Event WPR23FA083

Factual narrative

HISTORY OF FLIGHTOn January 4, 2023, about 1456 mountain standard time, a Piper PA-34-220T, N814WT, was destroyed when it was involved in an accident near New Harmony, Utah. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot had flown from his home base of Salt Lake City Airport (SLC) the morning of the accident to check on a residence in the St. George area, and the accident flight was to be his return trip. A concerned family member reported the airplane overdue, and the Federal Aviation Administration (FAA) issued an Alert Notice (ALNOT). A search for the airplane was initiated and the wreckage was found the following day in mountainous terrain, about 3 miles north of New Harmony, Utah. ADS-B data provided by the FAA indicated that the airplane departed from runway 19 at St. George Regional Airport (SGU) about 1439. The airplane continued on a northeast heading for six minutes, reaching a GPS reported altitude of about 10,000 ft. The airplane then began to descend and after reaching 9,000 ft one minute later, it made a 90° left turn while continuing to descend to 8,625 ft. For the next four minutes, the airplane continued on a northerly track toward rising terrain while crossing over and to the west of Interstate 15. After descending to 7,375 ft, the airplane turned 90° to the left toward an 8,300-ft-tall mountain peak. The airplane then began a climbing left turn, reaching 8,425 ft one minute later. The next ADS-B target, recorded 14 seconds later, indicated that the airplane had descend to 6,900 ft on a southerly heading. For the last 15 seconds, the airplane continued in a left turn, climbing to 7,525 ft about 2,000 ft west of the accident site (see figure 1). Figure 1 – ADS-B Image of flight (the green line represents the path between the last recorded targets and does not depict the true flight path). Multiple witnesses reported that the mountain range at the accident site was obscured by clouds. One witness, who was a pilot, stated that she was in her house in New Harmony, about 1 mile from the accident site, when she heard the sound of a low flying airplane. She checked its location using an aircraft flight tracking website, which showed the airplane flying directly overhead at 7,300 ft mean sea level (msl), an altitude she thought was unusually low for the area and terrain. She reported cloud bases of between 200 and 300 ft above ground level, with the surrounding mountainous terrain completely obscured. She watched on the website as the airplane made a 180° turn, and she listened outside but heard no significant changes in the pitch of the engines. She continued to listen as the airplane flew away, and the sound of the engines faded into the distance. PERSONNEL INFORMATIONThe pilot held a private pilot certificate with ratings for airplane single- and multi-engine land, and instrument airplane. According to his most recent FAA medical exam, dated February 24, 2022, he reported 2,625 total flight hours, with 50 in the last six months. The pilot’s logbooks were not recovered. Review of data extracted from the airplane’s integrated flight deck (IFD) indicated that most of the flights flown during the year leading up to the accident were direct between SLC and SGU, with some short local flights to airports just north of SLC. According to family members, the pilot was based in Salt Lake City, but had a house in the St. George area, and routinely flew the accident route. The reason for the flight was to check on his house and another construction project in the area. They were not aware of any urgent reason for him to return that day, and although he was planning on leaving for a vacation, it was not until the following week. The pilot’s daughter, who had a pilot’s certificate, stated that he was meticulous with his flight preparation and routinely flew using the autopilot. She stated that the airplane had a well-equipped avionics suite, including terrain awareness and weather. The pilot started flying in the 1990’s, and this was his third Seneca. She was not aware of any issues with the airplane or its autopilot, and while he sometimes flew under instrument flight rules (IFR) and in inclement weather, for the flights between Salt Lake and St George he typically flew under VFR and direct between the two airports. Earlier on the day of the accident, he had mentioned that there was a window in the weather before storms were coming through the area. AIRCRAFT INFORMATIONThe airplane was manufactured in 2014 and purchased new by the pilot. It was equipped with a Garmin G1000 IFD, which included a primary and a multi-function display and a GFC 700 Automatic Flight Control System (AFCS) autopilot. The airplane also included an Aspen Avionics EFD1000 primary flight display, configured as a backup system. The Garmin IFD included a synthetic vision system, which displayed terrain and obstacle clearance alerts on the primary screen, along with the topography immediately in front of the airplane. The system provided visual and audible alerts of terrain threats relative to the projected flight path. The G1000 Cockpit Reference Guide specifically stated that the terrain avoidance feature was not to be used as the sole means of navigation and terrain separation, and that it was only to be used as an aid to terrain avoidance. The AFCS included return-to-level (LVL) and Electronic Stability and Protection (ESP) features. When LVL is activated, the autopilot returned the airplane to a wings-level attitude and zero vertical speed. LVL mode was activated by pressing a switch at the top center of the instrument panel and could be activated while the autopilot was engaged or disengaged. Regardless of autopilot status prior to activating LVL Mode, the autopilot would become engaged in the lateral and vertical modes of LVL. Selecting another lateral or vertical mode while LVL was active would activate that mode and cancel the LVL in that axis. ESP functioned only when the autopilot was disengaged. When enabled, ESP provided a control force feedback “soft barrier” to return the airplane to a nominal operating envelope. If operating within the ESP envelope for an extended period of time, an “Engaging Autopilot” aural alert would sound, and the autopilot would automatically engage in LVL mode. The autopilot could be disengaged manually by pressing the A/P DISC / TRIM INTER switch on the control wheel or activating either half or both halves of the manual electric pitch trim switch on the control wheel, or by pressing the AP key on the MFD. Autopilot disconnects or failures were accompanied by aural alerts and visual annunciations on the PFD. The airplane was also equipped with an ice protection system, approved for flight into known icing conditions. It was designed for operation in light to moderate meteorological conditions defined in FAR 25, Appendix C, for continuous maximum and intermittent maximum icing conditions. The system consisted of pneumatic wing and empennage boots, a wing ice detection light, electrothermal propeller deice pads, electrically heated windshield panel, heated lift detectors, and a heated pitot head. The vacuum system consisted of a vacuum pump on each engine, plus plumbing, filtering and regulating equipment. The flight manual supplement for the ice protection system stated that continuous attention was required by the pilot to monitor the rate of ice buildup in order to accomplish the boot cycle at the optimum time. Boots were to be cycled when ice had built to between 1/4 and 1/2 inch thickness on the leading edge to assure proper ice removal; repeated boot cycles at less than 1/4 inch could cause a cavity to form under the ice and prevent ice removal. Boot cycles at thicknesses greater than 1/2 inch could also fail to remove ice. The airplane was serviced with the addition of 79.4 gallons of 100 low-lead aviation gasoline at SGU earlier in the day. Testing of fuel in the supply tanks at SGU revealed that it was clear and bright, with no contaminants. METEOROLOGICAL INFORMATIONThere was no record of the pilot filing an instrument flight rules flight plan or requesting flight following. A pilot who planned to depart SGU on a VFR flight to the SLC area about 1400 on the day of the accident stated that, before departure, he checked enroute weather and the reporting stations all indicated VMC along the route of flight. While on the airport ramp, he observed two airplanes flying in the traffic pattern, yet to the north, he could see clouds obscuring the mountains along his intended route. He considered departing and flying toward the New Harmony area to see if he could travel through the pass, but decided to cancel the flight and drive instead. As he drove through the pass and reached New Harmony, the area was completely enveloped in low clouds. Once he passed through to Cedar City, the cloud bases increased, and visibility was restored to what he considered to be VMC. Surface Observations About the time of the departure and accident, VMC conditions were reported at both the departure and arrival airports, along with airports enroute. Specifically: An Automated Weather Observing Station (AWOS) at SGU about 31 miles south-southwest of the accident site at an elevation of about 2,885 feet, reported at 1456 calm wind, 10 miles visibility, scattered clouds at 4,100 ft agl, a broken layer at 6,500 ft, and light rain. An Automated Surface Observing Station (ASOS) was located at Cedar City Regional Airport (CDC2), which was located along the presumed route of flight, about 14 miles north-northeast of the accident site at an elevation of about 5,620 feet. At 1453, the station reported 11knot wind from 220°, with 10 miles visibility, and few clouds at 12,000 ft agl. During the one-hour period before and after the accident, the SLC ASOS was reporting winds generally out of the south, with few clouds between 6,000 ft and 18,000 ft agl and 10 miles visibility. High-Resolution Rapid Refresh (HRRR) Model Sounding A HRRR model sounding along the airplane’s inbound flight path earlier in the day indicated the potential for few to broken clouds between about 6,300 and 8,500 feet. By 1500, weather conditions had deteriorated, with the model sounding for the accident site identifying clouds in the lower atmosphere from about 6,500 feet (msl) through 9,300 feet with the potential for freezing fog below. The freezing level was noted at about 6,300 feet. The potential for light rime icing was identified below about 8,800 feet, with moderate clear icing identified in about the lowest 100 feet of the atmosphere. Light low-level wind shear was also identified within the lowest 100 feet. The wind nearest the surface was from the south at a magnitude of about 10 knots, but the wind increased in magnitude to a westerly wind of about 30 knots near 15,000 feet. According to Leidos Flight Services (LFS) and its third-party vendors using the LFS system, there was no contact with the accident aircraft on the day of or the day before the accident. The pilot used ForeFlight for flight planning. Data provided by ForeFlight indicated that he had entered the route of flight into the application earlier in the day, and 20 minutes before takeoff he viewed weather imagery, including turbulence, lowest freezing levels, and aviation surface forecasts, along with wind speed forecasts at both the surface and 15,000 ft msl. Previous Flights Data extracted from the airplane’s IFD indicated that the pilot had flown the same route four times from July through to the period leading up to the accident. All flights followed the same general direct track between SGU and SLC. Weather for all those flights indicated VMC prevailed with 10 miles visibility and either clear skies, or few scattered or broken clouds along the route of flight. The flight parameters showed that, for the four previous flights between SGU and SLC, the pilot departed from runway 19 and initiated a climbing left turn onto the downwind leg. About midfield he would engage the autopilot, setting the roll mode to wings level (WL) and the pitch mode to vertical speed (VS). Northeast of the outer limits of St. George, and as he approached the mountain pass to New Harmony, he was usually at an altitude of between 7,000 and 9,500 ft and climbing. He would then switch the autopilot roll mode to either GPS or heading (HDG) as the airplane flew climbed through and out of the pass at altitudes of between 10,000 and 11,500 ft. The airplane would then remain on a direct north-northeast track of about 13° to the SLC area. The drive from SGU to SLC by car would have been about 320 miles and taken between 4 and 5 hours. AIRPORT INFORMATIONThe airplane was manufactured in 2014 and purchased new by the pilot. It was equipped with a Garmin G1000 IFD, which included a primary and a multi-function display and a GFC 700 Automatic Flight Control System (AFCS) autopilot. The airplane also included an Aspen Avionics EFD1000 primary flight display, configured as a backup system. The Garmin IFD included a synthetic vision system, which displayed terrain and obstacle clearance alerts on the primary screen, along with the topography immediately in front of the airplane. The system provided visual and audible alerts of terrain threats relative to the projected flight path. The G1000 Cockpit Reference Guide specifically stated that the terrain avoidance feature was not to be used as the sole means of navigation and terrain separation, and that it was only to be used as an aid to terrain avoidance. The AFCS included return-to-level (LVL) and Electronic Stability and Protection (ESP) features. When LVL is activated, the autopilot returned the airplane to a wings-level attitude and zero vertical speed. LVL mode was activated by pressing a switch at the top center of the instrument panel and could be activated while the autopilot was engaged or disengaged. Regardless of autopilot status prior to activating LVL Mode, the autopilot would become engaged in the lateral and vertical modes of LVL. Selecting another lateral or vertical mode while LVL was active would activate that mode and cancel the LVL in that axis. ESP functioned only when the autopilot was disengaged. When enabled, ESP provided a control force feedback “soft barrier” to return the airplane to a nominal operating envelope. If operating within the ESP envelope for an extended period of time, an “Engaging Autopilot” aural alert would sound, and the autopilot would automatically engage in LVL mode. The autopilot could be disengaged manually by pressing the A/P DISC / TRIM INTER switch on the control wheel or activating either half or both halves of the manual electric pitch trim switch on the control wheel, or by pressing the AP key on the MFD. Autopilot disconnects or failures were accompanied by aural alerts and visual annunciations on the PFD. The airplane was also equipped with an ice protection system, approved for flight into known icing conditions. It was designed for operation in light to moderate meteorological conditions defined in FAR 25, Appendix C, for continuous maximum and intermittent maximum icing conditions. The system consisted of pneumatic wing and empennage boots, a wing ice detection light, electrothermal propeller deice pads, electrically heated windshield panel, heated lift detectors, and a heated pitot head. The vacuum system consisted of a vacuum pump on each engine, plus plumbing, filtering and regulating equipment. The flight manual supplement for the ice protection system stated that continuous attention was required by the pilot to monitor the rate of ice buildup in order to accomplish the boot cycle at the optimum time. Boots were to be cycled when ice had built to between 1/4 and 1/2 inch thickness on the leading edge to assure proper ice removal; repeated boot cycles at less than 1/4 inch could cause a cavity to form under the ice and prevent ice removal. Boot cycles at thicknesses greater than 1/2 inch could also fail to remove ice. The airplane was serviced with the addition of 79.4 gallons of 100 low-lead aviation gasoline at SGU earlier in the day. Testing of fuel in the supply tanks at SGU revealed that it was clear and bright, with no contaminants. WRECKAGE AND IMPACT INFORMATIONShortly after the accident, the airplane wreckage became buried by snow due to a winter storm. An onsite examination was performed once weather conditions allowed, on January 8. The airplane collided with terrain in a ravine at an elevation of 6,600 ft msl, about 200 ft below the surrounding ridgeline in an area interspersed with brush, juniper, and pine trees. The first identified point of impact was a 15-ft-long, 60° swath cut through a tree. From the tree, a debris field containing fiberglass and metal shards associated with a wing continued on a heading of 095°. A propeller hub and 3 detached propeller blades were 20 ft from the initial point of impact, and the main wreckage came to rest inverted on a heading of 170° about 55 ft farther. The left wing remained partially attached to the fuselage and sustained leading edge crush damage. The inboard section of the right wing remained partially attached, and its outboard sections were comingled with the fuselage. The fuselage sustained extensive crush damage from the nose to the vertical stabilizer. The vertical stabilizer remained attached to the tail cone and was crushed and folded under the stabilator. Within the fuselage, remnants of fractured and separated seats, flight instruments, and cabin contents were identified. All primary flight control surfaces were located at the accident site. Examination of the flight control system did not reveal any anomalies that would have precluded normal operation, with all components exhibiting evidence of bending and overload damage consistent with impact. The avionics suite and autopilot sustained extensive fragmentation damage such that the operational status at impact could not be determined. Examination of both engines did not reveal any evidence of catastrophic internal failure, and all six propeller blades exhibited significant leading-edge damage, along with varying degrees of tip curl, serration, chordwise striations, and S-bending. The turbocharger compressor wheels for both engines sustained severe rotational damage to all their blades, and exhibited tearing and bending opposite the direction of rotation. Both engine-driven vacuum pumps were intact and did not show evidence of pre-impact failure. The IFD included a data logging feature, capable of storing a series of aircraft, autopilot, and engine parameters to an SD card mounted in the display. Although the IFD and the autopilot system were destroyed in the accident, the SD card survived, and its data was extracted. The data indicated that the parameters for both engines mirrored each other during the entire flight and that both were producing power at the time of impact. Although a series of autopilot parameters were recorded, including commanded heading, selected heading and altitude were not recorded. There was no evidence of bird strike or fire to the airframe, wings, or engines. MEDICAL AND PATHOLOGICAL INFORMATIONAn autopsy of the pilot was performed by the Office of the Medical Examiner, Taylorsville, Utah. The cause of death was blunt force injuries. Toxicology testing performed by the FAA Forensic Sciences Laboratory detected Amlodipine in liver and lung tissues. Amlodipine is a blood pressure medication that is generally considered not to be impairing. The pilot departed on a cross-country visual flight rules (VFR) flight on a route with which he was familiar. On the day of the accident, visual meteorological conditions (VMC) prevailed along most of the route; however, the mountain pass just north of the departure airport was obscured by low clouds and light rain. The pilot had obtained weather information before departure that would have reflected the instrument meteorological conditions (IMC), and he would have been able to see the mountain obscuration from the departure airport. Recorded data from onboard avionics revealed that, during previous flights on the accident route, the pilot typically departed and flew direct toward the destination through the mountain pass north of the departure airport, engaging the autopilot shortly after takeoff. The accident takeoff and departure were uneventful, but rather than taking the northern route through the pass as usual, the pilot chose an initial heading to the northeast, toward rising terrain. It is likely that the airplane entered IMC at this point and continued in IMC for the remainder of the flight. The airplane descended as it approached the terrain, and the pilot appeared to make corrective control inputs via the autopilot using the heading mode (HDG) function to turn left back toward the pass. The airplane responded appropriately, and once the airplane had reached the entrance of the pass, the pilot provided a series of small heading corrections toward the north. The airplane then continued on a track similar to previous flights, but veered to the left of the pass, then continued the left turn toward rising terrain. Recorded data indicated that, around this time, power was applied to both engines and the airplane started to climb, likely as a result of the terrain awareness system alerting the pilot to the rising terrain ahead. The airplane then began a series of extreme pitch and bank excursions while climbing and descending in a left turn. The airplane ultimately impacted the ground in a steep left wing- and nose-low attitude. Based on the recorded basic autopilot mode parameters, which included commanded (but not selected) altitude and bank values, the directional commands the pilot issued the autopilot could not be definitively determined; however, it is likely that, based on his use of HDG mode, he was guiding the airplane incrementally through the pass in an effort to avoid terrain and/or inclement weather. The pilot was likely attempting to negotiate the surrounding terrain by reference to the terrain awareness features of the airplane’s integrated flight display (IFD). This feature was not designed to be used as the sole source of navigation. Review of the data during the final stages of the flight indicated that the pilot was most likely disoriented and fighting against the autopilot. The autopilot was equipped with a return-to-level (LVL) safety feature, which can be activated by the pilot at any time. The LVL system works to return the airplane to a straight-and-level flight attitude. About 40 seconds before ground impact, the autopilot was turned off, and LVL mode was activated, likely by the pilot. The autopilot immediately issued commands to regain control, and although it appeared to respond, the descent and roll continued, possibly due to the pilot physically overpowering the autopilot’s control inputs via the control column. Examination of the flight control system did not reveal any anomalies that would have precluded normal operation. The recorded data indicated that both engine power levels mirrored each other during the entire flight, and damage signatures to the engine and propellers were consistent with them both producing power at the time of impact. Damage to the airplane prevented a complete assessment of the operational status of the IFD system; however, the recorded data confirmed that the autopilot was being used throughout the accident flight. The airplane was also equipped with a set of independent backup flight instruments; therefore, the pilot had the capability to disengage the autopilot and fly the airplane by reference to those instruments if needed; however, it could not be determined if he had practiced such procedures before or was current and capable of hand-flying the airplane in IMC. The weather conditions at the accident site were conducive to the accretion of airframe icing, and although the airplane was equipped with deicing equipment, whether it was in use during the flight could not be determined. The system’s operation was not automatic and would have required manual activation by the pilot at regular intervals, which would have represented additional workload and a diversion of his attention as he attempted to maneuver through the terrain. The pilot had no urgent personal activities that would have required him to return that day, but he was aware of the incoming weather system (which persisted for a few days after the accident), and he had a vacation planned for the following week. Returning by car would have resulted in a relatively long drive of over 300 miles. Although the pilot held an instrument rating, no pilot logbooks were available to review, and his recency of instrument flight experience could not be determined. Given his familiarity with the accident route of flight and the isolated nature of the IMC along the route, it is likely that the pilot became overconfident in the airplane’s automation to navigate through the relatively small area of mountain obscuration. The airplane’s erratic pitch and bank excursions just before the accident are consistent with the known effects of pilot spatial disorientation, and the pilot’s susceptibility to the development of spatial disorientation would have increased with a lack of recent IFR flight experience. Based on the available information, it is likely that the pilot’s decision to continue the visual flight rules flight into IMC resulted in his spatial disorientation, a subsequent loss of airplane control, and impact with 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).

• — Personnel issues-Task performance-Use of equip/info-Aircraft control-Pilot
• — Environmental issues-Conditions/weather/phenomena-Ceiling/visibility/precip-Below VFR minima-Effect on personnel
• — Personnel issues-Psychological-Perception/orientation/illusion-Spatial disorientation-Pilot
• — Personnel issues-Action/decision-Info processing/decision-Decision making/judgment-Pilot