Wednesday, December 25, 2019

Controlled Flight into Terrain: Piper PA-32R-300 Cherokee Lance, C-GYGY; fatal accident occurred February 22, 2018 in Monticello, San Juan County, Utah

Clint Kaupp, Bill Kaupp, Tim Mueller, and Ron Mckenzie. 

The National Transportation Safety Board traveled to the scene of this accident.

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; Salt Lake City, Utah
Lycoming Engines; Williamsport, Pennsylvania
Piper Aircraft, Wichita, Kansas
Transportation Safety Board of Canada; Edmonton, Alberta, Canada

Aviation Accident Factual Report - National Transportation Safety Board:

Investigation Docket - National Transportation Safety Board:

Location: Monticello, UT
Accident Number: WPR18FA095
Date & Time: 02/22/2018, 1056 MST
Registration: C-GYGY
Aircraft: PIPER PA32R
Aircraft Damage: Destroyed
Defining Event: Controlled flight into terr/obj (CFIT)
Injuries: 4 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal

On February 22, 2018, about 1056 mountain standard time, a Piper PA-32R-300 airplane, Canadian registry C-GYGY, was destroyed when it impacted terrain near Monticello, Utah. The private pilot and the three passengers were fatally injured. The airplane was privately owned and was being operated by the pilot as a Title 14 Code of Federal Regulations Part 91 personal flight. Undetermined meteorological conditions prevailed. No flight plan was filed for the flight. The airplane departed Grand Junction Airport (GJT), Grand Junction, Colorado, about 0937 for an undetermined destination.

The pilot and passengers were all Canadian citizens and resided in the province of Alberta. According to the pilot's daughter, on a return trip from the US to Alberta in the airplane in early February, the pilot left the airplane at Cut Bank International Airport (CTB), Cut Bank, Montana, reportedly because adverse weather prevented completion of the trip. The airplane remained hangared at CTB until February 21, when the pilot and passengers drove to CTB to begin the flight journey that would include the accident leg.

The pilot's daughter reported that the pilot and passengers had planned to fly from CTB to Albuquerque, New Mexico, on February 21, to allow the pilot to examine an airplane for possible purchase. She was not aware of any planned stops. She reported that the airplane departed CTB about 1000. However, due to weather, the flight landed at GJT, and the group overnighted in the local area. According to fixed base operator personnel at GJT, the airplane arrived about 1605 on February 21. Family members of the pilot and passengers were not aware of any intermediate stops between CTB and GJT, but they would not necessarily be aware of any such stops.

The direct line distance between CTB and Albuquerque was about 853 nautical miles (nm). The direct line distance from CTB to GJT was about 592 nm, and the direct line distance from GJT to Albuquerque was about 262 nm. Albuquerque is south-southeast of GJT. (See figure 1.)

Figure 1 - Trip Cities

According to GJT air traffic control tower information, on February 22, the airplane departed on the accident flight to the northeast. No further communications between the airplane and any air traffic control or other ground facilities were located.

Review of Federal Aviation Administration (FAA) ground-based radar data revealed a track from an unidentified aircraft broadcasting on the visual flight rules transponder code of 1200 appeared to be that of the accident airplane. The first radar return was received at 1004:04 about 16 nm west-northwest of GJT, at a radar-indicated altitude of 7,900 ft. The track was oriented towards the southwest, on a course of about 237° true. The airplane remained level at 7,900 ft until about 1005, when it began a climb to 8,500 ft, and then remained at that altitude until about 1015.

About 1015 the airplane began a climb to about 10,200 ft, where it leveled off. About 1017, the track turned to a course of about 189°, and remained there for about 9 minutes. About 1026, the track turned to the south-southeast, onto a course of about 157°. About 1031, the airplane began a descent of about 150 fpm, and about the same time, the track turned to the south, to a new course of about 173°. The final radar return was received at 1033:34. That return was located about 35 mile north-northwest of the accident site, at a radar-indicated altitude of 9,200 ft.

The approximate floor of radar system coverage in the area between the final radar return and the accident site was about 9,500 ft, and underlying terrain elevations were generally about 7,000 ft. This provided the airplane with a few thousand feet of altitude in which to fly while remaining below the radar coverage floor. Calculations using a nominal airplane cruise speed of 140 knots and a southerly wind of about 20 knots indicate that the airplane would have traveled about 53 nm in the time between the final radar return and the accident. This is about 22 nm more than the straight-line distance between the final radar return and the accident site. (see Figure 2 and Figure 3)

Figure 2 - Radar Track

Figure 3 - Radar Altitude

About 2200 on February 22, in response to a concerned party, the FAA issued an Alert Notice stating that the airplane was overdue. About 0215 on February 23, the US Air Force Rescue Coordination Center (AFRCC) reported that a 121.5 MHz emergency locator transmitter signal had been detected in the vicinity of La Sal Junction, Utah. Multiple ground and airborne searches were initiated that day, and at 1649, the airplane wreckage was located by a Civil Air Patrol search aircraft. Law enforcement personnel arrived at the scene soon thereafter, and the wreckage was confirmed to be that of the missing airplane. The wreckage was examined on scene by FAA, Piper, and NTSB personnel on February 26. The wreckage was recovered on February 27 for transport to, and subsequent detailed examination at, a secure facility. 

Pilot Information

Certificate: Private
Age: 64, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used:
Instrument Rating(s): None
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 3
Last FAA Medical Exam: 02/07/2018
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time: (Estimated) 597 hours (Total, all aircraft) 

The pilot held a Transport Canada (TC) private pilot license. According to a TC explanatory letter, the pilot's "license is endorsed with a blanket type rating for All Single Pilot Non-High-Performance Single Engine Land Aeroplanes." Subsequent communication from TC indicated that a high-performance airplane was defined as "an aeroplane that is specified in the minimum flight crew document as requiring only one pilot and that has a maximum speed (Vne) of 250 KIAS or greater or a stall speed (Vso) of 80 KIAS or greater." The pilot did not hold an instrument rating, and his license bore the restriction, "Valid Daylight Only," which applied in both Canada and the US.

Based on TC and FAA information, regarding the TC certificate restriction, the accident airplane was not considered "high-performance" and therefore did not apply, but the daylight restriction applied to the pilot whether he was flying in Canada or the US. Flight time records indicated that, as of February 9, 2018, the pilot had about 597 total hours of flight experience. His most recent TC Category 3 medical certificate was issued in February 2018.

The pilot's journey log was recovered in the wreckage. It had separated into a few major portions, and some pages were missing. The earliest entry was dated February 13, 1983, and the most recent was dated February 9, 2018. The first entry that cited the accident airplane was dated June 24, 2014. A review of the entries in the log indicated that the pilot had accumulated about 346 hours in the accident airplane. Due to the damage and missing pages, his total flight experience could not be determined from the recovered Journey log.

Aircraft and Owner/Operator Information

Aircraft Make: PIPER
Registration: C-GYGY
Model/Series: PA32R 300
Aircraft Category: Airplane
Year of Manufacture: 1976
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 32R7680182
Landing Gear Type: Retractable - Tricycle
Seats: 6
Date/Type of Last Inspection: 09/22/2017, Annual
Certified Max Gross Wt.:
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 2744 Hours as of last inspection
Engine Manufacturer: Lycoming
ELT: C91 installed, activated, aided in locating accident
Engine Model/Series: IO-540
Registered Owner: 1520795 Alberta Ltd
Rated Power:
Operator: On file
Operating Certificate(s) Held: None


TC information indicated that the airplane was manufactured in 1976 and was equipped with a Lycoming IO-540 series engine. The most recent annual or 100-hour inspection was completed in September 2017. The maintenance records indicated that, at the time of that inspection, the airplane had a total time (TT) since new of 2,743.5 hours, the propeller had a TT of 32.2 hours, and the engine time since overhaul was 762.8 hours.

The pilot was in the process of selling the airplane and an undated advertisement stated that the airplane and propeller had TT values similar to the maintenance records, but that the engine time since overhaul was cited as 682 hours. The advertisement noted that the airplane was equipped with an autopilot and an engine monitor with recording capabilities.

Fuel Capacity and Performance Information

The airplane was equipped with a total of four fuel tanks. These were configured as two fuel tanks and one filler neck per wing. The total fuel capacity was 98 gallons, of which 94 gallons were usable.

Takeoff, climb, and cruise fuel consumption vary as a function of several parameters, including airplane weight, ambient conditions, and power settings. No details regarding the route, altitude, or speed of the flight between CTB and GJT could be obtained; however, Pilot's Operating Handbook (POH) performance data indicated that the airplane would have consumed about 4 gallons during the takeoff and climb to altitude. POH cruise flight fuel burn rates ranged between 12 and 18 gallons per hour (gph), with true airspeed values in the 140 to 150 knot range. Based on these values, the approximate fuel required for a non-stop, direct trip from CTB to GJT would range between 55 and 72 gallons, with a trip duration of about 4 to 5 hours.

Fueling Information

According to FBO personnel at GJT, after the pilot landed at GJT, he requested a top-off of the fuel tanks, but he did not remain with the airplane for the refueling. The airplane was serviced at GJT with 17.6 gallons of fuel that same day. Queries to several airports between CTB and GJT did not reveal any evidence of any interim stops or fuel purchases, but those queries were not all-inclusive. Pilot and passenger family members were asked to review credit card statements for fuel purchases, but none were located.


Pilot Briefing Information

According to Leidos Flight Service, the pilot did not contact either Leidos or DUATS on the accident day. According to a representative of ForeFlight, a pilot information and flight planning software company, no weather briefings were requested for the airplane using ForeFlight Mobile before the accident flight, or for any flights immediately preceding the accident flight. It also "appeared" that the accident pilot did not sign in to and use his device on ForeFlight Mobile to view any weather imagery before the accident flight. As of the date of the accident, the ForeFlight system did not have the ability to record whether the pilot viewed any "live" weather overlays, such as radar or satellite imagery, over the map view before the flight. The ForeFlight system also did not have the ability record whether the pilot viewed any individual METARs, TAFs or "MOS" (Model Output Statistics) forecasts.

Weather Observations

An Automated Weather Observing System (AWOS) was located at Blanding Municipal Airport (BDG), Blanding, Utah, about 19 nm southwest of the accident location at an elevation of 5,870 ft. This station did not have a precipitation discriminator and sky condition was not reported. The 1055 observation included wind from 180° at 8 knots, visibility 10 statute miles, temperature 0°C, dew point -8°C, and an altimeter setting of 30.08 inches of mercury.

An Automated Surface Observing System located at Cortez Municipal Airport (CEZ), Cortez, Colorado, about 39 miles southeast of the accident location at an elevation of about 5,920 ft, was the closest reporting official ceilometer to the accident site. The 1053 CEZ observation reported wind from 230° at 11 knots with gusts to 18 knots, visibility 10 statute miles, a broken cloud ceiling at 4,800 ft above ground level (agl), overcast clouds at 6,500 ft agl, temperature 1°C, dew point -10°C, and an altimeter setting of 30.03 inches of mercury.

There were no publicly-disseminated pilot reports made within about 40 nm and 2 hours of the accident location for altitudes below 15,000 ft.

An atmospheric sounding valid for the accident time and location indicated a surface wind from the south-southwest of about 10 knots. Above this level, the wind veered to the west-southwest and increased steadily in magnitude to about 30 knots about 15,000 ft. Between about 9,000 and 13,000 ft, the relative humidity was between 88 and 93 percent. The freezing level was below the surface. A risk of light mixed, and rime icing was identified between about 9,000 and 13,000 ft. No layers of potential significant turbulence were identified below 20,000 ft.

Satellite visible and infrared imagery near the time of the accident depicted cloudy skies over the accident region with the infrared data indicating cloud top heights about 26,600 ft. Analysis of National Weather Service (NWS) forecast and weather model data indicated that the cloud bases in the region of the accident site (elevation 6,850 ft) were likely about 9,500 to 10,000 ft msl.

The local NWS reported that it faced, "A challenging aviation forecast on Thursday [February 22] afternoon with several instances of convective snow bands producing highly variable conditions from the Colorado border eastward. These bands have been capable of dropping visibility to under a mile and lowering ceiling heights to LIFR [low IFR] levels, however only for short periods of time." 

Meteorological Information and Flight Plan

Conditions at Accident Site: Unknown
Condition of Light: Day
Observation Facility, Elevation: BDG, 5868 ft msl
Distance from Accident Site: 19 Nautical Miles
Observation Time: 1055 MST
Direction from Accident Site: 225°
Lowest Cloud Condition: Unknown
Visibility:  10 Miles
Lowest Ceiling: Unknown
Visibility (RVR):
Wind Speed/Gusts: 11 knots / 18 knots
Turbulence Type Forecast/Actual:
Wind Direction: 230°
Turbulence Severity Forecast/Actual:
Altimeter Setting:
Temperature/Dew Point:
Precipitation and Obscuration:  Unknown Obscuration; Unknown Precipitation
Departure Point: Grand Junction, CO (KGJT)
Type of Flight Plan Filed: None
Type of Clearance: Unknown
Departure Time: 0937 MST
Type of Airspace: Unknown 

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: 3 Fatal
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 4 Fatal
Latitude, Longitude: 37.781667, -109.173333 (est) 

General Information

The partially snow-covered wreckage was in a field about 10 nm southeast of Monticello, Utah, about 85 nm south-southwest of the accident leg departure airport. Investigative examination of the site was conducted 4 days after the accident. Occupant watches indicated that the time of the accident was about 1056.

The debris field was oriented on a magnetic track of about 085° (095° true) and was about 550 ft long. The site elevation was about 6,850 ft msl. The wreckage was highly fragmented. An investigative team mapped the debris field and conducted an initial wreckage examination. All major components of the airplane, including all flight control surfaces, were identified at the scene. No fuel was observed on site. No evidence of any pre-impact mechanical deficiencies that would have precluded continued flight were observed. No evidence of any pre-or postimpact fire was observed.

Airframe Information

Both wings had fracture-separated from the fuselage. The flap and aileron were fracture-separated from the left wing. The aileron, outboard fuel tank, and wing tip were fracture-separated from the right wing. The right flap remained attached to the wing.

The horizontal stabilator, with its balance weight in place, remained attached to the hinges on the aft fuselage closeout plate assembly. The pitch trim was set to about halfway between the neutral and full airplane nose-up positions. The vertical stabilizer and rudder remained attached to the fuselage only at the fin root fitting. The flight control cables were fractured into multiple sections consistent with tensile overload. The flap setting at the time of impact could not be determined. The landing gear damage was consistent with it being retracted at the time of impact.

The cabin was crushed, twisted, and fragmented. The fuel selector valve was found set to the left fuel tank position. Most flight instruments, avionics, and circuit breakers were fracture-separated from the airplane. Most cockpit control positions, instrument indications, and switch positions were deemed unreliable due to the severity of airplane damage.

Engine Information

The engine was separated from the airframe at the engine mount during the accident sequence. The engine sustained significant impact damage, which separated the propeller assembly, the exhaust system, most accessories, the fuel injection servo, and the oil filter. Mechanical continuity was established throughout the engine internal rotating group, valve train, and accessory section during manual rotation of the crankshaft. The combustion chambers, valves, and spark plug electrodes remained mechanically undamaged and there was no evidence of foreign object ingestion or detonation. The gas paths and combustion signatures displayed coloration consistent with normal operation.

Propeller Information

The propeller hub was fracture-separated from the engine. The hub was fractured into multiple fragments and all three propeller blades were liberated from the hub. All three blades incurred moderate aft bending at their 1/2- to 2/3-span locations with multiple leading-edge nicks/gouges and moderate scouring on their leading edges and tips. These signatures were consistent with power being applied to the propeller at the time of impact.



The Utah Department of Health Office of the Medical Examiner, Taylorsville, Utah, conducted the autopsy on the pilot. The cause of death was "multiple injuries" due to impact. Examination for pre-existing or contributing medical conditions was not possible due to the injury level. Toxicology testing by NMS Labs for the Utah medical examiner did not reveal the presence of carbon monoxide, alcohol, or any tested-for drugs, except caffeine.

Toxicology testing on pilot tissue samples was also conducted by the FAA Forensic Sciences Laboratory. No carbon monoxide or cyanide testing was performed by this laboratory. Normally, central blood is needed to establish medication levels that can be used to estimate impairment, but only pilot's muscle tissue was available. No ethanol was detected in the pilot muscle tissue. No tested-for drugs, except Diphenhydramine, were detected in the pilot's muscle tissue. The detected level was below the FAA threshold for reporting the value of the quantity detected.

Diphenhydramine (generic and several brand name products such as Benadryl®, Sominex®, Advil® PM) is an over-the-counter antihistamine used to treat allergic conditions, and is helpful as a sleep aid. This medication could impair mental and/or physical ability required for the performance of tasks such as flying, and the FAA recommends waiting at least 60 hours after the last dose before performing safety-related duties.


Toxicology testing on samples from the three passengers was also conducted by the FAA Forensic Sciences Laboratory. Blood samples from all three individuals tested negative for carbon monoxide. 

Flight Recorders

The airplane was equipped with an Insight G2 engine monitor, which stored data on an SD memory card that the operator/pilot could insert into a slot in the front of the display instrument. The instrument was located in the wreckage, but the card slot was empty. It was not determined whether there was a card installed for the flight, and a detailed search did not locate any SD memory card in the recovered wreckage. 

Additional Information

Controlled Flight Into Terrain (CFIT)

FAA issued Advisory Circular 61-134: General Aviation Controlled Flight into Terrain Awareness defines a CFIT accident as a situation that occurs when a properly functioning aircraft "is flown under the control of a qualified pilot, into terrain (water or obstacles) with inadequate awareness on the part of the pilot of the impending collision."

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