Bad day at Huntington

September 23, 2010 by epubs

It’s a familiar refrain – continued VFR into IMC. This particular case was worse than most as it involved 6 fatalities. A Piper Seneca – more than fully loaded – went down in West Virginia. The VFR owner-pilot was flying a group of flying club members to check out an aircraft that was for sale. You can review the whole sad saga in the Air Safety Institute’s latest Accident Case Study: Cross-Country Crisis. It will also be a landmark accident feature in the December AOPA Pilot.

It’s really hard – impossible actually – to defend the indefensible. The sheer magnitude of this pilot’s ignorance, or willingness to take risk with both his own as well as other people’s lives, is staggering. No trip, no mission, no reward is worth the outcome you’ll see here. And as usual, we know what happened but do not understand why. I suspect there is no good answer other than “I thought I could make this work and didn’t want to inconvenience anyone.” Ego likely plays a part.

Please take a look at this case study and let us know what you think – good or bad. The decision was made not to let this accident slide quietly into oblivion but rather to hold this up as a really bad example of decision-making. Share it with your risk taking friends. There will be more to say on this topic in the near future – received a very thoughtful letter from a reader who poses a good question.

Bruce Landsberg
Senior Safety Advisor, Air Safety Institute

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  • Nate

    Wow. A very chilling re-enactment. As I sit here collecting my thoughts, I’m prepping for my instrument rating checkride.

    This was a great case to re-enact. It had all the red flags- weight and balance problems, fuel mismanagement, VFR into IMC, and poor ADM. I really like the way that the recreation engages the viewer with a call for some critical self-examination. All of us have traded in some luck for experience at some point- either in aviation or in another endeavor. These kind of reminders serve to jolt us with the reality of what awaits us if we cut corners.

  • Alastair

    The strangest part of this tragedy was that it appeared that this pilot had 2,200 VFR hous logged? How could such an experienced pilot make so many basic mistakes and have total disregard for the safety of his passengers, let alone himself or the plane? He must have had some previous close encounters during his 2,200 hours – you would have thought that would have taught him to have more respect and caution. This was clearly a disatser waiting to happen and it did.

  • http://AOPAASF Bob Luther

    Be aware that Complacency kills. As a retired military pilot and as a retired airline pilot, I’ve seen this way too many times. Regardless of your total number of flying hours. . . complacency kills. Be safe out there, Bob.

  • Mark

    A very expensive lesson in decesion making costing the lives of six people. Many mistakes made, everything from weight and balance (two different issues), to misrepresenting yourself to a controller who is there to help you. I can only hope the passengers were not listening.

  • Mike

    I have friends like this guy. They think that anything that fits through the doors can be carried safely – there is no convincing them otherwise. Their own good luck to date confirms their beliefs. I hope that each of them gets a scare that will awaken them to the reality of safely flying, and shatters their smugness before someone is injured or killed.

  • Jim Horner

    The term “familiar refrain” is the problem. This almost accepts that VFR to IMC incidents are and will continue to be common (see below). Einstein once defined insanity as doing the same thing and expecting a different outcome. So bemoaning this incident and pointing out the lack of judgement of the pilot, a result reached many times before with other similar incidents, then expressing surprise at a reoccurance seems to me to fit Einstein’s definition.

    So what can be done that is different? First a more thorough analysis ought to be done. I am sure the NTSB has done much more than this video reveals but I notice that no conclusion has been reached yet (>18 months later!). They do insert in their factual report the following: “According to National Transportation Safety Board (NTSB) and FAA data, one of the leading causes of GA accidents is continued VFR flight into IMC… The importance of complete weather information, understanding the significance of the weather information, and being able to correlate the pilot’s skills and training, aircraft capabilities, and operating environment with an accurate forecast cannot be emphasized enough….VFR pilots in reduced visual conditions may develop spatial disorientation and lose control.” This sounds like the same old thinking, weather, pilot skills, etc., it has been done! The expected NTSB conclusion that pilot error caused the incident is far too easy. In quality control circles the technique of “asking why five times” might expose more of the root cause. Then when a deeper understanding is reached searching for an answer which makes it impossible for pilots to make this error is the right direction. Assuming that somehow newly trained and enlightened pilots will not do this again is simply irresponsible. If the solution is simply more pilot training Einstein will be looking down on us and shaking his head.

  • Gregg

    Very troubling…especially for the passengers who trusted this pilot with their lives. In addition to the deadly effect on the passengers this accident also leaves in its wake a legacy of distrust and animosity toward ALL private pilots. I wonder at what point this pilot realized HE had crossed the line?

  • John Wright

    Very good illustration of why an instrument rating is essential even for a fair weather VFR only pilot. I felt tense watching the story unfold as the pilot had difficulty holding a heading in IMC. He and his passengers would very likely have walked away from this incident if he had instrument training and currency!

  • Ken Gordon

    As a 220 hour VFR pilot, I have come to realize that hours mean nothing regarding competence. In fact, in my personal experience, the higher the flight time a pilot has, the more likely that any discussion about procedures will go towards “you don’t really need to do that”, or ” after you get more experienced you won’t bother with all that” almost regardless of the subject.

    The subject at hand can be my insistence on visually checking fuel after the FBO tops it off, my planning policy of complete weather checks at 48, 36, 24, 12 and 1 hour before the proposed cross country flight.

    I only have 220 hours, and I have found the fuel caps not secured properly by FBO personnell 3 times already, including once where the cap was completely loose.Another time a “topped off” tank took 3 more gallons to completely fill it.

    I have only flown about 24 cross country flights, and 3 of those required diversion or precautionary landings due to rapid and unpredicted, unforecast changing weather conditions.

    Busting the pattern either on the wrong CTAF or without bothering to make a call is common enough that having my head on a swivel is the order of the day at uncontrolled airports.

    Flying is safe if you follow the rules. Start getting complacent or pushing the risk factors and it will bite you. As a new pilot, it is my observation there are a lot of GA pilots out there doing just that.

  • Steve

    It was all there in his voice, fear, pride, not wanting to admit he was totally in over his head, and barely concealed panic. The lie to the Tower about being instrument rated was really the end of the flight, only postponed but inevitable at that point. We can only guess his thoughts in the last seconds of the flight, knowing he was responsible for the lives about to be destroyed. Thanks for the spotlight on this story.

  • Melinda

    I would love to share this video and story with my risk-taking friends. Unfortunately, they all died in plane crashes–five in IMC and/or night conditions. And that doesn’t count the passengers they took with them.

  • J. Noddel

    To Ken Gordon: Nice note. I disagree with your premise that flying is a safe activity if the rules are followed. Anytime you are moving or have space between you and the earth’s surface, you are not safe. Flying is risky. The rules are there to reduce risk to a reasonable level, but the risk is never zero. Every flight has different risk factors, which evolve as the flight proceeds. We pilots should be continuously assessing risk on every flight and mentally re-planning to reduce that risk. High time pilots have had so many successful flights that some of them stop doing this.

    Unfortunately, we only get one unsuccessful flight…..

  • L. V. Lammert

    It would be a lot easier to share the details if there was a written synopsis; not everyone has the time, inclination, nor occasionally the compatible hardware to endure a flash presentation for 14 minutes.

  • http://aopa Wilton

    If VFR land short at the nearest of the two alternate airports that you should choose before any cross country flight. Then watch the IMC evolve or watch television until you can continue this same practice when you fly again.

  • Bill Hamilton

    Hope is NOT a strategy!!

    If the passengers were his “flying club buddies” I wonder at what point any of them began to question the outcome of the flight, and voice a concern. I have questioned the PIC on many occasions, and have been questioned myself, about intentions and at what point to go to plan B. With two or more pilots, it is quite possible to think “well he is not saying anything… so it must be going OK” while the other pilot is thinking the same thing!! If you are not comfortable with any aspect of the flight, speak up!! Have you ever thought to yourself “if I were by myself, I’d turn around”? If so, ask the question! If you ever start a thought with “I hope…” then it is time to act and change the outcome. Hope is NOT a strategy!!

  • Honza

    If VFR into IMC is the number one killer for VFR pilots, why FAA doesn’t require two – three times more “under the hood” training to obtain your private pilot license? Doesn’t that qualify as Einstein’s definition of insanity but from our government as well??? If private pilot license REQUIRED minimum of for example 7 hours instrument training and at least some approach, maybe we wouldn’t have to see this tragedy. OTOH why fly 2,220h and NOT strive for instrument rating? Beyond me.

  • rickr

    Did this plane not have a autopilot? if so he would be at home so would have jfk jr such a great tool in ifr conditions!!

  • Mark Carroll

    I have read through only half of the comments so far, but felt I needed to make a comment. I have listened to this account two times so far, once at my office and again at my house. Both times tears swelled just a bit in my eyes as I listened to the pilot responding to the controller.

    First of all, the controller did not ask the pilot if he was instrument rated and the pilot did not admit that he was. The controller asked if he was capable of instrument flight and the pilot said yes. The controller was smart in asking the question that way. I believe his training helped him realize that he need not intimidate the pilot by asking if he was rated. He just wanted to get a response related to his competency level. That’s really all he could do. The controller did not want to make a bad situation even worse.

    We are listening to a man’s last words before he dies. I think a little more compassion is in order from some of the commenters. True, he made mistakes that took sever peoples lives. Do you think, if he had made it to the airport and every one had survived, that he would have done the same thing over again? I don’t think so.

    We have all done incredibly stupid things and learned from them. At least I know I have. Some of the commenters need to watch and listen again. A few need a “reality check.” This wasn’t fiction. If looking/listening to this convinces one additional pilot to make the right decision, based on what he has learned here, then AOPA has done the right thing. BTW, the person responsible for putting this video together did a great job!

    In case you are wondering, I am a VFR pilot with just over 1,400 hours. I have owned three planes and have been flying for 32 years.

  • Mark C

    In response to Honza, requiring 2 – 3 times more instrument training would be almost useless – unless you maintain currency, you are not going to be successful in an emergency situation. You can hear it in this pilot’s voice when he answers “yes” to if he is instrument capable. Yes, I have instruments, yes, I have training, yes, I should be able to do this, but no, I haven’t actually ever done it nor have I practiced it recently but since I have no other options, I’ll give it my best shot and hope it works.

    You cannot legislate nor enforce good decision making. For those who cry for “someone” to “do something”, the closest we could come, is to mandate the filing of a VFR flight plan for every flight. Do you really want that? And how’s that working out in China? We have to act responsibly ourselves, and question others when they don’t. I’m a low time student pilot, and I’m not afraid to question a guy who has done something unsafe or even inconsiderate. It doesn’t have to be confrontational, just asking why or pointing out that something doesn’t seem quite right will get them thinking about it, and for most, that will help. Then, there will always be those few who are beyond educating, and they will continue to provide material for lessons such as this.

  • Melinda

    A recurring message in these posts is “get an instrument rating and you won’t end up like this pilot.” I disagree. With all due respect to instrument pilots–and I plan to join your ranks one day–an instrument rating is not the “magic bullet” that saves the day. Of the 5 pilots I personally knew who died by flying VFR into IMC, 3 had instrument ratings and 1 was close to taking his instrument checkride. They ranged in experience from thousands of hours to newly-minted. They didn’t lack education or piloting skills. They lacked good judgment–at least on one flight, which happened to be their last flight.

    I have flown VFR for 12 years all over the country, landing in 19 states, in a small single-engine aircraft with no weather radar. I have never, ever, not even ONCE, gotten myself into a situation where I needed instrument skills or ATC assistance. You check the weather when you’re on the ground and you look out the window when you’re in the sky. “Sky’s navy blue? Get a clue. Land.” “Can’t see through it? Don’t fly to it. Land.” It isn’t rocket science.

    As for Mr. Carroll’s excellent question, “Do you think, if he had made it to the airport and every one had survived, he would have done the same thing over again?” YES! Taking off over gross, pushing on into deteriorating weather, and running low on fuel suggest a long-term pattern of unacceptable risk-taking, not a momentary lapse of good judgment. Pilots who survive through sheer luck believe it’s their “skill” until their luck runs out.

  • Bruce Landsberg

    Thank you all for some excellent commentary! This week’s blog ( Thursday) continues the thread that Melinda has opened up. She has more eloquently stated my saying of ” What part of “cloud” don’t you understand?”

    Some of us seemed to be wired as risk takers – more to come.

  • Gerard

    A tragedy for those passengers who trusted this pilot and a disgrace to our GA community. I can only imagine how a non-pilot would react to this story. “If a 2000+ hour pilot can not be trusted with the lives of innocent passengers, who can be trusted?…… Where are the rules to stop more pilots from doing the same? … Why are GA pilots not regulated more heavily?….etc.”

    I think it is pointless to try and apply our sensible, PRM oriented logic to understaning what this pilot was thinking, It is safe to say he propably wasn’t a frequent visitor to the ASF website. So what can we do to prevent this kind of thing?
    1) Practice practical risk management on the ground and in the air,
    2) Take a professional attitude towards our flying and set a good example for our fellow pilots and the non-flying public,
    3)Speak up.. if you see a fellow pilot putting themselves or other at risk say something. If they disregard your warning, say something to the passengers and let them know they are at risk.

    There are old pilots and bold pilots, but no old, bold pilots.

  • Justin S.

    Another great product by ASF. After watching this I am going to make it part of my ground school syllabus. It’s just chilling when you sit back and watch how many times this person was given a option or a way out…I wonder how many my students can find.

    There has been a lot of great discussion about continued VFR into IMC and the role that competence plays in the safety of a pilot, but I will close by echoing what Melinda has said above: no certificate or license is a “magic bullet” or “get our of free jail card”. As a flight instructor I have had the opportunity to fly with a wide variety of pilots, all with varying levels or experience and capability, but nothing scares me more than an instrument rated pilot who has everything but a sense of his or her own limitations. One such flight comes to mind when in an attempt to reduce my already instrument rated student’s reliance on auto-pilot I challenged them to fly a 1 hour cross country in MVFR to occasional IFR conditions. After approx. 5 seconds of hitting the first cloud on departure I found myself starting at a 45 degree bank, dealing with a very confused departure controller and last but not least a clueless 1500 hr instrument rated student.

    I’ve since deployed with the military and have not heard from this individual since leaving, but I often ask and wonder about that person.

    Every license is simply a license to learn.

  • chukker

    I know there is no evidence to support my theory, but while viewing the video I wondered if the pilot wasn’t having a heart attack or became physically incapacitated in some way – aside from his abject fear. Some of his radio responses sounded like he was out of breath and somewhat dazed, then he doesn’t respond at all. Towards the end, the plane begins to climb and still no response; the climbing part seemed odd to me. If that plane had five others onboard, including someone in the righ seat, why didn’t anyone else respond to the ATC’s? This is a strange situation that leaves one with more questions than answers.

  • Arnold L. Goldman

    Great video! Shows the extreme in lack of judgment in a variety of ways. One interesting aspect not mentioned is the video re-enactment airplane appeared to have a Garmin 530 in the panel. Did the accident airplane? If so, that tool might have helped maintain the situational awareness necessary to find the airport or any airport. I can only assume the accident airplane did not have that or similar equipment. Which begs the question: If you have 2200 hours and you do not know how to use all the equipment in your airplane, why not? Also, with 2200 hours, and a multi-rating, why no instrument rating? Its just not that hard to do, especially when you already have good aviate, navigate, communicate skills…….

  • Student Pilot

    The pilot involved was friends with the pilot that got me involved with GA. Fortunately, my friend is very safety oriented, and it rubbed off on me as well. In the above IMHO some somewhat irrelevant information is missing. First of all, English was not the pilots primary language, so IMO some apparent panic was a heavy accent. The student pilot mentioned, was a glider pilot. I was told that There was NO GPS unit on the plane. This was a Glider Club outing, and 2 of the passengers were not involved with the Club. Most of the operations the Pilot was experienced with, was Glider towing in an uncontrolled airport.
    This info is second hand.

    I analyzed this tragedy in my head over and over again since it happened and could not understand it. Until one day with out warning it was a bad day for me to fly. One little mistake, and some stress compounded, in hind sight I noticed that my focus changed, and I could not even communicate with the ATC coherently. Fortunately for me, this was one of the days when my instructor was with me.

    Its obvious that the pilot made some huge mistakes to get into IMC. But I really think that once the pilot made contact with ATC, there was very little that could be done to change the outcome IMHO. The pilots responses sounded very much like mine did when I had a bad day. And the result was not due to his experience, but state of mind.
    IMHO I think the “Tunnel Vision” also should be addressed, ways to recognize it, and ways to snap out of it.