November four-zero-two, did you want to pick
up an IFR uh to Henderson if I can do that? Uh yeah I would take that Lance four-zero-two. December 19, 2015. The busy holiday travel
season is in full swing. A 42-year-old, non-instrument rated private pilot preflights a Piper Turbo
Lance, November 36402, for an afternoon flight from Reid-Hillview Airport in San Jose, CA,
to Henderson Executive in Henderson, NV. The 269-hour pilot is familiar with the route,
which he’s flown five times in the previous two years. But this is the first time he’ll
fly it in the Lance, in which he has logged more than 56 hours over the past six months.
The airplane is IFR certified, but not for flight into known icing, and it has an autopilot
that the pilot never received training on and presumably does not know how to use. The
six-seat airplane has plenty of room for his wife and three young kids, ages 9 to 14, though
the oxygen system only has three cannulas. The pilot checked the weather the night before
and received a briefing online before today’s flight. VFR conditions are forecast for the
departure and arrival airports but the en route forecast is another story. AIRMETs for
IFR conditions, mountain obscuration, and moderate icing from the freezing level up
to 18,000 feet are issued for the route—unfavorable conditions for anyone, especially a VFR-only
pilot with just under four hours of instrument training. Also, the Area Forecast for the
San Joaquin Valley, which the pilot plans to cross, calls for a ceiling beginning between
2,000 and 4,000 feet, with cloud tops at 15,000 to 18,000 from the northern valley to the
southern Sierra Nevada. Over a large area, visibility is expected to be 3 to 5 miles
with mist - and in the southern section of the mountains, light to moderate snow showers.
The pilot does not make a call to Flight Service and files his VFR flight plan electronically. He’s planned on departing San Jose at 2
p.m. local time, then heading southeast to avoid the towering Sierra Nevada with waypoints
at Paso Robles Municipal Airport, and Meadows Field Airport in Bakersfield, before flying
on to Henderson Executive at a VFR cruising altitude of 13,500 ft. The estimated time
en route is two hours and four minutes. The family of five will be visiting their
old hometown of Henderson, NV, where they are expected at a friend’s surprise party
this evening—a perfect start to their vacation. Undeterred by the forecast conditions en route,
and with four and half hours of fuel on board for a two-hour flight—enough to circumnavigate
the weather—the pilot decides to fly anyway. It’s 2:35 p.m. when the Lance departs. The beginning of the flight goes smoothly.
The pilot contacts NorCal Approach for VFR flight following. During the initial climb
he abandons his original planned altitude of 13,500 and requests an altitude of 15,500
feet to stay above the clouds as storms build over Central California. Soon after, Lance 402 encounters the forecast
weather conditions. At 3:12, just over half an hour into the flight,
the pilot begins an unannounced climb out of 15,500 feet. ATC asks him about the altitude
change. The pilot, flying south, responds that he is climbing and will level off at
16,500. But it’s not enough altitude. Trying to
avoid the clouds, he climbs even higher, and at 3:16 the pilot follows up with a request
for 17,500. One of the passengers takes photos of the clouds that now appear to be at their
altitude. Oxygen use is now likely a pressing concern. All along, air traffic control has alerted
pilots on frequency to bands of precipitation and the potential for airframe icing in the
area. Once again, ATC warns pilots of moderate precipitation nearby. In the Lance pilot’s
case, the weather is directly ahead and on his intended route of flight. The pilot of a Cessna 414 near the Shafter
VOR reports to LA Center that the tops are around 18,000 feet. The Lance pilot, now past
Paso Robles and flying toward Bakersfield, asks ATC to confirm what he heard. LA Center Lance three-six-four-zero-two uh
what was the position of that uh uh last aircraft, five-five? And November four-zero-two that traffic is
about uh one mile east of the Shafter VOR flight level one-eight-zero and uh from your
position uh about eleven o’ clock and uh three-zero miles Roger uh LA Center just wonder whether or
not I could get over to their altitude and clear the clouds And November three six four-zero-two I am
depicting areas of moderate to heavy precipitation um from yeah nine o’clock all the way to
about one o’ clock a along your route of flight uh, extends for about one zero miles The pilot asks if the controller happens to
know what the bottoms are. November four-zero-two I don’t have any
reports on the bottoms. I do have reports of some uh light rime icing all the way up
as high as flight level one-niner-zero uh and south east of your area Alright we’re gonna deviate to the south
and try to go around these and uh perhaps uh go through Barstow Lance four-zero-two November four-zero-two roger Another pilot contacts Center to say that
the tops in the Palmdale area are at about 21,000 feet. Center then alerts the Lance
pilot—that weather is in the direction he is heading. And November four-zero-two uh some reports
the tops reported around flight level two one zero um north west of the Palmdale area
which is eleven o clock from you and about uh uh four three miles in the direction that
you wanna head towards Uh LA Center Lance four-zero-two copies uh
we’ll just keep chasing the clouds uh towards Palmdale November four-zero-two roger The weather continues to deteriorate, and
ATC updates the Lance pilot on the conditions. November four-zero-two uh depicting areas
of moderate precipitation uh eleven to about a two o’clock uh extends for about one zero
miles along your route of flight uh just uh some small areas Uh roger At about 3:50, LA Center offers the pilot
an IFR clearance to Henderson. The non-instrument rated private pilot accepts. November four-zero-two, did you wanna pick
up an IFR to Henderson if I could do that? Uh yeah I would take that, Lance 402. November four-zero-two what uh altitude are
you requesting Uh fifteen thousand is fine Lance four-zero-two Four-zero-two are you ready for your IFR? Lance four-zero-two, ready to copy November four-zero-two now cleared to the
Henderson airport via direct Hector hotel-echo-charlie, direct, correction hotel-echo-charlie, Victor-twenty-one
to Boulder, bravo-lima-delta, direct, maintain one-five thousand The pilot attempts to absorb and execute the
IFR clearance. With a mounting workload, and no instrument rating, this undoubtedly takes
a great deal of mental effort. Roger, hector, hotel-echo-charlie via bravo
lima delta uh, fifteen thousand, Lance 402 The IFR clearance is meant to take the pilot
east toward Henderson, but the airplane begins a turn north, toward heavier precipitation,
and IMC conditions. As the pilot attempts to work his clearance, he has to focus attention
away from his gauges and unknowingly enters a scenario ripe for spatial disorientation
- changing aircraft attitude while looking away from the flight instruments. And November four-zero-two are you turning
north bound Uh roger I just took a heading off of Bakersfield
I'm gonna change it to the current uh assigned IFR November four-zero-two fly heading of zero
niner five Fly zero niner five Lance four-zero-two November four-zero-two make an immediate right
turn heading zero niner five At this point, Lance 402’s flight path has
become erratic. The airplane climbs and descends, and then spirals down. Air traffic control Lance four-zero-two mayday
mayday mayday In the clouds, very likely disoriented, with
insufficient training on how to handle the conditions, the situation rapidly turns tragic. November zero-four-delta say again Oh it's four-oh-two saying mayday mayday mayday. November four-zero-two LA Center Four-zero-two mayday mayday mayday November three-six-four-zero-two LA center
uh Bakersfield Airport is uh eleven o’clock and uh one zero miles north west bound November three-six-four-zero-two LA Center At 3:56 pm, a final radar target shows Lance
402 at 11,200 feet. ATC still tries to contact the pilot, but there is no response. November zero-four-delta are you able to see
any traffic off your left hand side uh about uh one zero miles Negative he's now would be in the clouds um
I saw his transponder go off uh uh so that scared me a little bit And November three-six uh four-zero-two Bakersfield
approach one-one-eight point eight November three-six-four-zero-two contact Bakersfield
approach one-one-eight point eight November three-six-four-zero-two if you hear
LA Center ident The weather isn’t good enough for Bakersfield’s
Air Support Unit to begin a search and rescue operation, and a ground search effort begins
instead. In the next hour, three Special METARs are released as weather drops to 1 ½ mile
visibility and a 200-foot ceiling with mist. At 7:42 pm, the Kern County Sheriff's Department
finds Novermber 36402’s high angle of impact crash site in an almond orchard almost directly
below the last radar target. All five aboard have perished. The NTSB found the probable cause of the accident
to be the pilot’s decision to conduct and continue the flight despite forecast and en
route conditions not conducive to safe visual flight, the pilot’s decision to accept an
IFR clearance despite not being instrument rated, and finally, flying into IMC during
cruise flight. The resulting spatial disorientation and loss of control led to the in-flight breakup
of the airplane and the crash. While icing could not be ruled out, any icing would have
been a direct result of the pilot’s decision to fly VFR into IMC. The NTSB also found that
the pilot’s self-induced pressure to arrive at the surprise party factored in to his decision
making. How can we learn from the risks this pilot
took to make us all safer pilots in the future? While we cannot know exactly what the pilot
was thinking, the external pressure of arriving for the party that night cannot be overlooked.
It’s likely that his focus on arriving as scheduled impaired his ability to assess the
bigger picture and make a more objective decision. Research has shown that when we have an especially
high level of self-interest, it’s difficult to make a sound judgment. We must all be on
guard anytime we know there are external pressures encouraging us to get to our destination. With weather such a factor, this perhaps would
have been a good time for the pilot to go beyond a standard textual weather briefing.
Flying single pilot, the additional human resource of a weather briefer could have been
a helpful aid to the decision-making process, and possibly a guard against self-imposed
pressures to make the trip. If the pilot had discussed with a briefer his route and planned
altitude of 13,500 feet, it is likely that VFR flight would not have been recommended
due to forecast weather en route. After departure, the pilot encountered difficulty
and had to change his plan almost immediately — a red flag for the weather to come. Once
en route, as the weather continued to deteriorate, the pilot could have asked for vectors to
a diversion airport or clear airspace, and alerted ATC that he was not instrument rated. The NTSB noted that the insufficient oxygen
system was likely a factor in the pilot’s decision not to climb higher. But given the
greater danger of flying into IMC, the pilot could have asked for a temporary emergency
climb above the weather and into Class A airspace. The NTSB determined that had he climbed, it
is probable that he would have been able to remain in visual conditions and maintain control
of the airplane. Declaring an emergency to LA Center or using his authority as pilot-in-command
to intentionally deviate from his cleared VFR altitude and into Class A airspace could
have resulted in a positive outcome. Accepting and then attempting to comprehend
an IFR clearance with very little training on the complexity involved is a demanding
task. Flying intentionally into IMC without an instrument rating compounds the risk. These
troubling decisions indicate the pilot underestimated the complexities of instrument flight and
how rapidly things deteriorate with spatial disorientation and loss of situational awareness. Research has shown that once we make decisions,
we tend to over-emphasize any data that supports the decision, and under-emphasize data that
indicates we should reconsider. It appears the pilot fell into that trap of confirmation
bias. In the face of visible evidence that the weather was worse than what he used to
make his go/no-go decision, he pressed on. We must be honest about the weather and not
be willing to bet our safety on a “hope” for things to get better. Investing in a datalink
weather receiver to improve situational awareness during flight can provide invaluable information
for decision making. It’s important to know the capabilities
of your airplane and the systems on board. In this case, use of the autopilot would very
likely have kept the pilot from losing control in the clouds. The flight path and data suggest
that the pilot was hand flying the airplane, and the NTSB’s findings suggest that he
did not know how to use the autopilot. It’s easy to sit here at zero knots and
1G, devoid of pressure and circumstance, and critique the decisions the accident pilot
made. What’s important for us to realize, though, is that we all have external pressures
that can push us to make bad decisions. The trick is knowing these external pressures
exist, and developing measures to deal with them. We must be ready to accept new information,
and be willing to re-assess our initial decision when the circumstances change. As pilots-in-command,
our passengers are relying on us to make clearheaded, objective decisions based on our training,
proficiency, equipment, and the conditions of the flight. If planning on flying GA to
an important event, take measures to reduce the time pressure. Consider going a day early.
Make sure people on the other end understand that general aviation is subject to changes
of plan based on uncontrollable factors like weather. Knowing that they will understand
if we must make alternate plans will make a no-go decision much easier.
It's unbelievable to me that there are non-instrument rated private pilots out there who will accept an IFR clearance through difficult weather when their family is on board.
This is beyond an error that any of us could make. This man killed his family because he was a moron.
This series is world class, I love it when they update
I've wanted ForeFlight to flash a "VFR NOT RECOMMENDED" warning at you when the weather looks dicey after a brief, but I wonder if there's liability they don't want.
Maybe it could say, "this ain't it, chief, take southwest."
I am not even a pilot but feel like I learn a ton from these videos.
No doubt these videos have saved lives.
This is the example I use to show pilots why it's important to get their IR.
Yes accepting an IFR clearance without an IR is dangerous and fucking stupid, but flying into clouds is not always something you can avoid. This guy was probably planning for it and fucked up. Imagine what it could do to someone who was NOT planning for it.
The music at the start of these gives me goosebumps. Incredible production quality, makes me proud to be an AOPA member.
I think there's one thing this video misses at the end as an option to reduce "get there itis": backup airline tickets. Anyone rich enough to be able to operate a Lance is also rich enough to buy refundable airline tickets as a backup in case the weather doesn't look good enough (or even simply just buy last minute airline tickets). It takes all the pressure off - if the weather looks even slightly doubtful, you can just take the Airbus instead - and if the weather's fine you can cancel your refundable tickets.
Interesting case study about a crash caused by a non-instrument rated pilot accepting an IFR clearance in bad weather.
NTSB report: https://www.ntsb.gov/_layouts/ntsb.aviation/brief.aspx?ev_id=20151220X04641&key=1
The fact that he thought he could fly through the clouds with only FOUR hours of instrument is quite surprising. Also that he thought he could follow a clearance. I have a hard enough time doing both and I am nearly done with my IR.