# NTSB WPR17FA025: Piper PA 28-181, N6912C, Upland, CA, November 22, 2016 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: November 22, 2016, 04:20 local (12:20 UTC) - Place: Upland, CA - Coordinates: 34.164443, -117.665 - Nearby events: https://openairdocs.org/map.md?lat=34.1644&lon=-117.6650&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-climb to cruise: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report July 5, 2018 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Lycoming Engines, Federal Aviation Administration, Piper Aircraft Inc - NTSB case key (mKey): 94414 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR17FA025 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/94414/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=94414 - Page: https://openairdocs.org/ntsb/WPR17FA025 ## Probable cause The pilot's failure to maintain clearance from rising terrain in dark night conditions, which resulted in controlled flight into terrain. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: altitude](https://openairdocs.org/ntsb-findings/01062012): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Piper PA-28-181, 9 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md?model=7102807), [All aircraft, 1,310 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md) - [Attention/monitoring: monitoring environment](https://openairdocs.org/ntsb-findings/02021545): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Piper PA-28-181, 11 cases](https://openairdocs.org/ntsb-findings/02021545/cases.md?model=7102807), [All aircraft, 809 cases](https://openairdocs.org/ntsb-findings/02021545/cases.md) - [Terrain: mountainous/hilly terrain](https://openairdocs.org/ntsb-findings/03021010): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Piper PA-28-181, 4 cases](https://openairdocs.org/ntsb-findings/03021010/cases.md?model=7102807), [All aircraft, 329 cases](https://openairdocs.org/ntsb-findings/03021010/cases.md) - [Light condition: dark](https://openairdocs.org/ntsb-findings/03036020): Environmental issues › Conditions/weather/phenomena · Effect on operation; cases with it: [Piper PA-28-181, 9 cases](https://openairdocs.org/ntsb-findings/03036020/cases.md?model=7102807), [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. - [Enroute-climb to cruise: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120) (defining event); cases with it: [Piper PA-28-181, 11 cases](https://openairdocs.org/ntsb-events/120/sequence.md?model=7102807), [All aircraft, 1,074 cases](https://openairdocs.org/ntsb-events/120/sequence.md) ## Analysis The private pilot departed from a non-towered airport in dark night conditions destined for an airport located about 15 nautical miles southeast; a direct route of flight between the two airports would require flight through controlled (Class C) airspace. Radar data showed that, after departure, the pilot conducted a left climbing turn, then proceeded north (as prescribed for noise abatement procedures at the airport), and remained clear of the controlled airspace, toward an area of dark, unpopulated, rising terrain. About 3 minutes after departure, the pilot contacted the local controller. While talking to the controller, the pilot's transmission suddenly stopped, and the airplane was lost from radar at an altitude about 3,000 ft mean sea level in the vicinity of the accident site. The accident site was located on steep, rising terrain at an elevation about 2,920 ft. Ground scars indicated that the airplane was in a nearly wings-level attitude at the time of impact. There were no preimpact anomalies with the airframe or engine that would have precluded normal operation. It is likely that, while communicating with the controller, the pilot did not monitor and maintain situational awareness as the airplane approached mountainous, unlit terrain. ## Factual narrative The 4-seat, low-wing, fixed-gear airplane, serial number 28-8590051, was manufactured in 1985. A review of the airplane's logbooks showed a total airframe time of 3,357.5 hours at the most recent annual inspection in October 2016. At the time of the accident, a total time of 3,409.9 hours was recorded on the Hobbs meter. The engine was a 180-horsepower Lycoming O-360-A4M, serial number L-31037-36A. The engine logbooks indicated that the most recent 100-hour inspection was completed in October 2016. The engine total time was recorded as 3,004.7 hours, with 1,004.7 hours since major overhaul. CCB is an uncontrolled airport located 5 nautical miles (nm) northwest and on the boundary of ONT Class C airspace. For noise abatement procedures, the normal VFR departure procedure from CCB runway 24 is to conduct a climbing left turn to downwind and then turn left over the runway numbers. The airport was equipped with security cameras. A review of the recorded video showed the pilot arriving at the airport at 0341. The airplane was then seen taxiing to the run-up area. At 0412, the pilot activated the runway lights, and the airplane departed runway 24 at 0417. RAL, the destination airport, is located 10 nm southeast of ONT. On November 22, 2016, about 0420 Pacific standard time, a Piper PA-28-181 airplane, N6912C, impacted mountainous terrain shortly after takeoff from Cable Airport (CCB), Upland, California. The private pilot was fatally injured. The airplane was substantially damaged. The airplane was privately owned and operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91. Night visual meteorological conditions (VMC) prevailed, and no flight plan was filed for the personal flight, which originated from CCB at 0416 and was destined for Riverside Airport (RAL), Riverside, California. After departure from CCB, the pilot contacted the Ontario International Airport (ONT) local controller about 0419. The controller instructed the pilot to identify using the airplane's transponder and issued the current altimeter setting. About 0420, the pilot acknowledged the instruction and reported that he "just departed Cable en route to Riverside we're VFR we just appreciate…." The transmission was cut short and radar contact was lost. The controller tried several times to reestablish contact with the airplane; however, there were no further communications from the pilot. About 15 minutes later, an Emergency Locator Transmitter (ELT) signal was identified and an Alert Notice (ALNOT) was issued at 0457. The wreckage was located shortly thereafter at an elevation about 2,920 ft mean sea level (msl) on the south face of rising mountainous terrain, about 3.5 nautical miles north of CCB. Recorded radar data indicated that, after the airplane departed runway 24, it made a climbing left turn then proceeded to cross over CCB. The target continued a northerly course, climbing to an altitude of 3,000 ft msl. Radar contact was lost near theaccident site about 3 minutes after takeoff. The San Bernardino County Sheriff's Department, Coroner Division, San Bernardino, California, conducted postmortem examinations of the pilot. The cause of death was reported as instantaneous blunt force trauma. The Federal Aviation Administration's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological testing on specimens of the pilot, which were negative for carbon monoxide and ethanol. Atenolol was detected in liver and muscle. Atenolol (generic and several brand names including Tenormin®) is a prescription medication used alone or in combination with other medications to treat high blood pressure. It also is used to prevent angina (chest pain) and improve survival after a heart attack. Atenolol is in a class of medications called beta blockers and is not considered to be impairing. The 0429 weather observation at ONT included calm wind, 10 statute miles visibility, broken clouds at 1,500 ft, temperature 50° F, dewpoint 48° F, and an altimeter setting of 30.08 inches of mercury. According to the U.S. Naval Observatory, Astronomical Applications Department, sunset occurred in Upland, California, at 1643, and civil twilight ended at 1710 the night before the accident. On the morning of the accident, civil twilight occurred at 0603, and sunrise occurred at 0630. There was a waning crescent moon, with 36% of its visible disk illuminated. Moon transit occurred at 0017, and moonset occurred at 1314. The pilot held a private pilot certificate with ratings for airplane single-engine land and instrument airplane. A review of the pilot's logbook indicated 2,557.6 total hours of flight experience. The logbook contained records of flights between September 2011 and January 2013; there were no flights recorded between January 2013 and August 2016. During the 3 months before the accident, the pilot completed a flight review and an instrument proficiency check. During this time, he logged 12.9 hours simulated instrument time, 15 instrument approaches, and 2.4 hours of night flight experience. The pilot had 12.6 hours in the accident airplane make and model, all of which occurred in the 20 days before the accident. The pilot had accumulated a total of 523 hours of experience in actual instrument conditions, none of which occurred within the 3 months before the accident. The pilot's most recent Federal Aviation Administration (FAA) second-class medical certificate was issued on August 22, 2016, with the limitation that he must wear corrective lenses and possess glasses for near/intermediate vision. The instructor who endorsed the pilot for his most recent instrument proficiency check stated that the pilot reported that he was uncomfortable flying in night conditions. The airplane impacted terrain in a slight left-wing-low, nose-high attitude. The hillside was comprised of low brush, rocky and loose soil on a slope of about 50°. The airplane came to rest at the initial impactpoint. There were no ground structures or lighting in the immediate area. All flight control surfaces were located at the accident site. Control continuity was established from the cockpit area to the flight control surfaces. Both wings remained at least partially attached at the wing roots. The left wing leading edge was crushed upwards along its span. The right wing sustained extensive ground impact damage, mostly to the bottom surface. The forward cockpit and instrument panel sustained extensive impact damage and rearward crushing. The rear empennage and tail section, including the vertical stabilizer, rudder, horizontal stabilators, and elevators sustained minor impact damage and were mostly intact. The engine remained attached to the airframe by the engine mounts. The engine sustained significant impact damage, particularly on the lower left side. A visual and subsequent teardown examination revealed no evidence of a preimpact mechanical failure or malfunction. The two-bladed, fixed-pitch propeller remained attached at the crankshaft flange. The spinner was attached to the propeller. The propeller blades (labeled as #1 and #2) remained attached to the propeller hub. Blade #1 displayed leading edge gouging, torsional twisting, chordwise striations across the cambered surface, and S-bending. An approximate 2-inch section of the blade tip had torn away. Blade #2 remained intact, straight, and sustained minor damage. A detailed engine and airframe examination report is included in the public docket. ## Aircraft - Registration: [N6912C](https://openairdocs.org/deregistered/N6912C-2019-03-06), registration cancelled 2019-03-06, S/N 28-8590051, built 1985 (OpenAirDocs) - Reported make and model: PIPER PA 28-181 (181) - Registry model: [Piper PA-28-181](https://openairdocs.org/model/piper-pa-28-181) (registry code 7102807) (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: 28-8590051 - Year built: 1985 - Airframe hours: 3409.9 - Engines: LYCOMING O&VO-360 SER 180 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, October 16, 2016, 40 hours before - Departed: CCB, UPLAND, CA - Destination: RAL, RIVERSIDE, CA - Airport: CCB, Cable - Equipment: None ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 66; injuries: fatal; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review November 1, 2016; seat: left; restraint: 3-point; toxicology performed; flight hours: 2,557.6 total, 12.6 in this make and model, 2,478.3 as pilot in command, 37 in the last 90 days, 18.5 in the last 30 days ## Weather - Conditions: Visual (VMC), Night/dark - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: 1,500 ft broken - Temperature: 50 °F, dew point 48 °F - Altimeter: 30.07 inHg - Observed at: KONT, 6 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 20161122018679A](https://openairdocs.org/incident/20161122018679A), Nov 22, 2016: Piper PA-28-181, Upland, CA, Substantial damage, 1 fatal. On nov. 22, 2016, N6912C departed runway 24 at cable (kccb) at 0417 PST in VFR conditions of total darkness. Pilot made a climbing left-hand 270 degree turn… ## Docket (21 files) The files NTSB released with the investigation on May 16, 2018, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=94414. - Witness Statement (Lines) (item 1, .PDF, 83 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40463251&FileExtension=.PDF&FileName=Witness%20Statement%20(Lines)-Master.PDF - Witness Statement (Cary) (item 2, .PDF, 140 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40463252&FileExtension=.PDF&FileName=Witness%20Statement%20(Cary)-Master.PDF - Sectional Chart with Airports (item 3, .PDF, 630 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40463253&FileExtension=.PDF&FileName=Sectional%20Chart%20with%20Airports-Master.PDF - Google Earth Image of Airport Locations (item 4, .PDF, 584 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40463254&FileExtension=.PDF&FileName=Google%20Earth%20Image%20of%20Airport%20Locations-Master.PDF - Google Map with Flight Overlay (item 5, .PDF, 393 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40463255&FileExtension=.PDF&FileName=Google%20Map%20with%20Flight%20Overlay-Master.PDF - ATC Brief of Communications (item 6, .PDF, 46 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40463256&FileExtension=.PDF&FileName=ATC%20Brief%20of%20Communications-Master.PDF - Radar Tracking (item 7, MP4, 805 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40463257&FileExtension=mp4&FileName=Radar%20Tracking-Master - ONT Radar with LC Audio (item 8, MP4, 7.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40463258&FileExtension=mp4&FileName=ONT%20Radar%20with%20LC%20Audio-Master - ROC (FAA and CFI) (item 9, .PDF, 239 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40463259&FileExtension=.PDF&FileName=ROC%20(FAA%20and%20CFI)-Master.PDF - FAA Email Statement (item 10, .PDF): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40463260&FileExtension=.PDF&FileName=FAA%20Email%20Statement-Master.PDF - FAA Email - Aircraft Rental Info (item 11, .PDF, 145 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40463261&FileExtension=.PDF&FileName=FAA%20Email%20-%20Aircraft%20Rental%20Info-Master.PDF - Airframe & Engine Examination Report (item 12, .PDF, 15 photos, 3.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40463262&FileExtension=.PDF&FileName=Airframe%20%26%20Engine%20Examination%20Report-Master.PDF - Cable Airport Noise Abatement (item 13, .PDF, 106 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40463263&FileExtension=.PDF&FileName=Cable%20Airport%20Noise%20Abatement-Master.PDF - Pilot Logbook (item 14, .PDF, 9.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40463264&FileExtension=.PDF&FileName=Pilot%20Logbook-Master.PDF - Airframe Logbook Excerpt (item 15, .PDF, 329 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40463265&FileExtension=.PDF&FileName=Airframe%20Logbook%20Excerpt-Master.PDF - Engine Logbook Excerpt (item 16, .PDF, 350 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40463266&FileExtension=.PDF&FileName=Engine%20Logbook%20Excerpt-Master.PDF - Propeller Logbook Excerpt (item 17, .PDF, 102 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40463267&FileExtension=.PDF&FileName=Propeller%20Logbook%20Excerpt-Master.PDF - Toxicological Report - Pilot (item 18, .PDF, 192 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40463268&FileExtension=.PDF&FileName=Toxicological%20Report%20-%20Pilot-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 19, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40463269&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 20, .PDF, 238 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40463270&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Master.PDF - NTSB Aerial Photos (item 21, .PDF, 5 photos, 4.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40463271&FileExtension=.PDF&FileName=NTSB%20Aerial%20Photos-Master.PDF From the NTSB's public API. 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