 knots gusting to 27 knots; visibility 7 statute miles; sky condition overcast clouds at 800 feet; temperature -6 degrees C; dew point -8 degrees C; altimeter; 30.34 inches of mercury. At 0335, the recorded weather about 47 miles and 312 degrees from the accident site at the Moriarty Airport, near Moriarty, New Mexico, was: Wind 110 degrees at 14 knots gusting to 17 knots; visibility 5 statute miles; present weather light snow; sky condition overcast clouds at 500 feet; temperature -7 degrees C; dew point -8 degrees C; altimeter; 30.21 inches of mercury. At 0321, the recorded weather about 37 miles and 330 degrees from the accident site at the weather reporting station near Clines Corner, New Mexico, was: Wind 100 degrees at 21 knots gusting to 27 knots; visibility 1/2 statute mile; present weather light snow with freezing fog; sky condition vertical visibility 200 feet; temperature -9 degrees C; dew point -11 degrees C; altimeter 30.11 inches of mercury; remarks snow began at 0311. The report's satellite imagery revealed an extensive area of low stratiform clouds extending over New Mexico immediately east of Albuquerque into western Texas. The estimated cloud tops were above 10,000 feet msl, according to radiative cloud top temperature measurements. The report showed that there were multiple pilot reports over the area for the route of flight. The pilot reports indicated the presence of turbulence and/or mountain wave conditions. Those pilot reports also indicated the presence of airframe icing in clouds and the location of cloud tops were near 9,000 feet. The NWS area forecast, current for the Salt Lake region, forecast the sky condition as broken clouds at 5,000 feet msl, with tops to 10,000 feet, and visibility as 3 to 5 miles in light snow and mist. The NWS published a series of Airman's Meteorological Information (AIRMET) notices. The AIRMETs, current for the route of flight and over the accident site, forecast areas of IFR and mountain obscuration conditions and forecast areas of moderate turbulence below 18,000 feet msl. Data from the United Stated Naval Observatory website indicated that moonset occurred at 0142 on December 30, 2014 A search for any formal preflight weather briefings indicated that there was no record of the pilot contacting the FAA Automated Flight Service Station or contacting any Direct Users Access Terminal System providers. The investigation could not determine what weather information the pilot may have reviewed prior to departure. AIRPORT INFORMATIONN2558M, a 1977-model Piper PA-28-181, was a single-engine, low-wing, fixed tricycle landing gear, semi-monocoque design airplane, with serial number 28-7890256. The airplane was powered by a 180-horsepower, normally aspirated, direct drive, air-cooled, horizontally opposed, carburetor equipped, four-cylinder Lycoming O-360-A4M engine, with serial number L-34549-36A. The engine drove a two-blade fixed pitch McCauley propeller. The airplane was configured to carry a maximum of four occupants. The airplane was equipped for flight in instrument meteorological conditions. The airplane's fuel system consisted of two 25-gallon tanks, with a useable capacity of 24 gallons in each tank. According to an airplane logbook endorsement, the airplane's last inspection was a 100-hour inspection dated December 11, 2014. At that time, the airplane had accumulated 5,903.33 hours of total time in service. WRECKAGE AND IMPACT INFORMATIONThe airplane came to rest about 7.5 miles and 198 degrees from the western cloverleaf intersection of US Highway 285 and US Route 54. Examination of the accident site revealed that the airplane impacted rising terrain in a level flight attitude. A ground scar was observed with a heading of about 186 degrees magnetic. Seat rails were observed, embedded in the ground scar, in the direction of the scar. The right wing separated from the fuselage and was found at the end of the ground scar. The fuselage remained attached to the empennage and they came to rest upright on an easterly heading about 280 feet from the start of the ground scar. The rudder and vertical stabilizer remained attached to the empennage. The horizontal stabilizer separated from the empennage. The left wing came to rest inverted east of the fuselage. Flight control cables were traced and all breaks in the cables were consistent with overload. No preimpact flight control continuity anomalies were detected. The engine throttle and mixture levers were in their forward positions and separated from their control cables. The engine control cables moved when their opposite ends were pulled with pliers. No preimpact engine control continuity anomalies were detected. The fuel selector was found selecting the left tank. The tachometer indicated 2,600 rpm and its hour meter indicated 5,930.95 hours. The primer was in and locked. The ignition switch was in the both position. The engine separated from the airframe and the propeller separated from the engine. Both were found east of the fuselage. The propeller blades exhibited leading edge abrasion, torsional twisting, chordwise striations across their cambered propeller backs, and "S" shaped bending. The carburetor was separated from the engine and was found under the forward fuselage. Disassembly of the carburetor did not reveal any anomalies. The engine driven fuel pump was attached to the engine and disassembly did not reveal any anomalies. A liquid consistent with the color and smell of avgas was found within the fuel pump. The engines bottom sparkplugs were removed and they displayed a normal wear appearance according to the Champion Spark Plugs Check-A-Plug chart AV-27 along with a color consistent with normal operation. The vacuum pump drive was sheared. Disassembly revealed the rotor assembly was fractured and its vanes were in-place. Both magnetos produced spark. The no. one and three cylinder pushrods sustained impact damage. All four cylinders produced a thumb compression when the crankshaft was rotated by rotation of a rear accessory drive pad. The exhaust heat muff was deformed and it did not exhibit any discoloration consistent with sooting. ADDITIONAL INFORMATIONThe Vaughn Municipal Airport, near Vaughn, New Mexico, was about 9.75 miles and 34 degrees from the accident site. The airport's elevation was 5,928 feet msl. The safety recommendation section in the operator's accident report, in part, stated: As [the operator], I will treat the owners of the leaseback airplanes the same as the renters, and they will sign [the] Renter's Agreement. [The] Renter's Policy does NOT allow night Cross-Country unless you are Instrument Rated or with a Flight Instructor. The Renter's Policy also states that any flight more than 50 NM, the renter will file a VFR or IFR Flight Plan. The owner, just like the rental customers will fill out [a] Flight Load Manifest. This includes actual weather for the departure and weather forecast for the destination. Current Weight & Balance for the Flight, a list of the passengers on board and their emergency contacts, the route of flight and emergency contact as well as contact number at destination. From now on for any renter wanting to fly after hours, the renters will fax or email their Flight Load Manifest before the aircraft will be dispatched for that flight. I will also notify the Flight Service Station immediately before we start our own search. I will also spend more time with an owner that we did not train to see where their knowledge level and attitude are. Make sure that the copies of the pilot certificate in eludes the front and the back of the certificates Instill in my instructors to make sure unusual altitudes and basic altitude instrument flying are part of the Flight Reviews. Stress the importance to the VFR pilot of not getting into IFR. Rather be on the ground wishing you were in the air, than in the air wishing you were on the ground. As well as spend more time emphasizing Aeronautical Decision Making and Risk Management. Spending time to make sure the pilot understands the importance of seeing the problem and making correct decisions for safe outcomes and not letting the external pressures push the pilot beyond their limitations. MEDICAL AND PATHOLOGICAL INFORMATIONAn autopsy was performed on the pilot by the Torrance County Office of the Medical Investigator. The report indicated that the pilot's cause of death was blunt trauma sustained during the accident. The FAA Civil Aerospace Medical Institute prepared a Final Forensic Toxicology Accident Report from samples taken during the pilot's autopsy and from an unidentified tablet found on the pilot. The report, in part, indicated: Amphetamine detected in Tablet(s) - Scored: No | Color: Pink | Shape: Round | Imprint: COR 0.0762 (ug/ml, ug/g) Tetrahydrocannabinol (Marihuana) detected in Liver 0.0755 (ug/ml, ug/g) Tetrahydrocannabinol (Marihuana) detected in Lung 0.033 (ug/ml, ug/g) Tetrahydrocannabinol (Marihuana) detected in Muscle 0.239 (ug/ml, ug/g) Tetrahydrocannabinol Carboxylic Acid (Marihuana) detected in Liver 0.0261 (ug/ml, ug/g) Tetrahydrocannabinol Carboxylic Acid (Marihuana) detected in Lung 0.011 (ug/ml, ug/g) Tetrahydrocannabinol Carboxylic Acid (Marihuana) detected in Muscle TESTS AND RESEARCHAn NTSB air traffic control specialist acquired radar data from the FAA. The data was examined and the flight's data was extracted and placed in a file for use by the senior meteorologist. The radar data is appended in the meteorologist's report associated with this investigation.
The noninstrument-rated pilot’s continued flight into night instrument meteorological conditions, which resulted in his failure to maintain clearance from terrain.
Source: NTSB Aviation Accident Database
Aviation Accidents App
In-Depth Access to Aviation Accident Reports
