NTSB Factual Report

HISTORY OF FLIGHT

On August 9, 2014, about 1200 mountain daylight time, a Piper PA 28R-201 airplane, N3509M, impacted mountainous terrain southeast of Steamboat Springs, Colorado. The pilot and passenger were fatally injured and the airplane was destroyed. The airplane was registered to VSP Aviators LLC and operated by Journeys Aviation Flying Club under the provisions of 14 Code of Federal Regulations Part 91 as an instructional flight. Visual meteorological conditions prevailed at the time of the accident and a visual flight rules (VFR) flight plan was filed. The cross country flight originated from the Steamboat Springs Airport (SBS), Steamboat Springs, Colorado, about 1145 and was en route to the Boulder Municipal Airport (BDU), Boulder, Colorado.

An Alert Notice (ALNOT) was issued at 1720 when the flight was overdue. A search for the airplane was initiated and the wreckage was located at 2146 in a mountain valley about 12 miles southeast of SBS.

Email correspondence between the private pilot and the flight instructor revealed that the intended route of flight for the day was from BDU, to Eagle, Colorado (EGE), to Glenwood Springs, Colorado (GWS), to EGE, to SBS, and terminating at BDU. The flight instructor was providing instruction to the private pilot to complete a mountain flying training course. The final leg of the flight was intended to start at SBS, continue over Milner Pass and finish at BDU; the exact route of flight was not discussed.

According to local pilots, when flying over the mountains from SBS, a popular place to fly over is Rabbit Ears Pass because of the landmarks and the highway below. There was a second mountain pass south of Rabbit Ears Pass which did not follow a highway. The main wreckage was found near the second mountain pass about 5 miles southwest of Rabbit Ears Pass and about 2 miles south of the highway.

PERSONNEL INFORMATION

The flight instructor, age 62, held a commercial pilot certificate with ratings for single engine, multi-engine land and instrument airplane. He also held a flight instructor certificate for single engine, multi-engine and instrument airplane. On November 30, 2012, the instructor was issued a limited second class medical certificate with the limitation to wear corrective lenses for near and distant vision. At the time of the medical certificate application he reported his flight experience as 3,310 total hours and 800 hours in six months preceding the examination. The pilot's total flight time was estimated to be 4,000 hours.

The pilot under instruction, age 60, held a private pilot certificate with a rating for airplane single engine land. On October 31, 2013, the pilot was issued a third class medical certificate without waivers or limitations. At the time of the medical certificate application he reported his flight experience as 73 total hours and 0 hours in the six months preceding the examination. According to the pilot's logbook, he had accumulated about 134 total hours and about 32 in the accident airplane make and model. He had logged 19 total hours in the last 30 days, 16 of which were in the accident airplane make and model.

AIRCRAFT INFORMATION

The Piper PA 28R-201 was a low wing, four place, retractable landing gear airplane manufactured in 1978. The airplane was powered by a 200-horsepower, normally aspirated, fuel injected Lycoming IO-360-C1C6 engine, which drove a two bladed constant speed McCauley propeller.

On May 21, 2014, at a tachometer time of 4,315.1 hours and an aircraft total time of 4,315.1 hours, a 100 hour/annual inspection was completed for the airframe and the airplane was returned to service.

On August 7, 2014, at a tachometer time of 4,413.99 hours and 1,585.29 hours since last major overhaul, a 100 hour/annual inspection was completed for the engine and the airplane was returned to service.

The investigation did not reveal any evidence of the airplane being refueled at SBS.

METEOROLOGICAL INFORMATION

At 1154, the automated weather report at SBS, 12 miles northwest of the accident site, reported wind from 210 degrees at 7 knots, visibility 10 miles, sky clear, temperature 68°F, dew point 46°F, and altimeter setting 30.32 inches of mercury.

The private pilot received standard weather briefings from ForeFlight for each leg of the trip. The final leg was planned for a cruise altitude of 12,500 feet and a cruise speed of 135 knots.

Calculations of the above meteorological data for the accident flight revealed that the density altitude was about 11,200 feet near the accident location.

WRECKAGE AND IMPACT INFORMATION

Examination of the accident site revealed that the airplane impacted trees and mountainous terrain about 12 miles southeast of SBS at an elevation of 9,100 feet above mean sea level (msl). The initial point of impact was identified by a pair of damaged tree tops on the edge of an open grassy field on the mountainside. A 120 yard path with several damaged trees was identified on a heading of 240 degrees. A large impact crater was noted 105 yards from the initial tree strike. The fuselage came to rest 15 yards southwest of the impact crater on its right side and was oriented on a heading of 350 degrees.

The left and right wings separated from the fuselage and came to rest in the debris path. The outboard section of the left wing was separated near the initial tree strike. The leading edge contained two distinct leading edge circular impact impressions. The left aileron had separated near mid span. The inboard section of the left wing was found 75 yards through the debris path and exhibited signs of thermal damage; the respective landing gear remained attached to the wing and was fully extended.

The outboard section of the right wing was also found near the initial tree strike and contained a large leading edge circular impact impression. The inboard section was found separated from the fuselage and near the initial tree impact area. The landing gear remained attached to the wing and was extended about 45 degrees.

The top of the fuselage was fractured near the cockpit; the first responders further opened the top of the fuselage to allow access during rescue operations. The empennage remained partially attached to the rear fuselage. The stabilator was twisted and bent upward 90 degrees. The vertical stabilizer and rudder were deformed and fractured near the rear fuselage.

The engine and propeller remained partially attached to and situated under the fuselage. The propeller nose cone was oriented on a heading of 180 degrees.

A postaccident examination of the wreckage was completed by the NTSB investigator-in-charge and a representative from Lycoming Engines, at Beegles Aircraft Service, Greeley, Colorado on October 15, 2014. The examination revealed the following:

The engine was separated from the firewall and hung from an engine hoist for the examination. The propeller was removed and the blades were labeled Blade A and Blade B for identification purposes only. Blade A was bent slightly aft with minor leading edge damage. Blade B was bent 90 degrees aft with leading edge damage, the blade tip was twisted and a portion was missing from the trailing edge. The fuel pump, vacuum pump, magnetos, valve covers and top spark plugs were removed. The spark plugs appeared normal as compared to the Champion Aviation Check-a-Plug Chart AV-27. The crankshaft was rotated by hand and suction and compression was established on all cylinders. Engine drive train continuity was established throughout. The cylinders were examined with a lighted borescope and no anomalies were noted. Engine control continuity was confirmed throughout. The left magneto was rotated by hand and produced a spark at each lead. The right magneto was rotated by hand and no spark was observed from any lead. The magneto was disassembled and no visual damage was observed. The right magneto was sent to Continental Motors' analytical department for examination and a bench test. The magneto was reassembled and the contact points were cleaned. With a slave harness attached the magneto produced a spark at each lead. The magneto wobbled slightly during the test; the discrepancy was attributed to impact damage. The oil pick up screen was found free of contamination. The fuel servo exhibited no signs of visual damage. The fuel servo brass plug was found tight and secured. The fuel inlet screen was found clear of contaminants. The fuel flow divider was found clear of contaminants and the diaphragm was intact and in good condition. The fuel injectors were found clear unobstructed. The engine driven fuel pump discharged fuel when operated by hand. The examination revealed no evidence of any pre-impact engine anomalies.

The rudder and stabilator control cables were cut near the cockpit area during the on scene recovery. The rudder cable was found pulled from the rear ball end and was continuous to the cockpit area. The rudder cable was continuous from the rudder pedal attach points to the cockpit area. The stabilator control cable was continuous from the flight controls to the cockpit area and also continuous from the cockpit to the stabilator attach points. The stabilator trim cable was separated and exhibited signs of tension overload. The stabilator pitch trim setting was found near neutral. The left aileron control cable was found wrapped around a tree about 50 feet high and exhibited signs of tension overload. The left aileron bellcrank was pulled through the wing skin and remained attached to the control cable. The right aileron control cable was separated outboard of the fuselage and exhibited signs of tension overload. The right aileron bellcrank remained attached to the right aileron control cable inside the wing. The flap chain and associated control cables were found loose in the wreckage and the cables exhibited signs of tension overload.

The cockpit instrument panel remained attached in the cockpit and the primary flight instruments appeared in good condition. The airspeed indicator read 0 knots. The altimeter's Kollsman window indicated a setting of 30.32. The clock stopped at 1159.

The throttle lever was found near mid-range. The mixture and propeller levers were found full aft. The left control yoke remained intact and was rotated about 90 degrees to the right. The right control yoke was bent downward at the firewall and the handle was rotated about 90 degrees to the right. The landing gear lever was found in the down position and locked by the detent. This airplane was not equipped with the automatic landing gear extension feature. The following switches were found in the ON position: master switch, fuel pump, landing light and beacon. The pitot heat was OFF. The circuit breakers were all in and secured; the auto pilot circuit breaker was labeled INOP.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was performed on the instructor pilot by the forensic pathology consultant of Routt County, Colorado, on August 10, 2014. The cause of death was blunt force injuries. The FAA Civil Aerospace Medical Institute completed a Final Forensic Toxicology Fatal Accident Report which revealed no significant findings. The instructor pilot sustained distinct injuries to both hands.

An autopsy was performed on the pilot receiving instruction by the forensic pathology consultant of Routt County, Colorado, on August 10, 2014. The cause of death was multiple blunt force injuries and the manner of death was an accident. The FAA Civil Aerospace Medical Institute completed a Final Forensic Toxicology Fatal Accident Report which revealed no significant findings. The private pilot sustained distinct injuries to one hand.

ADDITIONAL INFORMATION

Electronic Devices Onboard

The following electronic devices were found in the wreckage and sent to the NTSB Recorders Laboratory, Washington, DC for examination and download.

A Garmin GNS 530, s/n: 78412859, which sustained major impact damage. External power was applied and the device did not respond. No data was recovered from the device.

An Apple iPad Mini (1), s/n: DLXLV31PFLMP, which sustained major impact damage. The internal circuit board was removed and cleaned. The circuit board was placed in a surrogate iPad mini. Several attempts to power the surrogate unit with the accident circuit board were unsuccessful. No data was recovered from the device.

An Apple iPad Mini (2), s/n: F4KLV34SFLMN, which sustained major impact damage with noticeable bending throughout the device. An interior examination revealed the circuit board containing the device's memory had sustained deformation from flexure damage. Due to the impact damage, no recovery could be attempted and no data was recovered from the device.

A Go Pro Hero 3, s/n: unknown, which received minimal impact damage. The internal micro SD card containing the device's image data was located and removed. Two picture files were located and dated after the accident date and time; the pictures were determined to be from responders to the accident scene. No data pertinent to the investigation was found.

Density Altitude

According to an FAA safety document, FAA-P-8740-2 – AFS-8 (2008), density altitude is pressure altitude corrected for nonstandard temperature variations. A high density altitude means that air density is reduced, which has an adverse impact on aircraft performance. Altitude, temperature and humidity are factors that contribute to a high density altitude. An increase in density altitude can result in increased takeoff distance and a reduced rate of climb.

Mountain Flying

A Colorado Mountain Flying document was recovered from the wreckage and revealed the following information.

The Do's of Mountain Flying: Consult POH for takeoff, climb and ceiling capabilities of the aircraft before flown. When calculated climb rates are less than 200 feet/NM, do not depart. A high density altitude may prevent you from reaching the altitude listed in the POH as the service ceiling.

Enroute

Plan to cross all passes and terrain with a minimum 1,000 foot clearance. Know these elevations and use the altimeter – DO NOT GUESS. Monitor the rate of climb when climbing across terrain; shuttle climb if necessary. Cross all passes at a 45 degree angle so a turn toward lower terrain can be accomplished with 90 to 120 degrees of turning (Escape Maneuver). Reach pass crossing altitude (1,000 feet above pass terrain) 3 miles before reaching the pass.

Climb Performance

According to the airplane's pilot operating handbook (POH), at a density altitude of 11,200 feet with the landing gear and flaps retracted, the pilot could have expected a climb rate of 175-200 feet per minute. Based on the mountain flying information above and the airplane groundspeed speed of 90 knots, the required rate of climb would have been 300 feet per minute.

NTSB Probable Cause

The pilot’s inability to maintain a climb while attempting to cross over a mountain pass in high-density altitude conditions that degraded the airplane’s climb performance. Contributing to the accident was the pilot’s decision to attempt the flight in mountainous terrain and to enter the pass in such a way that an escape maneuver was not possible.