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.