Accident Case Study: Blind Over Bakersfield

Summary

This accident case study by the Air Safety Institute highlights the tragic flight of a non-instrument rated pilot who embarked on an ill-fated journey from San Jose to Henderson. Encountering adverse weather conditions, including icing and poor visibility, the pilot made several critical decisions under pressure, driven by the urgency to attend an event. The study underscores the significance of weather preparedness, understanding aircraft limitations, and the dangers of self-induced pressures leading to spatial disorientation. In the end, the pilot's misjudgment, propelled by confirmation bias and insufficient training, led to a catastrophic crash.

Highlights

• The 42-year-old VFR-only pilot undertook a flight despite adverse weather conditions, driven by a schedule. 🕗
• The pilot attempted to climb above clouds, but faced icing and poor visibility, leading to spatial disorientation. ☁️
• Accepting an IFR clearance without the required rating adds complexity and risk. 🚫
• Self-imposed time pressure and confirmation bias are dangerous in flight decision-making. 🧠
• A well-understood autopilot system could have stabilized the flight path, avoiding disaster. 🤖

Key Takeaways

• Understanding and respecting weather conditions is crucial for flight safety. 🌧️
• Avoid self-induced pressure that compromises sound decision-making. ⚠️
• Proficiency in aircraft systems, like autopilot, can prevent loss of control. ✈️
• Always have contingency plans to adapt to unforeseen changes. 🔄
• Never underestimate the complexities of instrument flight without adequate training. 📘

Overview

This riveting case delves into the ill-fated flight where poor decisions led a family of five into disaster. The pilot, fixated on reaching a friend's surprise party, overlooked critical weather conditions en route to Henderson.

The flight plan, though familiar, was met with adverse weather, including icing warnings and dense clouds. Despite these conditions, the pilot pursued higher altitudes without adequate oxygen, entered IFR without proper training, and struggled with spatial orientation.

By examining this tragedy, pilots can learn the importance of adhering to safety measures, understanding their limits, and valuing human life over timeliness. It's a powerful reminder to plan ahead, respect nature's forces, and prioritize informed decisions over hasty actions.

Chapters

• 00:00 - 02:00: Introduction and Flight Preparation In the introduction and flight preparation chapter, the discussion begins with the communication between the pilot of November four-zero-two and air traffic control. The pilot inquires about picking up an Instrument Flight Rules (IFR) clearance to Henderson, and the air traffic controller, who identifies the aircraft as Lance four-zero-two, acknowledges the request.
• 02:00 - 05:00: Weather Conditions and Initial Climb The chapter titled 'Weather Conditions and Initial Climb' describes an event on December 19, 2015, during the busy holiday travel season. A 42-year-old private pilot, who is not instrument-rated, is preparing a Piper Turbo Lance aircraft for a flight. The route is from Reid-Hillview Airport in San Jose, CA, to Henderson Executive in Henderson, NV. The pilot, who has 269 hours of flight experience, is familiar with this route as he has flown it five times in the past two years. However, this is the first time he will be flying the route in this particular aircraft, the Lance.
• 05:00 - 08:30: En Route Challenges and Altitude Adjustments This chapter discusses the complexities and risks involved in planning and executing a family flight trip. The pilot, while certified for IFR (Instrument Flight Rules), faces limitations because the plane is not equipped for flight in known icing conditions. Additionally, the autopilot system remains a challenge as the pilot hasn't been trained on its use. There's also concern over the aircraft's oxygen system, which inadequately accommodates the pilot, his wife, and their three children, aged 9 to 14, given that there are only three oxygen cannulas available. The pilot is diligent in his preparations, having checked the weather the night before and receiving an online briefing on the day of the flight, emphasizing the importance of readiness in aviation.
• 08:30 - 14:30: Acceptance of IFR Clearance and Consequent Disorientation The chapter titled "Acceptance of IFR Clearance and Consequent Disorientation" discusses the challenges faced by a VFR-only pilot when navigating through adverse weather conditions. The departure and arrival airports have VFR conditions, but the route includes AIRMETs for IFR conditions, mountain obscuration, and moderate icing up to 18,000 feet. The pilot, with limited instrument training, must contend with these unfavorable en route conditions, especially concerning the San Joaquin Valley area forecast.
• 14:30 - 17:30: Crash and Aftermath In this chapter, the narrative revolves around an aviation crash and its subsequent consequences. The weather conditions are challenging, with cloud ceilings between 2,000 and 4,000 feet and cloud tops reaching 15,000 to 18,000 feet. Visibility is notably reduced to 3 to 5 miles due to mist, complemented by light to moderate snow showers in the mountainous southern region. Despite the questionable conditions, the pilot, operating under Visual Flight Rules (VFR), chooses not to contact Flight Service, opting instead to electronically file his flight plan. This sets the stage for potential mishaps, given the adverse weather settings.
• 17:30 - 22:00: NTSB Findings and Lessons Learned This chapter outlines the itinerary planned for a family's flight from San Jose to Henderson, NV. The route includes waypoints at Paso Robles Municipal Airport and Meadows Field Airport, with a planned cruising altitude to avoid the Sierra Nevada. The expected flight duration is just over two hours.
• 22:00 - 25:00: Decision-making and Pilot Responsibilities The chapter titled 'Decision-making and Pilot Responsibilities' discusses a pilot's decision-making process before embarking on a flight. The pilot is preparing to attend a surprise party and, despite adverse weather conditions in the forecast, decides to proceed with the flight, having calculated that they have sufficient fuel to potentially reroute if necessary. The flight initially progresses smoothly, and the pilot establishes communication with NorCal Approach under Visual Flight Rules (VFR). This scenario underscores critical aspects of pilot decision-making and the responsibilities involved in ensuring safe flight operations.
• 25:00 - 28:00: Conclusion and Final Thoughts During the initial climb, the pilot changes his planned altitude from 13,500 feet to 15,500 feet to avoid clouds and worsening weather over Central California. As forecasted, adverse weather conditions soon develop. At 3:12, approximately 30 minutes into the flight, the pilot unexpectedly initiates an ascent.

Accident Case Study: Blind Over Bakersfield Transcription

• 00:00 - 00:30 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.
• 00:30 - 01:00 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
• 01:00 - 01:30 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
• 01:30 - 02:00 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
• 02:00 - 02:30 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.
• 02:30 - 03:00 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
• 03:00 - 03:30 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
• 03:30 - 04:00 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
• 04:00 - 04:30 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
• 04:30 - 05:00 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,
• 05:00 - 05:30 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
• 05:30 - 06:00 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
• 06:00 - 06:30 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
• 06:30 - 07:00 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
• 07:00 - 07:30 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
• 07:30 - 08:00 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.
• 08:00 - 08:30 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
• 08:30 - 09:00 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,
• 09:00 - 09:30 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
• 09:30 - 10:00 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
• 10:00 - 10:30 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
• 10:30 - 11:00 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.
• 11:00 - 11:30 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
• 11:30 - 12:00 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
• 12:00 - 12:30 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
• 12:30 - 13:00 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
• 13:00 - 13:30 — 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
• 13:30 - 14:00 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
• 14:00 - 14:30 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
• 14:30 - 15:00 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.
• 15:00 - 15:30 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
• 15:30 - 16:00 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,
• 16:00 - 16:30 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
• 16:30 - 17:00 a no-go decision much easier.