There was a demonstrably high probability this flight would end tragically. If we assess honestly all the risks identified, along with their likelihood (probability) and severity (consequences), it’s clear that mitigation was needed to reduce these high risk levels.
To do so, let’s begin by agreeing that an in-flight loss of control (I-LOC)is of potentially catastrophic severity—the loss of the aircraft and all of its occupants. If we agree about I-LOCs, then we must assess the likelihood of each hazard/risk to result that outcome. Let’s look at the risks we’ve identified and plug them into an assessment matrix like the one above.
Pilot
Under the weather conditions he faced, and without an instrument rating and the required proficiency, the likelihood of I-LOC for the Bonanza pilot on this flight was at least “occasional” and more likely “probable.” That’s clearly in the HIGH (RED) risk category and requires mitigation. In this case, it would either be canceling or re-scheduling the flight, or possibly waiting until daylight to depart.
Aircraft
The Bonanza was not equipped to fly in icing conditions and the pilot likely wasn’t familiar with its instrumentation, plus there was no working autopilot. Thanks in part to its light control feel and possibly being out of weight-and-balance limits, one result would have been an unstable instrument platform. The likelihood of an I-LOC event was probably more than “remote” and thus is another HIGH/RED risk requiring mitigation.
Environment
The potential for turbulence and icing, plus the overcast night sky and lack of horizon made instrument conditions a given, greatly increasing the possibility of I-LOC for a non-instrument rated pilot. Yet again, the environment in which the planned flight was to occur was a HIGH/RED risk requiring mitigation.
External Pressures
The combination of a young, inexperienced pilot subtly (or overtly) pressured to make this flight, combined with the other conditions, makes the possibility of an I-LOC event more than “remote,” again creating a HIGH/RED risk requiring mitigation.
While it’s always easier to make these assessments in hindsight, at least some of the certain dangers he faced on this flight should have been clear to Roger Peterson. Yet, in a world where Legal=Safe, he may have suppressed his gut feelings. The absence of risk management training certainly made it easier to rationalize.
