Practice English Speaking&Listening with: Accident Case Study: Blind Over Bakersfield

Difficulty: 0

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 hes flown five times in the previous

two years. But this is the first time hell 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 todays

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 routeunfavorable

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.

Hes 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 friends surprise party this eveninga 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 flightenough to circumnavigate the weatherthe pilot decides to fly anyway.

Its 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 its 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


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 pilots 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,


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 oclock 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 oclock all the way to about one oclock 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 dont 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 were 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 pilotthat 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 well just keep chasing the clouds uh towards


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 oclock 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


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 402s flight path has become erratic. The airplane climbs and descends,

and then spirals down.

Air traffic control Lance four-zero-two 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 oclock

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 isnt good enough for Bakersfields 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 36402s 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 pilots decision to conduct and

continue the flight despite forecast and en route conditions not conducive to safe visual

flight, the pilots 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 pilots decision

to fly VFR into IMC. The NTSB also found that the pilots 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. Its 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, its 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 pilots

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 ahope

for things to get better. Investing in a datalink weather receiver to improve situational awareness

during flight can provide invaluable information for decision making.

Its 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 NTSBs findings suggest that he did not know how to use the autopilot.

Its easy to sit here at zero knots and 1G, devoid of pressure and circumstance, and

critique the decisions the accident pilot made. Whats 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.

The Description of Accident Case Study: Blind Over Bakersfield