PIPER PA-28-181

Full Narrative

HISTORY OF FLIGHT On September 13, 2012, about 1453 mountain standard time, a Piper PA-28-181, N4188E, collided with steep terrain within a canyon near Strawberry, Arizona. CAE Global Academy Phoenix (CAE) was operating the airplane under the terms of a training services agreement with KLM Flight Academy, under the provisions of 14 Code of Federal Regulations Part 91, as an instructional/evaluation flight. The student pilot, certified flight instructor (CFI), and private pilot-rated passenger acting as an evaluator, sustained fatal injuries. The airplane sustained substantial damage during the accident sequence, and was subsequently consumed by post impact fire. The cross-country flight departed Falcon Field, Mesa, Arizona, at 1412, with a presumed destination of Payson, Arizona. Visual meteorological conditions prevailed, and a company flight plan had been filed.

The student pilot was enrolled in the KLM Flight Academy (KLS) Flight Training Program. The ground portion of the training was provided by KLS in the Netherlands, with the flight portion performed at the facilities of CAE in Mesa. The flight training was provided by CAE in accordance with the European Joint Aviation Authorities (JAA) standards JAR-FCL 1.055, as a European Joint Aviation Requirements (JAR) approved, integrated Airline Transport Pilot License (ATPL) program. CAE provided aircraft, flight instructors, and training facilities as part of the agreement. Progress/phase checks were administered by evaluator pilots employed by KLS, who held JAA examiner authorizations. CAE operated as a flight school under Federal Aviation Administration (FAA) 14 CFR Part 61.

The pilot rated passenger held a current European examiner authorization certificate, and was acting in the capacity of an evaluator for KLS. He held an FAA Private Pilot license, and the CFI who was employed by CAE, was utilized in the capacity of a "safety pilot," acting as pilot-in-command, so that the general limitations within 14 CFR Part 61.89 could be met.

The student pilot was located in the forward left seat, the CFI in the forward right seat, and the evaluator in an aft seat. Both the student and evaluator were citizens of the Netherlands, and the CFI was a United States citizen.

The purpose of the flight was to conduct a phase check for the student as part of his training towards JAA certification. Prior to departure, the evaluator reported to a CAE senior instructor that his intention was to have the student plan for a VFR flight to Winslow, Arizona, with a subsequent emergency practice diversion to Payson. In compliance with both the FAA and JAR practical test standards, the location of the diversion was unknown to the student pilot.

The airplane did not return at the expected time, and became the subject of an Alert Notice (ALNOT) about 2130. A search was conducted by the Civil Air Patrol and Gila County Sheriff's Office utilizing radar data and network-based cell phone signal analysis, and the airplane was located about 2100 the following day.

The airplane wreckage was located at an elevation of about 5,800 feet within a densely forested area of the Fossil Creek Wilderness, at the northeast end of Calf Pen Canyon. The general area fell within the slopes of the Mogollon Rim Escarpment, 4 miles northeast of the last radar target. The site was surrounded to the north, east, and south by steep canyon walls, rising to an elevation of about 6,800 feet.

PERSONNEL INFORMATION

All three occupants had never flown with each other either independently, or as a group, and no flight records were recovered indicating that the CFI or student pilot had flown to Payson Airport. CAE did not keep formal records of the KLS evaluator's flight time; as such, it could not be definitively determined if he had flown to Payson before.

CFI

The 25-year-old pilot held a commercial pilot certificate for airplane single-engine land, multiengine land, and instrument airplane. In July 2011, he was issued a flight instructor certificate with a rating for airplane single-engine land. He held a first-class medical certificate issued on March 16, 2012, with the limitation that he must wear corrective lenses.

Documentation provided by CAE revealed a total flight experience of 806 hours. His employment at CAE began on April 2, 2012, and he accumulated 226.8 hours of flight time between that date and the accident. About 205 flight hours took place in the Diamond DA20 airplane, with the remaining 21 hours occurring in the accident airplane make and model, which comprised his total flight experience in that type. According to the CAE Manager of Safety, the DA20 airplane, unlike the PA-28-181, was prohibited from being operated in the mountainous terrain north of Mesa.

His time at CAE was spent primarily training Vietnamese students under the CAE FAA-based training program, and he was not incorporated as an approved instructor as part of the KLS program.

On the day of the accident, another CFI who was a KLS-approved instructor was due to be the safety pilot for the accident flight. She stated that the evaluator arrived over an hour late, and therefore, she approached the CFI about swapping with her so she would not need to cancel the lesson she had scheduled following. The CFI accepted, but did not participate in the pre-flight briefing or oral portion of the examination with the student and evaluator.

Student Pilot

The student pilot, aged 19, held an FAA combined student pilot and first-class aviation medical certificate issued on August 1, 2011. The medical certificate had no limitations. KLS records indicated his first training flight took place on August 2, 2012, and between that time and the accident he had accumulated 79 total flight hours, 29 of which were as pilot-in-command. All of his documented flight experience was in the accident airplane make and model.

The student pilot's father was employed as a pilot for KLM. His father had known the evaluator since 1983, during which time he had received both flight training, and taken multiple checkrides with him at the Dutch State Flying Academy in Holland (later to become KLM Flight Academy (KLS). The student pilot's grandfather was also an instructor and examiner, and was a colleague with the evaluator while they were both at the Rijksluchtvaartschool (Dutch State Flight Academy).

Evaluator

The 68-year-old evaluator was the US single-engine flight training manager for the KLS division in Mesa. He held a JAA-issued airline transport pilot certificate with flight examiner and class examiner rating authorization.

His FAA private pilot's license had a rating for airplane single-engine land, and was issued initially in December 2005, and then re-issued on January 27, 2010, following its expiration. He held a JAA Airline Transport Pilot certificate, issued in February 1980, with flight instructor, single-engine piston, and instrument airplane ratings, as well as flight examiner and class-rating examiner authorizations valid until June 22, 2013. His most recent JAA examination occurred on May 25, 2012, and was for his flight instructor currency. The FAA license was issued on the basis of his JAA flight crew license. His flight history included time as a fighter pilot for the Netherlands Armed Forces, a Captain for Air Holland, and according to representatives from KLS, a pilot for KLM Exel.

He was issued a first-class medical certificate on August 31, 2012, by the Civil Aviation Authority of the Netherlands. The certificate had the limitation that he wear multifocal lenses.

AIRCRAFT INFORMATION

The airplane was manufactured in 1999, and equipped with a normally aspirated Lycoming O-360-A4M engine and a Sensenich fixed-pitch propeller. A review of the airplane's maintenance logbooks revealed a total airframe time of 14,975 hours at the last progressive inspection, which was completed the morning of the accident. At that time, the engine had accrued 14,309 total flight hours, 2,566 since its most recent overhaul in November 2009.

METEOROLOGICAL INFORMATION

An automated surface weather observation at Payson Airport (KPAN), Payson, (elevation 5,157 feet msl, 16 miles southeast of accident site) was issued at 1455. It indicated wind from 040 degrees at 14 knots gusting to 17, 10 miles with clear skies, temperature at 27 degrees C, dew point 06 degrees C, and an altimeter setting at 30.25 inches of mercury.

The NWS Surface Analysis Chart for 2100Z depicted a high pressure system over Kansas at 1030- hectopascals with a ridge extending southwestward into New Mexico. Thermal low pressure systems were noted over the Arizona and Utah border north of the accident site at 1019-hPa and to the west over the California-Arizona border at 1010-hPa. The station models depicted east-northeasterly winds at 10 to 20 knots over the region with scattered clouds, and no significant weather. Temperatures varied from near 38 degrees C over the southern portion of Arizona to the lower 30's in the northern portion of the state.

Geostationary Operational Environmental Satellite (GOES)-13 visible imagery from 1900Z through 2200Z depicted few to scattered cloud cover over the area. The accident site remained clear of clouds with some signs of orographic wind flow or downslope conditions on the leeward side of the Mogollon Plateau, with subsequent rising air and developing cumulus clouds further from the rim.

No AIRMETs for turbulence, icing, or IFR conditions were expected over Arizona. A Convective SIGMET was current at the time for developing thunderstorms, which did not impact the route of flight of the accident airplane.

Pilot Reports (PIREPS) indicated moderate clear air turbulence for the area during the period of the accident; with pilots at Prescott Airport (KPRC), located approximately 42 miles west of the accident site, reporting several encounters with low level wind shear on approach.

Utilizing the weather observation at Payson, the density altitude at the airplane's last known radar position would have been about 8,221 feet.

WRECKAGE AND IMPACT INFORMATION

The airplane came to rest at the base of a rock abutment, and was surrounded by pine trees ranging in height from 50 to 100 feet. Scaring was present on the bark of a tree adjacent to the wreckage, and fresh rock damage was noted to the abutment at the 50-foot level. About 150 feet west, freshly cut tree limbs were noted to a tree at the 75-foot level. No other trees were damaged.

The cabin structure, right wing, vertical stabilizer, and right stabilator were consumed by fire. The engine sustained thermal damage to its accessory case, but was otherwise intact and still attached to the firewall. The remnants of the empennage were located underneath the fuselage debris.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was conducted on all three occupants at the Forensic Science Center, Tucson, Arizona, on behalf of the Gila County Sheriff's Office. The cause of death was reported as the effect of blunt force and thermal injuries to the evaluator and CFI, and blunt force injuries to the student pilot.

Additional findings for the evaluator included, arteriosclerotic cardiovascular disease, coronary artery atherosclerosis - mild to moderate, cortical cyst of the right kidney, surgical replacement of the left hip, and surgical repair of the atria of the heart.

Toxicological tests on specimens recovered from the three occupants were performed by the FAA Civil Aerospace Medical Institute (CAMI). The results were negative for all screened drug substances and ingested alcohol for the CFI and student pilot. Their recovered specimens were not suitable for carbon monoxide or cyanide analysis. For the evaluator, the results were negative for ingested alcohol, with the following positive findings:

>> 16 (%) CARBON MONOXIDE detected in Blood (Heart)
>> 0.36 (ug/ml) CYANIDE detected in Blood (Heart)
>> Flecainide detected in Liver
>> Flecainide detected in Blood (Heart)
>> Metoprolol detected in Liver
>> Metoprolol detected in Blood (Heart)

Refer to the toxicology report included in the public docket for specific test parameters and results.

According to CAMI, Flecainide is an antiarrhythmic drug used in the treatment of ventricular tachycardia and premature ventricular contractions; and Metoprolol is a beta-adrenergic receptor antagonist, "beta blocker," used in the treatment of hypertension and certain arrhythmias.

TESTS AND RESEARCH

Engine and Airframe Examination

The airplane's cabin area from the firewall through to the aft section of the tailcone was consumed by fire, with only steel remnants, flight control cables and fittings, and seat frames remaining. The left wing sustained thermal damage and was consumed from the root through to the aileron seam. The right wing was consumed by fire, with only fragmented remnants of skin and spar material remaining. The engine remained attached to the firewall by its mounts, and had sustained thermal damage to its aft section, with the magnetos, engine driven and electrical fuel pump, carburetor and associated fuel lines partially consumed by fire. Cylinders 1, 2, and 4 sustained minimal damage, with cylinder 3 sustaining crush damage to the rocker cover. The top spark plugs for cylinders 1, 2, and 4, as well as the bottom plug for cylinder 3 were removed; no mechanical damage was noted, and the center and fine-wire electrodes exhibited light grey deposits, with wear signatures corresponding to normal operation when compared with the Champion Aviation Check-A-Plug AV-27 Chart (Photo 3). Visual inspection of the combustion chambers was accomplished through the spark plug bores utilizing a borescope; there was no evidence of foreign object damage or detonation, and all combustion surfaces exhibited light grey deposits consistent with normal operation. The propeller remained attached at the crankshaft flange. One blade was bent about 35 degrees aft at the root; the second blade exhibited a 90-degree aft bend midspan. The tip was bent a further 90-degrees inboard. The outboard 2-inch-long section of the tip had separated and was not located. The separation exhibited tearing features, with lengthwise scratches and red-colored rock fragments smeared along the forward blade surface.

Examination did not reveal any anomalies with the airframe or engine that would have precluded normal operation. Refer to the engine and airframe report included in the public docket for further details.

Radar Data and Flight Planning

Data from the airport surveillance radar sensor located at Phoenix Sky Harbor International Airport (PHX) was provided by the FAA. The first target corresponding to the accident airplane was recorded at 1412:36, and indicated a target departing Falcon Field Runway 22L, and initiating a climbing right turn to the north, where it followed the Verde River at an altitude of 3,300 feet mean sea level (msl). About 50 miles north of Falcon Field, the target changed heading to the north-northeast, where over the next 10 minutes it began a climb to 5,600 feet. It then made a 35-degree right turn, entering a northeast oriented canyon. For the next 2 1/2 minutes the target continued at 5,700 feet msl approximately level with the canyon rim. Prior to entering the canyon, the airplane had maintained a continuous ground clearance of between 500 and 1,500 feet. The last minute of radar data (which ended at 1450:43) indicated that the target climbed to an altitude of 5,800 feet as it entered the Calf Pen Canyon, 17 miles northwest of Payson. The canyon was about 7,000 feet wide at the airplane's entry altitude, reducing to 3,800 feet over the next 4 miles of the presumed flight path. Additionally during this period, the terrain rose from 4,800 feet to about 6,800 feet at the canyon's end. The target's ground speed averaged about 85 knots during the last 4 miles of recorded data.

A comparison between the radar data and the flight plan (located on the student pilot's laptop) revealed that the student's planned route would have taken them directly over the accident site. The accident occurred about midway between the fifth and six waypoints, which were located about 15 nautical miles apart. The terrain elevation at the fifth waypoint was about 4,800 feet with the sixth waypoint at 7,000 feet; however, the maximum elevation between waypoints was 7,200 feet, and was positioned about 9 miles from the fifth waypoint. The radar data indicated that the airplane remained on the planned route up to the last recorded radar target.

Review of the Phoenix FAA Sectional Aeronautical Chart indicated that the published maximum elevation figure (MEF) in the quadrangle that the accident occurred in was 8,400 feet.

Airplane Performance

The airplane's climb performance was calculated utilizing the Piper PA-28-181 Pilot's Operating Handbook (POH) applicable to the airplane's serial number. At a pressure altitude of 5,800 feet, outside air temperature of 27 degrees C, with the airplane loaded to its maximum gross weight, flaps fully retracted and best rate of climb airspeed of 76 knots indicated (KIAS), the climb rate would have been about 375 feet per minute (fpm).

Weight and Balance

Utilizing the occupants weights at their most recent FAA medical examination (evaluator 197 pounds, student pilot 152 pounds, CFI 170 pounds), 204 pounds of fuel, 15 pounds of cabin items, and the airplane's basic empty weight of 1,761.8 pounds, the gross weight at the time of the accident would have been about 50.2 pounds below the maximum gross weight of 2,550 pounds. The center of gravity was about 90.25 inches, and within the airplane's center of gravity envelope.

ADDITIONAL INFORAMTION

At the time of the accident, 208 students were enrolled at the CAE training facility in Mesa, which hosted 55 instructors and 42 aircraft.

The accident flight was a "D-42, PHASE 3" check, and marked the end of the VFR single-engine phase of training. The primary objectives of the check were to confirm the student's general aviation knowledge, and then have him plan for, and fly, a cross-country flight between two airports. The syllabus required an in-flight diversion during the navigation phase to an airport, the location of which was unknown to the pilot.

Flight School Employee and Student Interviews

Multiple employees of CAE were interviewed following the accident, as well as CFI's and the other KLS student pilots who had day-to-day interactions with the airplane's occupants. All provided similar and corroborating statements. The resounding sentiment from the CFI's was that the students in the KLS program were motivated, generally better prepared than students from other programs at CAE, and that most CFI's aspired to join the KLS program.

All who knew the student pilot stated he had just begun his flight training, was well-mannered, prepared and conscientious, and was excited to be flying.

His roommate provided a detailed statement regarding the pilot's activates in the 24-hour period leading up to the accident. The student had received his flight assignment from the evaluator mid-afternoon the day prior. He expressed concern with the assignment, stating that it was the hardest he had ever planned for. The route included a flight to Winslow at 1,000 feet agl with an en route target arrival waypoint 40 minutes after departure. He had never flown to the mountainous area northeast of Mesa before, and had never planned for a flight at such a low altitude. He utilized flight planning and mapping software on his computer, and was concerned that there were minimal visual references for him to safely initiate progressive altitude increases. He finalized the flight plan, and the following morning made adjustments based on the weather information he had garnered from a Direct User Access Terminal (DUAT) service. He continued to express concern about the flight, stating that the wind was not in his favor. His roommate felt that his concerns were "normal," and not unusual, and he tried to reassure him that he was well prepared.

With regard to the evaluator pilot, most CFI's stated that his style during phase checks was slightly different to that of the other evaluators, in that he would brief the CFI on the maneuvers to be performed, and have the CFI conduct the check flight while he observed from the rear seat. The consensus was that the other evaluators would typically play a more involved role in the progress of the flight. Prior to check flights, the evaluator and student pilot were always scheduled a block of time for reviewing the flight plan, requirements, and expectations of the student. The KLS operations manual did not specify that the CFI/safety pilot needed to be involved in this briefing, and most CFI's stated that due to other training commitments, they were often unable to be present for this briefing.

Another common sentiment throughout the interviews was that of low altitude flight operation. Most CFI's referred to a "cultural" requirement within the KLS program that most maneuvers and cross-country flights be conducted at lower altitudes than they had experienced in the past (varying between 500 and 1,500 feet agl). The presiding theory was that congestion and the airspace boundaries in Europe necessitated the need to learn to fly at low altitudes. One CFI stated that KLS evaluators and the, "program" encouraged cross-country flights at 1,500 feet agl, but that she refused to fly at these altitudes when training her students. She reported having discussions with KLS evaluators in the past regarding the low-altitude flights, but stated that they would often be stubborn. (KLS representatives subsequently stated that training is conducted at altitudes between 500 and 1,500 feet agl because of the prevailing weather conditions the students would ultimately encounter in Europe.) She further recalled that when she first flew as a safety pilot she was not entirely sure of her role or expectations, and expressed concern that any pilot who was new to the KLS program would probably have a similar experience. She did not recall any information in the KLS operations manual discussing the safety pilot's role.

The instructors who had previously acted in the capacity of safety pilots all stated that cross-country check flights generally were performed in areas to the south where terrain was lower and more predictable. One of the senior flight instructors expressed consternation at the choice of route chosen for the accident flight. He stated that he knew the evaluator very well, and his decision to allow the flight to proceed at such low altitudes over mountainous terrain was completely out of character. He stated that earlier in the day the evaluator had stopped by his office, and explained that he was going to have the student divert to Payson, to perform touch-and-go landings. The senior instructor recommended that due to altitude limitations and a sloping runway at Payson he instead should perform the practice at Mesa.

Operations and Training Manuals

Neither the KLS operations nor training manuals made any reference to a standard or preferred altitude for VFR cross-country flights, referencing instead the FAA minimum altitude requirements in accordance with 14 CFR 91.119. The following reference was additionally documented within the operations manual:

"3.2.3 Minimum Safe Altitude

...... For VFR the general legal requirements for minimum altitudes apply. It is emphasized that the legal requirement for built-up areas of minimum 1,000 ft over the highest obstacle does not relieve the PIC for his responsibility with relation to maintaining a safe glide distance from unobstructed terrain. This is to ensure a successful completion of a forced landing in case of an engine failure over built-up areas."

The manual explained that for solo cross-country flights, a copy of the navigation log must be left with the dispatch officer prior to flight. No such requirement was required for check flights; as such, no navigation log was available for review beyond that which was observed on the student pilot's laptop.

Examination regulations issued by the Netherlands Civil Aviation Authority, provided the following guidelines for conducting practical tests in pursuit of a private pilot's license:

"On the day of the exam the examiner will select the date, route to be flown [with] at least three navigation legs. The examiner will prepare and calculate this following information carefully. The maximum altitude during the cruise can be up to 2000 ft AGL[], unless other restrictions make this impossible."

According to the CAE appendix within the KLS Operations Manual, Payson Airport was an approved destination, with the following restriction, "High altitude airport, KLS TM-SE authorization mandatory for solo flights." Winslow was not an approved destination airport.

Almost the entire planned route took place over areas that were documented on the FAA Phoenix Sectional Aeronautical Chart as "Special Conservation Areas." These included the Fort McDowell and Verde River Breeding areas, followed by the Mazatzal and Fossil Springs Wilderness areas. Although FAA regulations do not mandate avoidance of these areas, FAA Advisory Circular 91-36D, "VFR Flight Near Noise-Sensitive Areas," encourages pilots to maintain a clearance of 2,000 feet agl laterally along the route of flight, or from the uppermost rim of a canyon or valley.

Neither the KLS nor the CAE operations of training manuals documented the role of a safety pilot during check flights.

Safety Changes

Following the accident, CAE issued a safety notice regarding minimum safe altitudes in mountainous terrain. The notice required an alternate minimum safe altitude the highest of which being either 1,000 feet over the statutory minimum, or 2,000 feet above the highest obstacle or terrain point within 5 nautical miles of the intended route.

A second safety notice was issued requiring an FAA flight plan to be filed, and for a copy to be left with dispatch for solo flights exceeding 25 nautical miles, dual flights exceeding 50 nautical miles, or any night flight outside of the traffic pattern.

Representatives from CAE also stated that since the accident, additions were made to the Operations Manual defining the role of the safety pilot, as well as requiring them to be present during preflight briefings.