N/A Airport
Aircraft Accident/Incident Report

Strawberry, Arizona 85544
Thursday, September 13, 2012 14:53 MST

NTSB Narrative Summary Released at Completion of Accident

The student pilot was enrolled in a European flight training academy, which, in conjunction with a US-based operator, provided training services in accordance with European Joint Aviation Authorities standards. The US operator provided aircraft, training facilities, and flight instructors as part of a service agreement with the European academy. The purpose of the flight was to conduct a phase check on the student pilot. The syllabus included a cross-country flight with a subsequent in-flight diversion to a location unknown to the student pilot. The student pilot was located in the forward left seat, a flight instructor was in the forward right seat, and an evaluator was in an aft seat. The evaluator had considerable aviation experience in Europe; however, he only held a Federal Aviation Administration (FAA) private pilot license. Therefore, the flight instructor was used on the flight as a "safety pilot," acting as pilot-in-command, to meet FAA regulatory requirements. The flight instructor had recently joined the US operator, but he was not incorporated into the European flight academy's flight training program; therefore, he had no prior experience as a safety pilot with the academy. The day before the accident, the evaluator provided the student pilot with instructions for the cross-country portion of the phase check, which included flight to a destination airport located in mountainous terrain with a directive to fly at an altitude of 1,000 feet above ground level (agl) throughout the flight. The student pilot was also asked to plan an en route 40-minute target arrival waypoint and to be ready to prepare for an in-flight diversion. The majority of the route planned by the student passed through a series of FAA-designated special conservation areas. Although the FAA did not prohibit flight through such areas, it did discourage it. Further, although the academy and operator did not explicitly prohibit flights to be performed along the chosen route, cross-country check flights were typically accomplished in areas south of the departure airport where terrain was lower. According to radar data, the student pilot successfully manipulated the airplane in precise coordination with his flight plan for about the first 35 minutes following departure. Shortly thereafter, the airplane approached and passed the 40-minute waypoint and then continued along the planned route while in a shallow climb. Examination of the student's flight plan revealed that, to maintain 1,000 feet agl clearance as the airplane approached the waypoint, he would have needed to fly the airplane level and then below rising canyon walls on either side of the route. Avoiding terrain just beyond the waypoint would have required a prompt climb or diversion because the rapidly rising terrain would have required the airplane to climb at a rate that exceeded its climb capabilities. Further, downdrafts and high-density altitude conditions were present in the canyon, which likely further degraded the airplane's available climb performance. Thus, the airplane entered a steep canyon (still along the planned route) that it could neither climb out of nor turn around in. Shortly after, with the airplane flying straight and level, it struck a cliff face at the end of the canyon, 1,000 feet below the canyon's rim. The majority of the airplane's structure was consumed by postimpact fire; postaccident examination revealed no anomalies with the engine or airframe that would have precluded normal operation. Radar data indicated that the airplane was climbing about 4 minutes before impact and that the accident location was at the same elevation as the last radar target. Therefore, the engine was likely producing power during the final stages of the flight. Although no indications of in-flight fire were observed, toxicological tests for the evaluator revealed that he had been exposed to the products of combustion (carbon monoxide and cyanide); however, this likely occurred during the postcrash fire. None of the occupants had ever flown with each other, and no records were recovered indicating that the flight instructor or student pilot had ever flown to the presumed diversion airport. The evaluator arrived late for the flight, so the original flight instructor, who had flight commitments later in the day, asked the accident flight instructor to join the flight at the last minute, which did not allow him sufficient time to participate in the preflight oral briefing and limited the time he had to evaluate the flight plan. From a regulatory standpoint, the flight instructor was the pilot-in-command and, thus, was responsible for the safety of the flight. However, given his relatively junior status within the organization and the young student pilot's lack of experience, it is likely that both pilots deferred responsibility for the flight to the evaluator and trusted that the route was appropriate. It is possible that the unsuitable route was discussed and understood by all of the occupants; however, the reason for not performing the diversion at an appropriate time could not be determined. The Dutch Safety Board (DSB) was a party to the investigation and appointed an accredited representative in accordance with the provisions of Annex 13 to the Convention on International Civil Aviation. The DSB submitted comments regarding the factual report, brief, and probable cause, and they are included in the public docket for this accident.

NTSB Probable Cause Narrative

The flight instructor's and the evaluator's failure to divert at an appropriate time during cruise flight, which resulted in the airplane's inability to maintain a sufficient altitude to clear rising terrain. Contributing to the accident was the flight evaluator's decision to allow the student pilot to plan for and execute a hazardous flight at an inappropriate altitude considering the terrain in high-density altitude conditions.

Event Information

Type of Event Accident
Event Date 9/13/2012
Event Day of the Week Thursday
Time of Event 1453
Event Time Zone Mountain Standard Time
Event City Strawberry
Event State ARIZONA
Event Country --
Zipcode of the event site 85544
Event Date Year 2012
Event Date Month 9
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 342727N
Event Location Longitude 1112901W
Event Location Airport N/A
Event Location Nearest Airport ID --
Indicates whether the acc/inc occurred off or on an airport Off Airport/Airstrip
Distance from airport in statute miles --
Degrees magnetic from airport --
Airport Elevation --
Weather Briefing Completeness --
Investigator's weather source Weather Observation Facility
Time of the weather observation 1455 Mountain Standard Time
Direction of event from weather observation facility (degrees) 300
Weather Observation Facility ID KPAN
Elevation of weather observation facility 5157
Distance of event from weather observation facility (units?) 16
Time Zone of the weather observation MST
Lighting Conditions Day
Lowest Ceiling Height --
Lowest Non-Ceiling Height --
Sky/Lowest/Cloud Conditions Clear
Sky Condition for Lowest Ceiling None
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) 10
Air Temperature at event time (in degrees celsius) 27
Dew Point at event time (in degress fahrenheit) 6
Wind Direction (degrees magnetic) 40
Variable Wind Indicator Wind direction could be determined
Wind Speed (knots) 14
Wind Velocity Indicator --
Wind Gust Indicator Gusting
Wind Gust (knots) 17
Altimeter Setting at event time (in. Hg) 30.25
Density Altitude (feet) --
Intensity of Precipitation --
METAR weather report METAR KPAN 132155Z AUTO 04014G17KT 10SM CLR 27/06
Event Highest Injury Fatal
On Ground, Fatal Injuries --
On Ground, Minor Injuries --
On Ground, Serious Injuries --
Injury Total Fatal 3
Injury Total Minor --
Injury Total None --
Injury Total Serious --
Injury Total All 3
Investigating Agency NTSB
NTSB Docket Number (internal use) 32827
NTSB Notification Source FAA LAX ROC
NTSB Notification Date --
NTSB Notification Time --
Fiche Number and/or location -used to find docket information --
Date of most recent change to record Jun 26 2014 6:37PM
User who most recently changed record coos
Basic weather conditions Visual Meteorological Cond
FAA District Office --

Aircraft Involved

Aircraft #1

Aircraft Registration Number N4188E
NTSB Number WPR12FA420
Missing Aircraft Indicator --
Federal Aviation Reg. Part Part 91: General Aviation
Type of Flight Plan filed Company VFR
Flight plan Was Activated? Yes
Damage Substantial
Aircraft Fire Ground
Aircraft Explosion None
Aircraft Manufacturer's Full Name PIPER
Aircraft Model PA-28-181
Aircraft Series Identifier --
Aircraft Serial Number 2843212
Certified Max Gross Weight 2550
Aircraft Category Airplane
Aircraft Registration Class --
Aircraft is a homebuilt? No
Flight Crew Seats --
Cabin Crew Seats --
Passenger Seats --
Total number of seats on the aircraft 4
Number of Engines 1
Fixed gear or retractable gear Fixed
Aircraft, Type of Last Inspection Continuous Airworthiness
Date of Last Inspection Sep 12 2012 12:00AM
Airframe hours since last inspection 1
Airframe Hours 14975
ELT Installed Yes
ELT Activated No
ELT Aided Location of Event Site Unknown
ELT Type C91-A
Aircraft Owner Name CAE GLOBAL ACADEMY PHOENIX INC
Aircraft Owner Street Address --
Aircraft Owner City MESA
Aircraft Owner State AZ
Aircraft Owner Country USA
Aircraft Owner Zipcode 85215-2560
Operator is an individual? No
Operator Name CAE GLOBAL ACADEMY PHOENIX INC
Operator Same as Owner? Yes
Operator Is Doing Business As --
Operator Address Same as Owner? Yes
Operator Street Address --
Operator City MESA
Operator State AZ
Operator Country USA
Operator Zip code 85215-2560
Operator Code --
Owner has at least one certificate None
Other Operator of large aircraft? --
Certified for Part 133 or 137 Operation --
Operator Certificate Number --
Indicates whether an air carrier operation was scheduled or not --
Indicates Domestic or International Flight --
Operator carrying Pax/Cargo/Mail --
Type of Flying (Per_Bus / Primary) Instructional
Second Pilot on Board Yes
Departure Point Same as Event No
Departure Airport Code KFFZ
Departure City Mesa
Departure State AZ
Departure Country USA
Departure Time 1412
Departure Time Zone MST
Destination Same as Local Flt --
Destination Airport Code KPAN
Destination City Payson
Destination State AZ
Destination Country USA
Specific Phase of Flight --
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record Jun 26 2014 6:37PM
User who most recently changed record coos
Since inspection or accident Last Inspection
Event Location Runway Number and Location N/A
Runway Length --
Runway Width --
Sight Seeing flight No
Air Medical Flight No
Medical Flight --