Safety Publications/Articles

High-performance aircraft, low-performance pilot

Could anything have been done?

One of the perplexing aspects of accident investigation is attempting to understand why pilots make the decisions that they do. After a fatal accident, everyone wants to know why certain decisions were made. An accident involving poor decision-making is especially difficult to fathom when the pilot in command gave every indication of being cautious and responsible.

The 59-year-old private pilot had a relatively new instrument rating (three years) and 600 hours total time, with only 35 hours in a high-performance aircraft - a Beech V35 Bonanza he had purchased five months earlier. Investigators spoke with several of his flight instructors after the accident and learned that the pilot was reputed to be cautious.

The pilot contacted approach control and asked for a VOR approach. There were several communications regarding navigation to the VOR and the pilot stated that he was "experiencing some disorientation and could you vector me please." The controller directed the flight to the final approach course and the pilot transmitted, "Yeah, I've got her in - I think I'm established now, thank you." There were no further communications.

The Bonanza crashed during a missed VOR approach in an area where conditions were estimated to be an 800-foot ceiling and 1.5 miles visibility. Witnesses observed the aircraft flying in the bases of the clouds until it made an abrupt pull-up into the clouds. The Bonanza was next seen descending out of the clouds in a near-vertical attitude. The pilot and three passengers were killed. A corporate pilot awaiting departure clearance estimated that the weather was at or below VOR landing minimums.

The pilot received a flight review in a Piper Cherokee the month before buying the Bonanza, and notes in his log stated, "good flight - safe pilot." After buying the Bonanza, he received a 15-hour high-performance checkout. The check pilot advised the owner to get some additional time and then come back for an instrument checkout. This was never done.

Of particular interest was the fact that two months before the accident, after buying the Bonanza, the pilot took and passed an instrument proficiency check (IPC) in a Cherokee. This instructor said, "He didn't seem to be a risk-taker." The Bonanza instructor who had recommended some IFR dual told the NTSB that the pilot had very little actual IFR time and none in high-performance aircraft. He stated that the weather was near or below minimums for the approach and that the pilot "had no business attempting the approach in the Bonanza - he was the last person I thought would do something like this." One local pilot, who flew as a safety pilot with the accident pilot earlier in the month, characterized the Bonanza pilot as "safety-conscious and cautious."

Was the pilot pressured by passengers to complete the flight? Was he embarrassed that he might have to return to the departure point in VFR conditions? Why didn't he complete the type-specific IFR checkout, and why did he take an instrument proficiency check in a simpler, slower aircraft after he purchased the high-performance machine? What else could the instructors have done to encourage the pilot to get additional training?

Of course we have no firm answers, just speculation - but consider how you might have handled this situation. These CFIs were not at fault, but a number of us work with pilots who are in similar circumstances and who will be coming to us for guidance. In this case even hindsight isn't especially revealing, and yet I suspect all of the instructors involved are asking, "What could I have done differently?"

Bruce Landsberg is executive director of the AOPA Air Safety Foundation.

By Bruce Landsberg

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