# NTSB LAX08FA001: Piper PA-28R-200, N3971X, Cedar City, UT, October 27, 2007 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: October 26, 2007, 20:06 local (Oct 27, 2007, 02:06 UTC) - Place: Cedar City, UT - Coordinates: 37.429164, -112.91333 - Nearby events: https://openairdocs.org/map.md?lat=37.4292&lon=-112.9133&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report January 14, 2009 - Report: Approved by Office Director - Parties: Federal Aviation Administration, Lycoming Engines, Piper Aircraft - NTSB case key (mKey): 66832 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX08FA001 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/66832/pdf - Page: https://openairdocs.org/ntsb/LAX08FA001 ## Probable cause The pilot's failure to maintain aircraft control while in cruise flight due to spatial disorientation. Contributing to the accident were the dark conditions. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, cruise - spatial disorientation, pilot in command (cause) - aircraft control - not maintained, pilot in command (cause) - light condition - dark night (contributing factor) - Airframe/component/system failure/malfunction, descent - uncontrolled - horizontal stabilizer - overload (contributing factor) - wing - overload (contributing factor) ## Analysis The non-instrument-rated private pilot's departure had been delayed, and he was in a hurry to fly home. The pilot elected to fly over mountainous terrain in dark, nighttime conditions. Recorded radar data shows that after cruising for nearly 2 hours, the airplane initially entered a slow descent from 12,600 to 11,100 feet. Thereafter, the radar track shows the airplane commencing a clockwise turn while continuing to descend. While reversing course, the pilot became spatially disoriented, and the airplane rapidly descended, as evidenced by its sudden disappearance from radar. During the descent the airplane broke apart. Wreckage was found on a 6,400-foot (mean sea level) mountain and was scattered over a 950 by 350 foot oval-shaped area. The major components that separated were the horizontal stabilator, the vertical tail surfaces, and the 6-foot-long outboard span of both wings. The propeller blades exhibited signatures consistent with the absorption of rotational energy during ground impact. No preimpact anomalies were found during the wreckage examination and all fractures were overload in character. The descending flight profile, followed by the course reversal away from the pilot's destination, was consistent with a spiral maneuver. The structural breakup resulted from aerodynamic forces induced by the pilot's recovery attempts that exceeded the airframe's strength. ## Factual narrative HISTORY OF FLIGHT On October 26, 2007, about 2006 mountain daylight time, a Piper PA-28R-200, N3971X, experienced an in-flight breakup while in an uncontrolled descent over mountainous terrain about 21 miles southeast of Cedar City, Utah. The airplane was destroyed during the breakup and post impact ground fire. The private pilot, who co-owned the airplane, and the passenger were killed. Dark nighttime visual meteorological conditions prevailed at the time. No flight plan had been filed for the business flight that was performed under the provisions of 14 Code of Federal Regulations Part 91. The flight originated from Bountiful, Utah, about 1815. The elevation of Bountiful's Skypark Airport is 4,234 feet msl. Skypark is located about 5 miles north of the Salt Lake City International Airport. At 1816 the pilot contacted the Salt Lake City Terminal Radar Approach Control Facility. The pilot reported that he had departed Bountiful and was at 4,800 feet mean sea level (msl). The pilot indicated that he planned to fly in a southerly direction. (Family members subsequently reported to the National Transportation Safety Board investigator that the pilot intended to fly south, passed the accident site, to an airport in Arizona.) The air traffic controller identified the airplane on radar and provided flight following service as the airplane climbed. At 1842 the airplane was at 9,500 feet, as indicated by the airplane's Mode C altitude encoding transponder, and the southbound airplane departed Salt Lake City airspace. Federal Aviation Administration (FAA) controllers had no further communications with the airplane pilot, and no additional radar flight following or other services were provided. A review of recorded FAA radar data for the area between Bountiful and the vicinity of the accident site, about 21 miles southeast of Cedar City, revealed one target having a flight path consistent with that of the accident airplane. A review of the target airplane's radar track revealed that it continued climbing while proceeding in a southerly direction. The pilot's wife reported to the Safety Board investigator that about 1930 she received a cellular phone call from her husband, who was flying home with his brother. The pilot indicated that their departure had been delayed, but they were currently en route home. Based upon information from the airplane's global positioning satellite receiver, their ground speed was 120 knots. They anticipated landing at 2021. The pilot's wife had no further communications with her husband. Between 1958:06 and 2005:04, the southbound airplane descended from about 12,600 feet to 11,100 feet. Thereafter, the radar data indicated that the airplane commenced a clockwise turn while continuing to descend. The airplane was last recorded on radar while on a northwesterly track at 2005:34, and seconds earlier had descended through 10,800 feet. The airplane's fuselage, wings, empennage, and other non-structural components were found scattered over a mountainside. The main wreckage was located about 1/3-mile from the last recorded radar position. No person reported to the Safety Board investigator having observed the accident airplane descend or impact the mountainous terrain. No homes, lights, or roadways exist in the vicinity of the accident site. PERSONNEL INFORMATION The pilot, age 29, held a private pilot certificate and was rated to fly single engine land airplanes. According to data contained in an insurance application dated July 2007, the pilot's total flight time was about 200 hours. He had about 40 hours experience flying in the accident model of airplane. FAA records indicated that on the pilot's May 2007 application for a third-class aviation medical certificate, he reported having 200 hours of flying experience. The pilot also reported having flown 6 hours during the preceding 6 months. AIRCRAFT INFORMATION The airplane was manufactured in 1975. The airplane's logbooks were not provided to the Safety Board investigator for examination, and they reportedly may have been in the airplane, which was consumed in the post impact fire. The mechanic who had been hired by the airplane owners to perform maintenance provided the Safety Board investigator with copies of logbook entries he had kept. In pertinent part, the records indicated that the airplane received an annual inspection in June 2007. The most recent 100-hour inspection was performed in August 2007, at an airplane total time of 3,370.5 hours. METEOROLOGICAL INFORMATION A review of the meteorological conditions in the vicinity of the accident did not reveal reports or forecasts of adverse convective activity. No evidence was found of conditions that would preclude flight under visual flight rules. The closest aviation weather observation station to the accident site is located at Cedar City, Utah (CDC), about 19 miles northwest of the accident site. At 1953, CDC reported the following weather: sky clear, visibility 10 miles, wind from 190 degrees at 4 knots, temperature 13 degrees Celsius, dew point -6 degrees Celsius, and altimeter 30.17 inches of Mercury. The United States Naval Observatory reported that on the accident day, the end of civil twilight occurred in Cedar City at 1908. The moon's disk was 99 percent illuminated, and the nearly full moon rose in the east at 1849. About 30 miles east of the 6,400 foot mean sea level accident site, the elevation of the mountaintops was between 8,000 and 9,400 feet msl. At the time of the accident, the moon would appear near the mountaintops. As the airplane turned westward, the moon would not have been visible from the airplane's cockpit. Within a few days preceding the accident, numerous forest fires were prevalent in California mountains south of the accident site. The smoke layer drifted into Utah. According to a Civil Air Patrol pilot who searched for the accident airplane, the layer of smoke from the fires impaired horizontal flight visibility. The pilot opined that the flight visibility in the accident site area would have been very bad at night. COMMUNICATION According to the FAA, no communications occurred with the accident airplane pilot following termination of radar flight following service. WRECKAGE AND IMPACT INFORMATION An examination of the accident site and airplane wreckage revealed that the airplane experienced an in-flight breakup. All of the airplane's structural components were located. Airframe components were found scattered over an estimated 950 foot long by 350 foot wide oval shaped area, and within a radius of 550 feet of the main wreckage. The long axis of the wreckage distribution path was oriented on a magnetic track of about 030 degrees. The main wreckage consisted of the fuselage with attached cockpit and engine assembly. The main wreckage was found upside down and pointed about 010 degrees, magnetic. Components south and west of the main wreckage principally consisted of the right wing, right aileron, and the vertical stabilizer. The remainder of the airplane, including the separated left wing (outboard section), left stabilator, and various skin panels, were located northwest to north of the main wreckage. Also, several localized areas of fire were noted in native shrub vegetation surrounding the wreckage area. The majority of the fuselage was consumed by fire. MEDICAL AND PATHOLOGICAL INFORMATION On October 27, 2007, an autopsy was performed on the pilot by the Office of the Medical Examiner, Utah Department of Health, Salt Lake City, Utah. The autopsy findings indicated that the pilot died from "massive deceleration injuries." Forensic toxicology was performed on specimens from the pilot. The Medical Examiner found no evidence of volatiles, marijuana or drugs. The FAA's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, also examined specimens from the pilot. The FAA rep ## Aircraft - Registration: [N3971X](https://openairdocs.org/deregistered/N3971X-2018-01-18), registration cancelled 2018-01-18, S/N 28R-7535371, built 1975 (OpenAirDocs) - Reported make and model: PIPER PA-28R-200 - Registry model: [Piper PA-28R-200](https://openairdocs.org/model/piper-pa-28r-200) (registry code 7102811) (OpenAirDocs) - Registry engine: [Lycoming I0360 series](https://openairdocs.org/engine/lycoming-i0360-series) (registry code 41515, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28R-7535371 - Airframe hours: 3370.5 - Engines: LYCOMING IO-360 200 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Business, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, August 2, 2007 - Departed: BTF, Bountiful, UT - Destination: AZC, Colorado City, AZ ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 29; injuries: fatal; private; airplane ratings: single-engine land; medical: class 3, without waivers/limitations; toxicology performed; flight hours: 200 total, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Night/dark - Wind: 190° at 4 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 55 °F, dew point 21 °F - Altimeter: 30.17 inHg - Observed at: CDC, 19 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 20071026824209A](https://openairdocs.org/incident/20071026824209A), Oct 26, 2007: Piper PA28R200, Cedar City, UT, Destroyed, 2 fatal. (-23) The aircraft departed bountiful, Utah at 1716 MDT on a VFR flight to Colorado city, Arizona. The pilot did not have an instrument rating. At 1830 MDT a… 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.