Rush Valley, UT, USA
N6323R
PIPER PA-28-140
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.
HISTORY OF FLIGHTOn 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 almost 1,100-mile cross-country trip from the pilot’s home airport of Havre City-County Airport (HVR), Havre, Montana, to El Centro NAF Airport (NJK), El Centro, California. The airplane departed HVR about 1600, and according to a friend of the pilot, the pilot planned to stop for fuel at Idaho Falls Regional Airport (IDA), in Idaho Falls, Idaho, then fly through the night to Cedar City Regional Airport (CDC), Cedar City, Utah, arriving in El Centro by 0600. The pilot was traveling with her granddaughter, and the trip was planned as a Father’s Day surprise for the pilot’s grandfather, who lived near El Centro. According to the friend, the pilot opted to fly overnight to avoid the heat and turbulence associated with flying over the desert during the day. She planned to sleep for 2 hours in the airport during the stop at CDC. The pilot was not using flight-following services, and the airplane was not equipped with an automatic dependent surveillance – broadcast (ADS-B) transponder; therefore, a flight track was compiled using radar data provided by the Federal Aviation Administration (FAA). The data indicated a target with the visual flight rules (VFR) 1200 transponder code departing IDA at 2100 and flying southbound directly toward the Malad City VOR. Fifty minutes later, having crossed directly over the VOR at a Mode-C reported altitude of 9,200 ft, the target began to descend. By 2224, the target had reached the Promontory Mountains, a peninsula on the northern shores of Great Salt Lake, about 35 miles northwest of Salt Lake City International Airport (SLC). For the next 20 minutes, the target followed a meandering, counterclockwise radial track around SLC, twice passing in and out of the edges of the airport’s Mode C and ADS-B out veil, at an altitude of about 8,200 ft (see figure 1). Figure 1 – Radar track for final 30 minutes of flight. By 2245, the target had reached the Stansbury Mountains, an 11,031-ft-tall, north-south oriented range situated west-southwest of SLC. The target crossed over the northern section of the range at an altitude of 8,200 ft, clearing terrain by about 400 ft vertically (see figure 2). The central area of the mountains was annotated as the Deseret Peak Wilderness Area within an approximate 3.5-mile-wide corridor between the SLC Mode-C and ADS-B out veil, and the SEVIER B & D military operation areas (MOAs). The target then flew south along the corridor, over the foothills of the mountain range, where at one point it came within 100 ft vertically and horizontally of terrain. By 2250, the target passed to the east of Desert Peak, the highest point in the range (11,031 ft), when it began a right turn directly through a valley and toward terrain (see figures 2 and 3). Figure 2 – Radar track for final 5 minutes of flight. Figure 3 – Approximate flight track viewed to the north. The last target was recorded at 2253:10 and indicated that the airplane was traveling on a heading of 221° about 0.75 miles from the 10,330-ft peak at an altitude of 8,200 ft, and airspeed of 98 knots. At 2320, the Tooele County Fire Department received a 911 call reporting that a fire had developed within the Stansbury Mountains. At 0700 the following morning family and friends of the pilot, having been unable reach her, informed the FAA of the missing airplane, and an ALNOT was issued. The wreckage was located by a Forest Service fire crew a few hours later. PERSONNEL INFORMATIONThe pilot graduated from United States Army Flight School in February 2001 and received a qualification to fly the CH-47D helicopter later that year. Records indicate that she was regularly stationed internationally through 2008, during which time she flew multiple combat missions, often in desert terrain. During that period, she logged a total flight time of 689.1 hours, 167.7 of which were flown at night, with 29.7 hours using night vision goggles. Based on her military experience, she held an FAA commercial pilot certificate with ratings for rotorcraft-helicopter and instrument helicopter. The pilot began flying civil fixed-wing aircraft in October 2020 and attained FAA private pilot privileges for airplane single-engine land on March 14, 2021. All of her 174.3 hours of fixed-wing flight experience was in the accident airplane type, 12.8 of which were at night. Logbooks indicated that she routinely flew missions lasting up to 4.5 hours long while in the Army, but the accident flight would have been the longest she had flown solo in a fixed-wing airplane. The pilot’s most recent FAA medical examination was conducted on August 7, 2020, and although the pilot needed to wear reading glasses, she was issued a third-class medical certificate without limitations. The pilot’s flight instructor, who performed her most recent fixed-wing training, stated that the pilot had never discussed plans to take the cross-country accident flight. He was surprised and disappointed that she did not call him to discuss, as he would have done his best to dissuade her from taking such a trip at night over such long distances. He had not provided, nor was he required to provide, any mountain flying training. Sleep History There were no witnesses to the pilot’s sleep schedule the night before the accident; however, according to the pilot’s friend, she typically awoke between 0430 and 0500. Typically, she arrived at work about 0600, and left at 1500. He last spoke to her the night before the accident by phone, at 2230. AIRCRAFT INFORMATIONThe pilot purchased the airplane in December 2020. Maintenance logbooks were not recovered and presumed to have been destroyed in the accident; however, a copy of the last annual inspection was provided by the mechanic who worked on the airplane most recently. The inspection was completed on January 13, 2021 and did not reveal any significant anomalies. The airplane was equipped with a conventional visual flight rules (VFR) instrument panel and a Bendix/King KT76 transponder. The pilot stated to an acquaintance that installing an ADS-B system was prohibitively expensive, and that it was not necessary based on her typical flying routine. The airplane was not equipped with any terrain awareness or moving map systems; however, the weekend before the flight, the pilot’s friend gave her his portable Garmin 696 GPS navigation system and a GDL 51 Portable SiriusXM receiver. The 696 unit was configured to display terrain and receive XM weather information through the GDL 51. He reported offering to teach the pilot how to use the Garmin unit, but she declined, saying that she would teach herself. The accident flight was the first time she had used it for flight. Along with the Garmin 696, the pilot’s friend also gave her a set of FAA VFR sectional and world aeronautical charts. He stated that the pilot also used a free flight planning application on her phone, which had a basic moving map feature that included sectional charts, but no terrain-warning capabilities. The friend stated that the pilot enjoyed pilotage and navigating from landmarks rather than using a GPS. He stated that she was very familiar with VFR sectional charts and preferred them to using GPS devices. She was observant of the obstruction altitudes in each sectional sector, and due to her military experience, was very sensitive about flying into MOAs and felt the general aviation community had a cavalier approach to airspace restrictions. He stated that she adhered to a rigid, rules-based style of operation due to her military aviation training. The pilot stated that she was concerned about fatigue for the flight but felt that having her granddaughter present would keep her awake. She stated that when in the Army, she was trained to use supplemental oxygen for night flights above 5,000 ft to help with night vision. Therefore, he lent her his supplemental oxygen system for the flight, which included one cannula and an oxygen tank, that had just been filled. According to family members, the pilot’s granddaughter typically flew in a booster seat mounted to the front right seat. METEOROLOGICAL INFORMATIONSEVIER D MOA had an altitude of 9,500 ft msl to 18,000 ft and was active at the time of the accident. SEVIER B covered the same footprint, but at an altitude of between 100 ft agl and 9,500 ft msl and was not active. The pilot did not file a flight plan, nor did she receive flight following. She stated to the friend that she planned to fly around the SLC Mode C and ADS-B out veil because the airplane was not equipped with an ADS-B transponder. She further stated that she was aware of the MOAs and had paid particular attention to their location during flight planning. The closest weather reporting facility to the accident site was from Bolinder Field-Tooele Valley Airport (KTVY), Tooele, Utah, located approximately 16 miles northeast of the accident site at an elevation of 4,322 ft. The facility reported calm to light wind throughout the evening, with clear skies and visibility of 10 miles. High-Resolution Rapid Refresh numerical model data for the accident site at 2300 MDT indicated a near surface wind from 250° at 7 knots with winds backing or slowly shifting to the west-southwest with height with gradual increasing wind speeds. The mean 18,000 ft wind was from 250° at 14 knots. The level of maximum wind was identified at about 27,500 ft from 270° at 46 knots. Numerical modeling of the data using the Universal Rawinsonde Observation (RAOB) program software did not reveal any strong vertical wind shears below 18,000 ft, and the winds were below the threshold for mountain wave development. RAOB analysis also supported scattered clouds with bases near 23,000 ft msl where the relative humidity reached 75% and a broken layer of cirriform type clouds near 33,000 ft msl. Civil twilight at the accident location ended at 2136. The moon was 34° above the horizon at an azimuth of 243° with approximately 50% of the moon’s disk illuminated. AIRPORT INFORMATIONThe pilot purchased the airplane in December 2020. Maintenance logbooks were not recovered and presumed to have been destroyed in the accident; however, a copy of the last annual inspection was provided by the mechanic who worked on the airplane most recently. The inspection was completed on January 13, 2021 and did not reveal any significant anomalies. The airplane was equipped with a conventional visual flight rules (VFR) instrument panel and a Bendix/King KT76 transponder. The pilot stated to an acquaintance that installing an ADS-B system was prohibitively expensive, and that it was not necessary based on her typical flying routine. The airplane was not equipped with any terrain awareness or moving map systems; however, the weekend before the flight, the pilot’s friend gave her his portable Garmin 696 GPS navigation system and a GDL 51 Portable SiriusXM receiver. The 696 unit was configured to display terrain and receive XM weather information through the GDL 51. He reported offering to teach the pilot how to use the Garmin unit, but she declined, saying that she would teach herself. The accident flight was the first time she had used it for flight. Along with the Garmin 696, the pilot’s friend also gave her a set of FAA VFR sectional and world aeronautical charts. He stated that the pilot also used a free flight planning application on her phone, which had a basic moving map feature that included sectional charts, but no terrain-warning capabilities. The friend stated that the pilot enjoyed pilotage and navigating from landmarks rather than using a GPS. He stated that she was very familiar with VFR sectional charts and preferred them to using GPS devices. She was observant of the obstruction altitudes in each sectional sector, and due to her military experience, was very sensitive about flying into MOAs and felt the general aviation community had a cavalier approach to airspace restrictions. He stated that she adhered to a rigid, rules-based style of operation due to her military aviation training. The pilot stated that she was concerned about fatigue for the flight but felt that having her granddaughter present would keep her awake. She stated that when in the Army, she was trained to use supplemental oxygen for night flights above 5,000 ft to help with night vision. Therefore, he lent her his supplemental oxygen system for the flight, which included one cannula and an oxygen tank, that had just been filled. According to family members, the pilot’s granddaughter typically flew in a booster seat mounted to the front right seat. WRECKAGE AND IMPACT INFORMATIONThe airplane came to rest on a 30° uphill slope within a valley, about 1,300 ft beyond, and at the same elevation as, the last radar target (8,200 ft). The terrain within a mile of the wreckage, and in the direction of the radar track, rose rapidly to an elevation of about 10,300 ft. The valley was about 3 miles north of “Johnson Pass,” a 6,515-ft pass denoted on both the Salt Lake City VFR sectional and terminal area charts. The terrain comprised loose rock and soil, dispersed with pine trees and brush. The first identified point of impact was an 18-inch-wide tree trunk, severed about 15 ft above ground level. The left wing had detached and was located about 10 ft upslope of the trunk. The wing had folded aft midspan and exhibited a semi-circular indentation in the wing spar, which matched the diameter of the trunk. A 10-ft-wide ground disruption was present to the right of the wing and contained fragments of painted aluminum, along with the nose wheel. The ground disruption was located about the same level horizontally as the severed tree trunk. The main wreckage, which included the burnt remnants of the cabin and right wing, along with the engine and empennage, was located an additional 20 ft upslope. The fuselage was oriented on a heading of about 220°. The engine remained partially attached to the firewall. The propeller had detached from the crankshaft and was the last section located in the debris field, an additional 15 ft upslope. No evidence of preimpact mechanical malfunction was noted to the airframe or engine during the examination, both on-site and after the airplane was recovered. Both fuel tanks exhibited evidence of hydrodynamic deformation consistent with containing fuel at impact, and both propeller blades exhibited deep leading-edge gouges and radial chordwise scoring, consistent with engine operation at impact. The instrument panel, including the altimeter, was destroyed. The oxygen tank sustained impact damage, but its valve was found in the open position. The belt buckles for all seat positions were recovered, and all appeared to be latched. MEDICAL AND PATHOLOGICAL INFORMATIONAccording to the autopsy report from the Office of the Medical Examiner, Utah Department of Health, the cause of the pilot’s death was blunt force injuries, and the manner of death was accident. No significant natural disease was identified. FAA Forensic Sciences Laboratory testing on pilot specimens was negative for all screened drug substances and ingested alcohol.
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.
Source: NTSB Aviation Accident Database
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