Pressure to fly

After departure, the pilot turned 30 degrees right toward the assigned heading of 140. He contacted ATC and reported climbing through 1,800 feet for 3,000 feet and ATC acknowledged he was in radar contact one mile southeast of the field. Less than 30 seconds later, ATC followed up by alerting the pilot that his track then appeared to be westbound and advised that he turn back to the southeast. No response was received and the aircraft subsequently descended into terrain less than a mile from the airport. All three on board suffered fatal injuries.

The NTSB final Aviation Investigation Report reveals how what was supposed to be a fun weekend at the beach turned deadly within minutes. The pilot’s plan offered challenges, each of which would give most pilots pause and, in concert, would have produced a clear “no-go” decision from a flight risk assessment tool (FRAT). The FAA promotes using FRATs to analyze the risky components of a flight and offer one of three recommendations: Green (low risk) means go, yellow (medium risk) suggests proceeding only after mitigating the higher-risk factors, and red (high risk) is an automatic no-go.

The report’s probable cause cited the pilot’s loss of control caused by spatial disorientation and, “contributing to the accident, was his decision to depart into low instrument meteorological conditions.” The narrative gives a more complete picture by enumerating the long list of risks the pilot chose to tackle by making the flight.

It might be tempting to consider the number of risks this pilot chose to accept and assume we’d never find ourselves in a similar situation. But it would be a mistake and a missed learning opportunity.Weather: The pilot availed himself of multiple weather briefings that warned of turbulence, low-level wind shear, low IFR conditions, and potential icing along the route. His concerns focused only on an icing encounter, so he filed for 3,000 feet msl to mitigate the risk of icing. The report didn’t detail the requested route but it’s worth noting that the tango routes and off-route obstruction clearance altitudes (OROCAs) near Gainesville are above 3,000 feet msl. At the time of the accident, fog and mist restricted the visibility, and the ceiling was reported to be 400 feet overcast. Winds were recorded from 70 degrees at 7 knots, gusting 18, consistent with the predictions for turbulence and low-level wind shear. The pilot chose to depart from Runway 11 instead of the longer Runway 5 that would allow for a smaller crosswind component. While the report makes no comment on this choice, it is curious that he didn’t opt for the better Runway 5.

Inexperience: At the time of the accident, the pilot was a relatively new instrument pilot with approximately 70 hours of combined actual and simulated instrument experience. While he passed his instrument exam, it’s not clear how much experience the pilot had on challenging cross-country flights in instrument conditions. He had logged about 384 total flight hours with less than 45 hours in his recently purchased Cessna 182RG. Instead of the glass panel to which he had become accustomed, the Cessna’s panel featured traditional “six-pack” instruments that he planned to upgrade soon. His friend, quoted in the accident report, labeled him as a “magenta line pilot” and recommended that he operate solely using visual flight rules until he upgraded the instruments and avionics. Heeding that advice, of course, would have prevented the devastating accident.

External factors: The passengers on the flight were the pilot’s wife and brother, and they were all likely excited to join their friends in Daytona Beach. Disappointing friends by delaying or canceling such a trip is something no pilot enjoys doing. Many FRATs and personal minimum worksheets recognize that flying with passengers, especially family, can be distracting and can add pressure to make an ill-advised flight happen. There are always other options, such as leaving the next day, driving to Florida, or flying on a commercial airliner. Forming an alternative plan means that the adventure can still happen.

In summary, N3652C’s pilot chose to use his recently minted instrument rating, in a new-to-him airplane with an unfamiliar avionics package and departed, as evening fell, from the shorter runway with the greater crosswind component, into gusty winds and low IFR conditions with his wife and brother on board. While there is nothing in that list that goes against regulations, it’s hard to imagine how the pilot could have reasoned the flight would be successful. A FRAT for this flight’s set of conditions produces a resounding “no-go.”

While I generally leave accident analysis to others, this one became personal for me because I was the pilot’s designated examiner during his private pilot practical test. My heart sank when a friend called soon after the accident happened to relate the news. The subject of personal minimums came up in his private test, as they do in all practical exams, and his response must have been acceptable because our time together finished when I issued him a temporary private pilot certificate. I’m sure that the examiner for his instrument rating discussed them too. Still, I’ve worried countless times over the years that there were signs his commitment to flight-risk analysis was lacking or he exhibited hazardous attitudes, like invulnerability, impulsivity or macho, that I missed.

It might be tempting to consider the number of risks this pilot chose to accept and assume we’d never find ourselves in a similar situation. But it would be a mistake and a missed learning opportunity. If you fly long enough, you’ll likely experience intense pressure to make a flight happen.

How many yellow and red flags should you see before tucking the airplane back in the hangar and exercising Plan B? If you haven’t considered an answer to that question, download a FRAT from Apple, Google, or other app repositories and a personal minimums worksheet from AOPA’s Air Safety Institute. A “no go” result paired with an alternative plan just means the adventure will happen in a different way. And pave the way for future adventures too.