NTSB Factual Report

HISTORY OF FLIGHT

On March 25, 2008, about 2124 mountain daylight time, a Piper PA-28-181, N432RM, collided with terrain approximately 17 miles southeast of Bridger, Montana. Rocky Mountain College was operating the flight under the provisions of 14 Code of Federal Regulations Part 91. The private pilot, the sole occupant, sustained minor injuries. The airplane sustained substantial damage. Night visual meteorological conditions prevailed along the planned route for the cross-country flight, and a visual flight rules (VFR) flight plan was filed for the roundtrip flight. The pilot departed Billings Logan International Airport, Billings, Montana.

According to the operator, the pilot was conducting a night cross-country flight in preparation for obtaining a commercial pilot certificate. The pilot was scheduled to return later that night. An emergency locater transmitter (ELT) was recorded in the area at 2152. When the pilot did not return to Rocky Mountain College's facility, an Alert Notice (ALNOT) was issued at 0157 AM on March 26.

A ground and aerial search was initiated. The pilot was located the following morning and rescued by a search and rescue helicopter in the Pryor Mountains, Custer National Forest. The elevation of the accident site was about 7,400 feet mean sea level (msl) and the highest point of the mountains rose to 8,646 feet msl.

According to personnel at the college, the pilot was to fly from Billings to Powell using visual flight rules navigational procedures. His planned route of flight would have taken him west of the Billings airport, and then south over a highway to his destination. The Pryor Mountains are located approximately 12 miles east of the pilot's planned route of flight.

PERSONNEL INFORMATION

The 18 year old pilot is a student at Rocky Mountain College. Several weeks prior to the accident, he had completed an instrument rating and was currently working on obtaining the required training for a commercial certificate. As part of the curriculum for the commercial certificate, the pilot was required to perform a solo, night, cross-country flight.

In an interview with the Safety Board investigator, the pilot reported that upon takeoff, he was given a heading of 130 degrees. Once he was out of the Billings airspace, he was told to maintain VFR. He opened his VFR flight plan and entered in a global positioning system (GPS) direct course to Powell Municipal Airport, Powell, Wyoming. He manually entered a course of approximately 192 degrees for the GPS course, which he recalled as his calculated true course for the flight. The pilot had also calculated his magnetic course using a magnetic variation between 13 to 14 degrees east prior to the flight, but did not enter it into the GPS. He did not recall verifying the ground checkpoints as indicated on the VFR flight plan. During the flight, the pilot encountered a storm consisting of rain and snow. The pilot could not see lights on the ground and decided to turn around.

To determine his location, he looked at his sectional chart. He believed that the terrain he was over was about 6,500 to 6,800 feet msl. The airplane was at 7,500 feet msl. The pilot entered a standard rate turn to the left and the two Garmin 430 GPS units in the airplane flashed a warning. The pilot pushed "enter" to look at a message and then saw that the airplane was close to terrain. The pilot pulled up, added power, and then he lost consciousness. The pilot stated that until he entered the instrument conditions he was using the autopilot.

Once the pilot woke up, he unbuckled his restraint system, turned the electrical system off, and turned on the Emergency Transmitter (ELT). He started to climb up the hill in the snow, but sank up to his neck in the snow. He then went back to the airplane, put on his hat and gloves, and did an inventory of his survival kit, which included flares. He used the space blankets to stay warm and curled up in the cockpit. During the night he relocated to the tail section of the airplane. Also during the night, the pilot shot off flares.

The pilot could hear search aircraft in the morning, so he hiked to the top of the hill. He tried his cell phone and was able to contact his certified flight instructor (CFI) to tell her what happened. He then used an orange tarp to increase his visibility to the over flying aircraft. A rescue helicopter used hand signals to show him where to go, and the pilot followed them to a clearing where they were able to land and pick him up.

The airplane was equipped with Avidyne Entegra Multi-Function Display (MFD) and Primary Flight Display (PFD) units, and two Garmin 430 GPS units. During the flight, the pilot had set the MFD to the engine page so it was not displaying terrain information. The pilot stated that the airplane and navigation systems operated normally during the flight.

The pilot said that he began his flight training in the state of Washington where he obtained his private pilot certificate. He started Rocky Mountain College in September of 2007 where he obtained his instrument rating several weeks prior to the accident. The majority of the pilot's flight time in Montana had been instrument work. The pilot most recently flew to Seattle, Washington area, and filed an instrument flight rules flight plan, but flew under visual meteorological conditions.

According to the pilot's CFI, the pilot had flown four flights since obtaining his instrument rating. The first flight was to get the pilot back into performing maneuvers and looking outside. The pilot had been on a VFR, day, dual cross-country flight to Gallatin Field Airport, Bozeman, Montana. For this flight, his CFI reviewed his flight plan but the actual flight was completed with another instructor. The pilot also completed a dual, local, night flight with the CFI, in addition to a local, night, solo flight of 2.1 hours.

The pilot had originally planned his flight for Monday, but due to weather it was moved to Tuesday. The CFI was debating on joining the pilot for the flight but elected to send him solo because she had classes the following day (a dual, night, cross-country flight is required but can commence after the solo, night, cross-country flight). She met the pilot at the airport where they discussed his flight plan and reviewed the weather. The pilot had planned checkpoints to use during the flight, and the CFI verified that he would be able to see the checkpoints at night. The pilot knew that the flight was to be completed using pilotage and "ded" reckoning, not using VHF (very high frequency) omni-directional range (VOR) or the autopilot, and limited use of the GPS.

He planned to fly to Powell and then return to Billings. Once he arrived at Powell, he would close his flight plan, and then open the return flight plan to Billings. After arriving at Billings, he would close his flight plan and then perform touch-and-go landings before terminating his flight. His total planned flight time was 2.9 hours. The instructor asked the pilot to call her once he arrived back to Billings. The CFI indicated that the pilot was a good student and enjoyed flying.

METEOROLOGICAL INFORMATION

The pilot obtained a weather briefing and filed his flight plan via telephone through the Lockheed Martin Denver Automated Flight Service Station (AFSS) prior to the accident flight. He was advised that VFR conditions were present along the route of flight. The AFSS specialist indicated that the Montana portion of the flight did not show any weather, and the Wyoming forecast showed isolated showers as well as airman's meteorological information (AIRMETS) for icing and mountain obscuration.

COMMUNICATIONS

Communication between the Billings Airport Traffic Control Tower and Lockheed Martin Prescott AFSS Hub (Salt Lake City Flight Watch) were reviewed. When the pilot departed, he was given a departure heading of 130 degrees. He then contacted Billings departure and was told to resume his own navigation to his destination. Between 2102 and 2105, the pilot contacted Flight Watch on 122.00 and requested to open his flight plan. The Flight Watch specialist advised the pilot that the pilot was not on the correct frequency to open his flight plan. The Flight Watch specialist then offered to assist the pilot and open the flight plan. The flight plan was opened and the Flight Watch specialist then advised the pilot that in the future when opening a flight plan from the Billings area he should contact Great Falls radio. The Flight Watch specialist then asked the pilot if he was aware of the AIRMET for mountain obscuration and the pilot indicated that he was aware.

TESTS AND RESEARCH

Restraint System

When investigators examined the wreckage following its recovery from the accident site, the pilot's shoulder harness attachment fitting was found still attached to a vertical fuselage C channel by three small screws. A Safety Board metallurgist examined this assembly. According to the metallurgist, the fractured pieces of the skin, doubler, and C channel were connected to the shoulder harness fitting by fasteners. Examination of the assembly did not reveal any material defects and all surfaces were consistent with overstress separations.

Cockpit Displays

The Avidyne PFD and MFD were sent to the Safety Board's Vehicle Recorder Division for examination. The duration of the power cycle for the PFD was approximately 36 minutes. In summary, the recorded data showed that the airplane flew at a pressure altitude of 7,500 feet. Prior to departure from the airport, Powell was set as the next waypoint. The desired course was set at approximately 192 degrees and during the flight, the active bearing changed from 180 degrees to 192 degrees to coincide with the desired course. The magnetic heading began at 130 degrees, changed to approximately 185 degrees, followed by about 155 degrees from 2107 to 2114, and then to approximately 195 degrees from about 2114 until impact. No operational anomalies were noted with the units.

ADDITIONAL INFORMATION

Training

According to Rocky Mountain College personnel, the accident flight was to be flown using pilotage and dead reckoning, with supporting use of the GPS. The use of the GPS is taught in VFR navigation courses. Additionally, they reported that during GPS ground school for the instrument rating, students are taught two methods to intercept instrument procedure courses referencing magnetic courses rather than true. The general process that the pilot described in loading the desired course into the GPS was consistent with an instrument procedure taught during the ground school, excluding his entry of a true course rather than a magnetic course. In this procedure, students are taught to highlight a waypoint (the airport in this case) and then press the "Direct" button. Then the pilot manually sets the desired course. All of the examples used during the instrument training are explained in reference to instrument flying techniques and intercepting courses. Because it was an instrument course, no VFR use of the GPS was demonstrated, nor were students taught to fly direct to airports on a specific course using the methods.

In January of 2008, the pilot had attended the Montana Department of Transportation Aeronautics Division Winter Survival Clinic.

NTSB Probable Cause

The pilot failed to maintain situational awareness during the flight. Contributing to the accident were the dark night, the pilot's failure to follow approved navigational procedures for the flight, and the pilot's over reliance on the avionics in the airplane.