One cloudy spring day a few years ago a Beechcraft Baron piloted by a high-time ATP and with a relatively experienced private pilot in the right seat hit a peak in the Ruby Mountains of eastern Nevada while en route from Truckee, California, to Salt Lake City. Both occupants were killed in the crash. The airplane, which was getting flight following from Salt Lake Center at the time of the mishap, hit terrain at 10,500 feet in controlled flight. An NTSB investigator concluded that the airplane had most likely been in visual conditions until just before it hit the steeply sloping terrain just a couple of hundred feet below the peak’s summit, which was the highest terrain in the area.
The tragic accident is also an intriguing one on several counts. First, the accident airplane was on the second leg of a two-leg trip that began earlier in the day in San Carlos, California. The flight was flown VFR, and the first leg, according to the NTSB report, went off without a hitch. The second leg, flown through the heart of the Sierra Nevada range in California and Nevada, was flown later in the day, also under VFR. The pilot did ask for and get VFR flight following services; with flight following, it’s important to understand that ATC’s role is limited. The pilot in command is responsible for maintaining adequate clearance from terrain and from clouds. In this case, it’s tragically clear that neither happened.
The NTSB’s finding of probable cause seemed to state the obvious, that the crash was caused by “the pilot’s continued VFR cruise flight into instrument meteorological conditions in mountainous terrain, and his failure to maintain clearance from terrain.” There was no sign of mechanical malfunction or medical emergency. The pilot apparently flew the Baron into the side of the mountain under control.
The question the NTSB does not attempt to answer in the report is why the pilot failed to avoid the mountain.
Why did investigators avoid the central issue in the investigation? We all know the answer. It’s because, most of the time, it’s impossible to say why pilots put themselves into situations that lead to their demise. There are a handful of commonly conjured answers: invulnerability, get-home-itis, machismo and improper crew coordination, among others. There’s also the possibility that the flight came to harm because of ignorance of the conditions or the risks, though that’s unlikely in this case, with a 13,600-hour ATP in the left seat.
I won’t attempt to speculate on why things went wrong, just that the risk was very high to begin with. You have a VFR flight off-airways being flown in mountainous terrain with mountain obscuration. The other higher risk factors are it being a multileg flight, there being two pilots on board for a noncrewed airplane, and the cloud tops being at or above oxygen altitudes.
While it’s almost always a good idea to be on an IFR flight plan when you can be, for those pilots who aren’t instrument rated, there are a number of things you can do to cut down on the risks. If the pilot of the Baron in question had recognized the risks and approached the flight differently, there’s a high probability, based on the statistics, that it would have ended happily instead of tragically.
Identify the Risks
The key to making VFR flight safer is to fly like the airlines do. Of course, that’s not always possible. A Bonanza pilot flying a 500 nm trip to an unfamiliar small airport doesn’t have the second pilot, the second (turbofan) engine, the dispatchers watching his back or the same level of required recurrent training as airline pilots have.
While flights of small airplanes come to harm for many reasons, the biggest risk factors can be summed up in three main categories: weather, terrain and loss of control. If we were to remove these offenders from the record, light airplane accidents likely would be cut by far more than half.