Probable Cause #16: Peer-Pressurized

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This article originally appeared in Aviation Safety, July 2004.

Probable Cause

Pilots must often deal with a wide range of competing emotions and pressures when faced with less-than-ideal conditions for a planned flight. These can range from doubts about one's skills and proficiency for the planned flight, to mechanical problems with the aircraft and to adverse weather. Another pressure point is potential embarrassment that the recently purchased, shiny airplane parked on the ramp can't be used to impress family and friends. In the same way that many accidents feature a chain of events or circumstances leading to an ultimate conclusion, sometimes merely a collection of pressures to make the flight can combine to bend metal, also.

That was apparently the case on June 6, 2003, when the pilot of a Beech Bonanza A36TC wanted to fly himself and three passengers from the Santa Monica (Calif.) Municipal Airport (SMO) to Las Vegas, Nev. According to the NTSB, the pilot's plan was to drop a passenger in Las Vegas and then continue on to Sun Valley, Idaho. Instead, the six-seat Bonanza crashed into an apartment building shortly after taking off, killing all four on board. Additionally, one person in the apartment building died and seven others on the ground were seriously injured. The accident made national news and, since it involved an airplane flying into a building in a major metropolitan area, much of the general media's initial coverage focused on terrorism. Nothing nearly so sinister was involved.

The flight departed in visual conditions and then tried to climb through a widespread, solid overcast only a thousand or so feet thick before proceeding on course. The non-instrument-rated Private pilot of the Bonanza had delayed the planned trip for several hours that day, apparently hoping that the overcast would clear, allowing a VFR departure and climb to cruising altitude. However, shortly after the pilot initiated the climb, the plane came right back down in a spin and with a high descent rate before it crashed into the apartment building. According to the NTSB, the probable causes of this accident included "the pilot's in-flight loss of control due to spatial disorientation, and failure to maintain airspeed, which resulted in a stall/spin. Also causal was the pilot's disregard of the weather information provided and his attempt to continue VFR flight into IMC. A factor in the accident was the pilot's self-induced pressure to complete the flight."

Weather Wishing

In the hours prior to the accident, the pilot contacted the Hawthorne Automated Flight Service Station (HHR AFSS) three times. The first telephone call was at 0803 local time, when the pilot was advised of overcast cloud conditions in the Los Angeles basin with bases from 2000 to 3000 feet and tops of 4000 feet. An AIRMET was in effect for IFR conditions and mountain obscuration. The situation had not changed much when the pilot again called HHR AFSS at 1125. The FSS briefer advised the pilot that the weather was not expected to improve and that VFR flight was not recommended. A final briefing was obtained from the HHR AFSS at 1301 local time. According to the NTSB, "The pilot inquired if he could legally fly, to which the briefer replied that yes, he was legal to fly, but that the weather conditions were marginal."

At about 1545 local time -- more than two hours after receiving a final weather briefing -- the flight departed SMO. The pilot told the tower controller that he was going to try and get out of the basin via Ontario, and he would try and pop up through the "broken layers/broken stuff" in the area. After a brief discussion involving nearby traffic, the accident airplane left the SMO ATCT frequency to contact SOCAL Approach. This was at approximately 1551 local time. The approach control facility has no record of the Bonanza contacting it.

Recorded radar data indicate that a target squawking Mode C with the VFR code 1200 and matching the accident aircraft's time of departure headed in an easterly direction after takeoff from SMO. The target maintained 2200 feet MSL for just over a minute; it then climbed to 2600 feet. At 1552:00, the Mode C return indicated 3100 feet. The highest Mode C altitude recorded was 3300 feet MSL at 1552:05. The last radar return, at 1552:19, indicated a Mode C altitude of 2400 feet MSL. A ground-based witness stated that he observed the airplane flying straight and level. The nose of the airplane pitched up, and the airplane began to climb. The witness lost sight of the airplane as it entered the clouds. When he saw the airplane again, it was in a nose-down attitude spinning towards the ground.

According to the NTSB, the closest official weather observation station was the Los Angeles, USC Campus (KCQT) Automated Surface Observing System (ASOS), which was 5.4 nm southeast of the accident site. The elevation of the weather observation station was 184 MSL. A special METAR for KCQT was issued at 1518 PDT. It reported an overcast ceiling at 3000 feet with visibility 10 miles and variable winds at six knots.

No information on the airplane's equipment is in the NTSB's final report. For example, we don't know if a two-axis autopilot with altitude hold and pre-select was installed. Neither do we know to what fix the pilot was navigating or how. We can reliably presume the non-instrument-rated pilot was hand-flying the airplane, trying to execute something approximating a "zoom" climb to VFR conditions on top of the cloud layer. While the NTSB post-crash investigation did not find any obvious mechanical problems with the accident airplane, one other factor sheds light on this accident's cause.

Pressure Points

According to FAA records, the aircraft was registered to the pilot on March 28, 2003, less than three months before the accident. The pilot's logbook was incomplete, but from the NTSB report we can estimate that the pilot had between 1100 and 1200 hours of experience. The NTSB does not mention how much, if any, instrument training the pilot had received or his total amount of simulated instrument flight experience. There is no way to estimate how much experience he had in the accident airplane or in similar types.

What's not difficult to estimate is the peer pressure the pilot was facing prior to takeoff: He had owned the turbocharged Bonanza less than three months. Here he was trying to fly his niece to Las Vegas and then continue with two friends on to Sun Valley. Instead, he and his passengers spent more than eight hours, according to the NTSB, sitting around the airport lounge, wishing the weather would clear long enough to get going.

Pressure to go, to stay, to fly a specific route, to ignore a mechanical problem, to make a schedule or to carry some extra weight -- among others -- are always factors for pilots. Succumbing to pressure, especially when the proposed flight will require us to do something for which we're not trained -- can have disastrous results. How will you respond under pressure?


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