Deadly Efficient Planning

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What mind-set would compel an experienced pilot to launch VFR into marginal conditions just to save some time picking up a clearance?

It makes little difference the type of aircraft or the installed equipment when a flight continues VFR into IMC conditions at critically low altitudes.

I recall an instructor, who before signing students off for the commercial checkride, would explain a few things he felt were critical when exercising commercial privileges.

First, commercial pilots had to be smooth. After all, paying passengers would not be impressed if we could not fly the airplane well.

Second, commercial pilots had to be efficient. No paying passenger is willing to pay for extra time on the ground, simply because the pilot is dallying around. However, the second point was tempered with a statement reminding the candidates that efficiency should never trump safety.

The above is great advice, and something all of us should follow, regardless of our certificate level. So why an experienced professional pilot would put safety aside, and launch into what is known to be one of the most unsafe conditions, VFR into IMC, begs some investigation?

Airline Pilot

The pilot’s logbook was not recovered, so the investigators had to reconstruct his experience based on FAA records, an insurance application, and his medical certificate paperwork.

The 61-year-old pilot flew for a major airline for 26 years. He possessed an airline transport pilot certificate for single- and multi-engine land, and instrument airplane ratings. He was type rated in numerous Boeing aircraft, the 727; 737; 757; and 767. Other type ratings included the Douglas DC-9; Fokker 100; and the Lockheed JetStar. His single–engine land rating was limited to commercial privileges.

The pilot was also a flight instructor—SMEL and instrument airplanes. He held a flight engineer certificate for turbojet aircraft as well. He was an experienced instrument pilot.

The most recent first-class medical was issued four months before the accident. On the application he reported 18,900 hours of total time, of which 400 were flown during the previous six months.

An insurance application for his personal airplane, a 1963 Beech P35 Bonanza, was also found by investigators. The pilot had purchased this Bonanza about a year before the accident. This application was dated three months before the accident, and it listed 19010 total hours of experience, of which 939 were flown in the previous year. It also listed 195 hours of flight experience in the Bonanza. The application also noted his last flight review occurred four months before the accident.

A Quick Turn

On a dreary Tuesday morning the pilot and a passenger arrived in the Bonanza at Chadron Municipal Airport (KCDR) on an IFR flight plan at about 1050 local. The flight had originated from North Platte Regional Airport (KLBF), in North Platte Nebraska, 150 miles to the southeast. Marginal VFR to IMC prevailed over a widespread area.

The surface weather at the time of the accident shows the recent passage of a cold front relative to the accident location.

An FBO employee noticed the pilot and passenger deplane. The pilot briefly chatted with the FBO employee about another Bonanza sitting in the FBO’s hangar, and then the pilot and passenger continued their walk to the FBO lobby to use the restroom. The pilot and passenger returned from the lobby, and they were observed walking around the accident Bonanza several times—presumably performing a preflight inspection.

A few minutes later the FBO employee noted the pilot seated alone in the airplane for several minutes. The aircraft had an IFR flight plan on file for the next leg of the journey, a short 50-mile trip to Alliance Municipal Airport (KAIA). Sitting alone in the airplane, the pilot may have been contemplating how he was going to pick up his instrument clearance, as the RCO was NOTAMed out of service, and the airport was non-towered.

There are essentially two alternatives. The first is staying on the ground while calling Flight Service on the phone to have them coordinate a clearance with ATC. This option can be frustrating and, should the call be dropped, it will require starting the procedure over again. The second option is to launch and remain VFR while picking up an IFR clearance airborne. This is a faster option, but it can be fraught with perils, even if you stay over the airport.

The local TAF forecasted the weather as winds from the east; visibility greater than six miles; scattered clouds at 700 feet, and an overcast ceiling of 2000 feet. The most recent AWOS (17 minutes before departure) reported calm winds; nine miles visibility; a broken ceiling at 1500 feet and an overcast ceiling at 3400 feet.

At 1110 local the airplane, with only the pilot on board, taxied from the ramp. The Bonanza was equipped with ADS-B, and investigators were able to obtain and review aircraft position data. They determined the Bonanza departed KCDR on runway 11 at 1121 local. After becoming airborne the aircraft turned right toward the south and began to proceed towards its destination, KAIA.

One minute later the pilot contacted Denver ARTCC and requested his clearance to KAIA. As luck would have it, the controller was busy with other traffic, and asked the Bonanza to standby. Eight seconds later, the controller came back with a transponder code, but still no clearance. The pilot acknowledged the code and it updated on the controller’s screen.

At this point the aircraft was heading south. Radar track data indicated the plane had a groundspeed of 145 knots, and it was flying at 4200 feet MSL, or approximately 1000 feet AGL. The flight continued south at speeds between 135 and 155 knots over the ground, with the altitude varying between 4200 and 4400 feet MSL.

For two and one-half minutes there was no communication between the controller and the pilot, as the controller was actively communicating with other aircraft operating in his sector. At 1125 the controller called the Bonanza with “…seven delta mike, radar contact nine miles south of the Chadron airport, say altitude.” There was no response from the Bonanza pilot.

Using ADS-B data it was determined the aircraft encountered rising terrain, 900 feet above the departure airport elevation, 10 miles south of KCDR. The Bonanza hit treetops and a ridge line completely destroying the aircraft on impact. Day IMC prevailed at the accident site.

A witness, who was working outside nearby, noted the weather throughout the morning had been light precipitation, mist, fog, and low clouds that obscured the surrounding ridge lines. According to investigators, the pilot likely encountered IMC just before hitting the ridge line. As so often seems to happen, the witness also noted the weather improved shortly before noon.

Investigators noted the probable cause as “The pilot’s decision to attempt VFR flight into instrument meteorological conditions resulted in controlled flight into rising terrain during cruise flight.”

They also noted correctly, that the pilot could have avoided the accident by having called Flight Service for a coordinated clearance or having remained over the airport instead of venturing towards his destination.


It’s a sad situation every time there is an aircraft accident, especially when a fatality occurs. It is easy to dismiss looking back with 20/20 vision, but it does give us a tool to learn about opportunities missed by others, in this case an experienced instrument pilot. Reviewing an accident allows for discussion to help us make the right choices when faced with a similar situation. Perhaps the biggest factor that could have broken this accident chain would have been for the pilot to slow down and obtain an instrument clearance on the ground, no matter how frustrating that experience can be.

This article is based on NTSB Number: CEN16FA005

Addressing The CFIT Problem

Controlled-flight-into-terrain (CFIT) has been a major factor in many aviation accidents over the years. There have been numerous attempts to address the various causal issues—with some success. But one of the most frequent problems is the pilot’s mind-set.

It could be said that the less experienced IFR pilot might be more prone to this type of accident because of their lack of appreciation of the risks involved. But as was noted in the accompanying accident, this pilot had exceptional experience. It’s often this high-level of competence that lulls pilots into believing the conditions are in their favor.

Often a lack of awareness of the local topography is the culprit. Abrupt rising terrain can easily be masked by clouds and fog. Descending cloud bases are often not easily discernible, and the pilot reacts to the encroaching mist by gradually descending to stay visual.

In this accident, the raising terrain as depicted in the accompanying illustration is not subtle, but rather rapidly raising. That the aircraft impacted after descending from 4300 feet to 4100 feet, it seems plausible that he was reacting to the lowering ceiling.

The Flight Safety Foundation has created a CFIT Checklist (PDF) that helps pilots examine the various risks and risk reduction factors to arrive at a CFIT Risk Score. Consider perusing this list. Unfortunately, many of the items on the list are more slanted towards part 121 and international operations, as well as corporate/company culture—although the list could easily be scaled back to the casual Part 91 flier.

While the list of items provides a reasonable assessment, it again doesn’t take into consideration the spur of the moment impulse that often launches pilots into harm’s way.

Ted Spitzmiller

Armand Vilches is a commercial pilot and instructor who lives in Brentwood, TN. His extensive background in risk management and insurance allows him to bring a unique perspective to aviation and flight instruction.

This article originally appeared in the September 2018 issue of IFR Refresher magazine.

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