# NTSB WPR13FA001: Piper PA-28-180, N7895W, Beatty, NV, October 3, 2012 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Field investigation · Final report - Date: October 2, 2012, 20:24 local (Oct 3, 2012, 03:24 UTC) - Place: Beatty, NV - Coordinates: 36.856666, -116.785278 - Nearby events: https://openairdocs.org/map.md?lat=36.8567&lon=-116.7853&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: Serious injuries - Injuries: 1 serious - Status: Completed, report November 6, 2013 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration, Lycoming Engines, Piper Aircraft Inc. - NTSB case key (mKey): 85225 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR13FA001 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/85225/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=85225 - Page: https://openairdocs.org/ntsb/WPR13FA001 ## Probable cause The pilot’s inadequate flight planning, subsequent loss of situational awareness, and failure to maintain clearance from the power lines during a dark night approach to a closed, unlit runway. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Planning/preparation: flight planning/navigation](https://openairdocs.org/ntsb-findings/02061025): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-28-180, 3 cases](https://openairdocs.org/ntsb-findings/02061025/cases.md?model=7102808), [All aircraft, 179 cases](https://openairdocs.org/ntsb-findings/02061025/cases.md) - [Knowledge: knowledge of geographic area](https://openairdocs.org/ntsb-findings/02032030): Personnel issues › Experience/knowledge · Pilot (probable cause); cases with it: [Piper PA-28-180, 1 case](https://openairdocs.org/ntsb-findings/02032030/cases.md?model=7102808), [All aircraft, 24 cases](https://openairdocs.org/ntsb-findings/02032030/cases.md) - [Perception/orientation/illusion: situational awareness](https://openairdocs.org/ntsb-findings/02022035): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Piper PA-28-180, 2 cases](https://openairdocs.org/ntsb-findings/02022035/cases.md?model=7102808), [All aircraft, 111 cases](https://openairdocs.org/ntsb-findings/02022035/cases.md) - [Light condition: dark](https://openairdocs.org/ntsb-findings/03036020): Environmental issues › Conditions/weather/phenomena · Ability to respond/compensate; cases with it: [Piper PA-28-180, 10 cases](https://openairdocs.org/ntsb-findings/03036020/cases.md?model=7102808), [All aircraft, 448 cases](https://openairdocs.org/ntsb-findings/03036020/cases.md) - [Object/animal/substance: wire](https://openairdocs.org/ntsb-findings/03022032): Environmental issues › Physical environment · Effect on operation; cases with it: [Piper PA-28-180, 3 cases](https://openairdocs.org/ntsb-findings/03022032/cases.md?model=7102808), [All aircraft, 588 cases](https://openairdocs.org/ntsb-findings/03022032/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: [Piper PA-28-180, 14 cases](https://openairdocs.org/ntsb-events/120/sequence.md?model=7102808), [All aircraft, 1,074 cases](https://openairdocs.org/ntsb-events/120/sequence.md) ## Analysis The pilot reported that a temporary flight restriction (TFR) was in effect for his intended destination airport and that he was unclear on whether the TFR would prevent him from landing at that airport. The TFR stated that transit operations were allowed only if a discrete code was assigned by air traffic control (ATC) before the airplane’s departure. The pilot mistakenly thought he could pick up the discrete code while airborne. Because the pilot was unable to contact ATC at his intended destination during the flight and the airplane was running low on fuel, he diverted to an alternate airport. At the alternate airport, the pilot initiated a straight-in approach to the runway in darkness, over flat, featureless terrain; the pilot reported that the only airport lighting he saw was the airport beacon. During the approach, the airplane struck high tension power lines about 1 mile south of the runway. Further, according to an applicable notice to airmen, the airport that the pilot diverted to was closed when the accident occurred. The pilot most likely flew a lower than desired approach altitude due to the night time conditions and featureless terrain. The pilot reported that there were no preimpact mechanical malfunctions or failures with the airplane or engine that would have precluded normal operation. ## Factual narrative HISTORY OF FLIGHT On October 2, 2012, about 2024 Pacific daylight time, a Piper PA-28-180, N7895W, sustained substantial damage when it struck high power tension lines near the Beatty Airport (BTY) Beatty, Nevada. The airplane was registered to and operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91. The commercial pilot, sole occupant of the airplane, was seriously injured. Visual meteorological conditions prevailed and a visual flight rules flight plan was filed for the personal flight which originated from the Reno/Stead Airport (RTS) Reno, Nevada at about 1520 with an intended destination of Henderson Executive Airport (HND), Henderson Nevada. The pilot reported that he originally departed Snohomish County Airport in Everett, Washington with three planned fuel stops and a final destination of HND. The pilot stated that he was attempting to arrive at HND prior to a Temporary Flight Restriction (TFR) along his intended route of flight to become active. Prior to departure from RTS, the pilot was unclear on whether the TFR would prevent him from landing at HND. The TFR stated that Air Traffic Control (ATC) could authorize transit operations through the restricted area but the airplane must have a discrete transponder code assigned prior to departure. The pilot stated that about 40 miles west of the Las Vegas Very High Frequency Omnidirectional Range (VOR) he made several radio transmissions in an attempt to secure a discrete transponder code. The pilot received no response on two frequencies, one which was the recommended frequency for transit in the TFR. The pilot further reported that due to no response from ATC, and being low on fuel with darkness closing in; he diverted to BTY. The pilot said that he initiated a straight in visual approach to runway 34 and configured the airplane for landing. As he approached the airport, he saw the airport beacon but no other airport lighting despite his attempts to activate the airfield lighting. The pilot stated that there were no mechanical malfunctions or failures with the airplane. PERSONNEL INFORMATION The pilot, age 69, held a commercial pilot certificate with a single-engine land and airplane instrument rating. A second-class airman medical certificate was issued on August 9, 2012, with no limitations stated. The pilot reported on the National Transportation Safety Board Form 6120.1 Pilot/Operator Aircraft Accident/Incident Report, that he had accumulated 1,528 total flight hours. According to the pilot, besides this accident flight, he had only flown at night two previous times in the past two years. One flight was flown on November 11, 2011 and the other flight was flown on October 7, 2010. AIRCRAFT INFORMATION Refueling records obtained at RTS revealed that the airplane had topped off with about 28 gallons of 100 low lead fuel at about 1510, on the day of the accident. METEOROLOGICAL INFORMATION A review of recorded data from the automated weatherobservation station (AWOS) at BTY revealed at 1952, conditions were wind calm, visibility 10 statute miles, clear sky, temperature 26 degrees Celsius, dew point minus 9 degrees Celsius, and an altimeter setting of 29.92 inches of mercury. Using the reported weather conditions and field elevation, the calculated density altitude was about 5,222 feet. The United States Naval Observatory Moon data for Henderson, Nevada, for the day of the accident, indicated sunset at 1821 and the end of civil twilight at 1847. Moonrise was at 1943. The Phase of the Moon was waning gibbous with 93 percent of the Moon’s visible disk illuminated. COMMUNICATIONS Review of the recorded conversation between the pilot and the Reno Flight Service Station (FSS) prior to his departure from RTS, revealed discussion about the TFR for the Las Vegas, Nevada area. The pilot stated that he was concerned about the TFR and getting into HND. He believed that he could fly into HND on the accident day and the TFR would be in effect the next day. Reno FSS advised him that the TFR was currently in effect and he needed to file the appropriate flight plan and squawk the proper code. The Reno FSS individual stated to the pilot that to get into HND he needed to be talking to ATC and squawking the code. The pilot inquired about getting the code while on the ground, however, the FSS individual advised him that ATC would want to talk to him in the air. AIRPORT INFORMATION Beatty Airport is a non-towered airport with a field elevation of 3169 feet. The airport was equipped with a single asphalt runway 16/34 (5,615 feet long and 60 feet wide). Runway edge lights of medium intensity are installed and are not pilot controlled. No runway end identifier lights, no touchdown point lights, and no precision approach path (PAPI) lights or visual approach slope indicator (VASI) lighting, are installed. There are no published instrument procedures for the airport. WRECKAGE AND IMPACT INFORMATION Examination of the accident site by a Federal Aviation Administration inspector revealed that the airplane struck the high tension power lines about 1 miles south of BTY. The power lines were about 50 feet in height and orientated in a north to south direction. The fuselage came to rest on its right side on a magnetic heading of about 225 degrees. Wreckage debris was located within about 175 feet from the main wreckage. The fuselage, engine, tail and left wing were located on the east side on the power lines. The right wing and remaining sections of the airplane were located on the west side of the power lines. The airframe, engine and inboard portions of the wings were consumed by fire. The measured elevation for the accident site was about 2,976 feet. TEST AND RESEARCH A post accident examination of the airframe and engine revealed no evidence of mechanical anomaly or failures that would have precluded normal operation. Examination of the engine revealed that it remained attached to the mounting assembly andsustained thermal damage. The propeller remained attached to the crankshaft propeller flange. Both propeller blades displayed scratches and were bent aft about mid span. Examination of the engine and its components revealed no evidence of preimpact mechanical malfunction. The airframe exhibited thermal damage, buckling and crush damage of the cabin and fuselage areas. The empennage section separated from the fuselage however, it was mostly intact with minor damage to the top portion of the vertical stabilizer and rudder. The left stabilator sustained damage and was bent downwards at about mid span. All major structure components were accounted for. The flight control system exhibited no anomalies that would have precluded normal operation. According to the Federal Aviation Administration Pilot’s Handbook of Aeronautical Knowledge (page 16-19) under the subject heading of night landing illusions; “Landing illusions occur in many forms. Above featureless terrain at night, there is a natural tendency to fly a lower-than-normal approach. Elements that cause visual obscurities such as rain, haze or a dark runway environment can also cause low approaches.” The featureless terrain illusion (page 16:9) states that “an absence of surrounding ground features, as in an overwater approach, over darkened areas, or terrain made featureless by snow, can create an illusion that the aircraft is higher than it actually is. This illusion is also referred to as the “black hole approach,” causes pilots to fly a lower approach than is desired.” ADDITIONAL INFORMATION Temporary Flight Restrictions (TFR) were issued under the number ZLA 2/9833 for the airspace surrounding the Las Vegas, Nevada area, effective September 30, 2012, through October 3, 2012. The Notice to Airmen (NOTAM) defined the National Defense Airspace area and the associated prohibited flight operations. The inner core was defined as the 8 to 10 nautical mile radius (nmr) from the Boulder navigational VORTAC 322 radial at 7 miles. Only specific listed flight operations were allowed. The outer rings were listed as between the 8/10 nmr to 30 nmr. Workload permitting Air Traffic Control (ATC) could authorize transit operations. All aircraft must be on an IFR or VFR flight plan with a discrete code assigned by an ATC facility. Aircraft must be squawking this discrete code prior to departure and at all times while in the TFR. The accident pilot did not secure a discrete code prior to his departure to HND. At the time of the accident, a NOTAM for BTY was active stating that the aerodrome was closed from 1300 on September 24, 2012 until 0100 November 11, 2012. ## Aircraft - Registration: [N7895W](https://openairdocs.org/deregistered/N7895W-2013-05-10), registration cancelled 2013-05-10, S/N 28-1923, built 1964 (OpenAirDocs) - Reported make and model: PIPER PA-28-180 - Registry model: [Piper PA-28-180](https://openairdocs.org/model/piper-pa-28-180) (registry code 7102808) (OpenAirDocs) - Registry engine: [Lycoming O&VO-360 series](https://openairdocs.org/engine/lycoming-o-vo-360-series) (registry code 41514, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-1923 - Engines: LYCOMING O&VO-360 SER 180 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Harris Bernard J Jr - Registered owner: Harris Bernard J Jr - Airworthiness certificate: Standard, Normal - Last inspection: Annual, September 12, 2012, 25 hours before - Departed: RTS, Reno-Stead, NV - Destination: HND, Henderson Exec, NV - Flight plan: VFR - Airport: BTY, Beatty Airport, runway 34, 5,160 × 60 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 69; injuries: serious; commercial, private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 2, without waivers/limitations; last flight review January 1, 2011; seat: left; flight hours: 1,528 total, 967 in this make and model, 1,450 as pilot in command, 38 in the last 90 days, 23 in the last 30 days, 12 in the last 24 hours ## Weather - Conditions: Visual (VMC), Night/dark - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 79 °F, dew point 16 °F - Altimeter: 29.92 inHg - Observed at: DRA, 45 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 20121002022429A](https://openairdocs.org/incident/20121002022429A), Oct 2, 2012: Piper PA-28-180, Beatty, NV, Substantial damage. See item 43 below. ## Docket (15 files) The files NTSB released with the investigation on August 8, 2013, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=85225. 6.5 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 3.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40396203&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Record of Conversation (item 2, .PDF, 112 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40396206&FileExtension=.PDF&FileName=Record%20of%20Conversation-Master.PDF - Record of Conversation (item 3, .PDF, 114 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40396209&FileExtension=.PDF&FileName=Record%20of%20Conversation-Master.PDF - Statements to Sheriff (item 4, .PDF, 119 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40395825&FileExtension=.PDF&FileName=Statements%20to%20Sheriff-Redacted.PDF - Accident Diagram (item 5, .PDF, 39 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40395819&FileExtension=.PDF&FileName=Accident%20Diagram-Master.PDF - Accident Diagram (FAA) (item 6, .PDF, 123 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40395820&FileExtension=.PDF&FileName=Accident%20Diagram%20(FAA)-Master.PDF - Beatty Airport Information (item 7, .PDF, 25 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40396205&FileExtension=.PDF&FileName=Beatty%20Airport%20Information-Redacted.PDF - Sun and Moon Data (item 8, .PDF, 16 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40395827&FileExtension=.PDF&FileName=Sun%20and%20Moon%20Data-Master.PDF - Sheriff Report (item 9, .PDF, 91 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40397953&FileExtension=.PDF&FileName=Sheriff%20Report-Redacted.PDF - Airport Master Record (item 10, .PDF, 22 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40395823&FileExtension=.PDF&FileName=Airport%20Master%20Record-Master.PDF - FAA Handbook of Aeronautical Knowledge (item 11, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40395822&FileExtension=.PDF&FileName=FAA%20Handbook%20of%20Aeronautical%20Knowledge-Master.PDF - Temporary Flight Restriction Notice to Airmen (NOTAM) (item 12, .PDF, 133 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40395824&FileExtension=.PDF&FileName=Temporary%20Flight%20Restriction%20Notice%20to%20Airmen%20(NOTAM)-Master.PDF - Notice to Airmen (item 13, .PDF, 31 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40395830&FileExtension=.PDF&FileName=Notice%20to%20Airmen-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 14, .PDF, 217 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40396295&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Audio 1 – Pilot conversation with Flight Service Station while at Reno/Stead Airport (item 15, .PDF, 196 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40396225&FileExtension=.PDF&FileName=Audio%201%20%E2%80%93%20Pilot%20conversation%20with%20Flight%20Service%20Station%20while%20at%20Reno%2FStead%20Airport-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.