NTSB Factual Report

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, assuming normal cruising speed:

(1) During the day, to fly after that for a least 30 minutes; or

(2) At night, to fly after that for at least 45 minutes."

The representative said that a pilot flying a night-VFR flight, with a 45 minute reserve and a 12 gallon per hour burn rate, could flight plan for an approximate 3 hours 15 minutes maximum flight.

The airplane's Pilot Information Manual states that its service ceiling was 15,000 feet, and its absolute ceiling was 17,000 feet.

METEOROLOGICAL INFORMATION

At 2053, the weather conditions at Canyonlands Field (CNY; elevation 4,553 feet), Moab, Utah, 300 degree 36 nautical miles (nm) from the accident site, were as follow: wind 220 degrees at 3 knots; visibility 10 sm; cloud condition clear; temperature 36 degrees Fahrenheit; dew point 19 degrees Fahrenheit; altimeter setting 30.20 inches. The official sunset on January 23, 2003 at Longmont, Colorado, occurred at 1708, and the end of civil twilight occurred at 1737. The moon rise, on January 23, 2003, was 2320.

The sounding data at Grand Junction, Colorado, at 1700 mountain standard time on the day of the accident, indicates that the wind at 12,000 feet was 285 degrees at 18 knots, at 14,000 feet it was 290 degrees at 27 knots, and at 16,000 feet it was 275 degrees at 33 knots.

WRECKAGE AND IMPACT INFORMATION

The airplane was found upright on up sloping terrain (N38 degree, 18.23 minutes; W109 degrees, 12.57 minutes; elevation 7,068 feet) which was approximately 50 percent vegetated with 8 to 15 foot high conifer trees and brush. A fifteen foot ground scar leads to the airplane's wreckage on a 280 degree orientation; the fuselage came to rest on a longitudinal orientation of 340 degrees. Separated tree limbs and branches, leading to the wreckage, suggest that the airplane was in a 40 degree right bank at the moment of impact.

All of the airplane's major components were accounted for at the accident site. The flight control surfaces were all identified and their control cables were intact except for the right wing. The landing gear was found in the down position; the flaps were up.

The right wing had separated from the airplane's fuselage at the wing root, and came to rest parallel and aft alongside the fuselage. The wing was bent and rotated at the midsection; the outboard half was inverted. The outer 3 feet of its wing tip was separated from the rest of the wing. The wing received extensive thermal damage.

The left wing remained attached to the fuselage. The outboard 4 feet had a 2 foot crescent shaped leading edge indentation, and there was a standing 8 inch tree in it. The remainder of the wing was unremarkable, but the inboard 4 feet was heavily thermal damaged. The fuselage, cockpit controls, and cockpit instrumentation were consumed by fire. The left horizontal stabilizer was crushed aft and broken. The vertical stabilizer was burned and charred. The right horizontal stabilizer received extensive thermal damage.

Forward of the engine's firewall exhibited minimal thermal damage. The engine mounts were fractured. The crankshaft flange was bent approximately 30 degrees to the right; the propeller assembly remained attached. The engine examination revealed no preimpact mechanical malfunctions to the case halves, cylinders, sump, or accessory housing. All spark plugs were observed to be very light in color, consistent with lean operation. The crankshaft rotated easily, demonstrating valve train continuity at all cylinders, and positive suction was also noted.

The propeller's spinner exhibited little impact damage. The propeller blades were marked "A" and "B" for identification purposes. Propeller blade "A" exhibited little damage except for a 6 inch elliptical abrasion area on the front face approximately 2/3 out the blades span. Propeller blade "B" was bent aft from approximately 6 inches from the hub, and the outboard 6 inches was twisted. It had leading edge green transfer material, and a 6 inch midsection abrasion area.

No preimpact engine or airframe anomalies, which might have affected the airplane's performance, were identified.

MEDICAL AND PATHOLOGICAL INFORMATION

The State of Utah's Department of Health, Office of the Medical Examiner, Salt Lake City, Utah, performed an autopsy on the pilot on January 27, 2003.

The FAA's Civil Aeromedical Institute (CAMI) in Oklahoma City, Oklahoma, performed toxicology tests on the pilot. According to CAMI's report (#200300031001), carbon monoxide and cyanide tests were not performed. No volatiles or drugs were detected in the heart, kidney, or liver samples.

TESTS AND RESEARCH

According to "Aviation Medicine," hypoxia is defined as a shortage of oxygen in the human body. Symptoms of hypoxia vary according to the degree of oxygen depravation which is a direct function of the altitude, the duration of flight at that altitude, and the individual's physiology. The first symptoms of oxygen deficiency are misleadingly pleasant, resembling mild intoxication from alcohol. Symptoms of hypoxia include personality change, lack of insight, loss of judgment, loss of self-criticism, euphoria, loss of memory, mental in-coordination, muscular in-coordination, sensory loss, and cyanosis. The airplane was not equipped with any supplemental oxygen.

The airplane manufacturer's representative performed two flight planning scenarios with different engine settings. The first scenario consumed 36.19 gallons to the time of engine stoppage, and the second scenario consumed 40.04 gallons to the time of engine stoppage [the airplane holds 50 gallons]. These two fuel consumption calculations were made using normal engine leaning procedures. Textron Lycoming Operator's Manual for the IO-360 engine states that engine leaning procedure for normally aspirated engines with fuel injectors is:

(1) Maximum Power Cruise (approximately 75% power) - Never lean beyond 150 degrees Fahrenheit on rich side of peak EGT unless aircraft operator's manual shows otherwise. [The airplane's Information Manual states: If the airplane is equipped with the optional exhaust gas temperature (EGT) gauge, refer to the Textron Lycoming Operator's Manual for leaning procedure].

(2) Best Economy Cruise (approximately 75% power an

NTSB Probable Cause

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.