N243WCessna 172L · 1971

On April 25, 2012, about 1540 mountain daylight time, a Cessna A185F, N243W, collided with terrain in the Dark Canyon Wilderness area near Blanding, Utah. The airplane was registered to, and operated by, the pilot under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91. The certificated flight instructor (CFI), private pilot/owner, and private pilot rated passenger were fatally injured. The airplane sustained substantial damage during the accident sequence, and was consumed by post impact fire. The cross-country personal flight departed from a backcountry airstrip known as Hidden Splendor about 1450, with a presumed destination of Carbon County Regional Airport/Buck Davis Field, Price, Utah. Visual meteorological conditions prevailed, and no flight plan had been filed.

The NTSB investigator traveled in support of this investigation, and performed an examination of the engine and airframe both on scene and following recovery.

The airplane departed Price about 0700, with the airplane's owner, his father, and the CFI, who was the Chief Pilot for the fixed base operator, Arrow West Aviation, Inc. (doing business as Redtail Aviation). According to friends of the CFI, he had extensive experience flying in the canyon areas of Southern Utah, and as such, was approached by the airplane's owner to act as a guide to navigate the local terrain and scenery. The wife of the passenger stated that they were concerned about flying in mountainous terrain, and did not feel happy doing so without an experienced pilot, and that after performing some research, they chose the CFI to be their guide.

Both the pilot and the CFI were carrying SPOT(tm) personal locator devices. The pilot's device was not configured to send automatic location updates. The CFI's device was configured to send GPS position reports at roughly 10-minute-intervals (no altitude information) to the SPOT data center. Data obtained from the SPOT service revealed that for the 30 minutes after takeoff, the airplane flew west towards the Scofield Reservoir, before circling back over the airport and east towards an airstrip at Rock Creek Ranch, on the banks of the Green River. The airplane landed about 0835, and at 0907, the SPOT device transmitted an "Everything Ok" message. Positional reports for the next 2 hours indicated that the airplane flew back towards Price, and then 45 miles south-southeast to Mexican Mountain Airstrip, where it landed about 1035. About 30 minutes later, the airplane departed to the southwest, landing at Hidden Splendor Airstrip, 40 miles away.

About 1200, employees at Redtail Aviation received a notification from the Federal Aviation Administration (FAA) Area Traffic Control Center that a commercial airplane overflying the Canyonlands area had received a message over the radio from the CFI. The message indicated that they had landed at Hidden Splendor, and that the airplane had a flat tire. About that time, Redtail Aviation received a "NEED HELP" alert from the SPOT service. A pilot and mechanic subsequently departed from Price with a spare tire and tools, to render assistance. They arrived mid-afternoon, and having assisted with the replacement of the tire, departed a short time later.

SPOT data indicated that the accident airplane having departed about 1450, continued on a southeast track with a position report at 1528, indicating they were 8 miles west of an airstrip located on the southern rim of Dark Canyon. Ten minutes later, the unit began a series of transmissions all from the same location, about 1.2 miles southeast of the airstrip. The transmissions continued at that location for the next 12 hours, and no emergency or alert notifications were received during that period.

The airplane had not arrived back at Price by 2030. The owner of Redtail Aviation therefore checked the SPOT service, and discovered that the unit had not moved since mid-afternoon. As such, about 2100, he reported the airplane missing to a pilot from the San Juan County Sheriff's office, and at 2130, the Sheriff's Deputy responsible for search and rescue (SAR) was notified. Based on the remote location of the airplane, and the lack of local air support, the SAR team elected to use a Utah Highway Patrol (UHP) Air Bureau helicopter based out of Salt Lake City, 230 miles from the accident site. The helicopter was dispatched from Salt Lake City, and arrived at Moab Regional Airport, Moab, Utah, at 0117, where it picked up two members of the SAR team. A search was initiated utilizing the coordinates provided by the SPOT device, and about 0210 the airplane wreckage was located.

The CFI, age 57, held a commercial pilot certificate with ratings for airplane multiengine land, airplane single engine land, airplane single engine sea, and instrument airplane. Additionally, he held a flight instructor certificate with ratings for airplane single engine land, and instrument airplane.

His second-class medical certificate was issued on March 29, 2012, with the limitation that he shall possess glasses for near/intermediate vision.

He had successfully completed an FAA, CFR 135.293, and 135.299 proficiency check in the presence of an FAA inspector, 5 days prior to the accident.

Flight records recovered from Redtail Aviation revealed that he accumulated a total of 6,197 total flight hours, 111 of which had taken place in the 90 days preceding the accident. His duties as chief pilot included performing charter flights, scenic tours, and flight instruction.

Pilot

The pilot, age 28, held a private pilot certificate with ratings for airplane single engine land and instrument airplane, issued May 25, 2006. He was issued a third-class medical certificate on September 10, 2007, with no limitations. No flight records were located, and presumed destroyed in the post-accident fire. At the time of his application for a medical certificate, he reported a total flight experience of 150 hours. Family members reported that he had flown regularly for the 5-year period preceding the accident.

A representative of the pilot's family stated that he had planned on taking the airplane for its annual inspection on the return leg of the trip, and as such, the logbooks were most likely onboard the airplane at the time of the accident. The logbooks were not recovered at the accident site, and presumed to have been consumed by fire.

Work order records obtained from the maintenance facility that performed the last annual inspection revealed that the airplane had undergone the inspection in May 2011. At that time, the airframe had accumulated a total of 1,346 flight hours. Low engine cylinder compression values were observed during the inspection, and as such, all six cylinder assemblies were replaced. Oil analysis documentation revealed that about that time, the engine had accrued 1,376 hours since new, and 549 since overhaul.

The most recent repair was performed 2 days prior to accident by a maintenance facility based at North Las Vegas Airport. The repair was to the alternator, and occurred at a tachometer time of 1,527.7 hours.

FAA airworthiness records indicated that in 1975, a Robertson STOL (short takeoff and landing) full span wing trailing edge flap system had been installed in accordance with supplemental type certificate SA1441WE.

Weight and Balance

The airplane was equipped with dual flight controls, and according to the owner's mother, the rear third-row passenger seat had been removed, and was later located at their home hangar. No baggage was located in the wreckage, and the occupant's belongings and luggage had been removed and stored at Redtail Aviation prior to the flight.

Fuel service records indicated that the airplane was serviced with 31.74 gallons of 100 low-lead aviation gasoline at Price Airport on the morning of the flight.

Utilizing the airplane's basic empty weight at the time of manufacture, with the fuel tanks filled to half of their capacity, and the combined weight of all occupants based on their most recent FAA medical certificate applications, the airplane would have been about 650 pounds below its maximum gross weight, and within its center of gravity limits.

The National Weather Service (NWS) Surface Analysis Chart for 1500 on the accident date depicted two high pressure systems located over southwestern Wyoming and northern Arizona at 1017-hectopascals (hPa), and another high over northwestern Wyoming at 1013-hPa. To the northwest over southern Idaho a low pressure system at 1005-hPa was located with an area of disturbed weather. A ridge of high pressure and a cold front existed over southeastern Utah.

The NWS Air Resource Laboratory North American Mesoscale Model for 1500 MDT depicted southwesterly winds over the region, with wind of 237 degrees at 16 knots over the accident area, with minimal wind speed change or direction through to a height of 10,000 feet.

The NWS had issued AIRMET Tango current over the region for moderate turbulence below 15,000 feet.

The closest official weather reporting locations surrounding the accident site were Blanding Municipal Airport, Blanding, Utah, located approximately 30 nautical miles east-southeast at an elevation of 5,868 feet. Blanding had an automated weather observation system (AWOS) installed, which at 1555 reported, wind from 250 degrees at 15 knots gusting to 25 knots; visibility 50 miles; skies scattered clouds at 9,000 feet, broken 14,000 feet; temperature 22 degrees C; dew point 4 degrees C; altimeter 30.16 inches of mercury; lightning observed distant northwest.

The mechanic who responded with the replacement tire stated that about the time he departed, the wind varied from calm to intermittent gusts of between 10 and 15 knots. The wind was not strong enough to create dust on the ground, but at about 1,000 feet agl, he encountered "waves" of wind, which resulted in 10-knot changes to the indicated airspeed.

The wreckage was located on the edge of a 3,400-feet-wide 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. The overall area followed a general upslope from west to east, culminating in the 9,300 feet peaks of Horse Mountain, 15 miles to the east, and the 11,360 feet Abajo Peak, a further 15 miles beyond.

The fuselage was on a heading of 040 degrees magnetic, facing uphill on a 20-degree sloping dry wash bed. The wash was comprised of flat sandstone, and the surrounding area consisted of brush and pine trees ranging in height of between 5 and 15 feet. The airplane remained upright, with the engine intact and impaled against a semicircular stratified abutment, which surrounded the airplane to the north. The fuselage sustained minimal longitudinal crush damage. The majority of the fuselage structure forward of the tail, including the cabin and a 30-foot-long swath of vegetation uphill, was consumed by fire. The tail section, aft of the fire line, sustained no discernible damage, and there was no debris path leading up to the wreckage.

The right wing was consumed by fire, and was uphill from the engine in line with the fuselage. Green lens fragments were present in the burnt wing remnants furthest from the fuselage. The inboard section of the left wing, and associated lift strut, remained partially attached to the consumed cabin components. The inboard leading edge and the fuel tank, were consumed by fire. The outboard wing portion sustained 45-degree crush damage to the leading edge at the tip, and had become folded back over the cabin structure. The sandstone abutment adjacent to the left wing displayed a 20-foot-long white paint imprint, with red lens fragments, and a section of the left wingtip, at the furthest point from the wing root. No damage was noted to any of the trees to the south of the airplane. The closest tree in that direction was about 10–feet-tall, and 45 feet behind the empennage.

The stall warning horn, located in the left wing, had become consumed by fire. The stall warning air inlet orifice, located in the left wing, and about 5 feet of its associated feed tube were clear and free of obstructions.

The rudder, elevator, and elevator trim cables were continuous from their control surface clevis fittings through to their associated cabin controls. The aileron control cables within the right wing remained attached to the outboard bellcrank, and were traced through to the wing root, where they had become separated. The cable separation features were broomstraw in appearance, consistent with impact overload, with the remaining cable sections continuous through to the aileron yoke chain. The yoke loop and chain were intact, with the left wing cables continuous through to the aileron bellcrank.

The right wing push-pull flap/aileron tubes had been consumed by fire. The right flap cable remained attached at the flap/aileron bellcrank mixing unit, and had separated with broomstraw failure features at a point midspan of the flap. The left wing flap cable remained attached to the flap/aileron mixing unit, and was continuous through to the cabin. Impact and fire damage precluded an accurate assessment of the flap position at impact.

The instrument panel had been consumed by fire. The engine throttle, mixture, and propeller control cables remained attached to their panel mounts, and were all in the full-forward position.

The engine had been partially consumed by fire, with the underside of the left cylinders melted, exposing the piston crowns. Both magnetos remained affixed to their mounting pads.

The propeller hub had become partially submerged in sand and rock, and remained attached to the crankshaft. All three blades were still attached to the hub. The outboard section of one blade had been consumed by fire about 10 inches from the root. The second blade was embedded within soft sandstone material and exhibited a 90-degree aft twist midspan, with thermal damage along the leading and trailing edges at the bend. The third blade exhibited similar bending and curl damage focused at the root, with the entire outboard section consumed by fire. The odor of aviation gasoline was present during excavation of the blade remnants.

All major sections of the airplane were accounted for in the immediate vicinity of the accident site.

A postmortem examination was conducted on all three occupants by the Utah Department of Health, Office of the Medical Examiner. Toxicological tests on specimens recovered by the medical examiner were performed by the FAA Civil Aerospace Medical Institute.

The cause of death for the CFI was reported as the effect of blunt force trauma. The toxicological results were negative for ingested alcohol, with 193.2 (ug/ml, ug/g) Acetaminophen detected in Urine.

Pilot

The cause of death of the pilot was reported as the effect of blunt force trauma. The toxicological results were negative for all screened drug substances and ingested alcohol.

Passenger

The cause of death for the pilot rated passenger was reported as the effect of blunt force trauma, with a finding of occlusive coronary artery disease. The toxicological results were negative for ingested alcohol, and 0.329 (ug/ml, ug/g) of Diphenhydramine was detected in the blood.

According to CAMI, Diphenhydramine is a common over-the-counter antihistamine used in the treatment of the common cold and hay fever, with warnings that it may impair mental and/or physical ability required for the performance of potentially hazardous tasks (e.g., driving, operating heavy machinery). The National Institutes of Health further reports that Diphenhydramine can also be used to prevent and treat motion sickness, and treat insomnia. The therapeutic low and high blood levels are 0.0250 ug/mL, and 0.1120 ug/mL respectively, with toxic levels of 5 ug/mL, and fatal levels of 10 ug/mL.

Refer to the attached toxicology report for specific test parameters and results.

Review of his private medical records revealed that he had not been diagnosed or treated for coronary artery disease; his wife further stated that she was not aware of such a condition, and he never exhibited the associated symptoms. She continued that he was not taking any medication other than Lipitor at the time of the accident, and that the only time he exhibited motion sickness was when fishing, during which time he would take a Dramamine(tm) tablet. He often took Claritin-D(tm) (Pseudoephedrine/loratadine) tablets during the spring season, to counter the symptoms of seasonal allergies.

Electronic Locater Transmitter

The airplane was equipped with an AmeriKing AK-451-2 (AF)(AP), non-GPS equipped Electronic Locater Transmitter (ELT). The unit appeared undamaged and was located outside of the airplane adjacent to its mounting station, which had been consumed by fire. The unit remained attached to its mounting bracket. Both the antenna BNC connector plug and the remote access plug remained attached to the ELT's case, however, their associated cables appeared to have been pulled free, and were not located.

The Deputy Sheriff who led the SAR team who were on scene, reported that the green ELT power light was flashing. AmeriKing documentation showed that such an illumination means that the ELT has been activated, and is transmitting.

The National Oceanic and Atmospheric Administration (NOAA), who are responsible for collecting and distributing ELT distress alert data, reported that their SARSAT (Search and Rescue Satellite Aided Tracking System) did not receive any alerts from the ELT.

SAR personnel recovered the occupants shortly after locating the accident site. Due to the remoteness of the site, the occupants were recovered prior to the arrival of the NTSB investigator-in-charge (IIC). The remoteness also inhibited SAR personnel from reporting the accident to the FAA and NTSB until they had recovered the occupants, and arrived back at Moab at 0345.

Photographs provided by the Sheriff's department were utilized to determine the seating locations. The forward left pilot's seat area was unoccupied, and the pilot was located outside of the wreckage, and positioned under the empennage. Ground disturbances and blood traces surrounding the left side of the airplane revealed that he had survived the initial impact, and was able to extricate himself from the wreckage, before crawling about 20 feet away from the airplane, and then back to the tail. The CFI was located in the forward right section of the cabin remnants, adjacent to the right seat frame. The passenger was located lying across the aft seat frame.

According to the Deputy Sheriff, the closest Emergency Medical Service (EMS) helicopter was located in Page, Arizona, about 100 miles southwest of the accident site; however, at that time the helicopter was unavailable.

According to the American Trauma Society, the closest level I medical trauma centers were located in Salt Lake City and Flagstaff, Arizona, both about 220 miles from the accident site. A level II trauma center was located in Grand Junction, Colorado, about 185 miles to the east.

A UHP pilot was interviewed regarding the SAR response. He stated that the helicopter was equipped with basic first-aid equipment, and that the second non-flying crewmember is a certified Emergency Medical Technician. He reported that if survivors had been found, and their condition was not critical, he would have had the capability of providing basic medical care, and the capacity to extract one supine occupant.

He further stated that if an ELT signal had been received, the UHP helicopter would have been immediately dispatched, and would have arrived at the accident site within 2 to 3 hours. He conjectured that if an EMS helicopter was available earlier in the day when the accident had happened, it could also have been part of the search and rescue effort and either arrived earlier, or have been prepositioned close to the ELT coordinates in advance of locating the airplane. On the night of the accident, because no ELT signal had been received, and the SPOT device continued to report a stationary location next to a runway with no alarm signal, both the UHP and Sheriff's SAR personnel presumed that the airplane had either encountered another minor maintenance issue, or the occupants had decided to spend the night camping in the wilderness.

The pilot's SPOT device was consumed in the post-accident fire. The CFI's unit survived the accident but was ejected from the wreckage and out of the pilot's view; as such he was unable to utilize the device's emergency alert feature.

Pilot Injuries

On-scene photographs, as well as autopsy, and toxicological reports were reviewed by the NTSB Chief Medical Officer, in an effort to determine the extent and survivability of the pilot's injuries.

His injuries were quantified utilizing the abbreviated injury scaling (AIS) system. The sum of each injury resulted in an injury severity score (ISS) of 22, which fell within the "severely" injured category.

Based on this score, prompt admission to a Level I or II trauma center would most likely have resulted in a mortality rate of between 19 and 25.5%. (Cudnik MT, N.C., Sayre MR, Steinberg SM, Level I versus Level II trauma centers: an outcomes-based assessment. J Trauma, 2009. 66(5): p. 1321-6),(Wong TH, L.W., Hardy BM, Lee K, Balogh ZJ., The impact of specialist trauma service on major trauma mortality. J Trauma Acute Care Surg, 2013 74(3): p. 780-4).

Recording Devices

A Garmin Oregon 450t GPS receiver, Canon SD780 digital camera, and Apple iPhone 3G were recovered from the accident site, and sent to the NTSB Vehicle Recorder Division for data extraction. The camera and GPS receiver sustained extensive thermal damage, and no data was recovered. The iPhone did not contain data pertinent to the accident. See the public docket for a full specialists report.

Airframe and Engine Exam

The engine and airframe remnants were recovered from the accident site, and examined at a remote storage facility. The engine sustained extensive thermal damage, and no evidence of preimpact mechanical malfunction or failure was noted during the examination. A complete examination report is contained within the public docket.

The airplane wreckage was located about 1.2 miles beyond, and 100 feet above, a dirt airstrip. The NTSB IIC flew multiple passes over the airstrip 2 days following the accident utilizing the UHP helicopter. No tire tracks were observed, and the airstrip appeared overgrown and unusable, with dense brush, scrub, and bushes obscuring the runway surface. The owner of Redtail Aviation reported that he drove to the runway on the night of the accident in an effort to find the airplane. He reported similar observations regarding the runway surface, and stated that there were no indications that it had been recently used.