WPR12FA184

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.

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.

HISTORY OF FLIGHT 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. PERSONNEL INFORMATION CFI 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. AIRCRAFT INFORMATION 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