On February 12, 2017, a Piper Arrow crashed into the Gulf of Mexico just off the Florida coast, killing the 65-year-old pilot, his wife and his 17-year-old son from a previous marriage. Local media reported on the tragic accident, but it didn’t get any national news coverage. From an investigatory perspective, and this isn’t easy to say, given the tragic loss of three human lives, there was nothing extraordinary about the accident. This type of accident is usually fatal, a fact the NTSB took pains to point out in this report, which can be read as much as a report on the accident type as an investigative summary of this particular mishap.
To those of us who pore over these official documents that seek to describe and explain disaster, the NTSB’s report was familiar reading. The Board found that the cause was, “The non-instrument-rated pilot’s improper decision to continue visual flight rules flight into instrument meteorological conditions, which resulted in spatial disorientation and a loss of airplane control.” It almost passes for boilerplate language. The accident type is that common and its outcome that predictable.
But the way the authors of the final report framed that statement, as the pilot’s “improper decision” to head off into instrument meteorological conditions, begs several critical questions: What was the pilot thinking? How did he get to the point in the flight where he lost outside visual references and, hence, stood little chance of recovery? And, just maybe, how did our training system fail him?
The pilot had built up just over 600 hours in his logbook. He held a Private Pilot certificate but no Instrument rating, a current Third Class medical certificate, and a biennial fight review, which he had completed just six months prior to the accident. During that flight review, the pilot had logged .3 hours of simulated instrument time. Overall, he had just 4.6 hours of hood time logged.
The flight originated at Brooksville-Tampa Bay Regional Airport (BKV) and was headed to George T. Lewis Airport, located on Cedar Key (CDK), a popular lunch destination along that section of the Florida Gulf Coast. Cedar Key has a single runway, 2,355 feet in length, with both approach ends mere feet from where the Key meets the Gulf waters. There are no published instrument approaches to Cedar Key.
The problem on that day was that the weather looked dicey, with no forecast for improvement during the hour-and-change-long trip, and, again, the pilot wasn’t Instrument rated. So while the NSTB called it the pilot’s “improper decision” to continue—the emphasis is ours—VFR into instrument conditions, the question is, why did he even take off on a trip to a destination that he most likely wasn’t going to be able to legally or safely complete?
There was no indication that the pilot got a weather briefing or even that he checked the weather, but that doesn’t mean he didn’t. In this day of wide and free availability of aviation weather products, there’s just no way to know whether a pilot got the pertinent weather information before a flight, and there’s no way for us now to know if he failed to do so, though one has to wonder why he would have departed on the flight had he obtained the weather forecast that called for instrument conditions.
The report, in fact, says, “Advisories issued at the time of this forecast warned of instrument meteorological conditions at and near the accident site and the destination airport.” Did the pilot have that information and depart anyway, hoping the conditions would improve while he was en route, or did he think he might find an opening in the forecast broken layer to descend through? Still, with reported ceilings of 400 feet at Cross City Airport, located 34 miles away from Cedar Key, the indications weren’t promising for VFR conditions to prevail below the forecast layer. So how would he land at Cedar Key?
Regardless, the first part of the flight from Brooksville was in visual conditions. It wasn’t until the pilot initiated a descent from his cruising altitude of 2,400 feet that things started to go south. Even the descent seems to tell a tale.
John F. Kennedy Jr. Parallels
In contrast to the crash of the Arrow that’s the subject of this NTSB report, which generated little media attention, the crash of John Kennedy Jr.’s Piper Saratoga near Martha’s Vineyard in 1999 made global headlines. All aboard the small plane—Kennedy, his wife, Carolyn Bessette, and her sister, Lauren Bessette—were killed in the crash.
In both cases, the pilots had limited overall flight experience, no instrument rating and very limited instrument experience. Kennedy had only 300 hours of total time, wasn’t Instrument rated, and had built most of that time in just over a year and a half, much of that with a flight instructor aboard. Like the Piper PA-28R Arrow in this report, Kennedy’s recently purchased PA-32 was a high-performance aircraft. In contrast, the pilot in the Florida accident had more than 300 hours in the Piper Arrow, most or all of it in that particular airplane.
While the Kennedy crash, which took place off the coast of Martha’s Vineyard, Massachusetts, was at night, it was very hazy, according to the NTSB. Kennedy likely lost visual reference to the horizon and subsequently lost control of the plane, which crashed into the water.
In short, in both cases, the NTSB found that the pilots who had stumbled into instrument meteorological conditions (or their equivalent) for which they were unprepared, lost control of the aircraft and crashed.
When the NTSB published its final report on the Martha’s Vineyard crash the following year, there was much talk in aviation circles of the risks involved in the type of accident the Board had concluded it was: a loss of control due to continued VFR flight into what amounted to IMC.
The Piper Arrow Crash
The board reported, “According to GPS data recovered from a handheld device onboard the airplane, the airplane flew a northwesterly track from BKV toward CDK at a cruising altitude of about 2,400 ft mean sea level (msl) over coastal islands and the Gulf of Mexico.”
At that point, the GPS data showed that the pilot began the descent toward Cedar Key—though initiating a descent from a fairly low altitude while still 20 miles from the destination airport isn’t a typical profile—and while the report doesn’t say so specifically, it seems to suggest that the pilot was descending to stay below what it identified as “a line of overcast cloud cover that ran from southwest to northeast.” Though the pilot presumably didn’t suspect it at the time, this was the beginning of the accident sequence.
After about three minutes, the shallow descent increased to 250 feet per minute, still very modest, though, again, there was precious little altitude to lose before arriving at pattern altitude 1,000 feet above Cedar Key.
Four minutes later, it was at 1,000 feet while still 7 nautical miles from the destination airport when the plane began a 180-degree left descending turn. There’s no sure way to know if it were at that point when the pilot ran into instrument conditions he could no longer descend below, but it’s likely.
It was during that turn that the plane’s rate of descent increased, ultimately hitting 2,900 fpm, a rate of descent that would result in impact with the surface of the Gulf in less than 20 seconds and at an extremely high rate of speed, which is, indeed, what happened.
The photos of the wreckage of the plane from the NTSB report (which we will not share here) show what a devastatingly violent impact it suffered. It was barely recognizable as an aircraft. The plane was recovered from the Gulf, and eventually the bodies of all three occupants were found, as well.
Investigators established that there were no pre-impact problems with the plane, that its engine was developing power and the controls all seemed to work, which is to say there was no reason to suspect that some cause other than spatial disorientation and the subsequent loss of control of the plane were to blame.
At the end of the report, the NTSB included its concerns and admonitions about such accidents, noting, “about two-thirds of general aviation accidents that occur in reduced visibility weather conditions are fatal.” It also stressed the importance of pre-flight weather briefings and suggested that the use of in-cockpit weather devices, which include inexpensive FIS-B aviation weather receivers, can help pilots stay up to date on the weather in order to avoid such weather traps.
“We often see pilots,” the authors wrote, “who decide to turn back after they have already encountered weather, at which point, it is too late. Pilots shouldn’t allow a situation to become dangerous before deciding to act.”
While that is excellent advice, it again begs the question of why pilots continue to find themselves in IMC conditions and discover also, too late, that they’re unprepared to come up with the skills the circumstances demand. And when they do encounter instrument conditions, they don’t have the training to perform the near-instantaneous responses instrument pilots do as second nature. What they learn to do is go immediately to the gauges to check on flight parameters, make quick but gentle-enough corrections, and stay on the gauges while navigating back to safety.
It’s become a truism that human beings don’t know what we don’t know and assume we’ll be able to deal with challenges as they arise. But when it comes to continued VFR into IMC, the skills required to do so aren’t only hard won but require regular practice. To expect a pilot not versed in instrument flying to be able to come up with the skills required when suddenly and unexpectedly encountering instrument conditions is wishful thinking.
Indeed, it might be precisely the kind of wishful thinking that some pilots are employing when they take off on a flight with such challenging weather conditions just an hour down the airway from their previously happy, carefree lives.