N106AW

Destroyed
Fatal

Piper PA-28R-200S/N: 28R-7535202

Accident Details

Date
Friday, January 24, 2003
NTSB Number
DEN03FA038
Location
La Sal, UT
Event ID
20030205X00165
Coordinates
38.288887, -109.206947
Aircraft Damage
Destroyed
Highest Injury
Fatal
Fatalities
4
Serious Injuries
0
Minor Injuries
0
Uninjured
0
Total Aboard
4

Probable Cause and Findings

the loss of engine power (total) due to fuel starvation, the pilot not following procedures/directives (fuel management procedures), and the pilot's inadequate preflight planning/preparation for the flight. Contributing factors were the pilot's inadequately equipping the airplane (lack of supplemental oxygen), the pilot's hypoxic physical impairment, and the pilot's total lack of experience in type of operation.

Aircraft Information

Registration
N106AW
Make
PIPER
Serial Number
28R-7535202
Engine Type
Reciprocating
Year Built
1975
Model / ICAO
PA-28R-200P28R
Aircraft Type
Fixed Wing Single Engine
No. of Engines
1

Registered Owner (Historical)

Name
AIR WEST FLIGHT CENTER INC
Address
10383 N 85TH ST
Status
Deregistered
City
LONGMONT
State / Zip Code
CO 80503
Country
United States

Analysis

HISTORY OF FLIGHT

On January 23, 2003, at 2037 mountain standard time, a PA-28R-200, N106AW, was destroyed when it impacted terrain during a night forced landing attempt near La Sal, Utah. A postimpact fire ensued. The non-instrument rated private pilot and her three passengers were fatally injured. Air West Flight Center Inc., Longmont, Colorado, was operating the airplane under Title 14 CFR Part 91. Visual meteorological conditions prevailed for the personal, night, cross-country flight that originated from Longmont, Colorado, at 1657. The pilot had filed and opened a VFR flight plan with a destination of Las Vegas, Nevada (VGT).

The operator of the airplane said the pilot had originally requested the airplane be available for departure at 1100. The pilot had flown a Cessna 172 from Jeffco Airport, Broomfield, Colorado, on January 21, 2003, to Albuquerque, New Mexico, and was delayed getting back to Jeffco Airport on January 23, 2003, due to early morning inclement weather in Albuquerque. The pilot landed the Cessna 172, at Jeffco Airport, at approximately 1430.

At 1624, the pilot called Denver Automated Flight Service Station (AFSS), to file a flight plan and get a weather briefing. She originally filed for Longmont, direct Grand Junction, and direct Las Vegas. The AFSS specialist reported that the weather over Corona Pass (elevation 12,000 feet plus) was: wind 270 degrees at 27 gusting to 33 knots; visibility 3 statue miles; broken clouds at 700 feet; temperature 27 degrees Fahrenheit; dew point 18 degrees Fahrenheit. The pilot changed her flight plan to Pueblo, Durango, St. George, to Las Vegas; an estimated 650 nautical mile flight. The pilot requested an altitude of 15,500 feet, a cruising airspeed of 140 knots, a time en route of 4 hours, and 8 hours of fuel onboard.

Witnesses reported that the airplane began to taxi for takeoff, between 1645 and 1650; the first radar return was recorded at 1658. At 1702, the pilot contacted Denver Radio to open her VFR flight plan. Denver Air Route Traffic Control Center (ARTCC) radar data indicates that the airplane flew south to Walsenburg, Colorado, and at approximately 1810 turned west towards Alamosa, Colorado. Radar data indicates that the pilot flew above 12,500 feet for 2 hours, 17 minutes, above 14,000 feet for 1 hour, 49 minutes, and at approximately 16,000 feet for an estimated 45 minutes.

While flying above 14,000 feet, from 1842 to 2031, the pilot received numerous heading corrections from ARTCC, some of them by as much as 70 degrees. On one occasion, the pilot reported that she was over Montrose, Colorado, and the ARTCC informed her that she was over Telluride, Colorado. The pilot responded with "roger that, I appreciate it, can't see a darn thing out here." The radio communication between the pilot and ARTCC became increasing difficult and erratic. Many other aircraft assisted in relaying information between the two.

The ARTCC radar data indicates that the airplane departed 14,800 feet at 2030. The rate of descent increased, and a maximum descent was calculated to be 1,077 feet per minute. At 2035, the pilot transmitted the following: "Denver radio, mayday, mayday, I've got myself in (unintelligible)." At 2037:42, a Federal Express flight 1290, flying in the area, said "yeah, we just picked up a strong Emergency Locator Transmitter (ELT) signal on 121.5, it's gone now." The ELT signal was not received again. On the morning of January 25, 2003, at approximately 0930, a rancher observed a column of smoke on his land. Upon investigation, he discovered the downed airplane.

PERSONNEL INFORMATION

The pilot held a private pilot certificate with a single engine airplane rating that was issued on December 23, 2001. She was issued a third class airman's medical certificate and student pilot certificate on March 19, 2001. The certificate contained no limitations. The pilot's flight logbook was not recovered. The pilot filled in an application (pilot information sheet) at Air West Flying Club (Wings of Denver Flying Club), Broomfield, Colorado, on January 8, 2003 [the pilot had miss-dated the application, January 8, 2002]. At that time, she reported having 128 hours total flight time, 40 hours of which were in a high performance, complex airplane.

The pilot flew with a flight instructor from Air West Flying Club, Broomfield, Colorado, on three occasions (between November 1, 2002 and January 13, 2003) for a total of 3.7 hours; he had a ground training lesson with her for 1.5 hours on January 8, 2003. The flight instructor was an FAA Safety Counselor, and he commented that the pilot "always seemed to be in a hurry." He said she would " run in the door, ready to go." All the flight time at Air West Flying Club was in a Cessna 172.

On January 20, 2003, the pilot rented a Cessna 172 and flew to Albuquerque, New Mexico, with one passenger. They were scheduled to fly back to Jeffco Airport (BJC), Broomfield, Colorado, on the morning of January 23, 2003. Due to inclement weather at Albuquerque, she departed late and landed at Jeffco Airport at approximately 1430. The pilot reported a total flight time for the trip of 7.6 hours. The pilot's total flight experience was estimated to be 140 hours.

The pilot had received some training in a high performance, complex airplane (the accident airplane), on May 5, 2002, and on May 30, 2002, but the flight instructor from Air West Flight Center, Longmont, Colorado, who flew with her said that he would not endorse her flight logbook for complex aircraft. He said that "she was a little behind the airplane in the traffic pattern." Subsequently, he never signed the flight schools' rental agreement card for the pilot, authorizing her to operate the schools PA-28R-200. On January 27, 2003, 5 days after the accident, the flight instructor noted that the flight schools rental agreement card had still not been initialed, by an instructor, to fly the accident airplane. Several days after that, the Investigator-In-Charge looked at the rental agreement card, and observed an "OK" in the PA-28R-200 space. When the staff was queried about the sign-off, no one knew where it came from. The pilot had flown, as a passenger, with one of her friends on several trips in a Piper Navajo, a high performance, complex airplane, but no documentation could be found that she had ever received the complex endorsement in her flight logbook.

According to Title 14 CFR (Code of Federal Regulations) Part 61, Chapter 31 (e) "no person may act as pilot in command of a complex airplane (an airplane that has a retractable landing gear, flaps and a controllable pitch propeller) unless that person has (i) received a onetime endorsement in the pilot's logbook from an authorized instructor who certifies the person is proficient to operate a complex airplane."

AIRCRAFT INFORMATION

The airplane was a single engine, propeller-driven, four seat airplane, which was manufactured by Piper Aircraft Company, in 1975. The airplane had a maximum takeoff gross weight of 2,650 pounds. It was powered by a Lycoming IO-360-C1C, four cylinder, reciprocating, horizontally opposed, direct drive, air cooled, fuel injected engine, which had a maximum takeoff rating of 200 horsepower at sea level. Maintenance records indicate a 100-hour inspection had been performed on the airplane on January 20, 2003. At the time of the last inspection, the airframe had 6,544.2 hours, and the engine had approximately 51 hours since it had been overhauled.

The airplane was not equipped with a supplemental oxygen system, and it was not pressurized. The operator reported that the pilot did not take a portable supplemental oxygen unit with her; no supplemental oxygen equipment was found at the accident site. According to FAR Part 91, Section 211 (a) "no person may operate a civil aircraft"

"(1) At cabin pressure altitudes above 12,500 feet (msl) up to and including 14,000 feet (msl) unless the required minimum flight crew is provided with and uses supplemental oxygen for that part of the flight at those altitudes that is of more than 30 minutes duration."

"(2) At cabin pressure altitudes above 14,000 feet (msl) unless the required minimum flight crew is provided with and uses supplemental oxygen during the entire flight time at those altitudes; and"

"(3) At cabin pressure altitudes above 15,000 feet (msl) unless each occupant of the aircraft is provided with supplemental oxygen."

The airplane was originally designed with an automatic gear extension system, regardless of gear selector position. This would have extended the landing gear at airspeeds below approximately 91 knots with power off. The accident airplane had this system removed from the airplane. The airplane's landing gear was held in the up position by electrically driven hydraulic pressure, not up locks.

The airplane was equipped with two fuel tanks, one in each wing containing twenty-five (25) U.S. gallons, giving a total of 48 usable gallons. The fuel tank selector, which allows the pilot to control the flow of fuel to the engine, is located on the left side wall below the instrument panel. It has three positions: OFF, LEFT TANK, and RIGHT TANK. The arrow on the handle of the selector points to the tank which is supplying fuel to the engine. The valve also incorporates a safety latch which prevents inadvertently selecting the "OFF" positions.

A representative of the airplane's manufacturer said "it is recommended for flight planning purposes to use an engine fuel burn rate of 12 gallons per hour [this is a rough calculation to include fuel required to climb]." FAR 91, section 151 states that "No person may begin a flight in an airplane under VFR conditions unless (considering wind and forecast weather conditions) there is enough fuel to fly to the first point of intended landing and, assum...

Data Source

Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# DEN03FA038