NTSB Factual Report

HISTORY OF FLIGHT

On February 23, 2003, about 0830 Pacific standard time, a Cessna 172N, N9885J, collided with mountainous terrain near Ely, Nevada. Corporate Air Services was operating the rental airplane under the provisions of 14 CFR Part 91. The private pilot and one passenger sustained fatal injuries; the airplane sustained substantial damage. The personal cross-country flight departed Garfield County Regional Airport, Rifle, Colorado, about 0630 mountain standard time, with a planned destination of Little River Airport, Little River, California. The planned en route stops for the flight are unknown. Visual meteorological conditions prevailed, and a flight plan had not been filed.

During a telephone conversation with a National Transportation Safety Board investigator, the accident pilot's certified flight instructor (CFI) stated that the pilot was working on obtaining his instrument rating. He worked with her throughout his private pilot training, during which he planned several personal cross-country flights. Every time the pilot wanted to make a cross-country flight he would query her, as if seeking her approval of the flight. Several times she advised him not to make flights due to weather conditions; every time she recommended him to not make a flight, he followed her advise.

The CFI further stated that she spoke with the pilot several days prior to the accident. During the conversation, he conveyed to her that he wanted to build simulated instrument time. In an effort to accomplish this, he was planning to make a long cross-country flight to California, where he would meet up with a friend and spend the night before heading back. After discovering that there was a potential for poor weather during days he wanted to fly the cross-country, she advised him to not make the flight during the time that he had planned.

After the accident, the CFI was surprised to find out that the pilot had rented the airplane and opted to make the flight regardless of her advice. On February 24, 2003, she became concerned when the pilot did not return, and the family alerted the Federal Aviation Administration (FAA) of the disappearance. The FAA subsequently issued an alert notice (ALNOT). The CFI noted that during his training, the pilot was exposed to flying in mountainous terrain and was comfortable maneuvering the airplane at higher altitudes. She added that although the airplane was not equipped with a global positioning system (GPS), the pilot owned and often used a handheld GPS.

On February 23, 2003, at 1214, the Air Force Rescue Coordination Center (AFRCC) detected an emergency locator transmitter (ELT) signal in the southern portion of White Pine County. Due to weather, rescue personnel were unable to locate the wreckage until February 26, 2003.

PERSONNEL INFORMATION

A review of FAA airman records disclosed that the pilot held a private pilot certificate with ratings for airplane single engine land, which was issued on September 19, 2002. The pilot held a third-class medical certificate issued without limitation on June 27, 2002.

In a written statement, the operator reported that the pilot had accumulated 100 hours total time in all aircraft, of which 95 were accumulate in the same make and model as the accident airplane. He indicated that the pilot had about 40 hours of simulated instrument time.

AIRCRAFT INFORMATION

The Cessna 172N airplane, serial number 17273948, was manufactured in 1980. The airplane and engine maintenance records were not located; however, the operator provided the airplane's last inspection information. The airplane had undergone a 50-hour maintenance inspection on January 24, 2003, at which time the airframe had accumulated 7,715.3 hours total time and 33.5 hours since the inspection prior. The engine had accumulated 3,205.9 hours total time and 1,209.7 hours since the last overhaul.

METEOROLOGICAL CONDITIONS

A Safety Board staff meteorologist prepared a factual report. The entire report part of the public docket. Pertinent parts of the report follow.

The closest official weather observation station was Ely, located about 29 nautical miles (nm) north of the accident site. The elevation of the weather observation station was 6,259 feet mean sea level (msl). At 0753, the recorded station weather conditions were winds 170 degrees at 8 knots; visibility 10 miles; clear at or below 12,000 feet; temperature -6 degrees Celsius; dew point -12 degrees Celsius; altimeter 29.88 inches of mercury. At 0853, the visibility remained the same; however, the winds were calm and the temperature/dew point changed to 0 and -12 degrees, respectively.

GOES-10 satellite imagery indicated that skies were clear in the accident area.

There were no AIRMETs (Airmen's Meteorological Information),SIGMETs (Significant Meteorological Information), Convective SIGMETs (Significant Meteorological Information), or weather advisories in effect for the time and area of the accident.

COMMUNICATIONS

The pilot was not communicating with any FAA air traffic control facility during the time period encompassing the accident sequence.

WRECKAGE AND IMPACT INFORMATION

The global positioning system (GPS) coordinates for the estimated 8,500-foot msl accident site were: 38 degrees 49.037 minutes north latitude by 114 degrees 54.587 minutes west longitude. Search and rescue personnel reported that the airplane came to rest in mountainous terrain on a slope of about 25 degrees. Upon arrival, they noted that about 4 feet of snow covered the wreckage.

The airplane came to rest on the right side of the fuselage, with the left horizontal stabilizer securely attached and oriented about perpendicular to the sloping terrain. The right wing, still partially connected, had folded aft and was situated parallel to the fuselage. The left wing, mostly still connected, folded over with the bottom of the wing facing upward; it was oriented perpendicular to the fuselage, resting on the upsloping terrain.

During a telephone conversation with a Safety Board investigator, the search and rescue helicopter pilot that initially responded to the accident stated that the wreckage was on the south side of a mountainous canyon, about 300 to 400 feet below the ridgeline. He described the terrain as gradual sloping, with scattered Aspen trees.

Wreckage recovery personnel arrived at the site via helicopter, in an effort to transport the airplane to a facility where investigators could perform a detailed examination. The person recovering the airplane stated that the accident site was in a valley contoured in an east/west direction, with rising terrain to the west, north, and south. The airplane had come to rest on the south side of the valley about 500 feet below the ridgeline. He noted that the airplane's energy path and debris field were toward an easterly heading.

Recovery personnel added that all airframe components were with the main wreckage along with all flight control surfaces, which had remained attached. The left fuel tank was intact, while the right tank was breached. During the wreckage retrieval process, they drained about 5 gallons of fuel from each fuel tank.

The nearest airport to the accident site was Ely Airport (Yelland Field), elevation 6,259 feet msl. At the GPS coordinates given in the Airport Facilities Directory, the airport was located about 29 nm north from the site.

A detective from the White Pine County Sheriff reported that when arriving at the accident site, he observed the pilot outside of the airplane. The pilot was clad in several layers of clothing and covered in snow. The passenger remained situated inside the cockpit, still restrained into the right front seat by seatbelts. Several feet from the airplane he found a dog with its leash tied around a tree. A plastic bag of marijuana was on the pilot and two bags of marijuana were on the passenger; several empty beer bottles were both inside and outside the airplane.

MEDICAL AND PATHOLOGICAL INFORMATION

Pilot

On March 1, 2003, the Washoe County Coroner performed an autopsy on the pilot. The autopsy report stated that the cause of death was "multiple injuries," due to blunt force trauma. The report also noted other conditions to be "environmental exposure (hypothermia)." The coroner opined that the pilot expired from injuries to his cerebellum, pelvis, hands, and legs, which were exacerbated by environmental exposure.

The FAA Toxicology and Accident Research Laboratory performed toxicological testing of specimens of the pilot. The report stated that no carbon monoxide, cyanide, or ethanol were detected in the pilot. The report contained positive results for the following: 0.0023 (ug/ml, ug/g) tetrahdrocannabinol detected in blood; 0.0155 (ug/ml, ug/g) tetrahdrocannabinol carboxylic acid detected in blood; 0.2162 (ug/ml, ug/g) tetrahdrocannabinol carboxylic acid detected in urine.

A review of the pertinent medical records information by the Safety Board Medical Officer is appended to this report in the public docket.

Passenger

The Washoe County Coroner performed an autopsy on the passenger, citing the cause of death as "craniocerebral injuries" due to blunt force trauma.

The FAA Toxicology and Accident Research Laboratory performed toxicological testing of specimens of the passenger. The report stated that no carbon monoxide, cyanide, or ethanol were detected. The report contained positive results for the following: 0.257 (ug/ml, ug/g) norpropoxyphene detected in blood; 1.507 (ug/ml, ug/g) norpropoxyphene detected in urine; 0.031 (ug/ml, ug/g) propoxyphene detected in blood; 0.118 (ug/ml, ug/g) propoxyphene detected in urine; 0.0036 (ug/ml, ug/g) tetrahdrocannabinol detected in blood, 0.00108 (ug/ml, ug/g) tetrahdrocannabinol carboxylic acid detected in blood; 0.1101 (ug/ml, ug/g) tetrahdrocannabinol carboxylic acid detected in urine; 0.038 (ug/ml, ug/g) tramadol detected in blood.

TESTS AND RESEARCH

Following recovery, investigators examined the airplane at the storage facility of Air Transport, Phoenix, Arizona. Present at the examination were a Safety Board investigator, inspectors from the FAA, and representatives from Cessna and Textron Lycoming.

Investigators rotated the engine via the propeller. They established the engine's internal mechanical continuity during rotation of the crankshaft and upon attainment of thumb compression. The engine representative removed all eight spark plugs. The spark plug electrodes were gray in color and had a slightly oval shape, which corresponded to normal operation according to the Champion Aviation Check-A-Plug AV-27 Chart. The magneto remained securely mounted to its corresponding flange. While investigators rotated the crankshaft, they could hear the impulse coupling and observed spark at each lead.

The two-blade propeller remained attached to the crankshaft flange. One blade's tip had separated and the blade exhibited trailing edge bending, with leading edge buckling. The other blade was slightly bent aft.

Investigators established control continuity throughout the airframe and flight controls. There was no evidence of premishap mechanical malfunction or failure observed during the examination of the engine and airframe.

ADDITIONAL INFORMATION

The Safety Board investigator released the wreckage to the owner's representative.

NTSB Probable Cause

the pilot's failure to maintain adequate terrain clearance while flying in a box canyon.