Primary finding
Probable cause
The pilot's decision to initiate a go-around after a bounced landing at an airport where go-arounds were not advised and his failure to maintain adequate airspeed during the go-around.
Investigator assessment
Analysis narrative
According to the airplane's operator, the airplane was part of a flight of four airplanes that were taking an organized tour group of revenue passengers on a sightseeing tour of southern Utah. While operating in a high density altitude environment, the pilot was flying into an airport that had a 1,000-foot cliff about 400 feet from the end of the runway he was landing on. Because of the presence of the cliff, the Airguide Publications Airport Manual stated that all landings should be made on the runway that was headed toward the cliff and that all takeoffs should be made on the runway that was headed away from the cliff. The manual also stated that a go-around during landing was not possible. During his approach, the pilot encountered a variable wind and downdrafts. During the landing flare, the airplane dropped onto the runway hard and bounced back into the air. The pilot then immediately initiated a go-around and began a turn away from the runway heading. While in the turn, he was most likely unable to maintain sufficient airspeed, and the airplane entered a stall/mush condition and descended into the ground. A postaccident examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation.
Source record
Factual narrative
HISTORY OF LFIGHT On May 23, 2011, about 1520 mountain daylight time, a Cessna T207A, N803AN, impacted the terrain during an attempted visual flight rules (VFR) go-around from Runway 16 at Monument Valley Airport, Monument Valley, Utah. The commercial pilot and two of his passengers received serious injuries, and the other three passengers received minor injuries. The airplane, which was owned by Yaki Point, LLC, and operated by Grand Canyon Airlines, sustained substantial damage. The 14 Code of Federal Regulations Part 135 on-demand sightseeing flight, which departed Grand Canyon Airport, Grand Canyon, Arizona, about one hour and forty minutes prior to the accident, was being operated in visual meteorological conditions. A company VFR flight plan had been filed. According to the airplane's operator, the airplane was part of a flight of four airplanes that were taking an organized tour group of revenue passengers on a sightseeing tour of Southern Utah. Although the final destination of the tour was Page Municipal Airport, Page, Arizona, there was a planned stop at the Monument Valley Airport, where the passengers were scheduled to spend time at the Goulding Lodge and Trading Post. The lead airplane of the group, and the first to land at Monument Valley, was a Cessna 208 Caravan. The other three airplanes were all Cessna T207's. The pilot of the Caravan reported that there were strong gusty winds in the area, and that twice while he was on final approach he hit downdrafts that caused the airplane to sink and lose airspeed. In both instances he had to apply "significant power" to recover. One of the downdraft encounters was while he was on short final. He also stated that once he was down on the runway, the winds were not as "squirrely" as they had been in the air, but more of a constant wind of about 10 knots out of the west. After landing, the Caravan pilot advised the following pilots that the winds on final were "weird," but not especially strong. The second pilot to land (flying the first T207) touched down about 3 or 4 minutes after the Caravan. That pilot reported that although there was some bumpiness while she was on final, while she was on short final she detected hardly any wind at all. She said that she was able to fly a smooth stabilized approach to a smooth normal touchdown. The pilot of the Caravan confirmed this description, stating that from his position it appeared that the first T207 had not encountered any strong downdrafts or unusual winds. The third airplane landed about 3 minutes after the second one. The pilot of that airplane said that although he had seen the windsock hanging limp when he overflew the airfield, once he was established on final approach it got really bumpy. He further stated that the winds were coming from all different directions, and that he had encountered a number of updrafts and downdrafts. He also stated that by the time he pulled off the runway and into his parking spot, that the winds were from about 240 degrees at about 25 knots, and that the wind sock was standing straight out. The accident airplane was the last to land, and the other pilots were watching it while it was on final approach. They reported that the pilot seemed to be a little high, and that the airplane's wings were rocking in a manner consistent with the pilot making corrections as a result of the airplane encountering variable winds. One of the pilots turned away before the airplane was on short final, but the other two who continued to watch reported that the airplane appeared to drop onto the runway and hit hard enough to bounce back into the air. At that point it appeared that the pilot added full power and initiated a go-around with what was described as a "very high" angle of attack. Soon thereafter it appeared that the pilot entered a left bank, and the airplane began sinking toward the terrain. It eventually impacted the terrain in a left wing low attitude, and appeared to the witnesses to cartwheel before coming to a stop. All the pilots agreed that the engine sounded as if it was running strong and smooth during the apparent go-around attempt. And it reportedly remained at a very high power setting until the airplane impacted the terrain. A review of the written statements provided by the passengers revealed that the airplane was being thrown around by gusty winds while on final. They also reported that when the airplane touched down it was somewhat sideways and not aligned with the runway, and that soon after contacting the runway, the pilot added power and executed a go-around. One passenger reported hearing a beeping sound, which she thought was some kind of warning, just before the airplane touched down, and again after the pilot initiated the go-around. She further stated that during the go-around, after the pilot initiated the left turn, the beeping appeared to get louder and faster. The passengers also stated that the pilot flew what appeared to them to be a "very tight turn," and confirmed that the airplane's left wing tip was the first part to impact the ground. PERSONNEL INFOMATION The 34 year old commercial pilot held Airplane Single-Engine Land and Airplane Instrument ratings. He also held Airplane-Single-Engine Land and Instrument Airplane Instructor ratings. Of his 965 hours of total flight time, 140 hours were in the make and model airplane involved in the accident. Of the 140 hours in make and model, 108 of those hours were accumulated in the 90 days prior to the accident. His last flight review, which was completed in a Cessna T207A, was signed off on March 10, 2011. His last FAA airman's medical, a class 2, was completed on March 29, 2011. The medical contained the limitation that the pilot had to wear corrective lenses while acting as a pilot. As of the date of this report, the pilot had no recollection of the sequence of events related to the accident. AIRCRAFT INFORMATION The airplane was a 1979 Cessna T207A, with a Teledyne Continental Motors TSIO520M, 310 horsepower engine, and a McCauley D3A34C401 controllable pitch propeller. The airplane's last 100 hour/annual inspection was completed on April 9, 2011, at which time the airframe had accumulated 13,417 hours. The engine had accumulated 1,326 hours since a major overhaul. At the time of the accident the airplane was below maximum allowable gross weight and within center of gravity limits. METEOROLOGICAL INFORMATION There was no weather recording or transmitting equipment at the Monument Valley Airport. The nearest weather reporting facility was at Kayenta, Arizona, which is located about 20 miles south of the accident site. According to the pilot of the third airplane to land, he listened to the transmission of the Automatic Weather Observation System at Kayenta while he was approaching Monument Valley, and the wind there was from 150 degrees at 25 knots, gusting to 30 knots. According to the operator, at the time of the accident, the temperature at Monument Valley was 26 degrees C (68 degrees F), with a barometric pressure of 29.74 inches of Mercury, giving a density altitude of 6,790 feet. The wind around the airport was varying widely, sometimes with gusts up to 25 knots from 240 degrees (80 degrees off the runway heading), and a few minutes later being light to calm. Some of the airplanes in the four-plane group encountered a strong variable wind and moderate turbulence while on final, but at least one airplane did not encounter those conditions. Some of the airplanes encountered downdrafts on final that required significant power inputs to recover from their sink rate and decrease in airspeed, while others encountered very little if any downdraft activity. One pilot reported that immediately after the accident the wind appeared to be, "very inconsistent." He described the wind as being perfectly calm for awhile, and then having a sudden strong gust come up that rocked the wings of the tied down air