# NTSB SEA95FA018: Cessna 172N, N584WA, Klamath Falls, OR, November 9, 1994 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: November 8, 1994, 18:13 local (Nov 9, 1994, 02:13 UTC) - Place: Klamath Falls, OR - Coordinates: 42.310337, -122.070243 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=42.3103&lon=-122.0702&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal, 1 serious - Status: Completed, report September 24, 1995 - Report: Approved by Office Director - NTSB case key (mKey): 42038 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=SEA95FA018 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/42038/pdf - Page: https://openairdocs.org/ntsb/SEA95FA018 ## Probable cause THE VFR PILOT'S ATTEMPT TO CONTINUE THE FLIGHT INTO INSTRUMENT METEOROLOGICAL CONDITIONS, AND HIS FAILURE TO MAINTAIN ALTITUDE/CLEARANCE WITH THE MOUNTAINOUS TERRAIN BELOW HIM. CONTRIBUTING TO THE ACCIDENT WAS A DOWNDRAFT. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight encounter with weather, cruise - weather condition - clouds - vfr flight into imc - attempted, pilot in command (cause) - weather condition - snow - altitude/clearance - not maintained, pilot in command (cause) - weather condition - downdraft (contributing factor) - light condition - dark night - In flight collision with object, descent - uncontrolled - object - tree(s) ## Analysis THE PRIVATE PILOT, WHO WAS NOT INSTRUMENT RATED, RECEIVED AN ACCURATE WEATHER BRIEFING FOR A CROSS COUNTRY BUSINESS FLIGHT OVER MOUNTAINOUS TERRAIN AT NIGHT. DURING THE FLIGHT, THE WEATHER CONDITIONS WORSENED, AS FORECAST. THE PILOT WAS TOLD OF THE WORSENING CONDITIONS. HE REPORTED TO AIR TRAFFIC CONTROL (ATC) THAT HE WAS ENTERING OBSCURATION AND EVENTUALLY LOST GROUND CONTACT. THE REPORTED WEATHER CONDITIONS NEAR THE ACCIDENT SITE INDICATED THAT THE CLOUDS, SNOW, AND GUSTING WINDS EXISTED AT THE ALTITUDE THE AIRPLANE WAS FLYING. ATC PROVIDED VECTORS, BUT THE PILOT GRADUALLY DESCENDED AND VEERED TOWARD RISING TERRAIN. THE PILOT STATED THAT THE AIRPLANE THEN ENCOUNTERED A STRONG DOWNDRAFT AND THAT HE COULD NOT CLIMB FASTER THAN THE RISING TERRAIN. THE AIRPLANE IMPACTED A TREE NEAR THE 7,200 FOOT LEVEL OF A MOUNTAIN. THE PILOT WAS SERIOUSLY INJURED AND WAS RESCUED 22 HOURS AFTER THE ACCIDENT. THE PASSENGER WAS FATALLY INJURED. NO PRE-IMPACT MECHANICAL MALFUNCTIONS WERE REPORTED. ## Factual narrative HISTORY OF FLIGHT On November 8, 1994, at 1813 Pacific standard time, N584WA, a Cessna 172N, operated by Kennewick Aircraft, Inc., Kennewick, Washington, impacted trees while maneuvering and was destroyed near Klamath Falls, Oregon. The private pilot was seriously injured and his passenger was fatally injured. Instrument meteorological conditions prevailed and a visual flight rules (VFR) flight plan was filed. The business flight departed Hermiston, Oregon, about 1505 and was destined for the Klamath Falls International Airport. The flight was conducted under 14 CFR 91. According to the pilot, the purpose of the flight was to visit various sites in the Klamath Falls area and check on packaging machinery that had been previously installed there by his employer. The pilot stated that he arrived at Kennewick on the day of the accident to rent an airplane for the trip to Klamath Falls. After the airplane was "topped off" with fuel, the pilot departed Kennewick and flew about 20 minutes to the Hermiston Airport. He was met by the passenger in Hermiston, who was also working for the same employer. The pilot stated that he called an FAA Flight Service Station (FSS) and received a weather briefing for his trip to Klamath Falls. According to the pilot, the weather briefer stated that the weather forecast was "favorable" for the flight, and that if he (the pilot) wanted to fly to Klamath Falls, the sooner the better because the evening forecast "didn't look good." According to a transcript (attached) and voice recording of the pilot's weather briefing provided by the FAA, the pilot requested a "standard briefing" for a VFR flight from Hermiston to Klamath Falls. The briefing began at 1436 and ended at 1440. The FSS briefer advised the pilot of one VFR flight precaution for "turbulence occasional moderate below 16,000 feet." The briefer also stated: "Klamath Falls has an amended forecast up until [1700] this evening. They're looking for 4,000 [feet above ground level (agl)] scattered, ceilings running 7,000 [feet agl] overcast with gusty winds out of the southeast 8 to 15 knots. They also look for ceilings occasionally down to 3,000 [feet agl] broken with light rain and light snow..." Following the briefing, the pilot stated: "Okay, sounds like a go then." The FSS briefer responded: "Yeah, it looks okay at this point. You might watch it pretty close on your destination ... with that snow and stuff...." The pilot then filed a VFR flight plan, briefed the passenger on the flight, ran up the airplane with no problems noted, and departed from Hermiston at 1505. The pilot stated that he climbed to a cruising altitude of 7,500 feet mean sea level (msl) after departure. He flew from Hermiston to the Kimberly Very High Frequency Omni Range (VOR), and then from the Kimberly VOR into the Klamath Falls area. He stated that he observed some "high clouds at 20,000 feet" during the first half of the trip. He stated that he was receiving "flight following" from the Seattle Air Route Traffic Control Center (ARTCC) during the flight. As he got closer to Klamath Falls, the pilot observed scattered layers of clouds in front of him. He climbed from 7,500 feet up to 8,200 feet to clear the clouds, then went back down to 7,500 feet. He stated that 7,500 feet was "well above the minimum sector altitude" along his route of flight. He stated that he was "VFR on top" and was "getting marginal VFR reports from other pilots" on the radio. He also stated that his ground speed was decreased due to strong headwinds, and he had the controller contact Flight Service and amend his flight plan. The pilot stated that he noted that he was "in between cloud layers" with "intermittent ground contact." He was also encountering snow showers and it was a dark night. He listened to the Klamath Falls Airport Automated Terminal Information Service (ATIS), and he remembered that ATIS reported 20 knot winds and a 1,300-foot ceiling. He then asked the controller to provide him with vectors to the airport. He stated that the controller gave him "suggestive vectors" toward Klamath Lake. He also stated that he was using the controller "as a big brother" and he rated the controller's performance as "very good." He also remembered setting the VOR to the radial given by the controller to bring him over the lake. The pilot stated that he was navigating by reference to his directional gyro, which he "correlated with the magnetic compass," and by the vectors provided to him. He stated that the airplane then encountered a brief updraft, followed by a "big" downdraft which made him feel like he "just stopped." He began to descend at 1,000 feet per minute. He added full power (from 75 percent power) and attempted to arrest the rate of descent. He stated that the engine responded and there were no problems with the airplane. He pulled back on the control yoke, but he "...didn't want to pull back too much" for fear that he may stall the airplane. His stated that his airspeed was about "75 to 80 knots." The rate of descent decreased from 1,000 feet per minute to 500 feet per minute, but he could not stop the descent. The pilot stated that during the descent, he entered the clouds. He then saw a tree in front of him; the airplane impacted the ground and then "bounced" into the tree. According to FAA ARTCC transcripts and radar data (attached), the pilot requested and received VFR flight following from the ARTCC controller at 1734. At 1756, the controller asked the pilot "...does it look like you'll be able to get into Klamath Falls VFR alright?" The pilot responded: "It appears to be so sir. [I see] a scattered layer about one thousand two to three hundred." The controller replied: "Roger [because] the airport itself is reporting twelve hundred scattered, two thousand broken, three thousand overcast and five miles with light snow, winds are estimated at one eight zero at one niner." The pilot then stated "...there's a lot of mountains out here that are kinda obscured and it's my first time in there. Could you set me up on an approach so I can get down below the scattered layer?" The controller then asked the pilot if he was instrument rated, and the pilot responded with "Negative sir." The controller stated that he could not "... give [the pilot] an approach..." but he provided a "best bet" vector of 210 or 220 degrees, and advised the pilot that he could "then go straight in from the northwest." At 1800, the controller advised the pilot to maintain a heading of 210 degrees and stated: "that'll take you over the lake and I'll bring you in from the lake down to the south right towards the airport, give you a nice area with no mountains in the way." The pilot was at an altitude of 8,300 feet msl at that time and asked the controller for the "minimum enroute altitude" for the area. The controller responded that the "minimum vectoring altitude is ninety-three hundred [feet]..." and "...the highest terrain around there at about seventy-six hundred [feet]." The pilot then responded: "Yeah, I have a chart here. I see it also." From 1806:46 to 1810:11, the airplane gradually climbed from 8,300 feet msl to 9,100 feet msl. At 1810, the controller asked the pilot if he had "any terrain in sight." The pilot responded with "affirmative." The controller then advised the pilot of his position relative to the airport and stated "if you continue ah the way you're going now you'll come over a lake and head straight down and it's pretty much of a valley going straight in...." At 1811, the pilot responded with "...I've got intermittent ground contact right now, right now I've lost it." The airplane was at 8,200 feet msl and descending at that time. The controller then advised the pilot that he would "be over the lake at about th ## Aircraft - Registration: [N584WA](https://openairdocs.org/deregistered/N584WA-1997-09-13), registration cancelled 1997-09-13, S/N 17271944 (OpenAirDocs) - Reported make and model: CESSNA 172N - Registry model: [Cessna 172N](https://openairdocs.org/model/cessna-172n) (registry code 2072434) (OpenAirDocs) - Category: Airplane - Serial number: 17271944 - Airframe hours: 8433 - Engines: LYCOMING O-360-A4M 180 horsepower reciprocating - Damage: Destroyed - Flight: Business, Part 91 - Operator: Kennewick Aircraft, Inc. - Registered owner: Webber, C.L. - Airworthiness certificate: Standard, Utility; Standard, Normal - Last inspection: 100 hour, September 30, 1994, 25 hours before - Departed: S22, HERMISTON, OR - Destination: LMT, KLAMATH FALLS, OR - Flight plan: VFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 35; private; airplane ratings: single-engine land; medical: class 3, valid medical--w/ waivers/lim; seat: left; flight hours: 430 total, 182 in this make and model, 392 as pilot in command, 69 in the last 90 days, 4 in the last 30 days, 3 in the last 24 hours ## Weather - Conditions: Instrument (IMC), Night/dark - Wind: 160° at 16 knots, gusting 22 - Visibility: 7 statute miles - Lowest ceiling: 2,000 ft broken - Temperature: 37 °F, dew point 30 °F - Altimeter: 29.00 inHg - Observed at: LMT, 16 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 19941108040789A](https://openairdocs.org/incident/19941108040789A), Nov 8, 1994: Cessna 172N, Klamath Falls, OR, Destroyed, 1 fatal. VFR pilot got between cloud layers at night. Encountered uncontrollable downdraft. Struck trees and ground. 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.