Pilot Debrief

CESSNA A185F near Blanding, UT — 2012-04-25

Final reportWPR12FA184
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Date
2012-04-25
Location
Blanding, UT, USA
Aircraft
CESSNA A185F
Registration
N243W
Category
Airplane
Highest injury
Fatal
Fatalities
3
Phase of flight
Descent

Probable cause

The pilot's failure to maintain airplane control during low-level maneuvering flight. Contributing to the pilot’s death was the lack of a timely emergency rescue response due to the lack of effective emergency signal transmissions from both the airplane’s emergency locator transmitter and the personal locator device, which were both ejected from the wreckage.

NTSB narrative

The airplane departed with an experienced flight instructor on board who had extensive experience flying in the local canyon areas. The intention was to perform a sightseeing flight, with multiple stops at backcountry airstrips. The flight instructor was carrying a personal locator device, which transmitted position data at 10-minute-intervals, with no altitude information. This data revealed that during the morning, the airplane landed at three airstrips. A short time after takeoff about mid-afternoon from the third airstrip, the personal locator began a series of transmissions all from the same location, about 1.2 miles beyond a disused airstrip. The transmissions continued at that location for the next 12 hours, and no emergency or alert notifications were received from the personal locator or ELT (Emergency Locator Transmitter) during that period. Examination of the airstrip's dirt runway surface revealed that they had not landed there. The wreckage was located on the edge of a plateau, in remote wilderness, at an elevation of 6,900 feet mean sea level (msl). The terrain immediately to the north and east of the accident site fell away to steep canyon walls, which descended to a confluence of rivers 1,500 feet below. Area weather conditions included low-level thermal activity, wind gusts, and light turbulence, which would have been further exasperated at the accident site due to the surrounding terrain. The airplane came to rest facing uphill within a 20-degree sloping wash. The fuselage remained upright, with fire consuming the majority of its primary structure. The tail remained undamaged, and ground scars and airframe crush signatures were consistent with a loss of control event, resulting in a nose and left-wing-low collision with the ground. Thermal damage precluded an accurate assessment of the engine's operational status; however, the damage to propeller blade remnants indicated that an undetermined amount of rotational energy was present at the time of impact. Thermal damage also precluded an accurate assessment of the remaining airplane systems, including the flap position. The flight instructor was positioned in the front right seat, with the pilot in the front left. The flight instructor and aft seat passenger were fatally injured on impact; however, the pilot sustained serious injuries, and was able to extricate himself from the airplane. He eventually succumbed to his injuries, and the airplane was discovered about 11 hours after the accident, utilizing position data from the personal locater. The airplane was equipped with a 406 Mhz. ELT. Evidence suggests that it activated during the accident, but had become separated from the airplane’s structure and thus its antenna, rendering it with a limited transmission range. No transmissions from the ELT were received by any search and rescue (SAR) satellite. Had the ELT remained connected to its antenna, it would have been able to transmit an alert signal, thereby providing SAR personnel with a rapid indication that an accident had occurred. As such, the airplane would most likely have been discovered during the hours of daylight, and within 3 hours of its occurrence. The pilot's injuries fell within the "severely" injured category and analysis of emergency evacuation and trauma treatment resources revealed that with prompt ELT notification, medical response would have been greatly augmented, and he may have survived the accident. Furthermore, although a personal locator device survived the accident intact, it became ejected from the airframe, and was not within easy reach of the pilot.

Analysis

Primary failure mode
Controlled flight into terrain
First missed decision gate
Pilot could have chosen to land at the nearby airstrip instead of continuing flight.

NTSB coding

Evidence available

  • ADS-B / radar
  • Photos
  • 31 docket documents
View NTSB final reportView NTSB docket

Docket documents31

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