Piper PA-28-181 accident near Strawberry, Arizona, September 13, 2012

The NTSB's narrative final · quoted from the NTSB record

The student pilot was enrolled in a European flight training academy, which, in conjunction with a US-based operator, provided training services in accordance with European Joint Aviation Authorities standards. The US operator provided aircraft, training facilities, and flight instructors as part of a service agreement with the European academy. The purpose of the flight was to conduct a phase check on the student pilot. The syllabus included a cross-country flight with a subsequent in-flight diversion to a location unknown to the student pilot. The student pilot was located in the forward left seat, a flight instructor was in the forward right seat, and an evaluator was in an aft seat. The evaluator had considerable aviation experience in Europe; however, he only held a Federal Aviation Administration (FAA) private pilot license. Therefore, the flight instructor was used on the flight as a "safety pilot," acting as pilot-in-command, to meet FAA regulatory requirements. The flight instructor had recently joined the US operator, but he was not incorporated into the European flight academy's flight training program; therefore, he had no prior experience as a safety pilot with the academy. The day before the accident, the evaluator provided the student pilot with instructions for the cross-country portion of the phase check, which included flight to a destination airport located in mountainous terrain with a directive to fly at an altitude of 1,000 feet above ground level (agl) throughout the flight. The student pilot was also asked to plan an en route 40-minute target arrival waypoint and to be ready to prepare for an in-flight diversion. The majority of the route planned by the student passed through a series of FAA-designated special conservation areas. Although the FAA did not prohibit flight through such areas, it did discourage it. Further, although the academy and operator did not explicitly prohibit  flights to be performed along the chosen route, cross-country check flights were typically accomplished in areas south of the departure airport where terrain was lower. According to radar data, the student pilot successfully manipulated the airplane in precise coordination with his flight plan for about the first 35 minutes following departure. Shortly thereafter, the airplane approached and passed the 40-minute waypoint and then continued along the planned route while in a shallow climb. Examination of the student's flight plan revealed that, to maintain 1,000 feet agl clearance as the airplane approached the waypoint, he would have needed to fly the airplane level and then below rising canyon walls on either side of the route. Avoiding terrain just beyond the waypoint would have required a prompt climb or diversion because the rapidly rising terrain would have required the airplane to climb at a rate that exceeded its climb capabilities. Further, downdrafts and high-density altitude conditions were present in the canyon, which likely further degraded the airplane's available climb performance. Thus, the airplane entered a steep canyon (still along the planned route) that it could neither climb out of nor turn around in. Shortly after, with the airplane flying straight and level, it struck a cliff face at the end of the canyon, 1,000 feet below the canyon's rim. The majority of the airplane's structure was consumed by postimpact fire; postaccident examination revealed no anomalies with the engine or airframe that would have precluded normal operation. Radar data indicated that the airplane was climbing about 4 minutes before impact and that the accident location was at the same elevation as the last radar target. Therefore, the engine was likely producing power during the final stages of the flight. Although no indications of in-flight fire were observed, toxicological tests for the evaluator revealed that he had been exposed to the products of combustion (carbon monoxide and cyanide); however, this likely occurred during the postcrash fire. None of the occupants had ever flown with each other, and no records were recovered indicating that the flight instructor or student pilot had ever flown to the presumed diversion airport. The evaluator arrived late for the flight, so the original flight instructor, who had flight commitments later in the day, asked the accident flight instructor to join the flight at the last minute, which did not allow him sufficient time to participate in the preflight oral briefing and limited the time he had to evaluate the flight plan. From a regulatory standpoint, the flight instructor was the pilot-in-command and, thus, was responsible for the safety of the flight. However, given his relatively junior status within the organization and the young student pilot's lack of experience, it is likely that both pilots deferred responsibility for the flight to the evaluator and trusted that the route was appropriate. It is possible that the unsuitable route was discussed and understood by all of the occupants; however, the reason for not performing the diversion at an appropriate time could not be determined. The Dutch Safety Board (DSB) was a party to the investigation and appointed an accredited representative in accordance with the provisions of Annex 13 to the Convention on International Civil Aviation. The DSB submitted comments regarding the factual report, brief, and probable cause, and they are included in the public docket for this accident.

The complete narrative as the NTSB published it. The NTSB's docket holds the report as a PDF and any photographs, statements and other documents from the investigation.

Other NTSB records under N4188E the same tail number, which may have belonged to a different aircraft at the time