Aftermath: A Mysterious Way

Pilots for Christ International, or PCI, is a service organization dedicated in part to connecting volunteer pilots with people needing transportation for medical or other reasons. In February 2012, one of the members of the Wyoming chapter of the organization, a 47-year-old, 500-hour private pilot and owner of a 1961 Cessna 210, offered to fly to Salt Lake City to pick up a nurse, who had accompanied her grandmother there for medical treatment, and return her to her home.

The trip from the pilot’s base in Douglas, Wyoming, to Salt Lake City is a little more than 300 nm, or about two hours in the Cessna 210. He left at around 10 a.m. The weather over Wyoming was clear, but a patch of marginal VFR ceilings and visibilities hung over Salt Lake and the surrounding mountains. The forecast called for scattered to broken clouds at 10,000 feet, with an airmet warning of possible mountain obscuration. On the whole, the weather was mild and stable — no fronts and no major precipitation, with the freezing level around 7,000 feet and 9-knot west winds at that level.

All the terrain along the route is above 5,000 feet, and a ridge rises above 8,000 and, in places, above 9,000 feet just east of Salt Lake. Approaching that ridge, the pilot encountered an overcast, probably at around 7,500 feet. Finding the way to Salt Lake City blocked, he landed at Morgan County Airport, some 35 miles by road north and east of Salt Lake City. He called the nurse and asked her to meet him there.

They departed on the return flight after 1:30 p.m. The pilot requested flight following at 1:46 p.m. A short time later, he reported that he was in a valley and was going to turn out of it. ATC radar picked up only half a dozen beacon returns from the 210; then it disappeared.

It is not clear what, if anything, the controller thought about the Cessna’s subsequent silence, but that evening, after the flight had failed to arrive at its destination, PCI personnel alerted the FAA. Hampered by clouds but aided by an ELT signal, helicopter searchers located the airplane the following afternoon about nine miles east-northeast of Morgan County and about 3½ miles from, and 600 feet above, the last position reported by its transponder.

Both pilot and passenger had died on impact. The fragmented wreckage — part of one wing remained in the top branches of a 70-foot tree — lay atop deep snow amid a grove of firs at the 7,700-foot level. It was near the top of a northwest-facing slope. The terrain is remote and rugged enough that the airplane was not recovered and inspected by the National Transportation Safety Board until the following summer.

Examination of the wreckage and engine revealed nothing to suggest a mechanical problem. Some of the control settings were noteworthy, however, although they remained in the accident docket and did not find their way into the NTSB’s final report. The throttle, mixture and propeller were all full forward, and the fuel boost pump was set on high.

None of the official weather-briefing sites had been contacted by the pilot. Most likely, he had, like many pilots, self-briefed from an online site. Whether self-briefing is as good as talking with a briefer depends on the pilot doing it, but the pilot was obviously aware of the local weather conditions when he took off from Morgan County because he had been flying in them a couple of hours earlier and looking at them ever since. His eyeball briefing was certainly at least as valuable as a generic warning of possible mountain obscuration.

We know nothing, obviously, of the pilot’s thought processes prior to the fatal flight. He was not instrument rated, and so that option was not open to him. The NTSB report contains no information about conversations he may have had while waiting on the ground at Morgan County, and there is no way to know whether he warned his passenger that they might have to turn back and await an improvement in the weather.

The radar track of the pilot’s inbound flight suggests that he approached the area following Interstate 80 and continued some-what past the point where it veers southward to approach Salt Lake City over a 7,000-foot pass. He first turned southward, but finding that way blocked, he then turned north toward where Interstate 84 approaches Ogden, Utah, through a much lower pass. That must have looked bad too, because after continuing past the Morgan County Airport, which lies at the east end of that pass, he returned and landed.

So far he had, to all appearances, acted cautiously. While the behavior of men has sometimes been known to change in the presence of attractive women, there is no reason to think that the pilot abandoned his previous caution on setting off with his passenger for Douglas. So it is noteworthy that he did not retrace his steps southward to rejoin I-80; instead, he set off directly eastward, following a long, gradually rising valley that ended in an 8,200-foot ridge about 14 nm from the airport. Why did he make this choice? Perhaps a local pilot told him that the route eastward was often open in this kind of weather; perhaps he caught a glimpse of clear sky to the east; perhaps he misinterpreted the elevation information on his sectional.

At any rate, at some point he found that he could not continue. What happened next is unclear. The NTSB chose the familiar formulation: continued visual flight rules flight into instrument meteorological conditions. “Given the forecast and reported weather conditions,” the board wrote, “it is likely that the pilot encountered instrument meteorological conditions and was unable to see the trees and terrain prior to the collision.”

We know that two to three minutes elapsed between his turning back at 7,100 feet and his hitting a tree at 7,770 feet. The balls-to-the-wall power setting suggests an attempt at a maximum-performance climb, and that, in turn, could suggest a pilot who has unintentionally strayed into cloud and knows he is near high terrain. That the fuel boost pump was set on high is puzzling; its effect would have been to reduce performance by making the mixture far too rich.

The decision to fly up a valley toward rising terrain under an overcast turned out to be a bad one. That may not, however, have been so obvious when it was being made. Go/no-go decisions can be very difficult to make, and always erring on the side of complete certainty would result in one making very few flights. Probably few of us can give a complete or even an honest account of why we make the decisions we make. A pilot might feel self-induced pressure to successfully complete a charitable act and not to disappoint its intended beneficiary, especially if he feels that he is doing God’s work. Even a tiny pressure might tip the delicate scale of his decision. On the other hand, the conditions may have looked much better to the pilot than they turned out to be, and he may not have considered the decision to go or to take the route that he did a difficult one at all.

We should not make too much in our speculations of the charitable motive of the flight or of the religious auspices under which it was arranged. Neither had any necessary role. Many a pilot on secular business, or no business at all, has flown up a valley only to find that he could not outclimb it, and many have collided with a ridge while trying to turn back, often in clear weather. Mountain flying is tricky, even for pilots who live in mountainous states. Despite the NTSB’s somewhat facile after-the-fact diagnosis of “poor planning,” mistakes do not always look like mistakes in advance. If they did, we wouldn’t make so many of them.

This article is based on the NTSB’s report of the accident and is intended to bring the issues raised to our readers’ attention. It is not intended to judge or to reach any definitive conclusions about the ability or capacity of any person, living or dead, or any aircraft or accessory.

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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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