Pilot Debrief

PIPER PA-28-140 near Moab, UT — 2023-10-02

Final reportWPR24FA002
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Date
2023-10-02
Location
Moab, UT, USA
Airport
KCNY
Aircraft
PIPER PA-28-140
Registration
N7153R
Category
Airplane
Highest injury
Fatal
Fatalities
4
Phase of flight
Takeoff roll

Probable cause

The pilot’s loss of visual reference to the horizon while departing during dark night, which resulted in the pilot experiencing spatial disorientation and subsequent controlled flight into terrain.

NTSB narrative

The pilot and three family members departed to return to their home airport. The departure was during dark nighttime conditions and into an area with little ambient light for visual reference. A witness statement, confirmed by video evidence, indicated that the pilot did not use the pilot-controlled runway lights and turned off the airplane landing light immediately after takeoff. Review of ADS-B data showed that, while at a low altitude, the airplane began a continuous 180° right turn that was described by the witness as steep and descending. Impact marks indicated that the pilot likely began a climb or held a nose-up attitude before the airplane’s landing gear struck a hill. The airplane continued beyond this first hill for about 540 ft, where it then descended in a nose-low attitude and impacted a second hill. The impacts fatally injured the occupants and substantially damaged the airplane. Before the accident flight, the pilot received a weather briefing that reported visual meteorological conditions for the departure airport, route of flight, and destination airport. The briefing did not include information on moon rise or illumination. A weather study revealed that, at the time of takeoff, the full moon had not risen completely above the horizon. The pilot did not use the functional pilot-controlled runway lights, thus eliminating this light source as a possible visual aid during the departure. Additionally, a local operator stated that their company pilots do not usually depart on the runway used by the accident pilot at night due to the dark conditions and the lack of visual references. The Federal Aviation Administration (FAA) Airplane Flying Handbook advised pilots flying at night that, after becoming airborne, the darkness of night often makes it difficult to note whether the airplane is getting closer to or farther from the surface. The handbook also stated to check flight instruments frequently during takeoff to ensure proper airspeed, attitude, and heading, and to climb to a safe maneuvering altitude before turning. The handbook noted that, when using the landing light at night during takeoff, a pilot should turn it off after the climb is well established. It is likely that the pilot neither had adequate visual references after takeoff nor monitored the airplane’s flight instruments appropriately to detect the airplane’s descent during the continuous 180° crosswind to downwind turn. This likely led to the pilot experiencing spatial disorientation, resulting in controlled flight into terrain. Postaccident examination of the airframe and engine revealed no evidence of preimpact mechanical malfunctions or failures that would have precluded normal operation. A review of the maintenance logbooks revealed no anomalies.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot could have ensured runway lights were on before takeoff.

NTSB coding

Evidence available

  • ADS-B / radar
  • Photos
  • 11 docket documents
View NTSB final reportView NTSB docket

Docket documents11

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