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WPR21FA231 · Piper PA-28-140

17 Jun 2021 · Rush Valley, UT, United States

Piper PA-28-140 · Accident: controlled flight into terrain/object (CFIT) en route

From Havre City County Airport (HVR) to Cedar City Regional Airport (CDC)

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Event

NTSB case
WPR21FA231
Event typeAccident: someone killed or seriously injured, or the aircraft substantially damaged (NTSB definition). Incident: an occurrence that affected or could have affected safety, short of that. Glossary
Accident
InvestigationHow far the investigation had got when the record was published: preliminary, ongoing, final or completed. Unknown where the source does not say. Glossary
Completed
API-reported fatalities
2 · all aircraft and ground
Ground fatalities
Unknown
OperationWhat kind of flying it was, grouped by the rules it flew under: airline (US Part 121), air taxi and commuter (Part 135), general aviation (Part 91 and similar), military or government. Glossary
General aviation
WeatherVisual meteorological conditions (VMC): good enough to fly by looking outside. Instrument conditions (IMC): cloud or low visibility, flying by instruments. Glossary
Visual Meteorological Cond

Piper PA-28-140

Aircraft type
Piper PA-28
Category
Airplane
RegistrationThe aircraft's tail number, such as N12345 or G-ABCD. Registrations are reissued, so the same one years apart can be a different aircraft. Glossary
N6323R
Operator
Unknown
Onboard fatalities
Unknown
Route
From Havre City County Airport (HVR), Havre, MTTo Cedar City Regional Airport (CDC), Cedar City, UT
Aircraft age
About 55 years (built 1966)
Flight rulesThe regulations the flight operated under: in the US, Part 91 (general aviation), Part 121 (airlines), Part 135 (air taxi and commuter) and others; for flights abroad, the NTSB's coarser commercial or non-commercial code. Glossary
Part 91: General Aviation
Phase of flightThe stage of the flight when things started to go wrong: standing, taxi, takeoff, initial climb, en route, maneuvering, approach or landing. Glossary
En route · cruise
Defining eventThe single coded event the NTSB judges best describes what happened (records from 2008 on). Older records name the first occurrence in the sequence instead. Glossary
Controlled flight into terrain/object (CFIT)
DamageDestroyed: beyond practical repair. Substantial: damage that affects the structure, performance or handling and normally needs major repair. Minor: less than that. Glossary
Substantial

Cause areas

  • Aircraft › Aircraft systems
  • Personnel issues › Action/decision
  • Personnel issues › Physical
  • Personnel issues › Psychological

Approximate · Coordinates as recorded by the NTSB; no uncertainty radius is established.

NTSB narrative

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.

Verbatim NTSB analysis and probable cause from the NTSB dataset

Sources

NTSB record WPR21FA231
Event ID
20210618103287
Case number
WPR21FA231
Dataset
full-current
Source SHA-256
5cf380f0061817c0331a6b2d8cc7e0ee3a79bea469a1001dc5c10e56f35f5ab3
Source notes (4)
  • Unreviewed is an editorial label, not an investigation status. API-sourced is not report-checked or human-reviewed. Explicit event totals are used without summing aircraft injury tables; onboard allocation is withheld. Unknown values remain unknown. The operation category is mapped from the NTSB-reported FAR part and has not been reviewed.
  • Filled from the NTSB case API where the bulk record had no value: local date, investigation status, cause areas. Values present in the bulk record are kept.
  • The date is the local date; the NTSB stores the UTC date 2021-06-18.
  • API snapshot SHA-256: 9be3a5ca810200525cb26061160c8b7f781efee37ebe7a531be3a3b5dae5363c; retrieved 2026-09-15T07:30:00.442Z.