On the day of the accident the sunset was at 6:04 p.m. local time, and the end of civil twilight was 6:32 p.m. Just after 7 p.m. the pilot contacted Denver Tracon and indicated that he would be airborne for "a couple of hours" practicing various approaches.
The pilot requested two turns in the holding pattern before flying his third approach. During the inbound leg of the first turn in the pattern, the pilot descended 1,400 feet from his assigned altitude without ATC intervention. After the hold, the pilot asked to depart to the southeast to "get out of the way of the approach course for awhile." He requested an altitude of 8,500 feet. The controller cleared both requests, but did not mention visual flight rules or changing the transponder code.
Shortly thereafter, the pilot made a turn toward rising terrain. No warnings were provided to the pilot by ATC after this maneuver. The aircraft wreckage was found on the mountainside near the position where radar contact was lost.
The pilot's wife said he intended to practice instrument approaches to prepare for an instrument proficiency check. She frequently flew with him as a safety pilot, but he said that he wanted to fly alone for this flight. The pilot told her that he would not be wearing a vision-restricting device, but instead would "turn his cabin lights up bright" to restrict his external vision.
The cause of this crash was the pilot's intentional restriction of his external vision and his subsequent failure to maintain clearance from the mountain, according to the National Transportation Safety Board. A contributing factor was the controller's failure to provide appropriate safety alerts for rising terrain.
FAR Part 91.109 (b) states, "No person shall operate an aircraft in simulated instrument conditions unless the other control seat is occupied by a safety pilot who possesses at least a private pilot certificate with category and class ratings appropriate to the aircraft being flown."
The controller's responsibilities for this flight are dictated under the definition of "Additional Services" in the Air Traffic Control Handbook: "Advisory information provided by ATC which includes but is not limited to the following: traffic advisories; vectors, when requested by the pilot; altitude deviation information of 300 feet or more from an assigned altitude as observed on a verified automatic altitude readout (Mode C); advisories that traffic is no longer a factor; weather and chaff information; weather assistance; bird activity information; and holding pattern surveillance.
"Additional services are provided to the extent possible contingent upon the controller's capability to fit them into the performance of higher priority duties and on the basis of limitations of radar, volume of traffic, frequency congestion, and controller workload."
When the pilot requested a direction and altitude change, the controller cleared him but did not terminate radar services. FAA Order 7110.65, paragraph 7-6-1 (Basic Radar Services), and paragraph 2-6-1 (Safety Alerts) requires the controller to provide basic radar services for VFR aircraft, including safety alerts, traffic advisories, and limited radar vectoring when requested by the pilot. Controllers are to issue a safety alert to an aircraft "if you are aware the aircraft is in a position/altitude, which, in your judgment, places it in unsafe proximity to terrain, obstructions, or other aircraft." Radar data indicates that the pilot flew south approximately 8 nm, and then turned to approximately 210 degrees and flew directly into rising terrain, with no controller advisories.
While this accident could have been prevented if the pilot had received altitude and terrain warnings, it was the pilot's responsibility to see and avoid the terrain. When practicing instrument procedures always follow the regulations--and always have a safety pilot on board.
Kristen Hummel manages the GA accident database for the AOPA Air Safety Foundation. She holds a commercial pilot certificate with multiengine and instrument ratings.
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