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Probable Cause #61: Illegal IFR Flight

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This article originally appeared in IFR Refresher, Sept. 2007.

Probable Cause

Another pilot once told me he had been caught on top of cloud layers several times during his flying career but always escaped safely by simply calling ATC for an IFR clearance to get below the cloud decks and fly on VFR to his destinations. What was so unusual was that this pilot had never earned an instrument rating. What bothered me most was this pilot's obvious disregard for the regulations, not once but several times. In fact, he made this all sound like "I'm going to get there no matter what" was a normal procedure for him. He thought ATC would prefer to know he was there to begin with. He assumed that what he did was better than just shutting off his transponder and descending through the clouds on his own. Apparently, it never occurred to him that these trips were all illegal. Perhaps that same attitude was present when a pilot crashed a Mooney near the Van Nuys, Calif., airport in June 2005. He also did not have an instrument rating and crashed while executing the ILS approach to Runway 16 through the clouds at Van Nuys one night after the control tower had closed. The pilot was the sole occupant of the aircraft. He was killed when the aircraft impacted the south slope of a shallow ravine approximately five miles north of the VNY airport.

The Facts

Mooney M20C

According to the NTSB report of this accident, the pilot of the Mooney called the aircraft's owner at approximately 1622 PDT to say he was preparing to depart San Jose for John Wayne Airport at Santa Ana. The aircraft owner told investigators that they spoke about the weather and that he (the pilot) said he would check it regularly since the forecast did not look good. His plan was to fly to John Wayne Airport for dinner and then on to the Whiteman Airport located four miles northeast of VNY Airport. The NTSB does not mention the conditions under which the pilot compensated the Mooney's owner for the flight time, nor why the owner seemed to exercise little control over his own asset. The aircraft departed San Jose between 1630 and 1700 for John Wayne some 375 miles to the southeast and was expected to arrive between 1900 and 1930 and did, in fact, land at 1915 local. The female witness who met the pilot upon landing said he was in a good mood, did not seem tired and did not mention weather concerns before she returned him to the airport at around 2115. The witness noticed clouds and asked the pilot if he was sure he wanted to fly. The pilot replied that the weather was 100-percent fine. She did not see the pilot officially check the weather reports before departure. The aircraft departed John Wayne at 2145 for Whiteman under VFR. The pilot was in contact with the ATC during most of the flight and the topic of weather did emerge early on. On initial contact, ATC asked the Mooney pilot if he could climb to a higher altitude to clear airspace ahead, to which the pilot said "No" due to cloud cover. The controller asked if the pilot was IFR qualified. When the Mooney pilot answered yes, the controller queried him about why he had not departed John Wayne IFR, since clouds extended all the way to Van Nuys. The Mooney pilot responded by asking the controller for an IFR clearance. When the controller said he was unable, the pilot said he would continue VFR and return to John Wayne and land if he was unable to proceed.

The Approach

Van Nuys ILS 16 (excerpt)

At 2256 the aircraft was over Santa Clarita, about 25 miles northwest of Los Angeles, at 4500 feet when the pilot contacted SOCAL (Southern California Combined Approach Control) and requested an ILS approach into Van Nuys. The controller suggested the pilot fly towards the final approach course VFR, but issued a transponder squawk. SOCAL verified that the pilot had the Van Nuys weather, radar identified the Mooney and told the pilot to expect an IFR clearance once the aircraft was on the localizer. At 2258 the controller suggested a VFR heading of 130 to intercept the localizer and issued the IFR clearance when the aircraft was four miles from the marker. A few minutes later, ATC told the Mooney pilot he was slightly left of the centerline and asked if he was turning back. The pilot responded he was trying and ATC seemed to confirm the correction a minute later when they also announced that the aircraft was over the marker. ATC told the pilot about some local VNY traffic before instructing him to change to advisory frequency and report his time on the ground. A moment later, the Mooney pilot announced on the Common Traffic Advisory Frequency (CTAF) that he was on a six-mile final for Runway 16. Shortly thereafter, the Mooney pilot called SOCAL again reporting an undefined problem and announced he was "climbing out." Radar history showed the aircraft made a sudden turn to the right that took the aircraft off the localizer just before he made that transmission. The pilot did not acknowledge ATC's first call to proceed southbound and climb to 5000 feet. He did acknowledge SOCAL's second call with an affirmative. It was also the last transmission received from the aircraft. Radar data revealed that the aircraft's track along the localizer was not straight and had overshot the course initially to the east and then corrected back on to the centerline at the outer marker. It then deviated to the east again and corrected back to the final approach course before making an abrupt 90-degree turn away from the final approach course to the west. At first, the Mooney headed west, climbing from 2100 feet to 2500 feet, before descending back down to 2400 feet. It then turned south for half a minute before again climbing from 2400 feet to 3000 feet. The last ground track showed the aircraft headed northwesterly with altitude changes from 3000 feet to 2400 feet, and then down to the accident elevation of 1253 feet.

The Pilot

FAA records revealed that the pilot held a private certificate with a single-engine-land rating, but did not possess an instrument rating. His third-class medical certificate was valid. Officials at the site recovered the pilot's logbook. It revealed that the pilot had a total of 205.6 flight hours as of the last entry, on Jan. 30, 2005, nearly six months prior to the accident. He had logged 11.5 hours of simulated instrument time, but no actual. The last instrument training flight recorded was 13 months before the accident flight. There was also no record of the pilot ever having taken so much as a single lesson related to instrument flying. A relative of the pilot, who happened to be instrument rated, said he had flown safety pilot for the victim five or 10 times, all on practice ILS approaches to VNY. The relative said he was not aware of the pilot's total instrument time, or whether he had ever actually flown in the clouds.

The Weather

Missed Approach

The surface analysis chart for the evening of the accident showed a weak, onshore flow with high relative humidity along the central California coast. At 2251 the wind recorded by the Van Nuys Automated Surface Observation System (ASOS) was 150 degrees at 6 miles, with a 1400 feet overcast and six miles visibility with haze added to a temperature of 16-degrees Celsius and a 13-degree dewpoint. Reported weather an hour later was virtually the same. There is no record of the pilot receiving a weather update before the flight. The area forecast that night called for broken clouds between 1000 and 2000 feet MSL with tops at 4000 feet for the coastal areas and an outlook for marginal VFR conditions. Inland areas were to be clear of clouds until 2300 local time when it was expected that clouds would fill in the area with bases at 1000 feet and tops at 3000 feet. The outlook for southern coastal waters was for IFR due to ceilings and mist.

The Witnesses

The aircraft owner showed investigators an invoice for the overhaul of the Mooney's attitude indicator six weeks before the crash. The owner indicated that the pilot might have installed it himself. There were no entries in the aircraft logs indicating that any work had been completed by a licensed mechanic. Again, why the aircraft owner seemed to exercise so little control over his own aircraft is unknown. A series of photos recovered from the pilot's digital camera -- dated May 19, 2005 -- seemed to confirm the indicator problem. This pilot seemed to believe that landing where he wanted, when he wanted, was the most important issue that night. No one knows why the aircraft never arrived at nearby Whiteman that evening. What went wrong? There is no record of the pilot ever having checked weather, although that doesn't necessarily mean he didn't. He seemed to be aware of the weather conditions when he spoke to SOCAL controllers, and claimed he was aware of the VNY weather when ATC cleared him for the approach. No pun intended, but the pilot had clearly stacked the deck against himself from the very beginning. A quick, after-dinner check of weather would have revealed deteriorating conditions. Did the pilot simply plan to file an IFR flight plan if he got himself in a corner? While there is no way to know for certain, every indication is that he felt capable of flying in the clouds though he did not possess an instrument rating. Did this pilot perhaps climb through the clouds without a clearance to get on top so that he would be high enough to pick up an IFR clearance over Santa Clarita? Most likely, since the cloud deck was pretty solid from Santa Ana to Van Nuys and beyond. Perhaps climbing and descending through the clouds gave him the confidence that he could fly the ILS approach into Van Nuys. After all, he had tried that approach many times before, even if it was under VFR with a safety pilot. What role did the aircraft's equipment issues pose? The pilot was obviously aware there was a potential instrument problem that should have precluded him from flying that night. The NTSB determined that the cause of the accident was the pilot's decision to attempt flight into instrument meteorological conditions, which resulted in loss of control due to spatial disorientation. Factors that contributed to the accident included restricted visibility, low ceilings, night lighting condition, an undetermined attitude-gyro problem, and -- most of all -- the pilot's lack of qualification/experience for flight in instrument conditions. Ironically, a flight like this would have been an easy and quick one for a proficient instrument pilot.
More accident analyses are available in AVweb's Probable Cause Index. And for monthly articles about IFR flying including accident reports like this one, subscribe to AVweb's sister publication, IFR Refresher.

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