CFIT Accident Piper PA-28-140 Cherokee N6323R,
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ASN Wikibase Occurrence # 264175
 
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Date:Friday 18 June 2021
Time:22:53
Type:Silhouette image of generic P28A model; specific model in this crash may look slightly different    
Piper PA-28-140 Cherokee
Owner/operator:Private
Registration: N6323R
MSN: 28-21490
Year of manufacture:1966
Total airframe hrs:5387 hours
Engine model:Lycoming O-320-E2C
Fatalities:Fatalities: 2 / Occupants: 2
Aircraft damage: Destroyed
Category:Accident
Location:Deseret Peak Wilderness near Rush Valley, UT -   United States of America
Phase: En route
Nature:Private
Departure airport:Idaho Falls-Fanning Field, ID (IDA/KIDA)
Destination airport:Cedar City Airport, UT (CDC/KCDC)
Investigating agency: NTSB
Confidence Rating: Accident investigation report completed and information captured
Narrative:
On June 17, 2021, about 2253 mountain daylight time, a Piper PA-28-140, N6323R, was destroyed when it was involved in an accident near Rush Valley, Utah. The pilot and passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 flight.

The accident flight was the second leg of an overnight, multi-leg cross-country from the pilot’s home airport in Northern Montana to her grandfather’s house in Southern California. The pilot was traveling with her granddaughter, and the trip was planned as a Father’s Day surprise. The pilot opted to fly overnight to avoid the heat and turbulence associated with flying over the desert during the day.

The airplane was not equipped with an ADS-B transponder. In order to avoid both the Salt Lake City International Airport (SLC) Mode-C and automatic dependent surveillance -broadcast (ADS-B) system out veil an adjacent military operation area (MOA), the pilot chose to fly through a narrow, mountainous corridor. Due to the altitude limitation of the MOA, the pilot could not fly over the mountain range.

Radar data confirmed that the airplane passed very close to terrain as it avoided the SLC Mode C veil, and ultimately turned into a valley and rising terrain just short of a mountain pass that led away from the airspace and in the direction of the destination. Although the moon was in a position where it would have silhouetted the mountains, it was only 50 percent illuminated, and a broken cloud layer was present that would have obscured most of the available moonlight.

The pilot had already worked a full day and departed on the flight late in the afternoon. The accident occurred at about the halfway point of the trip, about 7 hours after departure from her home airport, almost 18 hours from when she likely woke to report for work, and about the time she would normally have gone to sleep. Therefore, she was likely suffering the effects of fatigue as a result of the flight time and extended time awake. Additionally, her circadian systems were not actively promoting alertness because she was operating the airplane at a time she would normally have been asleep.

The majority of the pilot’s flight experience was as an Army helicopter pilot, with about ¼ of her flight time accrued at night, often over desert terrain, frequently with night vision goggles. Since then, she had taken a long break from flying, and recently purchased the accident airplane and attained her fixed wing private pilot’s license. The accident flight was the longest flight she had flown since leaving the Army, and her longest flight single-pilot in a fixed-wing airplane. The pilot’s decision making associated with the timing of the flight over mountainous terrain suggests overconfidence based on her previous flight experience.

The pilot was carrying oxygen to aid with her night vision; although she had taken a borrowed GPS moving map system that was capable of displaying terrain features, this was the first time she had used it, and she was likely not proficient in its operation.

The airplane crossed into the Mode-C and ADS-B Out veil twice as it followed a meandering track around the SLC airspace and came perilously close to terrain on two occasions, further indicating that the pilot was possibly suffering the effects of fatigue and either not proficient in the operation of the GPS unit or not using it. It is likely that the pilot lost situational awareness and turned prematurely into the valley, possibly mistaking it for the pass, resulting in controlled flight into terrain.

Probable Cause: The pilot’s misidentification of a mountain pass at night, which resulted in controlled flight into terrain. Contributing to the accident were the pilot’s overconfidence based on her previous aviation experience and fatigue due to both the time of the flight and her work schedule. Also contributing was the pilot’s decision not to install an automatic dependent surveillance-broadcast (ADS-B) system, which forced a flightpath close to mountainous terrain to avoid the Mode-C and ADS-B Out veil.

Accident investigation:
cover
  
Investigating agency: NTSB
Report number: WPR21FA231
Status: Investigation completed
Duration: 1 year and 7 months
Download report: Final report

Sources:

https://www.fox13now.com/news/local-news/two-dead-after-small-plane-crash-in-tooele-county
https://www.havredailynews.com/story/2021/06/22/local/former-havre-judge-granddaughter-die-in-plane-crash-in-utah/534367.html

NTSB
FAA
https://registry.faa.gov/AircraftInquiry/Search/NNumberResult?nNumberTxt=N6323R

Location

Images:



Photos: NTSB

Media:

Revision history:

Date/timeContributorUpdates
18-Jun-2021 19:32 Captain Adam Added
20-Jun-2021 06:19 gerard57 Updated [Total fatalities, Total occupants, Other fatalities, Source, Embed code, Narrative]
20-Jun-2021 06:19 gerard57 Updated [[Total fatalities, Total occupants, Other fatalities, Source, Embed code, Narrative]]
22-Jun-2021 21:49 Geno Updated [Registration, Cn, Operator, Location, Nature, Source]
26-Jun-2021 17:13 Anon. Updated [Source, Narrative]
21-Jul-2021 08:35 aaronwk Updated [Time, Phase, Departure airport, Destination airport, Source, Damage, Narrative, Category]

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