The evidence and sources

“The pilots explained that in previous years, the ‘box canyon turn’ maneuver was practiced over flat terrain where imaginary canyon boundaries were established by using ground-based landmarks such as barns or other buildings. This enabled pilots to practice this type of flying while ensuring their safety by allowing space for error.”

Memorandum 66A-HQ-1255145, page 23 of 186.

“the plane being utilized was underpowered for this type of exercise”

Memorandum 66A-HQ-1255145, page 24 of 186. Third of four items the board listed as playing a major part in the accident. The other three were entering a narrow canyon from which they could not escape, an instructor pilot relatively inexperienced in Colorado mountain flying, and a relatively inexperienced Bureau pilot.

“The consensus of the investigating team members and the AARB was that the training provided by Colorado Skyways consisted of no curriculum, no checklists, no checks and balances and that training left little margin for pilot error.”

Memorandum 66A-HQ-1255145, page 23 of 186.

“advised that he was unaware that Colorado Skyways was utilizing a low wing Piper Archer in place of the agreed upon Cessna aircraft.”

“Cessna 172 planes would be utilized for the training with the provision that larger sized pilots could opt to fly a larger Cessna 182RG. The Cessna 172 was chosen in order to provide the pilots with more of a Challenge in flying the course.”

Memorandum 66A-HQ-1255145, page 21 of 186. The speaker's name is withheld under exemptions b6 and b7C. A second passage in the same production adds that he “might not have objected to the use of this airplane, provided that the pilot was allowed to complete a few touch and go patterns in the aircraft before flying into the mountains.”

“the mountain flying course provided by Colorado Skyways was obtained through Government Purchase Order (GPO) rather than contract due to the less than $25,000 cost. A GPO, unlike the conditions that would be specified in a contract, did not describe a specific course of instruction to be provided, did not set minimum instructor experience or aircraft requirements, and did not set standards of instruction, or any course completion requirements.”

“Members noted the lack of any random onsite visits by members of ASOU to ensure that the training being conducted by Colorado Skyways was adequate. Furthermore, ASOU did not oversee the training provided by Colorado Skyways to ensure that it was being conducted properly and safely.”

Memorandum 66A-HQ-1255145, pages 21 and 23 of 186. The purchase order was for $19,000, to train 25 Bureau pilots per summer. Page 21 records that it was suggested by the Aviation Program Manager of the Aviation and Special Operations Unit, and that in three years no on-site visit was conducted.

“The finding of cause for the accident was that the aircraft was flown into a narrow canyon from which it could not escape and the problem was made worse by a probable down draft that existed at the time of the accident.”

Memorandum 66A-HQ-1255145, spanning pages 22 and 23 of 186.

“On 08/08/2000, the AARB met to discuss the above captioned aircraft incident. Deputy Assistant Director… Office of Inspections, Inspection Division, chaired the meeting…”

Memorandum 66A-HQ-1255145, page 21 of 186. Voting members included a Chief Inspector from the same Office of Inspections. Names withheld under b6 and b7C.

“Failure to pay for this release within thirty (30) days from the date of this letter will close any pending FBI FOIPA requests from you. Non-payment will also cause an automatic denial of any future FOIPA requests.”

Cover letter, page 1. The amount is $26.50, covering duplication of three interim releases at $11.50 each less an $8.00 credit against the first.

“250 pages were reviewed and 160 pages are being released.”

Cover letter, page 1. The two Deleted Page Information Sheets account for exactly 90 withheld pages: 66 on one document and 24 on the other. Eighty are marked Duplicate. Ten, at pages 19 to 24 and 28 to 31 of one sheet, are marked Referral/Direct and were sent to the National Transportation Safety Board for separate response.

Property record FD-192A, item 1C 2: “PHOTOS OF PIPER ARCHER PA 28-181” plus “FD-340 WITH NOTES.” Property acquired 01/13/2000. Date entered 05/08/2008. Case number 321D-IR-8062. Owning office, Critical Incident Response.

Third interim release, document D165004099, page 53. The original case number for this material was 66H-IR-A5346.

Caption: “PROBABLE FLIGHT PATH OF N4366D PIPER ARCHER II,” hand-drawn on a USGS topographic sheet. The printed scale reads only “SCALE 1:2” before the page edge, and the contour interval line is cut off entirely.

Third interim release, document D165004055, page 6. An X marked Crash Site sits near the 11,800 foot contour, with Hunts Peak (13,071 feet) marked to the east and the Fremont and Saguache county line running between.

Property record item 1C 1: “FBI INVESTIGATIVE REPORT OF AIRCRAFT ACCIDENT, INCLUDING PHOTOGRAPHS, INVOLVING SA PAUL LEVEILLE (DECEASED) ON 9/1/1999.”

Third interim release, document D165004055, pages 1 and 2. Acquired 05/24/2000 from FBI Phoenix, entered 06/07/2000, case 66H-IR-A5346. A separate report cover page dated April 13, 2000 carries a handwritten distribution list.

“NOTE: AVIATION LAW ATTORNEYS RECOMMENDED BY USC INSTITUE FOR SAFETY SYSTEMS MANAGEMENT”

redacted  [withheld, b6 / b7C]

“BOTH OF THESE ATTORNEYS ARE ON THE STAFF AT USC TEACHING AVIATION LEGAL MATTERS”

Third interim release, document D165873014, page 9. Agent-to-agent fax transmittal, subject line “NTSB PRELIMINARY REPORT,” three pages to follow. The spelling “INSTITUE” is as typed on the original.

“TO: SA redacted ROOM 204  FAX: 207-883-6352”
“FROM: SA redacted  FAX 623-869-6828”

Same page. Area code 623 is metropolitan Phoenix, consistent with FBI Phoenix, which ran this investigation. Area code 207 is Maine.

A Freedom of Information Act request to the FAA Chief Counsel, dated October 18, 1999, on letterhead reading “Investigations by Former Special Agents of the FBI,” 1 Lone Circle Suite G, San Antonio, Texas 78258-6412.

It asks for Charles Burns' pilot logbook, Colorado Skyways' Part 141 certificate application, any Letters of Investigation issued to Burns or to Colorado Skyways, enforcement action records, Airworthiness Directives, witness statements, the assigned FAA inspectors, photographs, and the aircraft and powerplant logbooks.

Third interim release, document D165873014, pages 10 to 12.

Item 71 on the Lycoming Air Safety Investigation mishap photo log: “The paper clip found in the oil sump.”

Third interim release, document D165004055, page 4. Engine model O-360-A4M, serial L-27490-36A. The log runs to 103 numbered photographs of a full engine teardown.

Photo log headed “PA-28-181 28-8490088 / 99090102 N4366D Villa Grove, CO,” in two sets: “On Scene General Wreckage Photographs; September 2, 1999” and “Engine Examination Photographs; October 20, 1999,” the engine “as first viewed at the facilities of Beegles Aircraft, Greeley, CO.”

Third interim release, document D165004055, pages 40 and 41.

“View looking in the direction the aircraft came from in the canyon.”

“View of the canyon area as seen from the accident site.”

“The inboard right wing was destroyed by fire.”

Third interim release, document D165004055, page 40, captions 8, 9 and 33.

The Federal Acquisition Regulation requires a contracting officer to promote competition to the maximum extent practicable (FAR 13.003(b), 13.104), to solicit sources that reasonably appear capable of doing the work (13.106-1(a)), to seek quotes from at least two sources (13.106-1(b)(2)), to document a price reasonableness determination when there is no competition (13.106-3(a)(2)), to perform quality assurance inspection (46.103), and to document an acquisition plan (7.102).

This matches a single vendor considered, no competing quotes sought, no price comparison, no acquisition plan on file, and no on-site inspection in three years.

Federal agencies are required by 29 CFR Part 1960, Executive Order 12196, and 29 U.S.C. § 668 to maintain an effective occupational safety and health program for their own employees, including furnishing places and conditions of employment free from recognized hazards likely to cause death or serious harm.

Matched against the finding of no curriculum, no checklists, no checks and balances, and the finding of no competitive process, no oversight visits in three years. Separately, the Bureau's Director of Flight Training stated in his FD-302 that he asked twice to personally inspect this training and was refused both times by his supervisor, once on a return trip he was already making through the area. His supervisor's later account disputes that any refusal happened.

“BURNS talked [the trainee] through a second maneuver which had not been briefed the day before... [the trainee] stated that the maneuver confused him and failed to work as it should have, so he requested BURNS demonstrate the maneuver correctly. BURNS then took control of the aircraft and re-entered the box canyon where he performed the maneuver successfully. Although the maneuver worked for BURNS and not for [the trainee], he was unable to accurately describe exactly what was involved in the maneuver or how it could have worked... but somehow it worked for BURNS despite his failure to understand precisely what was happening.”

FD-302, case 66H-IR-A5346, interview conducted 10/04/99, pages 27 and 28 of the 186-page production. The trainee's name is withheld under exemptions b6 and b7C. Log book entries elsewhere in the same production date this flight to August 18 or August 25, 1999, in the Piper Archer, one to two weeks before Paul died. The first maneuver's exit from the canyon is recorded at 100 to 200 feet above ground level.

“The teaching techniques that the Flight Instructor Mr. Burns was known to have utilized were contrary to accepted practices which the Federal Aviation Administration expects Certified Flight Instructors to utilize. FAA Publication AC-60-14, Aviation Instructor's Handbook, clearly requires that an instructor demonstrate a maneuver prior to the student performing the same maneuver.”

The handbook itself, a copy of which sits in the same file: “the instructor should identify the most important learning outcomes; next, explain and demonstrate the steps involved in performing the skill being taught; and finally, allow the students time to practice each step.”

FD-204 investigative report, case 66H-IR-A5346, dated January 11, 2000, Finding 17, page 38 of the 186-page production. The AC 60-14 excerpt is at page 141, filed as exhibit item 21 in the same report.

“[He] always demonstrates a maneuver to his student before permitting the student to repeat his actions on his own. For box canyon turnouts, he will select a wide canyon and complete the demonstration maneuver at relatively high altitude for the student and then back out to the valley and use an open area with a simulated box canyon as the area for the student to practice in… Although less realistic than accomplishing the maneuver in an actual box canyon, it is also a safer course of action.”

The same instructor, asked how he judges a completed turn: “if the student is able to successfully reverse course with a minimal amount of altitude loss he considers the maneuver to have been properly flown… the criteria is that a life be saved and not that a precise maneuver be flown.”

FD-204 investigative report, case 66H-IR-A5346, interview conducted 01/11/00, pages 30 and 31 of the 186-page production. The instructor's name is withheld under exemptions b6 and b7C.

Asked to check his log book for flights “in the same basic valley area where BURNS and LEVEILLE had their accident” in the week before the crash, the same instructor “was able to state that on August 25, 1999 he flew 7.7 hours with SA [redacted] in a Cessna 182 and that they had been in the vicinity of the accident site during that day. Additionally, [he] flew 7.1 hours in the Piper Archer on August 18, 1999, with SA [redacted].”

FD-204 investigative report, case 66H-IR-A5346, page 30 of the 186-page production.

Another Colorado Skyways instructor, a civil engineer, hiked to the crash site and calculated that “the box canyon selected by BURNS for his practice turnout was only approximately three quarters of a mile wide and that this was way too narrow to have been able to successfully complete such a maneuver.” He “himself has looked at the canyon from the air and likewise concluded that he would not have used that particular canyon for his box canyon practice.”

FD-204 investigative report, case 66H-IR-A5346, page 30 of the 186-page production.

“After setting the Purchase order, Mr Kruczynski stated that he requested Mr. Shine to allow him to periodically go to Colorado Spring to monitor the course, and that Mr.Shine refused this request. During the next three years Mr. Uhalt frequently asked Mr. Kruczynski to come out to evaluate the training being given by Colorado Skyways. On one occasion when Mr. Kruczynski was returning from monitoring the Bureau sponsored Pilot maintenance course at Santa Maria, California (This is a non-flying Pilot maintenance course which is normally monitored by ASOU personnel), he asked to be allowed to stop off in Colorado Springs to review the ongoing training. Mr.Shine again refused his request telling him that he could adequately monitor the results of the training through the pilot evaluations sheets, which were completed at the end of each course and passed through Colorado Skyways to ASOU.”

FD-302, case 66H-IR-A5346, interview of Anthony Kruczynski, 09/23/1999. “Colorado Spring” in the first sentence is typed that way in the original.

“At no time did SSA Shine refuse to allow Kruczynski the right to personally monitor the training at Colorado Skyways because it was part of Kruczynski's job. SSA Shine had no specific recollection of refusing Kruczynski permission to stop by Colorado Skyways on his way back from Santa Maria, California, to conduct an on-site evaluation of the mountain flying training. SSA Shine stated that there would have been no reason for him to refuse Kruczynski. It would have been a good use of his time since it was on a return trip from California.”

FD-302, case 66H-IR-A5346, interview of SSA James Shine, 07/17/2000.

“Mr. Burns entered this canyon in the wrong direction based on the prevailing winds at the time of the accident. Proper mountain flying techniques required that the aircraft should have entered the canyon away from the wind from the North side... While the winds in this area are normally from the Southwest during this time of year, weather reports and testimony from the U.S. West Helicopter pilot indicated that the winds were from the Southeast. By entering the canyon on the South side, Mr. Burns exposed the aircraft to a more significant down draft factor.”

FD-204 investigative report, case 66H-IR-A5346, Associated Causal Factors, page 36 of the 186-page production.

“The vendor did not seek authorization from ASOU to use this particular type of aircraft for this course of instruction.”

FD-204 investigative report, case 66H-IR-A5346, Finding 20, page 38 of the 186-page production.

“There was no indication of any type of engine malfunction... There was no indication of any type of aircraft breakup or control malfunction prior to impact... There were no Air Traffic Control (ATC) factors involved with this accident... There was no indication of fuel starvation or other fuel problems... There is no indication that the aircraft was being operated in an overweight condition, or outside of its normal Center of Gravity (CG) range.”

FD-204 investigative report, case 66H-IR-A5346, Findings 11 through 15, pages 37 to 38 of the 186-page production. The same findings state drug and alcohol screens were negative for both pilots and that no behavioral or medical factor was found.

“The Flight Instructor, Mr. Burns was fairly inexperienced for giving this type of instruction in a very hostile environment with aircraft that were being operated at the limit of their performance capabilities... Before starting his employment with Colorado Skyways, all of his flight experience is reported to have taken place in Southern California.”

FD-204 investigative report, case 66H-IR-A5346, Finding 22, page 38 of the 186-page production. The same passage describes Burns as characterized by students and fellow instructors as cautious, and notes he routinely flew higher than the other aircraft on these training flights.

“The flight was authorized and approved. SA Leveille was in current flight status. SA Leveille was on duty at the time of the accident. SA Leveille held a current medical certificate. The flight Instructor Mr. Burns was current and qualified in the aircraft to act as Pilot-in-Command. Drug/Alcohol screens were negative for both pilots.”

FD-204 investigative report, case 66H-IR-A5346, Findings 1 through 6, page 37 of the 186-page production.

“The PIC Mr. Burns selected an area to perform the maneuver which lead to the accident that was unsuitable and unsafe.”

FD-204 investigative report, case 66H-IR-A5346, Finding 7, page 37 of the 186-page production.

“One Environmental factor that may have played an unknown role in the Crash was the possibility of bright sunlight shining over the ridge line into the aircraft's windshield as the aircraft began the ‘Box Canyon Turn’ maneuver.”

FD-204 investigative report, case 66H-IR-A5346, Finding 10, page 37 of the 186-page production.

Piper PA-28-181 Archer (the aircraft Paul flew): 64.7% success, net vertical rate -926 ft/min.
Cessna 172 Skyhawk: 89.5% success, net vertical rate -830 ft/min.
Cessna 182 Skylane (the aircraft originally assigned): 95.6% success, net vertical rate -567 ft/min.

1,000 Monte Carlo iterations per aircraft. Full methodology and inputs below.

All three aircraft could physically fit the turn radius inside the canyon. The Archer's 35.3% failure rate was overwhelmingly a vertical problem: modeled altitude loss during the turn, roughly 250 to 450 feet, against roughly 300 feet of terrain clearance actually available. The Cessna 182's 4.4% failure rate was almost entirely the opposite, occasional turn-radius edge cases at higher airspeed, with the aircraft still climbing throughout.

Modeled using standard turn-radius and climb-rate-degradation formulas.