N4188E

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...