NTSB CAROL · Event
Event WPR17FA025
Aircraft involved
Probable cause & findings
The pilot's failure to maintain clearance from rising terrain in dark night conditions, which resulted in controlled flight into terrain.
Factual narrative
HISTORY OF FLIGHTOn November 22, 2016, about 0420 Pacific standard time, a Piper PA-28-181 airplane, N6912C, impacted mountainous terrain shortly after takeoff from Cable Airport (CCB), Upland, California. The private pilot was fatally injured. The airplane was substantially damaged. The airplane was privately owned and operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91. Night visual meteorological conditions (VMC) prevailed, and no flight plan was filed for the personal flight, which originated from CCB at 0416 and was destined for Riverside Airport (RAL), Riverside, California. After departure from CCB, the pilot contacted the Ontario International Airport (ONT) local controller about 0419. The controller instructed the pilot to identify using the airplane's transponder and issued the current altimeter setting. About 0420, the pilot acknowledged the instruction and reported that he "just departed Cable en route to Riverside we're VFR we just appreciate…." The transmission was cut short and radar contact was lost. The controller tried several times to reestablish contact with the airplane; however, there were no further communications from the pilot. About 15 minutes later, an Emergency Locator Transmitter (ELT) signal was identified and an Alert Notice (ALNOT) was issued at 0457. The wreckage was located shortly thereafter at an elevation about 2,920 ft mean sea level (msl) on the south face of rising mountainous terrain, about 3.5 nautical miles north of CCB. Recorded radar data indicated that, after the airplane departed runway 24, it made a climbing left turn then proceeded to cross over CCB. The target continued a northerly course, climbing to an altitude of 3,000 ft msl. Radar contact was lost near the accident site about 3 minutes after takeoff. PERSONNEL INFORMATIONThe pilot held a private pilot certificate with ratings for airplane single-engine land and instrument airplane. A review of the pilot's logbook indicated 2,557.6 total hours of flight experience. The logbook contained records of flights between September 2011 and January 2013; there were no flights recorded between January 2013 and August 2016. During the 3 months before the accident, the pilot completed a flight review and an instrument proficiency check. During this time, he logged 12.9 hours simulated instrument time, 15 instrument approaches, and 2.4 hours of night flight experience. The pilot had 12.6 hours in the accident airplane make and model, all of which occurred in the 20 days before the accident. The pilot had accumulated a total of 523 hours of experience in actual instrument conditions, none of which occurred within the 3 months before the accident. The pilot's most recent Federal Aviation Administration (FAA) second-class medical certificate was issued on August 22, 2016, with the limitation that he must wear corrective lenses and possess glasses for near/intermediate vision. The instructor who endorsed the pilot for his most recent instrument proficiency check stated that the pilot reported that he was uncomfortable flying in night conditions. AIRCRAFT INFORMATIONThe 4-seat, low-wing, fixed-gear airplane, serial number 28-8590051, was manufactured in 1985. A review of the airplane's logbooks showed a total airframe time of 3,357.5 hours at the most recent annual inspection in October 2016. At the time of the accident, a total time of 3,409.9 hours was recorded on the Hobbs meter. The engine was a 180-horsepower Lycoming O-360-A4M, serial number L-31037-36A. The engine logbooks indicated that the most recent 100-hour inspection was completed in October 2016. The engine total time was recorded as 3,004.7 hours, with 1,004.7 hours since major overhaul. METEOROLOGICAL INFORMATIONThe 0429 weather observation at ONT included calm wind, 10 statute miles visibility, broken clouds at 1,500 ft, temperature 50° F, dewpoint 48° F, and an altimeter setting of 30.08 inches of mercury. According to the U.S. Naval Observatory, Astronomical Applications Department, sunset occurred in Upland, California, at 1643, and civil twilight ended at 1710 the night before the accident. On the morning of the accident, civil twilight occurred at 0603, and sunrise occurred at 0630. There was a waning crescent moon, with 36% of its visible disk illuminated. Moon transit occurred at 0017, and moonset occurred at 1314. AIRPORT INFORMATIONThe 4-seat, low-wing, fixed-gear airplane, serial number 28-8590051, was manufactured in 1985. A review of the airplane's logbooks showed a total airframe time of 3,357.5 hours at the most recent annual inspection in October 2016. At the time of the accident, a total time of 3,409.9 hours was recorded on the Hobbs meter. The engine was a 180-horsepower Lycoming O-360-A4M, serial number L-31037-36A. The engine logbooks indicated that the most recent 100-hour inspection was completed in October 2016. The engine total time was recorded as 3,004.7 hours, with 1,004.7 hours since major overhaul. WRECKAGE AND IMPACT INFORMATIONThe airplane impacted terrain in a slight left-wing-low, nose-high attitude. The hillside was comprised of low brush, rocky and loose soil on a slope of about 50°. The airplane came to rest at the initial impact point. There were no ground structures or lighting in the immediate area. All flight control surfaces were located at the accident site. Control continuity was established from the cockpit area to the flight control surfaces. Both wings remained at least partially attached at the wing roots. The left wing leading edge was crushed upwards along its span. The right wing sustained extensive ground impact damage, mostly to the bottom surface. The forward cockpit and instrument panel sustained extensive impact damage and rearward crushing. The rear empennage and tail section, including the vertical stabilizer, rudder, horizontal stabilators, and elevators sustained minor impact damage and were mostly intact. The engine remained attached to the airframe by the engine mounts. The engine sustained significant impact damage, particularly on the lower left side. A visual and subsequent teardown examination revealed no evidence of a preimpact mechanical failure or malfunction. The two-bladed, fixed-pitch propeller remained attached at the crankshaft flange. The spinner was attached to the propeller. The propeller blades (labeled as #1 and #2) remained attached to the propeller hub. Blade #1 displayed leading edge gouging, torsional twisting, chordwise striations across the cambered surface, and S-bending. An approximate 2-inch section of the blade tip had torn away. Blade #2 remained intact, straight, and sustained minor damage. A detailed engine and airframe examination report is included in the public docket. MEDICAL AND PATHOLOGICAL INFORMATIONThe San Bernardino County Sheriff's Department, Coroner Division, San Bernardino, California, conducted postmortem examinations of the pilot. The cause of death was reported as instantaneous blunt force trauma. The Federal Aviation Administration's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological testing on specimens of the pilot, which were negative for carbon monoxide and ethanol. Atenolol was detected in liver and muscle. Atenolol (generic and several brand names including Tenormin®) is a prescription medication used alone or in combination with other medications to treat high blood pressure. It also is used to prevent angina (chest pain) and improve survival after a heart attack. Atenolol is in a class of medications called beta blockers and is not considered to be impairing. The private pilot departed from a non-towered airport in dark night conditions destined for an airport located about 15 nautical miles southeast; a direct route of flight between the two airports would require flight through controlled (Class C) airspace. Radar data showed that, after departure, the pilot conducted a left climbing turn, then proceeded north (as prescribed for noise abatement procedures at the airport), and remained clear of the controlled airspace, toward an area of dark, unpopulated, rising terrain. About 3 minutes after departure, the pilot contacted the local controller. While talking to the controller, the pilot's transmission suddenly stopped, and the airplane was lost from radar at an altitude about 3,000 ft mean sea level in the vicinity of the accident site. The accident site was located on steep, rising terrain at an elevation about 2,920 ft. Ground scars indicated that the airplane was in a nearly wings-level attitude at the time of impact. There were no preimpact anomalies with the airframe or engine that would have precluded normal operation. It is likely that, while communicating with the controller, the pilot did not monitor and maintain situational awareness as the airplane approached mountainous, unlit terrain. 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).
- C Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Altitude-Not attained/maintained - C
- C Personnel issues-Psychological-Attention/monitoring-Monitoring environment-Pilot - C
- — Environmental issues-Physical environment-Terrain-Mountainous/hilly terrain-Contributed to outcome
- — Environmental issues-Conditions/weather/phenomena-Light condition-Dark-Effect on operation
Verbatim from NTSB's published report. Source file
NTSB_2016_WPR17FA025.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 (controlled flight into terrain). Sourced from NASA NTRS, NTSB Safety Studies, FAA CAMI, AOPA Air Safety Institute, Embry-Riddle Scholarly Commons, arXiv, and the Semantic Scholar academic graph.
- 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.
- NASA NTRS 2019 · Technical Publication (TP)
Flight Simulator Evaluation of Synthetic Vision Display Concepts to Prevent Controlled Flight Into Terrain (CFIT)
In commercial aviation, over 30-percent of all fatal accidents worldwide are categorized as Controlled Flight Into Terrain (CFIT) accidents, where a fully functioning airplane is inadvertently flown i…
- NASA NTRS 2019 · Other
Preliminary Effect of Synthetic Vision Systems Displays to Reduce Low-Visibility Loss of Control and Controlled Flight Into Terrain Accidents
An experimental investigation was conducted to study the effectiveness of Synthetic Vision Systems (SVS) flight displays as a means of eliminating Low Visibility Loss of Control (LVLOC) and Controlled…
- NASA NTRS 2019 · Technical Memorandum (TM)
Rating the Relevance of QUORUM-Selected ASRS Incident Narratives to a "Controlled Flight into Terrain" Accident
An exploratory study was conducted to identify commercial aviation incidents that are relevant to a "controlled flight into terrain" (CFIT) accident using a NASA-developed text processing method.
- Embry-Riddle Scholarly Commons 2001 · Journal article (JAAER)
Controlled Flight into Terrain: How the Airlines and the Federal Aviation Administration are Addressing the Problem
Controlled Flight into Terrain (CFIT) is not a new problem. It has been around since the beginning of manned flight. A CFIT accident occurs when an airworthy aircraft, under the control of a pilot, is…
- Embry-Riddle Scholarly Commons 2023 · Conference paper
Aircraft Energy Management: A Best Practice for Integrating Safety and Efficiency
Aircraft Energy Management: A Best Practice for Integrating Safety and Efficiency The airplane is the quintessential energy system, constantly transforming, transferring, distributing, storing, and ex…
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