# NTSB GAA16CA212: Cessna 140, N4242H, Poplar Grove, IL, April 30, 2016 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: April 30, 2016, 03:00 local (08:00 UTC) - Place: Poplar Grove, IL - Coordinates: 42.323333, -88.926666 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=42.3233&lon=-88.9267&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report June 1, 2016 - Report: Approved by Office Director - NTSB office: General Aviation Accidents - Parties: FAA - NTSB case key (mKey): 93094 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA16CA212 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/93094/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=93094 - Page: https://openairdocs.org/ntsb/GAA16CA212 ## Probable cause The pilot's visual disorientation and failure to monitor the altimeter during a night approach, which resulted in controlled flight into terrain. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Attention/monitoring: monitoring equip/instruments](https://openairdocs.org/ntsb-findings/02021525): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Cessna 140A, 1 case](https://openairdocs.org/ntsb-findings/02021525/cases.md?model=2071604), [All aircraft, 142 cases](https://openairdocs.org/ntsb-findings/02021525/cases.md) - [Perception/orientation/illusion: visual illusion/disorientation](https://openairdocs.org/ntsb-findings/02022015): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Cessna 140A, 1 case](https://openairdocs.org/ntsb-findings/02022015/cases.md?model=2071604), [All aircraft, 51 cases](https://openairdocs.org/ntsb-findings/02022015/cases.md) - [Performance/control parameters: descent/approach/glide path](https://openairdocs.org/ntsb-findings/01062040): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cessna 140A, 1 case](https://openairdocs.org/ntsb-findings/01062040/cases.md?model=2071604), [All aircraft, 809 cases](https://openairdocs.org/ntsb-findings/01062040/cases.md) - [Performance/control parameters: altitude](https://openairdocs.org/ntsb-findings/01062012): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cessna 140A, 3 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md?model=2071604), [All aircraft, 1,310 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md) - [Light condition: dark](https://openairdocs.org/ntsb-findings/03036020): Environmental issues › Conditions/weather/phenomena · Effect on personnel; cases with it: [Cessna 140A, 1 case](https://openairdocs.org/ntsb-findings/03036020/cases.md?model=2071604), [All aircraft, 448 cases](https://openairdocs.org/ntsb-findings/03036020/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120) (defining event); cases with it: [Cessna 140A, 2 cases](https://openairdocs.org/ntsb-events/120/sequence.md?model=2071604), [All aircraft, 1,074 cases](https://openairdocs.org/ntsb-events/120/sequence.md) ## Analysis The pilot reported that during a night visual meteorological condition flight he was about 5 nautical miles away from the destination airport and could see the runway lights. The pilot further reported that he was not able to see the terrain and it was a "black hole approach." As the pilot initiated a descent toward the runway, the airplane impacted terrain in a wooded area about 4 nautical miles west of the runway threshold. The pilot reported that he did not observe the terrain any time before the impact, but could see the bright runway lights. The left and right wings were substantially damaged. The pilot did not report any mechanical malfunctions or failures with the airplane that would have precluded normal operation. The Federal Aviation Administration Pilot's Handbook of Aeronautical Knowledge states in part: "A black-hole approach occurs when the landing is made from over water or non-lighted terrain where the runway lights are the only source of light. Without peripheral visual cues to help, pilots will have trouble orientating themselves relative to Earth. The runway can seem out of position (downsloping or upsloping) and in the worse case, results in landing short of the runway. If an electronic glide slope or visual approach slope indicator (VASI) is available, it should be used. If navigation aids (NAVAIDs) are unavailable, careful attention should be given to using the flight instruments to assist in maintaining orientation and a normal approach. If at any time the pilot is unsure of his or her position or attitude, a go-around should be executed." ## Factual narrative The pilot reported that during a night visual meteorological condition flight he was about 5 nautical miles away from the destination airport and could see the runway lights. The pilot further reported that he was not able to see the terrain and it was a "black hole approach." As the pilot initiated a descent toward the runway, the airplane impacted terrain in a wooded area about 4 nautical miles west of the runway threshold. The pilot reported that he did not observe the terrain any time before the impact, but could see the bright runway lights. The left and right wings were substantially damaged. The pilot did not report any mechanical malfunctions or failures with the airplane that would have precluded normal operation. The Federal Aviation Administration Pilot's Handbook of Aeronautical Knowledge in part states: "A black-hole approach occurs when the landing is made from over water or non-lighted terrain where the runway lights are the only source of light. Without peripheral visual cues to help, pilots will have trouble orientating themselves relative to Earth. The runway can seem out of position (downsloping or upsloping) and in the worse case, results in landing short of the runway. If an electronic glide slope or visual approach slope indicator (VASI) is available, it should be used. If navigation aids (NAVAIDs) are unavailable, careful attention should be given to using the flight instruments to assist in maintaining orientation and a normal approach. If at any time the pilot is unsure of his or her position or attitude, a go-around should be executed. ## Aircraft - Registration: [N4242H](https://openairdocs.org/aircraft/N4242H), registered now, S/N 15304, built 1949 (OpenAirDocs) - Reported make and model: CESSNA 140 (A) - Registry model: [Cessna 140A](https://openairdocs.org/model/cessna-140a) (registry code 2071604) (OpenAirDocs) - Registry engine: [Continental C90 series](https://openairdocs.org/engine/continental-c90-series) (registry code 17009, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 15304 - Year built: 1949 - Airframe hours: 2976 - Engines: Continental C-90-14F 90 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Utility - Last inspection: Annual, June 1, 2015 - Departed: 1C8, ROCKFORD, IL - Destination: C77, Poplar Grove, IL - Airport: C77, Poplar Grove, runway 12, 3,773 × 50 ft, asphalt - Equipment: None ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 25; injuries: none; private; airplane ratings: single-engine land; medical: class 2, without waivers/limitations; last flight review December 7, 2014; seat: left; restraint: 3-point; flight hours: 208 total, 84 in this make and model, 134 as pilot in command, 11 in the last 90 days, 5 in the last 30 days ## Weather - Conditions: Visual (VMC), Night/dark - Wind: 70° at 9 knots - Visibility: 10 statute miles - Lowest ceiling: 2,500 ft overcast - Temperature: 45 °F, dew point 37 °F - Altimeter: 30.07 inHg - Observed at: KRFD, 15 nm away ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20160430003499A](https://openairdocs.org/incident/20160430003499A), Apr 30, 2016: Cessna 140A, Belvidere, IL, Destroyed. The pilot of N4242H stated that he departed cottonwood airport (1C8) at approximately 3:00AM local on a pleasure flight to poplar grove airport (C77) to… ## Docket (5 files) The files NTSB released with the investigation on May 25, 2016, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=93094. 6.2 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40440369&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Record of Conversation (Pilot in Command) (item 2, .PDF, 61 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40440372&FileExtension=.PDF&FileName=Record%20of%20Conversation%20(Pilot%20in%20Command)-Master.PDF - Accident Area Overview Map (item 3, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40440371&FileExtension=.PDF&FileName=Accident%20Area%20Overview%20Map-Master.PDF - FAA Pilot Handbook of Aeronautical Knowledge Night Operations (item 4, .PDF, 732 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40440373&FileExtension=.PDF&FileName=FAA%20Pilot%20Handbook%20of%20Aeronautical%20Knowledge%20Night%20Operations-Master.PDF - Accident Photos (Courtesy of FAA) (item 5, .PDF, 3 photos, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40440374&FileExtension=.PDF&FileName=Accident%20Photos%20(Courtesy%20of%20FAA)-Master.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.