NTSB Factual Report

HISTORY OF FLIGHT

On November 25, 2012, about 1300 mountain standard time, a Piper PA-28-181 airplane, N8314E, was substantially damaged following impact with remote mountainous terrain while maneuvering about 9 nautical miles (nm) west-northwest of Aurora, Utah. The certified private pilot, who occupied the left front cockpit seat, the certified student pilot, who occupied the right front cockpit seat, and the sole passenger who occupied one of the rear cabin seats sustained fatal injuries. Visual meteorological conditions prevailed for the cross-country flight, which was being operated in accordance with 14 Code of Federal Regulations Part 91, and no flight plan had been filed. The flight departed Fillmore Municipal Airport (FOM), Fillmore, Utah, about 1245, with the Gillette-Campbell County Airport (GCC), Gillette, Wyoming, as its intended destination.

In a telephone interview with the National Transportation Safety Board (NTSB) investigator-in-charge (IIC) 9 days after the accident, and 2 days subsequent to the airplane's wreckage being located, a family member of the pilot reported that the pilot and his 2 passengers had flown from GCC to the Shafter-Minter Field (MIT), Shafter, California, via Fillmore, Utah, about a week earlier to celebrate Thanksgiving; he also reported that the pilot had made this same trip over the same route 3 or 4 times previously, but had no actual knowledge of the pilot's mountain flying experience. The family member stated that the pilot had informed the 2 female passengers prior to their departure from GCC, that due to the additional weight of the two dogs that would be accompanying them, they would not be able to take their suitcases, but that they could take a back pack instead. The family member further stated that each of the airplane's three occupants had their own back packs and warm weather coats with them when they departed MIT, and that they had purchased additional clothing while in California.

Additionally, the family member, who was a pilot, stated that on the morning of the departure, when he noticed how much baggage the pilot was loading into the airplane, he used a program on his computer to assist the accident pilot with his weight and balance calculations. He said he estimated the weight of each passenger, the three back packs, the two dogs, a rifle that the pilot was taking with him, and used full fuel for the calculation of each leg of the flight. He said that the airplane was right at its maximum gross takeoff weight in each instance, and that the airplane was within its weight and balance limits.

The family member reported that the pilot departed MIT for GCC, but stopped at the Tehachapi Municipal Airport (TSP), Tehachapi, California, to refuel and visit with relatives prior to departing for FOM on their way to GCC; TSP is located 43 nm southeast of MIT. The family member further reported that the pilot and his 2 passengers arrived at MIT at 0540 Pacific Standard Time (PST), and departed for TSP at 0615 PST. He thought the flight arrived TSP about 0645 and departed for FOM about 0730 or 0800, but wasn't certain of the exact time.

When the flight failed to arrive at GCC on the evening of November 25, concerned family members contacted the Federal Aviation Administration (FAA) for assistance in locating the airplane. An Alert Notification (ALNOT) was issued by the FAA at 1148 on November 26. Subsequent to a multi-state search and rescue effort, the airplane was located by a Utah State Department of Public Safety helicopter pilot on December 2, about 0800. The accident site was located in remote mountainous terrain, about 11 nm due east of the departure airport, at an elevation of about 9,000 feet mean sea level (msl).

On December 4, 2012, the airplane was recovered to a secured storage location for further examination.

PERSONNEL INFORMATION

Left seat pilot

The left seat pilot, age 37, held a private pilot certificate with an airplane single-engine land rating, which was issued on December 6, 2011. The pilot held a third-class Federal Aviation Administration (FAA) airman medical certificate, dated January 11, 2010, with no limitations or restrictions. While the pilot's personal logbooks were not recovered during the investigation, a family member reported that he thought the pilot's total flight time was about 200 hours, or a little more.

Right seat pilot

The right seat pilot, age 33, held a student pilot certificate, and was issued a third-class FAA airman medical certificate on April 17, 2009. No pilot records indicative of the pilot's flight times or aircraft flown were recovered during the course of the investigation.

AIRCRAFT INFORMATION

The single-engine, low wing Piper PA-28-181, serial number 28-8390016, was manufactured in 1982. Maintenance records revealed that the airframe and engine had accrued a total time in service of 3,916 hours as of its most recent annual inspection, which was performed on October 6, 2012. The Lycoming O-360 –A4M engine, serial number L-22551-36A, had accumulated a total 1,610.5 hours since its most recent major overhaul, which was performed on August 27, 1994.

During the investigation, the NTSB IIC was provided with fuel records by the city of Fillmore, Utah. The records revealed that the accident airplane was refueled at the FOM self-serve fuel station at 1233 on the day of the accident with 26.87 gallons of 100 Low Lead aviation fuel. There were no witnesses at FOM on the day of the accident who observed the airplane refuel or depart.

SURVIVAL FACTORS

A National Transportation Safety Board Survival Factors Specialist reviewed the Search and Rescue (SAR) data during the investigation and reported the following:

The first information in the AFRCC log regarding this accident was an Information Request (INREQ) received from the FAA at 1801Z (1301 EST, 1101 MST) on November 26, 2012. The INREQ contained information indicating the VFR flight with 3 occupants originated at Shafter Airport (MIT), Shafter, California, with expected stops at Tehachapi Municipal Airport (TSP) California, Fillmore City Airport (FOM), Utah, and Huntington Municipal Airport (69V), Utah. The final destination was Gillette-Campbell County Airport (GCC) in Wyoming, and the airplane was expected by family to land at approximately 2230Z (1530 MST) on November 25, 2012. The INREQ was apparently a result of a family concern phone call from the pilot's brother. After leaving a message for the pilot on his cell phone, Air Force Rescue Coordination Center (AFRCC) contacted Fillmore City Airport (KFOM) and learned that one of the known passengers on the airplane had purchased fuel with a credit card at 1233 MST on November 25, 2012. The FAA issued an ALNOT for the airplane at 1848Z on November 26, 2012, and AFRCC contacted the Utah Department of Aviation (DOA). Utah DOA requested a Civil Air Patrol (CAP) mission be opened, which was done a short time later. At the same time, missions were also opened for CAP radar data review and cell phone forensics. AFRCC contacted and requested ramp checks of both 69V and GCC with negative results for the airplane.

About 4 hours after the INREQ was initially received, the CAP cell phone forensic analyst reported text message activity from the passenger's cell phone from FOM at 1152 MST on November 25, 2012. When the recipient of the message was contacted, it was learned that the message stated "In the air. Should be home in a few hours." (It was also learned that a second passenger on the airplane also was carrying a cell phone.) The timing and content of this communication did not match with the fuel credit card transaction information, leading to speculation about the exact time the airplane took off from FOM. Radar analysts could find no radar tracks of aircraft departing FOM near these times, leading investigators to believe the airplane's crash site was likely in the vicinity of the airport. Review of cellular data from the second passenger's phone indicated an arrival time at FOM of approximately 1116 MST.

By 2349Z on November 25, 2012, the Utah CAP had dispatched two airplanes to search for N8314E. No new significant information developed until 1454Z on November 27, 2012, when the CAP cell phone forensic analyst confirmed that by 1205 MST on November 25, 2012, the cell phones on the airplane were offline, indicating that the airplane likely took off from FOM between 1128 and 1152 MST on November 25, 2012. Speed/distance calculations from this data indicated that the airplane was likely within 26 miles of FOM.

The UTAH CAP daylight search continued on November 27, 2012, with negative results. On November 28, 2012, the Utah CAP requested assistance from both Wyoming and Colorado CAPs, both of whom joined the search. An AFRCC log entry on November 29, 2012, at 1117Z, indicated that both WY CAP and CO CAP were searching with 2 aircraft, while the Utah CAP was searching with 5 aircraft and 2 ground teams. They were searching various areas of the route with a focus of 50 to 60 miles distant from the FOM.

Daylight searches of the area continued until the airplane was located by a Utah Department of Public Safety helicopter in mountainous terrain on December 2, 2012, at 1527Z (0827 MST).

A summary of CAP personnel, sorties, and hours flown is below:

UT CAP (11/26-12/2)

Personnel: Between 8-46 each day

Aircraft: Between 2-7 aircraft each day

Sorties: 62

Total aircraft search time: 94 hours

WY CAP (11/28-12/2)

Personnel: Between 10-12 each day

Aircraft: 2 aircraft daily

Sorties: 15

Total aircraft search time: 30 hours

CO CAP (11/29-12/1)

Personnel: Between 6-8 each day

Aircraft: 1 or 2 aircraft each day

Sorties: 9

Total aircraft search time: 11.6 hours

METEROROLOGICAL INFORMATION

At 1259, the FOM weather reporting facility, which was located about 11 miles west of the accident site, reported wind 290 degrees at 4 knots, visibility unlimited, temperature 12° Celsius (C), dew point -3° C, and an altimeter setting of 30.02 inches of mercury. The density altitude was calculated to be 9,663 feet.

An NTSB meteorologist reported that after a review of the weather data in the vicinity of the accident site on the day of the accident, there was nothing to suggest that a significant weather hazard existed in the area at the time of the accident. The meteorologist opined that there were no AIRMETS or SIGMETS, no significant PIREPS, the radar was clear, and there appeared to be light winds. Additionally, the FOM airport manager stated that it was "a real nice day."

WRECKAGE AND IMPACT INFORMATION

On December 3, 2012, the NTSB IIC, accompanied by representatives from the FAA, Piper Aircraft, and Lycoming Motors, were escorted to the accident site by members of the Sevier County Sheriff's Department, Richfield, Utah, using multiple all-terrain vehicles.

An initial survey of the wreckage site revealed that the airplane had topped several trees about 50 feet tall on a southeasterly heading prior to impact with ground terrain. It was observed that after the airplane impacted the ground, it then rotated about 180 degrees counter-clockwise, before coming to rest oriented on a northwest heading. A postcrash fire erupted, which consumed both the cabin and cockpit areas of the airplane. It was determined that after examining the wreckage, all components necessary for flight were accounted for at the accident site.

The accident site was located within a stand of trees on the gentle slope of a canyon about 11 nm east of the departure airport. The initial impact point, which was evidenced by the topping of several trees about 40 to 45 feet high, was on a measured magnetic heading of 140° for about 150 feet, followed by the impact of the airplane's left wing with a tree. The impact rotated the airplane to the left, where it came to rest upright on a measured magnetic heading of 330°. The main wreckage was located at coordinates 38 degrees 57.244 minutes north latitude and 112 degrees 07.466 west longitude, at an elevation of 8,992 feet mean sea level (msl). About 790 feet directly east and in line with the accident site was the lowest point of the nearest ridge, located at an elevation of 9,186 feet msl, or 194 feet below the ridge line's low point.

A survey of the wreckage revealed that the airplane's center section sustained extensive postcrash fire damage and was almost entirely destroyed. The roof section of the airplane and side skins were mostly consumed. The tail section was separated forward of the vertical tail surface due to thermal damage.

The forward cockpit and instrument panel was separated from the fuselage due to fire. All flight instruments and avionics were destroyed. The forward cockpit controls sustained heat and impact damage. The aileron control chain remained intact and both aileron primary cables were attached to both ends of the chain. The horizontal stabilator cables remained attached to the tee-bar assembly. The rudder cables remained attached to the rudder tube assembly.

The throttle and mixture cables were observed separated from their mounting structures. Both cables were found to be in the full forward position, consistent with a full throttle and full rich condition. The carburetor heat control had separated from the panel due to fire. The control was in an intermediate position between heat on and cold.

The left wing was separated from the fuselage at the root but otherwise remained intact. The wing leading edge sustained aft crushing along its span, consistent with tree impact. Remnants of both the flap and aileron surfaces were present on site. The fuel tank was breached due to impact forces. The fuel cap remained secure to the tank. Both the primary and balance aileron cables remained attached to the bellcrank assembly.

The right wing remained attached to the fuselage. The inboard section of the wing sustained fire damage but was otherwise mostly intact. The wing separated into two sections between the aileron and flap surface. The outboard section of the wing came to rest upside down. The wing leading edge sustained aft crushing along its span, consistent with tree impact. Both the primary and balance aileron cables remained attached to the bellcrank assembly.

The airplane's tail section had separated from the empennage just forward of the vertical stabilizer fin due to fire. The rudder surface remained attached to the vertical surface. Both rudder cables remained attached to the rudder bellcrank. Both the rudder and stabilator surfaces sustained heat and impact damage, but were otherwise mostly intact. The stabilator remained attached to the rear bulkhead assembly. The outboard left side horizontal surface exhibited an impact damage that was consistent with a tree impact. The right side horizontal surface was mostly intact.

The engine remained attached to the firewall by the engine mount assembly and came to rest in an upright position.

As a result of the fire which consumed the cockpit and cabin and areas of the airplane, it was not possible to discern the amount, type and weight of the baggage that was on board the airplane. Additionally, the gross weight of the airplane at the time of takeoff could not be determined.

MEDICAL AND PATHOLOGICAL INFORMATION

Left seat pilot-in-command

An autopsy was performed on the pilot who occupied the left front cockpit seat on December 3, 2013, by the Office of the Medical Examiner, Utah Department of Health, Salt Lake City, Utah. The cause of death was reported as blunt force injuries.

The FAA's Civil Aerospace Medical Institute (CAMI), Oklahoma City, Oklahoma, performed toxicological tests on specimens that were collected during the autopsy. Tests result revealed no carbon monoxide detected in Blood (Heart), testing for cyanide not performed, no ethanol detected in Urine, and no drugs detected in Urine.

Right seat student pilot

On December 3, 2013, an autopsy was performed on the student pilot who occupied the right front cockpit seat. The autopsy was conducted at the Office of the Medical Examiner, Utah Department of Health, Salt Lake City, Utah. The cause of death was attributed to a combination of hypothermia and blunt force injuries.

The FAA's Civil Aerospace Medical

NTSB Probable Cause

The pilot's failure to maintain clearance with terrain while maneuvering in a remote mountainous region. Contributing to the accident was the pilot's improper decision to traverse the remote mountainous area in high-density altitude conditions with the airplane near its maximum gross weight. Contributing to the delay in the search and rescue (SAR) was the lack of a 406-MHz ELT signal, which would have allowed SAR responders to initiate a more timely search and find the accident site more quickly.