# NTSB WPR22FA354: Piper PA-28-140, N7063R, Sisters, OR, September 22, 2022 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: September 22, 2022, 14:39 local (21:39 UTC) - Place: Sisters, OR - Coordinates: 44.569412, -121.80544 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=44.5694&lon=-121.8054&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-climb to cruise: VFR encounter with IMC](https://openairdocs.org/ntsb-events/401) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Western Pacific Region - Parties: Piper Aircraft Company, Federal Aviation Administration, Lycoming Engines - NTSB case key (mKey): 105990 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR22FA354 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105990/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=105990 - Page: https://openairdocs.org/ntsb/WPR22FA354 ## Probable cause The non-instrument-rated pilot’s flight into instrument meteorological conditions, which resulted in spatial disorientation and a subsequent loss of airplane control. Contributing to the accident was the pilot’s degraded judgement due to fatigue. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-28-140, 103 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7102802), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Ceiling/visibility/precip: low visibility](https://openairdocs.org/ntsb-findings/03035015): Environmental issues › Conditions/weather/phenomena · Effect on personnel (probable cause); cases with it: [Piper PA-28-140, 2 cases](https://openairdocs.org/ntsb-findings/03035015/cases.md?model=7102802), [All aircraft, 175 cases](https://openairdocs.org/ntsb-findings/03035015/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA-28-140, 43 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=7102802), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Ceiling/visibility/precip: low ceiling](https://openairdocs.org/ntsb-findings/03035010): Environmental issues › Conditions/weather/phenomena · Effect on personnel (probable cause); cases with it: [Piper PA-28-140, 3 cases](https://openairdocs.org/ntsb-findings/03035010/cases.md?model=7102802), [All aircraft, 190 cases](https://openairdocs.org/ntsb-findings/03035010/cases.md) - [Perception/orientation/illusion: spatial disorientation](https://openairdocs.org/ntsb-findings/02022025): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Piper PA-28-140, 6 cases](https://openairdocs.org/ntsb-findings/02022025/cases.md?model=7102802), [All aircraft, 358 cases](https://openairdocs.org/ntsb-findings/02022025/cases.md) - [Alertness/Fatigue](https://openairdocs.org/ntsb-findings/02013500): Personnel issues › Physical · Pilot (probable cause); cases with it: [Piper PA-28-140, 1 case](https://openairdocs.org/ntsb-findings/02013500/cases.md?model=7102802), [All aircraft, 48 cases](https://openairdocs.org/ntsb-findings/02013500/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: VFR encounter with IMC](https://openairdocs.org/ntsb-events/401) (defining event); cases with it: [Piper PA-28-140, 5 cases](https://openairdocs.org/ntsb-events/401/sequence.md?model=7102802), [All aircraft, 392 cases](https://openairdocs.org/ntsb-events/401/sequence.md) ## Analysis The non-instrument rated pilot departed from California to reposition his airplane to southern Washington. He flew for about 7 hours, which included multiple fuel stops along his route of flight through eastern California and Oregon. Witnesses heard the airplane followed by the impact. One witness reported the engine sounded normal and the other witness reported hearing the engine sound increase before the impact. The impact occurred about 29 minutes after the last en route departure. The wreckage was located on the face of a mountain peak about 20 nautical miles (nm) from the pilot’s last departure airport. Postaccident examination of the airframe and engine revealed no evidence of mechanical anomalies or malfunctions that could have precluded normal operation. The airplane impacted the ground at a near-vertical, nose-down attitude consistent with an inflight loss of control rather than a controlled flight into terrain. A friend of the pilot who helped plan the trip reported they checked the weather the day before the departure and the pilot was aware that the weather was not favorable for a direct flight, but the weather would be better if he flew up the east side of the Cascade Mountains. A review of weather information indicated updrafts and downdrafts from mountain wave development in the area at the accident time. A scattered to broken cloud cover from the ground with tops around 6,000 ft was also present and was corroborated by witness observations at the surface near the accident site, who reported rain, fog and strong wind at the time of the accident. The ceiling forecast was available in the form of graphical weather forecasts that had been issued earlier on the day of the accident. Forecasts indicated instrument meteorological conditions (IMC) prevailed on the pilot’s designated route of flight; however, it is unclear if the pilot received an updated forecast before the flight, or if he received the forecasts and chose to continue the flight regardless. The pilot had flown for almost seven hours preceding the accident and was likely feeling the effects of physical and mental fatigue which lowers one’s ability to reason and concentrate. Although the data typically used to determine spatial disorientation (SD) was not available for this accident, there is a high probability the pilot was unable to maintain spatial orientation when he encountered IMC, resulting in his subsequent loss of control of the airplane. Contributing to the pilot’s susceptibility to SD was the fatigue he was likely feeling after seven hours of flying, his desire to continue the flight despite evidence indicating that doing so was unsafe, and his lack of an instrument rating. The limited postmortem toxicological testing detected the volatile substances ethanol, n-butanol, isopropanol, and acetone. Given this combination of substances, as well as the condition and delayed recovery of the pilot’s remains, it is likely that some or all of these detected substanceswere products of postmortem microbial activity and therefore not considered a factor in this accident. ## Factual narrative A friend of the pilot stated that the airplane remained in the pilot’s hangar for several years. During this time the pilot might have accumulated 2-4 hours of total flight time in the airplane. On September 22, 2022, about 1439 Pacific daylight time, a Piper PA-28-140, N7063R, was destroyed when it was involved in an accident near Sisters, Oregon. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot used an online flight planning tool for his en route and destination performance planning. Data retrieved from the online tool showed that the pilot had planned to depart a private strip in Llano, California, about 0700 and then fly a succession of waypoints and fuel stops while en route to his destination of Curtis, Washington (0WA2). The data did not include any flight tracking information such as global position system coordinates. His planned route of flight comprised the following waypoints (in the reported order): Rosamond Skypark Airport (L00), Rosamond, California, Harris River Ranch Airport (9CA7), Sanger, California, followed by a stopover at Westover Field/Amador County Airport (JAQ), Jackson, California. Fuel records from the JAQ airport showed that the pilot purchased 25 gallons of 100 low-lead aviation grade gasoline at 0953. The pilot’s subsequent waypoints included Nevada County Airport (GOO), Grass Valley, California, followed by Sisters Eagle Air Airport, (6K5), Sisters, Oregon, where the pilot purchased another 29 gallons of fuel at 1400. According to an airport surveillance video, the pilot departed 6K5 about 1410. He had planned to overfly Scappoose, Oregon, before landing at his destination. A witness located about 0.50 nm north of the accident site reported that between 1430 and 1445 she heard a small airplane that was flying close to her that caught her attention. She heard a “thud” sound about 30 seconds later, at which point she began to look for the airplane. The witness stated that the engine sounded smooth and continuous before the impact. Another witness, who was located about 1,000 ft from the accident site, stated that he heard the airplane impact the ground about 1439. The Linn County Medical Examiner’s Office, Albany, Oregon, produced a medical examiner report that included information about the death investigation and the visual examination of the recovered remains. According to this report, the pilot’s cause of death was massive blunt and sharp force trauma, and his manner of death was accident. The remains were recovered from the remote crash site on the day after the accident. Due to the condition of the pilot’s remains, effective examination for natural disease was not possible. The Federal Aviation Administration (FAA) Forensic Sciences laboratory performed toxicological testing of a postmortem muscle tissue specimen from the pilot. This testing detected ethanol at 0.057 g/hg, n-butanol at 0.016 g/hg, isopropanol at 0.093 g/hg,and acetone at 0.01 g/hg.2 The toxicology report noted that the specimen was unsuitable for general drug screening. The specimen was screened for drugs of abuse with negative results. No other specimen was available for FAA toxicological testing. Ethanol can sometimes be produced by microbes in a person’s body after death. Postmortem ethanol production is made more likely by extensive trauma and delayed recovery of remains. According to the pilot’s friend, he helped him plan the flight from California to Washington. After they reviewed the weather conditions the weekend before the flight and noticed incoming inclement weather, they selected Thursday (the day of the accident) for the pilot’s departure, and they reviewed the weather again the day before. However, after reviewing winds, obscurations using automated weather observing system data, a foreflight moving map, and weather forecasts from an internet website, they discovered that the weather conditions were still unfavorable for a direct route of flight. Instead, they found that the weather conditions were better on the east side of California and east of the Cascade mountains. The pilot’s friend reported that he texted the pilot at 0630 on the day of the accident to inform him that the weather to the north of the Oregon border wouldn’t be clear until the mid-afternoon or later, but he never received a response. A National Weather Service Surface Analysis Chart for 1400 showed a low-pressure system over north central Washington with a trough of low-pressure extending north and south from the low. Troughs and fronts can act as lifting mechanisms to help produce clouds and precipitation if sufficient moisture is present. The accident site was located immediately ahead, or east, of the surface trough. The 1700 sounding from Salem, Oregon, indicated an unstable environment from the surface through 3,500 ft mean sea level (msl), with a combination of conditional unstable layer and stable layers between 3,500 ft and 14,000 ft. Clouds were indicated by a Radiosonde observations (RAOB) analysis software to be present from 4,000 ft through 6,750 ft. The 1700 sounding wind profile from Salem, Oregon, indicated a near surface wind from 165° at 5 knots with the wind becoming westerly by 5,000 ft. The wind speed increased to 15 knots by 2,000 ft and as high as 20 knots by 7,000 ft. The RAOB analysis program did not indicate low-level wind shear (LLWS) below 2,000 ft, but RAOB did indicate several layers of light to moderate clear air turbulence (CAT) from the surface through 14,000 ft. Areas of mountain waves were noted by RAOB with 1,000 ft/min downdrafts indicated around 4,500 and 6,400 ft. At the accident elevation of 6,500 ft, the wind was from the northwest at 17 knots. While there were no notifications or forecasts for mountain wave development at the time of the accident, there were pilot reports for LLWS at airports surrounding the accident site at the time. A graphical forecast for aviation(GFA) issued at 0902 and valid at the time of the accident showed clear skies in northern California, with ceilings and few clouds in southern Oregon. Ceilings and mountain obscuration were reported all over northwestern Oregon and southern Washington at the pilot’s destination airport. A subsequent GFA issued at 1202 showed similar cloud activity and obscurations. Pilot weather reports captured within 2 hours of the accident showed ceilings from 4,000 ft to about 5,000 ft msl near Portland, Oregon, about 68 nm northwest of the accident site. Figure 1: Graphical forecast for aviation issued at 0902 on the day of the accident. The pilot’s son stated that his father started planning the flight about 4 years before the accident to relocate the airplane to his new home in Chehalis, Washington. The pilot spoke with his son about his route of flight, but they did not discuss the weather conditions. According to the pilot’s son, his father had not completed any cross-country flights to Oregon or Washington. The longest flight he completed was about 2.5 hrs except for a flight in a Mooney to Montana. The distance between 6K5 and the accident was about 20 nm. According to the performance section of the pilot’s operating handbook, the flight would have taken about 16 minutes to fly 21 nm and climb to about 8,000 ft. Figure 1: Accident site on slope of South Cinder Peak (2 days after the accident) The airplane came to rest on a 60° slope on the northeast side of South Cinder Peak in the Jefferson Wilderness at a field elevation of about 6,500 ft msl. All four corners of the airplane were accounted for at the accident site. The first point of impact (FPI) was about 500 ft from the top of the peak and was marked by a large ground scar about 6 ft wide. The main wreckage was located down the hill about 20 ft northeast of the FPI and was comprised of both wings, the fuselage, and empennage. The engine was collocated with the FPI. Postaccident examination of the airframe and engine did not reveal any preimpact mechanical anomalies that could have precluded normal operation. ## Aircraft - Registration: [N7063R](https://openairdocs.org/aircraft/N7063R), registered now, S/N 28-21763, built 1966 (OpenAirDocs) - Reported make and model: PIPER PA-28-140 - Registry model: [Piper PA-28-140](https://openairdocs.org/model/piper-pa-28-140) (registry code 7102802) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-21763 - Year built: 1966 - Airframe hours: 5102 - Engines: LYCOMING O-320-E2A 180 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, March 1, 2021, 70 hours before - Departed: 6K5, Sisters, OR - Destination: 0WA2, Curtis, WA - Equipment: Electronic flight bag or handheld device ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 66; injuries: fatal; private; airplane ratings: single-engine land; medical: basicmed, with waivers/limitations; seat: left; toxicology performed; flight hours: 979 total ## Weather - Conditions: Instrument (IMC), Day - Wind: 310° at 13 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 70 °F, dew point 43 °F - Altimeter: 30.11 inHg - Observed at: KRDM, 34 nm away - METAR: KRDM 222056Z 31013KT 10SM CLR 21/06 A3011 RMK AO2 SLP179 T02110061 58006 ## 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 20220922021899A](https://openairdocs.org/incident/20220922021899A), Sep 22, 2022: Piper PA-28, Deschutes, OR, Destroyed, 1 fatal. Fatal aircraft crash due to unknown circumstances 22 miles north east of sisters Oregon. An alnot report was received September 09/22/2022 about an aircraft… ## Other investigations on N7063R (2) 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. - [NTSB LAX74DYA29](https://openairdocs.org/ntsb/LAX74DYA29), Apr 19, 1974: Piper PA-28 (N7063R), Twin Falls, ID, minor damage - [NTSB SEA71DXM26](https://openairdocs.org/ntsb/SEA71DXM26), Feb 28, 1971: Piper PA-28 (N7063R), Burley, ID, substantial damage ## Docket (14 files) The files NTSB released with the investigation on May 2, 2024, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=105990. 454 MB in all. - Materials laboratory factual report (item 1, PDF, 28 pages, 34 photos, 6.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15751920&FileExtension=pdf&FileName=23-050%20-%20Materials%20Lab%20Factual%20Report%20(WPR22FA354)-Rel.pdf - Medical factual report (item 2, PDF, 6 pages, 177 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16172516&FileExtension=pdf&FileName=WPR22FA354_MedicalFactualReport-Rel.pdf - Weather factual report (item 3, PDF, 20 pages, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14760405&FileExtension=pdf&FileName=WPR22FA354_weatherfactualSuffernfinal-Rel.pdf - Weather - attachment 1 (item 4, PDF, 5 pages, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14760005&FileExtension=pdf&FileName=attachment1_GFA-Rel.pdf - Record of conversations (item 5, PDF, 5 pages, 156 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16173894&FileExtension=pdf&FileName=record%20of%20convos-Rel.pdf - Foreflight tracking data, California home to jackson, California (item 6, PDF, 2 pages, 221 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16123281&FileExtension=pdf&FileName=Foreflight%20pilot%20home%20to%20JAQ_Redacted-Rel.pdf - Foreflight tracking data, jackson, California to curtis, Washington (item 7, PDF, 7 pages, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16121444&FileExtension=pdf&FileName=Foreflight%20JAQ%20to%20Curtis%20WA_Redacted-Rel.pdf - NTSB on-scene examination report (item 8, PDF, 4 pages, 3.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17008180&FileExtension=pdf&FileName=NTSB%20Onscene%20Examination%20Report-Rel.pdf - NTSB wreckage examination report (item 9, PDF, 8 pages, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16123457&FileExtension=pdf&FileName=NTSB%20Wreckage%20Examination%20Report-Rel.pdf - Email correspondence with refueller from sisters, Oregon (item 10, PDF, 3 pages, 171 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16123477&FileExtension=pdf&FileName=email%20correspondence%20fuel%20sisters%20OR_Redacted-Rel.pdf - Engine and propeller logbook (item 11, PDF, 7 pages, 13.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16123936&FileExtension=pdf&FileName=engine%20log_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 12, PDF, 2 pages, 110 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16122874&FileExtension=pdf&FileName=Release%20of%20Wreckage_Redacted-Rel.pdf - Pilot toxicology (item 13, PDF, 1 page, 167 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16123946&FileExtension=pdf&FileName=pilot%20toxicology_Redacted-Rel.pdf - Video of airplane taxiing out for departure (item 14, AVI, 422 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16123650&FileExtension=avi&FileName=T%20Hangar%202%20Fuel_20220922-N7063R%20Departing%20Fuel%20Island-Rel.avi 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.