NTSB CAROL · Event
Event ERA23FA108
Aircraft involved
Probable cause & findings
The pilot’s controlled flight into terrain while descending over mountainous terrain at night.
Factual narrative
HISTORY OF FLIGHTOn January 11, 2023, about 1809 eastern standard time, a Piper PA-32R-301 airplane, N43156, was destroyed when it was involved in an accident near Dayton, Virginia. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to radar and radio communication information obtained from the Federal Aviation Administration (FAA), the pilot departed from Winchester Regional Airport (OKV), Winchester, Virginia, at 1739. The airplane then turned toward the southwest and established a flight track that roughly corresponded to a direct course between OKV and Shelby County Airport (EET), Alabaster, Alabama. At 1741, the pilot contacted Potomac Consolidated Terminal Radar Approach Control and advised that he had departed OKV to the southwest, was climbing through 3,500 ft mean sea level (msl) for 6,500 ft, and requested and received visual flight rules (VFR) flight following services enroute to EET. About 1749, the pilot checked in with the Washington Air Route Traffic Control Center while flying level at 6,500 ft. At 1802, the pilot advised the controller that he was going to descend to 5,500 ft for a few minutes. The controller acknowledged and instructed the pilot to maintain VFR, which the pilot acknowledged. No further transmissions were received from the pilot. ADS-B data showed that, about 1809, the airplane turned about 20° to the left from its previously established flight track to about 200° magnetic, as it continued to descend (see figure 1). The airplane’s last ADS-B-observed position was recorded at 1809:43, at an altitude about 4,100 ft. The controller broadcast that radar contact was lost about 1810. Figure 1. The airplane's ADS-B-observed flight track for the final portion of the flight, with the location of the wreckage at the accident site annotated. Emergency services personnel located the wreckage of the airplane at 0330 on January 12th in the Maple Spring area of the Shenandoah Mountains. The accident site was located about 470 ft south of the airplane’s last ADS-B-observed position at an elevation of 3,980 ft mean sea level (msl). PERSONNEL INFORMATIONAccording to FAA airman records, the pilot held a private pilot certificate. He did not possess an instrument rating. Review of an excerpt of the pilot’s personal flight logs revealed that, as of December 30, 2022, he had accumulated 1,772 total hours of flight experience, of which 300 hours were at night. The logbook entries reviewed did not annotate experience in instrument meteorological conditions. METEOROLOGICAL INFORMATIONThe 1755 recorded weather at Bridgewater Air Park (VBW), Bridgewater Virginia, located about 13 miles southeast of the accident site at an elevation of 1,165 ft, included wind from 190° at 7 knots (kts), 7 statute miles visibility, a broken cloud ceiling at 3,800 ft above ground level (agl), a temperature of 4°C, a dew point of 1°C, and an altimeter setting of 30.13 inches of mercury. The weather conditions reported at 1755 at Shenandoah Valley Regional Airport (SHD), Harrisonburg, Virginia, located about 19 miles southeast of the accident site at an elevation of 1,201 ft, were similar to those at VBW, and included 10 statute miles visibility in light rain, an overcast ceiling at 3,800 ft agl, temperature of 3°C and dewpoint of 1°C. A High-Resolution Rapid Refresh (HRRR) numerical model sounding for the vicinity of the accident site for 1800 depicted a near-surface temperature of 0.2°C, dew point temperature of -3.4°C, and relative humidity of 77%. The sounding depicted a frontal inversion from the surface through 1,913 ft agl (about 5,000 ft msl), where the temperatures increased with altitude and resulted in near-freezing temperatures at the surface and warmer air aloft. Analysis of the data supported a broken-to-overcast layer of nimbostratus type clouds from about 3,000 ft agl (6,200 ft msl) with tops near 17,000 ft msl, and supported the development of rain with the precipitable water. Multiple freezing levels were identified from just above the surface, with temperatures at -0.2 to -0.4°C below 1,000 ft above the surface, with temperatures above freezing above this layer. The second freezing level was identified at 6,800 ft with below freezing temperatures above this level. The wind profile for the sounding indicated southerly surface winds of 10 kts with winds veering to the west with height. A low-level wind maximum was identified around 5,000 ft with wind from 200° at 24 kts. At the accident airplane’s initial cruising level of 6,500 ft, the sounding indicated wind from 215° at 22 kts with a temperature of 0.5°C and a relative humidity near 92%. At 5,500 ft, the sounding indicated wind from 200° at 23 kts with a temperature near 1.5°C. The Complete rawinsonde observation (RAOB) analysis program did not indicate any structural icing potential below 6,500 ft. The NOAA Geostationary Operational Environmental Satellite No. 16 (GOES-16) infrared imagery for 1811 indicated an area of enhanced clouds over the accident site with radiative cloud top temperature of 239 Kelvin, or -34°C, which corresponded to cloud tops near 34,000 ft msl based on the HRRR sounding. The closest NWS Weather Surveillance Radar 1988 Doppler (WSR-88D) was located about 82 miles northeast of the accident site. Figure 2 shows the base reflectivity image for 1808 with the accident airplane’s flight track overlaid. The radar image depicted echoes of less than 30 dBZ (light intensity) over the route of flight where the pilot advised air traffic control of his intent to descend from 6,500 ft to 5,500 ft. No echoes were detected over the accident site. Figure 2. WSR-88D base reflectivity image for 1808 with the flight track overlaid (magenta line). The Graphic Forecast for Aviation (GFA), issued at 1400 and valid for 1900, depicted an area of restricted visibility over the accident site with a greater than 60% chance of rain and southerly winds of 10 to 15 kts. The GFA cloud forecast for the same period depicted overcast clouds with bases at 2,800 ft with tops to 23,000 ft, which, based on the accident site elevation, would be consistent with mountain obscuration conditions over the area. A review of the inflight weather advisories indicated that no SIGMETs, Convective SIGMETs, or Center Weather Advisories (CWA) were current surrounding the time of the accident. Two G-AIRMETs were issued at 1545 and were current over the route of flight and the accident site that warned of mountain obscuration and icing conditions. The Terminal Aerodrome Forecast (TAF) issued at 1704 for Charlotteville-Albemarle Airport (CHO), Charlottesville, Virginia, located about 40 miles southeast of the accident site at an elevation of 640 ft, was an amended forecast. The forecast current for the period surrounding the accident time expected wind from 270° at 3 kts, visibility better than 6 miles, ceilings overcast at 25,000 ft agl, with temporary conditions between 1700 and 1800 of wind from 170° at 4 kts, visibility 6 miles in light rain, and a broken ceiling at 11,000 ft. A search of the FAA contract Automated Flight Service Station provider, Leidos, indicated that neither they and nor any other third-party weather vendor using their flight planning system had any contact with the accident pilot for any weather briefings or flight plans before the accident flight. The vendor ForeFlight indicated that the pilot did have account, but that he had not filed a flight plan or created a “Flight,” which would have generated a weather briefing for a planned flight. The pilot had created several route strings before the flight and had viewed the airport data pages for EET, OKV, and HQU [Thomson/McDuffie County Airport, Thompson, Georgia], which would have included the latest surface observations, TAFs, and NOTAMs for those airports. According to data obtained from the US Naval Observatory, sunset occurred at 1715 and the end of civil twilight occurred at 1745 on the day of the accident. WRECKAGE AND IMPACT INFORMATIONExamination of the accident site revealed that the airplane impacted trees on an approximate magnetic heading of 194° and came to rest about 520 ft from the initial impact point. Examination of the wreckage revealed that it was highly fragmented. The left wing was impact-separated from the fuselage and fragmented. The right wing was separated from the fuselage at the root and separated about 3 ft from the wingtip. Semicircular impressions consistent with tree impact were noted on the leading edge at the area of separation. The stabilator, rudder, and aileron control cables remained attached to their respective attach points and were separated consistent with overload. The fuel selector was impact-damaged and was in the “OFF” position. The gascolator bowl was impact fractured. No debris was present in the bowl or the filter. The three-blade, constant-speed propeller was separated from the engine. The propeller spinner was fragmented. The propeller blades exhibited leading edge damage and S-type bending consistent with high engine rpm at impact. Examination of the engine revealed that it was partially impact-separated from the engine mounts of the fuselage. The engine sustained impact damage primarily to the lower front accessories and its bottom left side. The fuel injection servo was partially impact separated from the air housing of the engine. The throttle and mixture cables remained attached to the unit. The fuel inlet screen was clean. The dual magneto unit remained secured to the engine accessory housing and was undamaged. The dual magneto produced spark at all leads when rotated. The engine drivetrain rotated when force was applied to the crankshaft flange. Thumb compression was established on all cylinders except for the No. 2 cylinder, which was damaged in the rocker box area around the intake valve. Several digital avionics devices were recovered from the wreckage but none contained non-volatile memory relevant to the investigation. ADDITIONAL INFORMATIONReview of the sectional aeronautical chart for the area surrounding the accident site revealed that the maximum elevation figure for the area was 5,100 ft msl. According to the FAA Chart Users’ Guide, “The Maximum Elevation Figure (MEF) represents the highest elevation within a quadrant, including terrain and other vertical obstacles (towers, trees, etc.).” MEDICAL AND PATHOLOGICAL INFORMATIONAccording to the autopsy report from the Office of the Chief Medical Examiner, Commonwealth of Virginia, Manassas, Virginia, the pilot’s cause of death was multiple blunt force injuries, and the manner of death was accident. No significant natural disease was identified by the medical examiner. Toxicology testing performed by the FAA Forensic Sciences Laboratory detected cetirizine in samples of the pilot’s blood at 71 nanograms per milliliter (ng/mL) and 3,124 ng/ml in samples of the pilot’s urine. Cetirizine is a second-generation antihistamine used to relieve hay fever and allergy symptoms. It is available over the counter, commonly marketed as Zyrtec. Although designed to be less sedating than the first-generation antihistamines, cetirizine does have some sedating properties. The therapeutic range is between 190 and 1,450 ng/mL; the elimination half-life is between 6.5 and 10 hours. The FAA provides guidance on wait times before flying after using this antihistamine. The pilot departed on the visual flight rules (VFR) cross-country flight at night. Shortly after departing, the pilot established the airplane along a course directly toward the destination airport, climbed to a cruise altitude of about 6,500 ft mean sea level (msl), and contacted air traffic control to request flight following services. About 10 minutes later, the pilot advised the controller that he was descending to 5,500 ft msl, and the controller advised the pilot to “maintain VFR.” No further transmissions were received from the pilot. The airplane descended below 4,500 ft and deviated about 20° left of its previously established course. The airplane continued its steady descent until it impacted mountainous terrain at an elevation about 4,000 ft msl. The accident site was located less than 500 ft horizontally and 100 ft vertically from the airplane’s last ADS-B-observed position, and the debris path was oriented roughly along the airplane’s previously established course line. The length of the debris path, impact signatures observed on the wreckage, and the degree of fragmentation of the wreckage were all consistent with a controlled flight into terrain-type impact. Examination of the airframe and engine displayed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. The accident pilot held a private pilot certificate and had accumulated nearly 1,800 total hours of flight experience, but did not hold an instrument rating. Review of forecast and observed weather conditions revealed that light rain and overcast clouds prevailed along the route of flight, and that the airplane many have been flying through light rain showers around the time when the pilot advised air traffic control that he was descending. AIRMETS valid at the time of the accident warned of mountain obscuration, and surface observations from nearby airports confirmed that there was likely an overcast cloud ceiling around 5,000 ft msl in the area; however, based on the available weather information, it could not be determined whether the pilot encountered instrument meteorological conditions (IMC) in flight or was descending in order to avoid IMC when the impact with terrain occurred. Given the night lighting conditions and the lack of ambient cultural lighting available in the area of the accident site, it is likely that the pilot was unable to see the terrain below. Postmortem examination of the pilot’s remains identified no significant natural disease. Toxicology testing detected likely subtherapeutic concentrations of the sedating antihistamine, cetirizine, in his blood; however, side effects from low levels of this over-the-counter allergy medication would not likely influence his decision-making ability or his ability to control the airplane. The pilot’s use of cetirizine was likely not a factor in this accident. Source: NTSB Aviation Accident Database Retrieved: 2026-02-12
NTSB Findings
Hierarchical cause / factor breakdown from the FAA bulk avdata database. Each finding tagged C (Cause) or F (Factor).
- — Personnel issues-Action/decision-Info processing/decision-Identification/recognition-Pilot
- — Environmental issues-Conditions/weather/phenomena-Light condition-Dark-Response/compensation
- — Environmental issues-Physical environment-Terrain-Mountainous/hilly terrain-Awareness of condition
- — Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Altitude-Not attained/maintained
Verbatim from NTSB's published report. Source file
NTSB_2023_ERA23FA108.txt.
Findings + structured fields enriched from FAA avall.mdb.
Full investigation docket on
data.ntsb.gov ↗.
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Related research
What the literature says.
Academic papers and agency reports matching this event's aircraft type or causal vocabulary (icing, controlled flight into terrain, imc). Sourced from NASA NTRS, NTSB Safety Studies, FAA CAMI, AOPA Air Safety Institute, Embry-Riddle Scholarly Commons, arXiv, and the Semantic Scholar academic graph.
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Icing Physics Studies Using the 3D SIDRM Test Article: 2023 Icing Tests Analysis
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- arXiv 2025 · arXiv preprint
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- Embry-Riddle Scholarly Commons 2025 · Journal article (JAAER)
A Mathematical Model on the Temporal Dynamics of Aviation Competitive Pricing
This study investigates the competitive dynamics of airport pricing using U.S. airport data to validate the findings. It employs linear and nonlinear ordinary differential equation models to analyze t…
- NASA NTRS 2025 · Presentation
NASA Icing Update – March 2025
This NASA Icing Update was prepared for presentation to the SAE International AC-9C Inflight Icing Technology Committee. This update includes the following topics: planned Rotational Icing Scaling tes…
- arXiv 2024 · arXiv preprint
An energy-stable phase-field model for droplet icing simulations
A phase-field model for three-phase flows is established by combining the Navier-Stokes (NS) and the energy equations, with the Allen-Cahn (AC) and Cahn-Hilliard (CH) equations and is demonstrated ana…
- NASA NTRS 2024 · Presentation
NASA Icing Update – Oct 2024
This presentation provides a status update on select NASA icing research activities for the SAE AC-9C Icing Technical Committee Meeting on Oct 21, 2024.
Browse the full corpus — academia portal ↗