WPR21FA231

The pilot’s misidentification of a mountain pass at night, which resulted in controlled flight into terrain. Contributing to the accident were the pilot’s overconfidence based on her previous aviation experience and fatigue due to both the time of the flight and her work schedule. Also contributing was the pilot’s decision not to install an automatic dependent surveillance-broadcast (ADS-B) system, which forced a flightpath close to mountainous terrain to avoid the Mode-C and ADS-B Out veil.

The accident flight was the second leg of an overnight, multi-leg cross-country from the pilot’s home airport in Northern Montana to her grandfather’s house in Southern California. The pilot was traveling with her granddaughter, and the trip was planned as a Father’s Day surprise. The pilot opted to fly overnight to avoid the heat and turbulence associated with flying over the desert during the day. The airplane was not equipped with an ADS-B transponder. In order to avoid both the Salt Lake City International Airport (SLC) Mode-C and automatic dependent surveillance -broadcast (ADS-B) system out veil an adjacent military operation area (MOA), the pilot chose to fly through a narrow, mountainous corridor. Due to the altitude limitation of the MOA, the pilot could not fly over the mountain range. Radar data confirmed that the airplane passed very close to terrain as it avoided the SLC Mode C veil, and ultimately turned into a valley and rising terrain just short of a mountain pass that led away from the airspace and in the direction of the destination. Although the moon was in a position where it would have silhouetted the mountains, it was only 50 percent illuminated, and a broken cloud layer was present that would have obscured most of the available moonlight. The pilot had already worked a full day and departed on the flight late in the afternoon. The accident occurred at about the halfway point of the trip, about 7 hours after departure from her home airport, almost 18 hours from when she likely woke to report for work, and about the time she would normally have gone to sleep. Therefore, she was likely suffering the effects of fatigue as a result of the flight time and extended time awake. Additionally, her circadian systems were not actively promoting alertness because she was operating the airplane at a time she would normally have been asleep. The majority of the pilot’s flight experience was as an Army helicopter pilot, with about ¼ of her flight time accrued at night, often over desert terrain, frequently with night vision goggles. Since then, she had taken a long break from flying, and recently purchased the accident airplane and attained her fixed wing private pilot’s license. The accident flight was the longest flight she had flown since leaving the Army, and her longest flight single-pilot in a fixed-wing airplane. The pilot’s decision making associated with the timing of the flight over mountainous terrain suggests overconfidence based on her previous flight experience. The pilot was carrying oxygen to aid with her night vision; although she had taken a borrowed GPS moving map system that was capable of displaying terrain features, this was the first time she had used it, and she was likely not proficient in its operation. The airplane crossed into the Mode-C and ADS-B Out veil twice as it followed a meandering track around the SLC airspace and came perilously close to terrain on two occasions, further indicating that the pilot was possibly suffering the effects of fatigue and either not proficient in the operation of the GPS unit or not using it. It is likely that the pilot lost situational awareness and turned prematurely into the valley, possibly mistaking it for the pass, resulting in controlled flight into terrain.

The pilot graduated from United States Army Flight School in February 2001 and received a qualification to fly the CH-47D helicopter later that year. Records indicate that she was regularly stationed internationally through 2008, during which time she flew multiple combat missions, often in desert terrain. During that period, she logged a total flight time of 689.1 hours, 167.7 of which were flown at night, with 29.7 hours using night vision goggles. Based on her military experience, she held an FAA commercial pilot certificate with ratings for rotorcraft-helicopter and instrument helicopter. The pilot began flying civil fixed-wing aircraft in October 2020 and attained FAA private pilot privileges for airplane single-engine land on March 14, 2021. All of her 174.3 hours of fixed-wing flight experience was in the accident airplane type, 12.8 of which were at night. Logbooks indicated that she routinely flew missions lasting up to 4.5 hours long while in the Army, but the accident flight would have been the longest she had flown solo in a fixed-wing airplane. The pilot’s most recent FAA medical examination was conducted on August 7, 2020, and although the pilot needed to wear reading glasses, she was issued a third-class medical certificate without limitations. The pilot’s flight instructor, who performed her most recent fixed-wing training, stated that the pilot had never discussed plans to take the cross-country accident flight. He was surprised and disappointed that she did not call him to discuss, as he would have done his best to dissuade her from taking such a trip at night over such long distances. He had not provided, nor was he required to provide, any mountain flying training. Sleep History There were no witnesses to the pilot’s sleep schedule the night before the accident; however, according to the pilot’s friend, she typically awoke between 0430 and 0500. Typically, she arrived at work about 0600, and left at 1500. He last spoke to her the night before the accident by phone, at 2230. According to the autopsy report from the Office of the Medical Examiner, Utah Department of Health, the cause of the pilot’s death was blunt force injuries, and the manner of death was accident. No significant natural disease was identified. FAA Forensic Sciences Laboratory testing on pilot specimens was negative for all screened drug substances and ingested alcohol. The pilot purchased the airplane in December 2020. Maintenance logbooks were not recovered and presumed to have been destroyed in the accident; however, a copy of the last annual inspection was provided by the mechanic who worked on the airplane most recently. The inspection was completed on January 13, 2021 and did not reveal any significant anomalies. The airplane was equipped with a conventional visual flight rules (VFR) instrument panel and a Bendix/King KT76 transponder. The pilot stated to an acquaintance that installing an ADS-B system was prohibitively expensive, and that it was not necessary based on her typical flying routine. The airplane was not equipped with any terrain awareness or moving map systems; however, the weekend before the flight, the pilot’s friend gave her his portable Garmin 696 GPS navigation system and a GDL 51 Portable SiriusXM receiver. The 696 unit was configured to display terrain and receive XM weather information through the GDL 51. He reported offering to teach the pilot how to use the Garmin unit, but she declined, saying that she would teach herself. The accident flight was the first time she had used it for flight. Along with the Garmin 696, the pilot’s friend also gave her a set of FAA VFR sectional and world aeronautical charts. He stated that the pilot also used a free flight planning application on her phone, which had a basic moving map feature that included sectional charts, but no terrain-warning capabilities. The friend stated that the pilot enjoyed pilotage and navigating from landmarks rather than using a GPS. He stated that she was very familiar with VFR sectional charts and preferred them to using GPS devices. She was observant of the obstruction altitudes in each sectional sector, and due to her military experience, was very sensitive about flying into MOAs and felt the general aviation community had a cavalier approach to airspace restrictions. He stated that she adhered to a rigid, rules-based style of operation due to her military aviation training. The pilot stated that she was concerned about fatigue for the flight but felt that having her granddaughter present would keep her awake. She stated that when in the Army, she was trained to use supplemental oxygen for night flights above 5,000 ft to help with night vision. Therefore, he lent her his supplemental oxygen system for the flight, which included one cannula and an oxygen tank, that had just been filled. According to family members, the pilot’s granddaughter typically flew in a booster seat mounted to the front right seat. The airplane came to rest on a 30° uphill slope within a valley, about 1,300 ft beyond, and at the same elevation as, the last radar target (8,200 ft). The terrain within a mile of the wreckage, and in the direction of the radar track, rose rapidly to an elevation of about 10,300 ft. The valley was about 3 miles north of “Johnson Pass,” a 6,515-ft pass denoted on both the Salt Lake City VFR sectional and terminal area charts. The terrain comprised loose rock and soil, dispersed with pine trees and brush. The first identified point of impact was an 18-inch-wide tree trunk, severed about 15 ft above ground level. The left wing had detached and was located about 10 ft upslope of the trunk. The wing had folded aft midspan and exhibited a semi-circular indentation in the wing spar, which matched the diameter of the trunk. A 10-ft-wide ground disruption was present to the right of the wing and contained fragments of painted aluminum, along with the nose wheel. The ground disruption was located about the same level horizontally as the severed tree trunk. The main wreckage, which included the burnt remnants of the cabin and right wing, along with the engine and empennage, was located an additional 20 ft upslope. The fuselage was oriented on a heading of about 220°. The engine remained partially attached to the firewall. The propeller had detached from the crankshaft and was the last section located in the debris field, an additional 15 ft upslope. No evidence of preimpact mechanical malfunction was noted to the airframe or engine during the examination, both on-site and after the airplane was recovered. Both fuel tanks exhibited evidence of hydrodynamic deformation consistent with containing fuel at impact, and both propeller blades exhibited deep leading-edge gouges and radial chordwise scoring, consistent with engine operation at impact. The instrument panel, including the altimeter, was destroyed. The oxygen tank sustained impact damage, but its valve was found in the open position. The belt buckles for all seat positions were recovered, and all appeared to be latched. On June 17, 2021, about 2253 mountain daylight time, a Piper PA-28-140, N6323R, was destroyed when it was involved in an accident near Rush Valley, Utah. The pilot and passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 flight. The accident flight was the second leg of an almost 1,100-mile cross-country trip from the pilot’s home airport of Havre City-County Airport (HVR), Havre, Montana, to El Centro NAF Airport (NJK), El Centro, California. The airplane departed HVR about 1600, and according to a friend of the pilot, the pilot planned to stop for fuel at Idaho Falls Regional Airport (IDA), in Idaho Falls, Idaho, then fly through the night to Cedar City Regional Airport (CDC), Cedar City, Utah, arriving in El Centro by 0600. The pilot was traveling with her granddaughter