WPR17FA215

The flight instructor's failure to completely and properly evaluate the student pilot's incorrectly- planned flight, and his failure to use all available resources to maintain situation awareness during the flight, which resulted in controlled flight into terrain.

The flight instructor and student pilot were conducting the student's first night flight: a cross-country visual flight rules flight to two other airports which concluded with a return to their home airport. Review of the student's flight planning documents, which included the penciled flight route on a Sectional Aeronautical chart and a hand-filled paper flight planning form, revealed that the student had planned to conduct the entire flight at an altitude of 3,500 ft msl. The student's plotted course for the last leg of the flight, which was drawn directly from the departure airport to the destination, passed over a peak with a charted elevation of 3,440 ft. While in the airplane, and prior to engine start, the student and instructor reviewed the planned flight and current weather. The first leg was flown using air traffic control (ATC) flight following services. This northeast-bound leg was flown at 4,500 ft, an altitude that was contrary to the FAA hemispheric rule (easterly flights should be flown at odd-thousand ft altitudes and westerly flights should be flown at even-thousand ft altitudes); ATC did not assign or question this altitude selection. The second leg was westbound and did not use ATC flight-following; the leg was flown at 3,500 ft, again contrary to the FAA hemispheric rule. The final, southbound accident leg was also flown at 3,500 ft; this altitude selection was erroneous for two reasons. First, it was contrary to the hemispheric rule, but more significantly, the student pilot's plotted course line on the Sectional chart passed directly over a peak that was charted as having an elevation of 3,440 ft. The airplane impacted the terrain immediately prior to that peak at an elevation about 3,075 ft mean sea level (msl). Examination of the airplane and engine did not reveal any pre-impact mechanical deficiencies or failures that would have precluded continued normal operation. Review of flight track and data from onboard personal electronic devices (PEDs) was consistent with a controlled flight into terrain (CFIT) event. Further review of the flight planning form showed an airport listed as a waypoint for the accident leg; the airport was located just east of the direct route between the departure and destination. If the pilots had chosen to navigate first toward this airport then to the destination rather than flying direct, the flight would have avoided the mountainous terrain. Additionally, the student's planned altitudes did not comply with Federal Aviation Administration regulations regarding cruise flight altitudes. The investigation was unable to determine why neither the student nor the flight instructor detected the erroneous planned and flown altitude. Although the student's work schedule in the days leading up to the accident may have been conducive to the development of fatigue and, subsequently, his error in planning, there was insufficient evidence to determine the presence or role of fatigue. Further, as pilot-in-command, the instructor should have reviewed the flight planning documents and detected these errors. Both the student pilot and the flight instructor owned multiple portable electronic devices (PEDs) equipped with flight planning and operating software capable of displaying geo-referenced flight and terrain information. As part of his training regimen, the flight instructor did not let the student use any PEDs during flight; however, the student stated that the flight instructor would typically use his PEDs to monitor or augment the flight while they were airborne. Whether the flight instructor was using his PEDs during the accident flight could not be determined; however, he had sufficient time, tools, and knowledge to detect the flight's improper altitude and proximity to terrain with or without the use of PEDs, and why he failed to do so and instead allowed the flight to remain on that track at that altitude could not be determined.   CFIT prevention is primarily dependent on pilots' complete and accurate situational awareness, which can be aided by many safety tools and measures. Despite the fact that the flight instructor held the knowledge, tools, and responsibility to ensure proper and safe conduct of the flight, particularly with regard to appropriate altitude selection, the circumstances of the accident indicate that neither he nor the student possessed complete and accurate situational awareness, most critically for the accident leg, which resulted in the CFIT event.

The SHN 2053 automated weather observation included winds from 250° at 6 knots, visibility 10 miles, clear skies, temperature 13° C, dew point 11° C, and an altimeter setting of 30.02 inches of mercury. At 2300, the approximate time that the flight would have returned to SHN, the skies remained clear, the wind speed had increased, and temperatures had decreased slightly. Bremerton National Airport (PWT), Bremerton, Washington was located slightly east of the direct route between SHN and PAE. The PWT 2056 automated weather observation included calm winds, visibility 10 miles, clear skies, temperature 8° C, dew point 7° C, and an altimeter setting of 30.05 inches of mercury. The 2239 observation indicated scattered clouds at 1,800 ft and a broken ceiling at 6,000 ft. The PAE 2053 automated weather observation included winds from 010° at 6 knots, visibility 10 miles, broken ceiling at 3,600 ft, overcast ceiling at 4,600 ft, temperature 13° C, dew point 8° C, and an altimeter setting of 30.05 inches of mercury. At 2153 the ceiling was overcast at 3,700 ft, and at 2253 the ceiling was overcast at 4,400 ft. The 0S9 2035 automated weather observation included calm winds, visibility 10 miles, overcast ceiling at 4,000 ft, temperature 13° C, dew point 10° C, and an altimeter setting of 30.03 inches of mercury. By 2055 the ceiling had lowered to 3,800 ft, and by 2115 was at 3,600 ft. The 2135 observation included a broken ceiling at 3,600 ft and overcast ceiling at 4,100 ft. At 2155, which was about the time that the airplane was at 0S9, the observation included few clouds at 3,600 ft, and an overcast ceiling at 4,200 ft. Flight Instructor The flight instructor was a retired airline pilot with multiple type ratings. Insurance application information indicated that he had a total flight experience of over 27,000 hours, including more than 2,000 hours in fixed-gear, single-engine airplanes. His most recent FAA second-class medical certificate was issued in December 2016. No records of either his flight instruction or PA-28 experience could be determined. No information was located to indicate that the flight instructor instructed at any flight training schools. Student Pilot The student pilot obtained his FAA third-class medical certificate in September 2015. He had logged 44.5 hours of flight time, not including the accident flight, in his personal logbook. His first flight was in December 2016, and all his flights except one were conducted in the accident airplane. On-Scene The accident location was about 1/4 mile south of the last radar return, and coincident with a direct track from 0S9 to SHN. Site elevation was about 3,075 ft. A partial swath of topped or damaged trees, presumed to have been made by the airplane, was observed. The swath had an approximate alignment of 110°, and a descent angle of about 30°. Most trees appeared to be Douglas Fir, with trunks up to about 18 inches in diameter, and heights of 75 ft or more. The fuselage came to rest upright, on an approximate heading of 180°, at about a 30° airplane nose down angle; the aft end was supported by vegetation. The engine remained attached to the fuselage, and the propeller remained attached to the engine. The propeller and engine were partially embedded in the soil. The cockpit volume was compromised by crushing in the aft direction. Both fuel tanks were breached, and no fuel was observed at the time of the site examination. Both wings and the left horizontal stabilizer were fracture-separated from the fuselage. All aerodynamic and flight control surfaces appeared to be present at the accident site. The key remained in the ignition switch, which was set to the "BOTH" position. The cockpit fuel selector valve handle was found set to the right fuel tank. The tachometer registered 5,495.38 hours. The 121.5 Mhz emergency locator transmitter (ELT) was found still attached to its antenna cable, and the switch was found in the "AUTO" (armed) position. The wreckage was recovered to a secure facility for subsequent detailed examination. Post-Recovery All major portions of the airplane and all flight control surfaces were identified in the recovered wreckage. Flight control continuity was confirmed to the extent possible, given the condition of the wreckage. The flaps were in the retracted position at impact. The pitch trim components suggested that the stabilator was set to neutral to slightly airplane nose up at impact, but damage precluded positive determination. No pre-impact anomalies or mechanical deficiencies of the airframe were observed that would have precluded continued normal operation. The engine was partially damaged by impact. No evidence of any pre-impact internal failures of the engine was observed. Both magnetos were intact and produced sparks at all towers when rotated by hand. All spark plugs displayed normal in-service appearance and condition. Engine valve and drive train continuity was confirmed by hand rotation of the engine. All cylinders appeared normal during borescope examination. The carburetor was partially fractured but remained attached to the engine. Both the throttle and mixture controls remained attached to the carburetor. The carburetor was disassembled, and the metal floats exhibited hydraulic crushing on their outboard sides. The carburetor fuel inlet screen was found free of debris. The engine driven fuel pump produced pressure when operated by hand. The vacuum pump was disassembled, and the rotor and vanes were found intact. No pre-impact anomalies or mechanical deficiencies of the engine that would have precluded continued normal operation and flight were observed. FAA information indicated that the airplane was manufactured in 1967, and was purchased by Shelton Flight in August 2015. Maintenance records indicated that the airplane was equipped with a Lycoming O-320-E2A series engine. The engine was overhauled and installed in the accident airplane in October 1994, at which time the airplane tachometer registered 4,791.0 hours. The most recent annual inspection was completed in September 2017, at which time the airplane tachometer registered 5,461.9 hours. On September 29, 2017, about 2213 Pacific daylight time, a Piper PA-28-140, N9549W, was destroyed when it impacted trees and terrain near Brinnon, Washington (WA) during a night cross-country flight. The student pilot was seriously injured, and the flight instructor was fatally injured. The airplane was owned and operated by the Shelton Flight flying club as a Title 14 Code of Federal Regulations Part 91 instructional flight. Night visual meteorological conditions prevailed in the vicinity of the accident site about the time of the accident. The airplane had departed Jefferson County International Airport (0S9), Port Townsend, Washington, and was destined for its base and origination point of Sanderson Field Airport (SHN), Shelton, Washington when the accident occurred. The pilot who flew the airplane immediately prior to the accident pilots stated that he flew the airplane for about an hour, and that the airplane operated normally, with no irregularities or problems. That pilot topped off the fuel tanks, and then turned the airplane over to the accident pilots about 2015. The flight was the student pilot's first night flight, and was to consist of three legs, with full-stop landings at each of the two intermediate airports. The accident pilots did not file a flight plan for any of the legs but were in radio communication with air traffic control (ATC) for the first leg and the first part of the second leg. The trip originated when the airplane departed SHN about 2050. The pilots requested and received visual flight rules (VFR) flight following services by ATC, with a stated destination of Snohomish County Airport (Paine Field, PAE), Everett, Washington. The airplane conducted a full stop landing at PAE about 2130, and then departed PAE for 0S9. About