NTSB Factual Report

HISTORY OF FLIGHT

On October 3, 2003, at 1524 mountain daylight time (mdt), a Piper PA-28-180, N7357W, was destroyed when it impacted the top of a mountain 11 miles southeast of Teasdale, Utah. The student pilot and passenger on board the airplane were fatally injured. The airplane was reported missing at 2145. It was located on October 4, 2003, at 1425. The personal, cross-country flight from Holbrook, Arizona, to Provo, Utah, was being conducted under the provisions of Title 14 CFR Part 91 without a flight plan. Marginal visual meteorological conditions prevailed at the time of the accident.

The student pilot contacted the Prescott, Arizona, Flight Service Station (FSS) at 1116 mountain standard time (1216 mdt) and requested a weather briefing. The student pilot then filed a visual flight rules flight plan with a proposed takeoff time of 1200, and a flight time en route of 3 hours and 15 minutes. The student pilot informed Prescott FSS that he was the only person on board the airplane. Prescott FSS reported the student pilot never activated the flight plan.

A computer-generated flight plan sheet recovered from the accident airplane showed the student pilot proposed to take off at 1155 mountain standard time. The flight plan showed the student pilot planned an en route altitude of 12, 500 feet, and an estimated time en route of 3 hours and 11 minutes.

At approximately 1520, a pilot flying a Cessna T210, in the vicinity of Joe's Valley Reservoir, approximately 67 miles north of the accident site, requested a pilot report (PIREP). The pilot of the Cessna said he received a response from an airplane whose pilot said he was out of Arizona, en route to Redmond, Utah. The Cessna pilot said the pilot told him they had passed Bullfrog Basin and were through the Boulder Mountains. The pilot told the Cessna pilot that the weather in that area was "bad to the ground". The Cessna pilot said that the pilot giving him the PIREP didn't seem hesitant to fly into the weather.

At 1344:35, Denver Air Route Traffic Control Center (ARTCC) radar picked up the airplane as a primary target over Lake Powell, on the Arizona - Utah border. The airplane was tracked on a straight line, flight path toward Provo. Approaching the Boulder Mountains, the airplane turned west toward high terrain. Denver ARTCC radar data showed the airplane make three consecutive 360-degree left turns within a 1/2-mile area before radar contact was lost at 1524:02. When radar contact was lost, the airplane was at latitude 38 degrees 06.98 minutes north and longitude 111 degrees 25.70 minutes west.

Concerned family members began looking for the student pilot and passenger when the airplane did not arrive. An alert notification was issued at 2145 mountain daylight time and a search for the airplane commenced. The airplane was located the following day by a search and rescue unit from the Wayne County, Utah, Sheriff Department.

PERSONNEL INFORMATION

The student pilot held a third class medical and student pilot certificate dated September 2, 2003. The certificate held the following limitation: Holder must wear corrective lenses.

According to his logbook, the student pilot was approved for solo cross-country flight from Holbrook to Provo, on September 17, 2003. According to his flight instructor, the route of flight the student pilot was approved for was Holbrook to Kayenta [Arizona], to Hite [Utah], to Hanksville [Utah], to Price [Utah], then into Provo.

The student pilot's logbook showed that as of September 20, 2003, he had 44.6 total flying hours. All of the student pilot's time was in the accident airplane. The logbook showed no record of instrument instruction.

According to his flight instructor, the student pilot had received instruction for flight with reference to instruments. The instructor pilot stated that he purposely flew the student at night so that the student would have to rely on his flight instruments. The instructor pilot said he taught the student pilot what to do if he encountered bad weather and how to perform "90-270 degree heading turns" to reverse course when encountering weather.

AIRCRAFT INFORMATION

The airplane, serial number 28-1237, was manufactured in 1963 and owned by the student pilot. The airplane was used for the student pilot's training. The airplane's current registration was dated August 25, 2003.

According to the airplane's logbooks, the airplane underwent an annual inspection on November 17, 2002. The total airframe time recorded at the annual inspection was 2,459.9 hours. This was the last entry recorded in the logbook.

METEOROLOGICAL INFORMATION

At 1453, the weather reporting station at Bryce Canyon, Utah (BCE), 41 miles southwest of the accident site, reported winds 340 degrees at 4 knots; scattered clouds at 3,600 feet; ceiling 4,600 feet overcast; 10 miles visibility; light rain; temperature 46 degrees Fahrenheit (F); dew point 39 degrees F; and altimeter 30.13.

At 1116 pacific daylight time, the student pilot received a weather briefing from the Prescott Flight Service Station. The briefer told the student pilot that Hanksville, Utah, was reporting 7,000 feet overcast, 50 miles visibility, and calm winds. The briefer informed the student pilot of flight obscuration and a thunderstorm advisory for his route of flight. He told the student pilot there were no significant winds along his route of flight. The briefer informed the student pilot of radar reports of convective activity east of his route of flight. He also informed the student pilot of an Air Route Traffic Control Center weather advisory for thunderstorms, tops at flight level 320 for northeast Arizona and northwest New Mexico. The Prescott FSS Quality Assurance Supervisor said that following the briefing the student pilot commented, "It looks like a good VFR day. Well, maybe an average VFR day."

A Garfield County, Utah, Sheriff deputy described the weather in the Boulder, Utah area, approximately 10 miles south of the accident site, as overcast skies and cool temperatures throughout the day. He reported there were low clouds and what looked like precipitation occurring over Boulder Mountain.

WRECKAGE AND IMPACT INFORMATION

The National Transportation Safety Board's on scene investigation began on October 5, 2003, at 1530.

The accident site was located in an open area of mountain tundra surrounded by spruce trees at the top of the Boulder Mountains, elevation 11, 354 feet, at latitude 38 degrees 06.977 minutes north and longitude 111 degrees 25.766 minutes west. The site was also located approximately 1/2 mile north of an east-west running jeep trail.

The accident site consisted of the airplane main wreckage and a debris field that ran north and east of the wreckage.

The accident site began with an impact crater that was due east of the airplane wreckage. The crater was approximately 4 feet long, 6 feet wide, and 12 inches at its deepest point, near its center. The crater contained aeronautical charts, white paint chips, engine components, and portions of broken fiberglass from the engine cowling.

The airplane main wreckage rested on the west edge of the impact crater. The main wreckage consisted of the airplane's engine, propeller, nose gear, cabin, wings, main landing gear, fuselage and empennage.

The propeller was broken torsionally at the crankshaft just aft of the flange. The spinner was crushed aft, twisted counterclockwise, and broken. One propeller blade, blade "A," showed torsional bending and chordwise scratches near the blade tip. Several gouges were observed in the front face of the blade near mid span, and along the leading edge. Blade "B" was bent torsionally, showed chordwise scratches and gouges, and was broken aft approximately 12 inches inboard of the blade tip.

The bottom engine cowling was crushed upward, broken aft, and fragmented. The upper cowling was broken out and bent aft. The engine was broken aft and downward, and twisted right approximately 30 degrees. The engine firewall was crushed and broken forward over the aft upper portion of the engine block. The nose gear was bent aft and broken. The wheel pant was broken aft and fragmented.

The airplane's forward cabin was broken open. The instrument panel, glareshield, and forward windscreen were broken out and fragmented. The front cabin floor and rudder pedals were crushed upward. The left forward cabin wall was crushed and broken aft. The Plexiglas windows were broken out and fragmented. The cabin door was broken at the window frame. The window was broken out and fragmented. The bottom portion of the door was broken aft. The left and right front seats were broken forward. The aft cabin floor was crushed upward. The cabin walls were crushed aft and down. The aft cabin windows were broken out and fragmented. The aft cabin seats were broken upward. The cabin ceiling was crushed aft and twisted approximately 20 degrees to the right.

The baggage compartment was broken downward. The baggage door was bent and twisted aft. The aft fuselage was twisted and broken clockwise just aft of the baggage compartment. The right side of the aft fuselage was crushed inward approximately 25 inches aft of the baggage compartment bulkhead. The fuselage was twisted clockwise approximately 20 degrees and crushed downward beneath the base of the vertical stabilizer and rudder.

The left wing leading edge was crushed aft to the front spar from the root to the tip, and bent downward. The wing surfaces aft of the front spar were bent and buckled. The aft portion of the wing at the root was separated from the airplane's fuselage. The left fuel tank was broken open and crushed aft. The smell of fuel was prevalent at the tank and in the soil beneath the wing. The left wing tip was broken aft longitudinally along the rivet line. The forward half of the wing tip was broken out and fragmented. The left aileron was bent downward. The left flap was intact and in the up position. The left main landing gear was broken aft. The wheel pant was broken aft and fragmented. Flight control continuity was confirmed to the left aileron.

The right wing was crushed and twisted aft and bent upward approximately 15 degrees at the root. The outboard 5 feet of the wing and aileron were broken off. The aileron bellcrank remained with the inboard wing section. The right main fuel tank was crushed aft and broken open. The smell of fuel was prevalent at the tank. The right flap was broken downward. The right main landing gear was broken aft. The wheel pant was broken aft and fragmented.

The outboard portion of the right wing and right aileron rested 8 feet east of the main wreckage. The wing was broken aft longitudinally along a rivet line approximately 5 feet inboard of the wing tip. The wing section was crushed aft and buckled. The wing tip leading edge was broken aft. The top portion of the wing tip was broken aft longitudinally along the rivet line. The right aileron was broken out at the inboard and center hinges. It was bent and twisted at the outer edge and buckled along its entire span. Flight control continuity was confirmed to the right aileron.

The vertical stabilizer was intact and showed minor skin wrinkles. The rudder was intact and attached to the vertical stabilizer. The left side of the rudder, approximately 14 inches up from the base, was bent inward. Flight control continuity to the rudder was confirmed.

The left side of the horizontal stabilator and the left side stabilator trim tab showed no damage. The right side of the horizontal stabilator, near the tip, was crushed downward. The upper skin showed wrinkling. The leading edge of the stabilator tip was broken aft. The right side stabilator trim tab was bent upward approximately 13 inches outboard of centerline. Flight control continuity to the stabilator was confirmed. The trim tabs were at the neutral position.

A debris field extended outward from the north side of the main wreckage for approximately 57 feet. The field described a triangle that fell between 350 degrees and 065 degrees. The debris field was approximately 74 feet wide. The debris field contained fragmented pieces of clear Plexiglas, the emergency locator beacon, clothing items, a flight bag, and other personal effects, pieces of the glareshield and instrument panel, the top frame of the cabin door, engine components, pieces of cabin interior, pieces of broken wheel pants, navigation instruments, and paint chips.

An examination of the airplane's engine and remaining systems components was conducted on October 27 and 28, 2003, at Spanish Fork, Utah. The examination revealed no pre-impact anomalies in any of the airplane's systems.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy of the pilot was conducted by the Utah State Medical Examiner's Office, Salt Lake City, Utah, on October 5, 2003.

FAA toxicology testing of specimens from the pilot revealed the following volatile concentrations:

>> DEXTROMETHORPHAN detected in Urine.

>> DEXTROMETHORPHAN detected in Liver.

>> DEXTROPHAN present in Urine.

>> DOXYLAMINE present in Urine.

>> DOXYLAMINE detected in Liver.

>> EPHEDRINE detected in Urine.

>> PHENYLPROPANOLAMINE detected in Urine.

>> PHENYLPROPANOLAMINE detected in Liver.

>> PSEUDOPHEDRINE present in Urine.

>> PSEUDOPHEDRINE present in Liver.

Doxylamine is a sedating over-the-counter antihistamine often used in sleep aids. Over the counter medications containing doxylamine are required to warn of potentially marked drowsiness. Dextromethorphan is an over-the-counter cough suppressant. Ephedrine is sold as a stimulant, weight loss product, or as a decongestant. It is also used as an asthma medication. Pseudoephedrine is a common decongestant with a trade name Sudafed. Phenylpropanolamine is a metabolite of ephedrine and pseudoephedrine.

Federal Aviation Regulations, Part 91.17 states, "No person may act or attempt to act as a crewmember of a civil aircraft ... While using any drug that affects the person's faculties in any way contrary to safety ..."

ADDITIONAL INFORMATION

Parties to the investigation were the FAA Flight Standards District Office, Salt Lake City, Utah, the New Piper Aircraft Company, and Textron Lycoming.

The airplane wreckage was returned and released to the owner's insurance company on October 28, 2003.

NTSB Probable Cause

The student pilot's improper in-flight planning/decision and his failure to maintain aircraft control. Factors contributing to the accident were the student pilot's inadvertent flight into adverse weather conditions, the low ceiling, the rain, the student pilot's lack of experience with flying in instrument meteorological conditions, and the inadvertent stall/spin.