Sometimes in Flight, There Is No Safety in Numbers

Formation-flight tragedy in California accentuates the importance of airside discipline.

Did flying in formation cause the other pilots to rely too much on the lead pilot on that fateful day? [File Photo: Adobe Stock]

A group of Southern California pilots and friends would gather on Sunday mornings to fly in formation to nearby airports for breakfast. On a June morning in 2002, they met at Van Nuys Airport (KVNY) for a trip up the coast to a little seaside airport called Oceano (L52). Eight airplanes were in the group: two Bonanzas, three Comanches, a 210, a 310, and a Glasair. After the flight leader, 59, a 3,000-hour commercial and instrument pilot, conducted a formation safety and procedures briefing, they departed in two sections of three trailed by the remaining pair.

The coast runs generally westward from Los Angeles before bending north at Point Conception, south of Oceano. The flight headed west for half an hour at 4,500 feet before the leader turned northward and instructed the others to transition to single file. The second Bonanza remained in close formation with the lead.    

The terrain below soon became a jumble of ridges and canyons, oriented generally west-northwest, with rapid changes in elevation from 1,500 to 5,500 feet. Here, the lead pilot dropped down and entered a canyon, as he had done many times before. His wingman stayed with him. In loose trail, and at a somewhat higher altitude, the Glasair and one of the Comanches followed. Three of the other airplanes broke out of the formation, transmitting that they would rejoin the others at breakfast.

The Fun Ends

As the four airplanes approached the head of the canyon, the pilot of the Glasair, who was doing about 120 knots, saw that he was gaining on the Bonanzas and that the second Bonanza was gaining on the first. He heard a fragmentary transmission, and made out only the word "ninety." The second Bonanza now appeared to him to be only a few yards behind the first, and both were approaching the steeply rising end of the canyon. Anxiously, he asked the lead whether he was going to clear the ridge. He inadvertently kept his mike keyed and did not hear the reply, but another pilot did: "I don't think so."

Seconds later, the Glasair pilot made the decision that saved his life. He pulled up hard to the left. The lead Bonanza was at his two o'clock when he saw it collide with the flank of the ridge and explode in flames. An instant later, the second Bonanza crashed beside it. The Glasair cleared the canyon's edge by 50 feet; the Comanche crossed it safely as well.

By the time ground rescue units reached the scene, little remained of the two Bonanzas beyond their outlines in ash on the ground. They had pancaked, 75 feet apart, into a 45-degree brush-covered slope, 500 feet below, and half a mile from the saddle at the head of the canyon. Six people, five of them pilots, died.

A lighthouse at Point Conception in California. [Courtesy: National Marine Sanctuaries]

Fate Both Cruel and Kind

The Fates handed out good luck and bad that day, in their usual capricious way. In the second airplane were an older couple who did not usually fly with the group. The husband, a retired high school woodshop instructor, had once flown cropdusters. His wife had a sore knee on the day of the flight, and it had been decided that, rather than squeeze her into the back seat of one of the Comanches as originally planned, she and her husband would ride in the second Bonanza. The pilot who gave up the front seat to her moved to the back seat of the lead airplane.

On the other hand, the Fates smiled upon the owner of another Bonanza. He had taxied out to join the group that day, but turned back when he found that his alternator was not working. Had his alternator not failed, he probably would have been the one on the leader's wing. 

Another who was spared was a woman who had often gone on these breakfast flights in the lead's airplane. She was working on her instrument and commercial at Van Nuys, and her instructor, who knew the lead and thought his formation and canyon flying was reckless, pressed her to stop flying with him, eventually threatening to quit giving her instruction if she persisted. Reluctantly, she changed her work schedule to give herself an excuse for not flying on Sundays. When the instructor called to tell her what had happened, she said, "You saved my life. I would have been in the right seat."

After the Glasair pilot cleared the ridge, he noted the outside air temperature; it was 87 degrees. The density altitude at 4,900 feet, the pressure altitude at which the Bonanzas struck the ridge, was therefore around 7,800 feet. Under those conditions, a naturally aspirated Bonanza with three aboard can climb at about a five-degree angle, or one foot up for 11 feet forward. That corresponds roughly to the slope of the canyon bottom until a point, about a half mile from the ridge, where the terrain suddenly begins to ascend more steeply.

Assuming that the lead airplane was slowing to its best-angle-of-climb speed—and that is why the second Bonanza was gaining on it—it would travel half a mile in about 20 seconds. A mile from the ridge, there is a tributary canyon on the left through which the Bonanzas might have escaped if the leader had turned into it; but at that point the slope of the canyon bottom had not yet begun to steepen, and the danger of a 500-foot obstacle a mile ahead may somehow not have been obvious.

Possibly the lead pilot, who was familiar with the area, mistook the fatal canyon for a different one with an easier exit. In mountainous terrain it is very easy to mistake one ridge or canyon for another. It is also very difficult, if not impossible, to accurately gauge the slope of the terrain ahead and to estimate the airplane's ability to clear it. Flying close to terrain at the bottom of a canyon is, as one of the pilots in the group later said, "quite a rush," but the rush is the same whether you fly down the canyon or up, and downhill is obviously safer. 

Apparently, the lead pilot did not recognize the danger he was in, and into which he was taking others, until too late. He never called "Break!" to dismantle the formation. The attention of the pilot of the second Bonanza was fixed on the lead; he probably never saw what was coming. But there were two other pilots in the lead airplane. Did they have misgivings about descending into the canyon? Did they say something? Or was their reliance on the expertise and judgment of the charismatic lead pilot, whom they may have considered their superior and mentor—so great that they passively accompanied him into that fatal cul-de-sac? 

When we read about airplane accidents, the persons involved may appear as two-dimensional beings defined by one or more characteristics—impatience, laziness, ignorance—or as faceless figures with no characteristics at all. But real people, and the situations in which they find themselves, possess many complexities. All the more when the cast consists not of a single pilot but of a whole group of pilots and their passengers, many of whom are pilots themselves. Many accidents have demonstrated that the presence of multiple pilots, when they are not operating as a disciplined crew, does not increase the safety of a flight.  

There is happiness to be had in taking risks, and we are free to pursue it. But it is one thing to take risks alone, and another to take them on behalf of others. 

Editor's note: This article is based on the NTSB report of this accident, and is intended to bring the issues raised to our readers' attention. It is neither intended to judge nor to reach any definitive conclusions about the ability or capacity of any person, living or dead, or any aircraft or accessory. 

Peter Garrison taught himself to use a slide rule and tin snips, built an airplane in his backyard, and flew it to Japan. He began contributing to FLYING in 1968, and he continues to share his columns, "Technicalities" and "Aftermath," with FLYING readers.

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