NTSB Factual Report

HISTORY OF FLIGHT

On May 16, 1995, approximately 2032 mountain daylight time (MDT), a Piper PA-34-200T, N2883D, operated by Sky Harbor Air Service, Inc., a 14 CFR 135 on-demand air taxi certificate holder, collided with terrain approximately 15 miles north of Cheyenne, WY. The airplane was destroyed by impact forces and a post-crash fire. The commercial pilot, who was the sole occupant of the airplane, was fatally injured. The aircraft was en route from Natrona County International Airport, Casper, WY, to Cheyenne. Instrument meteorological conditions prevailed in the accident area. A company visual flight rules (VFR) flight plan had been filed for the 14 CFR 91 flight.

The aircraft trip log indicates the airplane departed Cheyenne at 1600 MDT on the day of the accident with one passenger on a 14 CFR 135 on-demand air taxi flight to North Big Horn County Airport, Cowley, WY. After dropping off his passenger, the pilot departed Cowley alone on a 14 CFR 91 return trip to his base at Cheyenne, stopping at Casper for fuel. The pilot called for a weather update from the Casper automated flight service station (AFSS) before departing Casper. The Casper AFSS preflight briefer who briefed the pilot made the following statement concerning the briefing:

At 0135 UTC, a man who identified himself as the pilot of N2883D called on the local telephone line. He stated he was on the ground at Casper, going to Cheyenne, and asked for Cheyenne's last hour weather. I gave him the Cheyenne 0103 special, not including wind and altimeter, as he interrupted me. I asked him if he had the advisories for turbulence, he said yes, and I ended the briefing by asking for pilot reports.

The pilot did not file a FAA flight plan for the Casper to Cheyenne flight, but Sky Harbor's director of operations stated that company flight-following and dispatch procedures were utilized throughout the trip and that the company was aware of the intended return flight. According to air traffic information furnished by the FAA, the flight was cleared for takeoff from Casper at 1941 MDT.

A recording of the Cheyenne approach control frequency shows that at 2022 MDT, the pilot made the first of three unsuccessful attempts to contact Cheyenne approach control. In each of these three attempts, Cheyenne approach control answered the pilot's radio call but the pilot did not respond. Contact with Cheyenne approach control was established on the pilot's fourth attempt at 2027 MDT. The pilot reported that he was 24 miles north of the airport and would be landing. Approach control answered: "Seneca 83 Delta roger, I did hear all your previous transmissions, apparently you weren't hearing mine, contact Cheyenne tower on one one eight point seven five miles north of the airport, there is a thunderstorm in the vicinity of the airport, north through northeast moving north, occasional lightning cloud to ground and a previous aircraft reported severe turbulence." The pilot's reply to this call was: "I flew down from Casper it was a pretty smooth ride." This was the last radio transmission received from N2883D, occurring at approximately 2027:31 MDT. The tape recorded the controller stating in reply: "Maybe it's moved on, thanks."

No further communication attempts between Cheyenne approach control and N2883D were recorded on the tape until 2050 MDT. Between that time and 2055 MDT, Cheyenne approach control made three unsuccessful attempts to contact N2883D. An emergency locator transmitter (ELT) signal was subsequently detected and triangulated to an apparent location 23 miles north of Cheyenne. This was reported to the Laramie County Sheriff via the Wyoming Department of Transportation at 2323 MDT. A deputy was then dispatched to this area to investigate the report. In his report on the incident, the deputy noted that when he arrived in the search area, he was met by personnel he identified as "U.S. Air Force security police", who "...advised me they attempted to get a Search and Rescue helicopter from F.E. Warren Air Force Base to fly the area but the ceiling was about 100 feet above the ground." His report states that dispatch was advised at 0634 MDT the following morning that the wreckage had been located.

The accident occurred during the hours of dusk (approximately 20 minutes after local sunset) at 41 degrees 24.49 minutes North and 104 degrees 48.47 minutes West.

PERSONNEL INFORMATION

The pilot was employed by Sky Harbor Air Service primarily as their aircraft sales manager. He flew trips for the company on an as-needed basis. He was a commercial pilot with airplane single- and multi-engine land ratings. He was instrument-rated but was not qualified to fly under instrument flight rules under Sky Harbor's air carrier operating certificate. In a post- accident interview, Sky Harbor's director of operations stated that the pilot had requested a company instrument flight rules checkout the week prior to the accident, but that he had denied the request due to concerns about the pilot's ability to deal with emergency conditions while flying on instruments, based on observations of the pilot's performance while flying under simulated instrument conditions.

Sky Harbor's flight and training records on the pilot date back to May 1990. They indicate the pilot was qualified on the Piper PA-28R, Cessna 414, Piper PA-34, Cessna 340, and Cessna 172RG aircraft. The pilot successfully completed a 14 CFR 135 proficiency check in the PA-34 on March 7, 1995. According to the record of the check, instrument flying was not evaluated on this check. The operator indicated that the pilot had over 6,700 hours total time.

Company flight and duty time records indicate this was his first trip since April 12, 1995, and that he flew 28 hours and ten trips with Sky Harbor (all multi-engine, mostly in the PA-34), including the accident trip, in the 90 days before the accident. Additionally, the operator stated that the pilot had flown two flights before his charter trip on the day of the accident: a 1.3 hour flight as a safety pilot, and a 0.7 hour test flight of a Cessna T210 (which had just received an annual inspection) with the director of operations. The operator stated that the pilot had no flights the day before the accident.

To the best of the operator's knowledge, the pilot had departed work at about 1600 the day before the accident and arrived for work at about 0830 on the day of the accident. The operator stated that to his knowledge, the pilot "had no pressing concerns in Cheyenne that evening nor did he have any illnesses to speak of."

AIRCRAFT INFORMATION

The aircraft, a Piper model PA-34-200T, was manufactured in 1979 and was owned and operated by Sky Harbor Air Service of Cheyenne. It was equipped for flight under instrument flight rules (IFR). The aircraft logbook indicated that the last inspection of the airplane was on April 6, 1995 at 7,098.2 aircraft hours. This inspection was signed off by the inspection authorization (IA) mechanic as a 100-hour inspection. Left and right engine logbook inspection entries on the same date were signed off as annual inspections. The previous inspection in the aircraft log, also signed off as a 100-hour inspection, was on December 13, 1994, at 7,025.2 aircraft hours. The most recent inspection annotated in the aircraft logbook as an annual inspection was on March 29, 1994 at 6,532.3 aircraft hours. The company's aircraft inspection/overhaul report (SHAS Form A) indicated that the airplane's next annual inspection was due in April 1996. The operator indicated in his report on the accident that the last inspection of the airplane had been a combined annual/100-hour inspection on April 6, 1995.

The aircraft discrepancy log contained no unresolved discrepancies from October 1994 to the accident date.

METEOROLOGICAL INFORMATION

The 0103 UTC (1903 MDT) Cheyenne special observation, which the Casper AFSS preflight briefer passed to the pilot before departure from Casper, indicated scattered clouds at 4,500 feet, measured broken ceiling at 10,000 feet, overcast clouds at 25,000 feet, visibility 15 miles in thunderstorms, wind from 160 degrees magnetic at 12 knots, and altimeter setting 29.81 inches Hg. Encoded remarks indicated thunderstorms in the vicinity of the station to the north, moving northeast, and occasional cloud-to-ground lightning.

The Cheyenne terminal forecast for the period from 0100 UTC to 0400 UTC (1900-2200 MDT on May 16), issued at 1836 MDT on May 16, forecast scattered clouds at 4,500 feet, a broken ceiling at 10,000 feet, wind from 080 degrees at 10 knots, with occasional broken ceilings of 3,500 feet in thunderstorms, light rain showers, and hail. The Salt Lake area forecast correction issued at 2045 UTC (1445 MDT) on May 16, and valid until 0800 UTC (0200 MDT) on May 17, contained the following encoded forecast for the southern half of Wyoming until 2200 MDT: "100 SCT-BKN 16. WDLY SCT RW/TRW WITH CB TOPS 350...." There is no evidence that the pilot asked for or received these forecasts during his call to Casper AFSS.

The 2005 MDT Cheyenne special observation, taken about 27 minutes before the accident (while the pilot was enroute from Casper to Cheyenne) and current at the time of the accident, indicated scattered clouds at 1,300 feet, a measured broken ceiling of 4,000 feet, overcast at 10,000 feet, and visibility 15 miles with thunderstorms. Wind was from 350 degrees magnetic at 18 knots with gusts to 27 knots. Altimeter setting was 29.83 inches Hg. Encoded remarks indicated thunderstorms in the vicinity of the station north through northeast, moving north; occasional cloud-to-ground lightning; stratus fractus clouds northwest to north; and a wind shift to 350 degrees magnetic at 10 minutes past the hour.

The on-scene deputy's incident report notes that extremely low ceilings ("less than 100 feet") precluded search aircraft from operating during the search for the missing airplane. Cheyenne weather observations recorded rapidly deteriorating weather during this period: at 2223 MDT, measured broken ceiling at 300 feet, visibility 10 miles; 2250 MDT, measured broken ceiling 300 feet, visibility 7 miles in light rain with rain beginning at 47 minutes past the hour; 2235 MDT, measured overcast ceiling 100 feet, visibility 2 miles in light rain, and from 2350 to 0052 MDT, measured overcast ceiling 100 feet, visibility 2 miles in light rain and fog. Winds observed during this period were from the northeast.

AERODROME AND GROUND FACILITIES

According to the U. S. government Airport/Facility Directory (A/FD), Cheyenne airport was a Class D airspace area, with separate frequencies for approach/departure control and control tower, at the time of the accident. An Automatic Terminal Information Service (ATIS) broadcast is available. The aerodrome has instrument landing system (ILS), VHF omnirange (VOR), non-directional beacon (NDB), and Global Positioning System (GPS) instrument approaches published in U. S. government flight information publications. The airport elevation is 6,156 feet above mean sea level.

A National Weather Service forecast office equipped with an operating (although not yet commissioned at the time of the accident) WSR-88D Doppler weather radar system is located at the airport. In addition to ATIS, pilots can obtain weather information via radio from Casper AFSS through a remote communication outlet (RCO) at Cheyenne.

WRECKAGE

The airplane wreckage was examined at the accident site on May 18, 1995. The examination of the wreckage revealed no evidence of aircraft malfunction. All major airframe components, both engines, and both propellers were located at the site. The wreckage was oriented in a pattern 610 feet long, on a magnetic heading of 119 degrees, from the first ground scar to the main wreckage.

The initial ground scar contained fragments of red glass. A series of eight ground slashes, oriented approximately perpendicular to the impact track and measuring 19 feet from first slash to last, was found 45 feet past the initial impact ground scar. Another series of six ground slashes, oriented approximately 45 degrees from the impact track and measuring 10 feet 10 inches from first slash to last, was found 100 feet past the initial impact scar. A 3-foot high terrain lip containing a large gouge was located approximately 150 feet past the initial impact scar. Immediately beyond this terrain lip and gouge was a large area of burned ground and grass which contained numerous small aircraft pieces. Large pieces of wreckage including the nose baggage door, an engine cowl, and a section of the airplane's nose, along with additional ground scars oriented in a southeasterly direction, were located generally along the line from the initial ground scar to the main wreckage. Control surfaces were scattered along the last 200 feet of the impact track. The right propeller (found on its hub) was 140 feet west of the main wreckage.

The main wreckage consisted of the cabin (destroyed by fire), empennage (scorched and sooted with the right horizontal stabilizer damaged), wing root section with nacelles and right engine (broken off mount), and left propeller (found on its hub.) The left engine (separated from nacelle and propeller) and two wing/fuel tank sections (one burned) were just short of the main wreckage. The main wreckage had come to rest in an inverted attitude headed approximately east. Coroner photographs documented the location of the pilot in the wreckage as on the ground in the area under the horizontal and vertical tails.

The left engine turbocharger had separated from its engine and was located just beyond the main wreckage. The left propeller exhibited blade twist, tip curling, chordwise scratching and leading edge abrasion on all three blades. The right propeller exhibited chordwise scratching and leading edge damage on all three blades. Two blades exhibited twist and two exhibited forward tip curl. Two of the blades were bent back 90 degrees and two blades had tips broken off. The broken-off blade tips were found in other locations at the accident site.

Terrain in the vicinity gradually rose from the initial ground scar to the 3-foot high terrain lip with the large gouge. Beyond the terrain lip, the terrain leveled out into a level open field. The accident site was approximately 6,100 feet above sea level.

FIRE

A post-crash fire destroyed the cabin and instrument panel and scorched the empennage. The fire also burned a large area of grass at the accident site. No evidence of in-flight fire was noted.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was performed by AnaPath Diagnostics of Cheyenne, WY on May 17, 1995. The autopsy concluded: "The cause of death appears to have been third degree burns secondary to a flash fire caused by the plane crash. The only evidence of significant trauma was a compound fracture of the left ankle. Careful examination...does not reveal evidence that death occurred due to natural causes." The examination also "[did] not reveal evidence of inhalation of smoke or soot."

Toxicological tests on the pilot performed by the FAA Civil Aeromedical Institute (CAMI) detected the presence of chlorpheniramine, pseudophedrine, and phenylpropanolamine in the pilot. The CAMI toxicology specialist indicated that chlorpheniramine is an antihistamine commonly used as an active ingredient in over-the-counter cold medications such as Chlor-Trimeton. Pseudophedrine is an active ingredient in over-the-counter medications such as Sudafed, and phenylpropanolamine is a decongestant which is an ingredient of over-the-counter and prescription medications such as Comtrex, Entex, Tavist-D, and Triaminic. In a letter to the NTSB investigator, an FAA flight surgeon stated the following regarding these medications:

Chlorpheniramine['s]...most frequent adverse reactions are drowsiness, sedation and dizziness. The use of chlorpheniramine should ground an airman for at least twenty-four hours after last dose.

Pseudophedrine...may cause restlessness, anxiety, headaches, tremors and dizziness. It may also c

NTSB Probable Cause

failure of the pilot to maintain sufficient altitude/clearance from rising terrain. Factors relating to the accident were: low light conditions at dusk, low ceilings with thunderstorms in the area, and continued flight by the pilot into adverse weather conditions.