Pilot Debrief

PIPER PA-32S-300 near Forest Falls, CA — 2008-11-09

Final reportWPR09FA034
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Date
2008-11-09
Location
Forest Falls, CA, USA
Airport
L26
Aircraft
PIPER PA-32S-300
Registration
N312AG
Category
Airplane
Highest injury
Fatal
Fatalities
4
Phase of flight
Descent

Probable cause

The pilot's continued flight into instrument meteorological conditions and subsequent impact with mountainous terrain.

NTSB narrative

The flight departed in visual flight rule (VFR) flight conditions on a cross-country flight back to the pilot's home airport. About 35 miles southeast of the destination airport, the airplane impacted the northwest side of an 11,000-foot mountain approximately 150 feet below the mountain's crest. Based on an analysis of the meteorological conditions existing at the time of the accident and in the vicinity of the accident site, the cloud bases were near 7,000 feet with the cloud tops above 15,000 feet. An Airman's Information (AIRMET) report for icing and turbulence had been issued for the time of the accident, in the accident area. An airframe and engine inspection revealed no preimpact mechanical anomalies that would have precluded normal operation. The pilot had a history, known to the FAA, of an abnormal heart rhythm (atrial fibrillation) for which he was taking a blood thinner to reduce stroke risk, and a color vision deficiency. The accident forces prevented the evaluation of any pre-existing disease, and it is unclear what, if any, relevance the pilot’s cardiac abnormalities or color vision deficiency had to the accident.

Analysis

Primary failure mode
Controlled flight into terrain
First missed decision gate
Pilot could have avoided flying into mountainous terrain under adverse conditions.

NTSB coding

Evidence available

  • ATC audio
  • ADS-B / radar
  • Photos
  • 16 docket documents
View NTSB final reportView NTSB docket

Docket documents16

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