GAA16CA212
2016-04-30 · Poplar Grove, Illinois, United States · None · 1 aircraft · Status: Completed
Airport C77
Current FAA registration · N4242H
- Make / Model
- CESSNA 140A
- Year of manufacture
- 1949 · 67 years old at event
- Engine
- CONT MOTOR C90 SERIES (95 hp)
- Seats / Engines
- 2 seats · 1 engine
- Last airworthiness date
- 19560323
- ADS-B equipped
- Yes — Mode-S A50D21
Source: FAA Aircraft Registry (releasable master file).
Aircraft involved
Probable cause & findings
The pilot's visual disorientation and failure to monitor the altimeter during a night approach, which resulted in controlled flight into terrain.
Factual narrative
The pilot reported that during a night visual meteorological condition flight he was about 5 nautical miles away from the destination airport and could see the runway lights. The pilot further reported that he was not able to see the terrain and it was a "black hole approach." As the pilot initiated a descent toward the runway, the airplane impacted terrain in a wooded area about 4 nautical miles west of the runway threshold. The pilot reported that he did not observe the terrain any time before the impact, but could see the bright runway lights. The left and right wings were substantially damaged. The pilot did not report any mechanical malfunctions or failures with the airplane that would have precluded normal operation. The Federal Aviation Administration Pilot's Handbook of Aeronautical Knowledge in part states: "A black-hole approach occurs when the landing is made from over water or non-lighted terrain where the runway lights are the only source of light. Without peripheral visual cues to help, pilots will have trouble orientating themselves relative to Earth. The runway can seem out of position (downsloping or upsloping) and in the worse case, results in landing short of the runway. If an electronic glide slope or visual approach slope indicator (VASI) is available, it should be used. If navigation aids (NAVAIDs) are unavailable, careful attention should be given to using the flight instruments to assist in maintaining orientation and a normal approach. If at any time the pilot is unsure of his or her position or attitude, a go-around should be executed. The pilot reported that during a night visual meteorological condition flight he was about 5 nautical miles away from the destination airport and could see the runway lights. The pilot further reported that he was not able to see the terrain and it was a "black hole approach." As the pilot initiated a descent toward the runway, the airplane impacted terrain in a wooded area about 4 nautical miles west of the runway threshold. The pilot reported that he did not observe the terrain any time before the impact, but could see the bright runway lights. The left and right wings were substantially damaged. The pilot did not report any mechanical malfunctions or failures with the airplane that would have precluded normal operation. The Federal Aviation Administration Pilot's Handbook of Aeronautical Knowledge states in part: "A black-hole approach occurs when the landing is made from over water or non-lighted terrain where the runway lights are the only source of light. Without peripheral visual cues to help, pilots will have trouble orientating themselves relative to Earth. The runway can seem out of position (downsloping or upsloping) and in the worse case, results in landing short of the runway. If an electronic glide slope or visual approach slope indicator (VASI) is available, it should be used. If navigation aids (NAVAIDs) are unavailable, careful attention should be given to using the flight instruments to assist in maintaining orientation and a normal approach. If at any time the pilot is unsure of his or her position or attitude, a go-around should be executed." Source: NTSB Aviation Accident Database Retrieved: 2026-02-12
NTSB Findings
FAA avdata. C = Cause, F = Factor.
- C Personnel issues-Psychological-Attention/monitoring-Monitoring equip/instruments-Pilot - C
- C Personnel issues-Psychological-Perception/orientation/illusion-Visual illusion/disorientation-Pilot - C
- C Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Descent/approach/glide path-Not attained/maintained - C
- C Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Altitude-Not attained/maintained - C
- — Environmental issues-Conditions/weather/phenomena-Light condition-Dark-Effect on personnel
Verbatim from NTSB's published report. Source file
NTSB_2016_GAA16CA212.txt.
Findings + structured fields enriched from FAA avall.mdb.
Full investigation docket on
data.ntsb.gov ↗.
Search this event elsewhere
External sources are reported, not agency: signal that something happened, not fact about what happened.
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Related research
Matched on aircraft type or causal vocabulary (controlled flight into terrain, go-around). All research papers
- NASA NTRS 2025 · Conference Paper A Training Study to Improve Monitoring During A Go-Around
As part of an FAA program to improve go-around (GA) safety, we were asked to determine if we could improve the performance of the Pilot Monitoring (PM) during a GA maneuver.
- Flight Safety Foundation 2024 · FSF / AeroSafety World Go-Around Safety Forum Findings
Foundation Go-Around Safety Forum technical findings — examines why pilots fail to execute go-arounds when criteria are met (stabilized approach gate not met, energy state out of envelope, traffic con…
- Flight Safety Foundation 2023 · FSF / AeroSafety World Controlled Flight Into Terrain (CFIT) — A 2023 Industry Refresh
Foundation 2023 CFIT data refresh — three decades after the original CFIT Task Force eliminated >95% of air-carrier CFIT, the GA + Part 135 communities still account for most CFIT fatalities.
- Semantic Scholar 2022 · Article (Journal of Safety Research) Go-around accidents and general aviation safety.
INTRODUCTION Changes in General Aviation (GA) accident rates, specifically in the go-around phase, are examined by comparing the number of accidents, the proportion of fatal accidents, and the proport…
- Semantic Scholar 2021 · Article (Aerospace) Classification and Analysis of Go-Arounds in Commercial Aviation Using ADS-B Data
Go-arounds are a necessary aspect of commercial aviation and are conducted after a landing attempt has been aborted. It is necessary to conduct go-arounds in the safest possible manner, as go-arounds …
- NASA NTRS 2021 · Accepted Manuscript (Version with final changes) Go-Around Criteria Refinement for Transport Category Aircraft
Presently, airline pilots are trained to go around if, when lower than 500 ft above the ground, they are outside of a handful of parameters such as airspeed, position, and rate of descent.