Sometimes it’s obvious how an accident report is going to end from the very first sentence.

NTSB Identification: CEN15FA400

“The airplane owner, who was a noninstrument-rated private pilot and did not hold a multiengine airplane rating, was conducting a visual flight rules (VFR), personal cross-county flight in the multiengine airplane.”

I almost did not bother to read any further, I have to admit. But something about the inevitability of this recent accident made it impossible to tear my eyes away.

The pilot held a private pilot’s certificate with a single-engine land airplane rating. For the avoidance of doubt, that means that he fly single-engine airplanes on land in clear weather. No multi-engine aircraft, no flying in clouds.

At his last medical, in 2003, he reported 1,000 hours flight time, of which 200 were in the last six months.

The pilot’s daughter said that he flew F-4 Phantoms. A Big Bear employee also commented that the pilot had told him that he flew F-4 Phantoms in the military and then transitioned to helicopters and was injured in Vietnam. The pilot had also told him that he was a doctor and “had an MD”. But the employee had some reservations, as some of the things the pilot had told him turned out not to be true.

He was right to be skeptical. The pilot had served in the US military, but in the Marine Corps as a lance corporal: one rank above private first class and below corporal. There is no record of any military flights at all. He did not fly for the Marines and certainly not F-4 Phantoms.

I’m not going to bother with the rest of the small fry stuff: medicals out of the date, lack of training, no airworthiness certificate for the Cessna, etc… because although these show a generally slapdash attitude, they did not directly contribute to the accident.

His log book, which covered from 2006 to the accident in 2015, showed 801 hours flight time in total, of which 255 were listed in single engine aircraft and 218 in multi-engine airplanes.

The aircraft was a Cessna 310H, a six-seat, low-wing, twin-engined aircraft, which the pilot had purchased in July, 2014. The pilot’s logbook showed that he first flew the twin the day after he got it, with no reference whatsoever to any training in the aircraft. There were 72 entries in the log book flying the twin, including with passengers, despite his lack of a type rating for twin engine or any training in the Cessna 310. He had a friend who was also a pilot and one of his logbook entries had the note, “I let [him] fly part way back.”

There was a 2013 entry showing 10.5 hours of flying in a Piper Apache twin engine with a total multi-engine flight time of 150 hours, but the entry was the first multi-engine flight in the log book. The log book is specifically meant to prove the individual flights a pilot flew in order to demonstrate the total hours but in this case, the ‘total number’ carried over simply appears in 2013 with references to to justify why.

His log book had a number of other interesting entries.

“Flew over parade 10 feet off ground made six passes.”

“Landed on Rt 66 4 July Parade. With Mayor.”

“Flew to the barn landed on Rt. 66 for auto show.”

Now yes, we’ve all heard of a pilot landing on a highway in an emergency. But for normal operation, it is illegal to operate an aircraft in the US closer than 500 feet to any person, vessel, vehicle or structure. Buzzing a parade or landing on the highway to attend a car show is definitely not reasonable.

Another entry said:

“Big Bear airshow. made it. speed passes over runway.”

A staff member at Big Bear City Airport remembered the day well.

From the final report:

When the airport opened for departures, the pilot departed with passengers. Upon the pilot’s return to the airport, he turned the airplane onto the final leg of the airport traffic pattern and did not have the airplane radio on. The shows’s air boss cleared another airplane to depart from the active runway while the accident pilot was flying his airplane on short final. He stated that, instead of the pilot offsetting the airplane to the side of the runway during the go-around, the pilot performed a “low-level left turn over the crowd” with the landing gear and flaps extended.

So the man had a bit of reputation at Big Bear already. He kept the Cessna 310 there in the summer and then later at Barstow-Daggett Airport.

About a week before the accident, the pilot asked one of the staff at Big Bear City Airport if he would go along on a trip as co-pilot. According to the staff member, the pilot asked “a lot of different pilots” to go with him. The staff member said that the pilot had purchased the Cessna 150 not too long ago and that the aircraft radios were very old and the instruments were not all that good.

On the 4th of September 2015, the day before the accident, the pilot fuelled up the aircraft at Big Bear City Airport, purchasing 20 gallons of fuel.

He was in frequent touch with his daughter and, on the day of the accident, she said that he departed Big Bear City Airport at 6:15 in the morning local time, arriving at Barstow-Dagget Airport at 6:30 to pick up his passengers. His plan was to then fly to Amarillo Texas by following Interstate 40. They would have dinner in Amarillo and then return the same day. She said that there was another pilot onboard and that they had a GPS.

The staff member at Big Bear Airport confirmed that the pilot departed there “pretty early in the morning” to pick up passengers elsewhere.

He appears to have picked up his passengers at Barstow-Daggett Airport in Daggett, California. Then he continued with four souls on board to Flagstaff where he wanted to refuel before continuing.

His first contact with air traffic control that day was to contact Flagstaff tower.

N1099Q: Flagstaff traffic this is Piper Comanche N1099Z I’m sorry quebec we’re approximately thirty miles miles west of the field anybody know what how the weather is down there you socked in there cause we are flying over the top here.

Now I don’t generally like to pick on GA pilots’ radio telephony and lord knows I’ve made more than my share of bad radio calls but as a starting point, there’s a lot wrong here.

First off, his identification is wrong. The aircraft is not a Piper Comanche (a single-engine small plane), it’s a Cessna 310. Different model, different make, different number of engines.

He then got his call sign wrong and then corrected it without repeating it, which is a bit confusing. He asks “you socked in there”, not quite standard terminology but not unreasonable for a US airport: If an airport is socked in, it means it is closed because of bad weather. And finally, flying over the top means he is flying above the clouds, out of sight of the ground. Rules differ by country as to whether a visual pilot can fly “on top” of the clouds, presuming he didn’t fly through the clouds to get there, but in the the US, you must be an instrumented rated pilot to do this. The pilot was not instrument rated and should maintain visual contact with the ground.

[I got this this wrong! Apparently VFR on top is fine in the US as long as you don’t need to pass through the clouds and are not a student pilot. Thanks to the people who let me know!]

Flagstaff Tower: Comanche 1099Q, Flagstaff Tower. We are open. The uh… the ATIS is also broadcasting. We’re 900 broken, 1,600 broken, 2,400 overcast, visibility 10.

Translation: the airfield is open and you could have gotten this information by listening to the Automatic Terminal Information Service (ATIS).

This is a continual broadcast of airport and weather information on a specific frequency. When you fly into a busy airport, you listen to the ATIS, where each update is identified by a letter. Then you tell air traffic control that you have received ATIS information [letter], for example information charlie to let them know that you checked the current airport information and which version. This means that if there’s been an update since you listened, they can warn you.

The point is that you can get the information on your own, without tying up the frequency and an air traffic controller. This controller is pretty nice though and gives him the key information: broken clouds at 900 feet, another layer of broken clouds at 1,600 feet and overcast at 2,400 feet, with a (horizontal) visibility of 10 miles.

It’s no wonder that the Comanche, sorry, no, I mean Cessna, can’t see the ground.

N1099Q: Oh thank you, I just turned the ATIS then. I appreciate it thank you Flagstaff.

At least he’s understood the issue. But in terms of brief and to the point radio calls, this isn’t great.

N1099Q: Flagstaff tower 1099Q about to land. We are approximately 10 miles west of the airport.

Bet that ‘about to land’ woke up the controller!

Flagstaff Tower: Comanche 99Q, Flagstaff Tower. The uh… We’re IFR at the airport 900 broken 1600 broken visibility 10.

Translation: I just told you about the cloud cover. This is not suitable for Visual Flight Rules and yet you do not seem to be making an Instrument approach.

N1099Q: We are now approximately 8,000 feet we have visibility looks like greater than 10 miles.

At 8,000 feet he can’t possibly have the ground in sight, there’s three layers of cloud below him. His horizontal visiblity may be 10 miles but that’s not all that useful. Flying under visual flight rules, he still can’t descend through the cloud.

Flagstaff Tower: Comanche 99Q I concur with the visibility. Uh, are you requesting something special?

ATC is at a loss as to what’s going on . Edit: ATC is clearly hinting that he should be requesting special-VFR, which I missed. See the comments for more. Regardless, the controller doesn’t get a response. Luckily for the pilot, though, the weather is getting better.

Flagstaff Tower: Comanche 99Q the field is now VFR. The ceiling is … well I have a scattered layer of 1,200 ceiling 1,600 report a right base for runway 21.

The clouds have cleared enough that the controller is happy for the Comanche Cessna to come in under Visual Flight Rules. It’s now scattered clouds at 1,200 feet with the cloud ceiling at 1,600 feet. He asks the pilot to report when he’s making the right base turn for runway 21.

N1099Q: Report right base for runway 21, will do, quebec.

This call is a straight-forward acknowledgement. Quebec is simply a reference to the Q in the call sign, shortened from 99Q, which the controller shortened from N1099Q.

Flagstaff Tower: Comanche 99Q, verify you have Information Charlie.

This is that Automatic Terminal Information Service we talked about earlier. The controller is making sure that the pilot has listened to the most recent version, C.

N1099Q: Copy that we have we got a little bit of a … here.

Translation:

No, sorry, I’m not sure what he’s trying to say here. Best guess: I have received your transmission and I can’t deal with it right now.

Flagstaff Tower: Comanche 99Q, roger. The wind is 220 at 8, temperature 16 density altitude is 8,400 dew point 13 and the altimeter 30.26.

The ATC controller gives the pilot the relevant information for landing. The altimeter setting is important: the pilot sets that in the cockpit so that his altitude is shown correctly for the current air pressure. If that setting is wrong, the plane will appear, from the cockpit, to be higher or lower than it actually is, which is a problem when trying to land an aircraft on the very specific level where the runway is.

N1099Q: 30.36, thank you.

Flagstaff Tower: Altimeter 30.26. Twenty-six.

I imagine the controller’s voice getting a wee bit stressed by now as he corrects the pilot, bear in mind the pilot should have already had this set up after listening to the ATIS.

N1099Q: Flagstaff tower this is quebec were gonna report left base runway 21 I just want to confirm that quebec.

LEFT base?

Some airports have both right and left-hand circuits. Here’s a quick sketch to show you how this might look:

The important point here is that generally in a circuit, all the aircraft are going the same way. The Flagstaff controller had asked him to report right base, for a right hand circuit. But the aircraft has just let him know that he will report left base. You can see left and right base on the right side of the image. Sure, the controller can keep the traffic separate but part of that is knowing who is where. Also, it makes no sense.

Flagstaff Tower: Comanche 99Q, are you set up for a right base or a left base? You’re coming from the west, you said.

If you look at the image, you can see that if you were coming down to the runway from the top, joining the pattern on right base would be pretty easy. Coming in from the top and then joining the left base, however, means flying past the runway and turning around. This is why the controller is confused. There’s no good reason to do this.

N1099Q: Oh, its showing left base on my GPS left traffic on runway 21

Note the reference to the GPS, it’ll be important later.

Flagstaff Tower: Comanche 99Q uh we can make whichever way you want I just need to know which direction you’re coming from.

Are Flagstaff always this laid back? Because I’d be having kittens by now.

N1099Q: Well we’re comin… we’re coming from 270 right now.

270° is west, sure enough. The aircraft is travelling due east. Coming in from the west. Gottit. Now, I have some sympathy for this because I have gotten myself completely confused once or twice. But it should be pretty easy to sort out from here.

Flagstaff Tower: From 270 you should be west of the…airport. Where was the destination you left from?

Flagstaff Tower understandably is wanting to be absolutely clear on this.

N1099Q: Well, we can report… let’s see, the winds are from uh what…

Nooooo. The answer is “Barstow-Daggett Airport”.

Flagstaff Tower: Comanche 99Q the wind is 240 at 6. Just report base.

Flagstaff tower appear to have completely given up. Left base, right base, we don’t care. Just tell us before you turn final.

N1099Q: Well…we’re…right now…

Flagstaff Tower: Comanche 99Q, that came in broken and unreliable.

I’ve never heard ATC refer to radio transmission as unreliable but I can understand the controller’s feelings.

N1099Q: The winds are 210.

Flagstaff Tower: Wind 210 at 8.

Flagstaff Tower: Comanche 99Q, how far from the airport are you?

Translation: I’m desperately trying to find you so that I know what the heck you are doing.

N1099Q: We’re downwind 21 left. We’re setting up for base for 21 left.

Left base means a left-hand circuit. 21 left means the left-hand runway where there are two parallel runways, which Flagstaff does not have.

Flagstaff Tower: Okay, we only have runway 21. Okay, I see you now. You are on a left downwind for runway 21. Cleared to land, wind 210 at 8.

Translation: Let’s get this guy on the ground ASAP.

N1099Q: …the end of the runway now…on the downwind we’ll make base to final.

Flagstaff Tower: Comanche 99Q, runway 21, cleared to land.

Translation: Do not give me a running commentary of your flight, just confirm my call.

N1099Q: Cleared to land runway 21.

Well done! And to the relief of everyone involved, the landing seems to have been just fine.

Flagstaff Tower: N99Q, are you going to the wiseman aviation? The FBO?

A Fixed Base Operator is a commercial company that provides aviation services at an airport, for example fuel.

N1099Q: Yes, we want to gas up. Can we exit?

The controller gives him instructions to the self-serve fuel point and the details of the Fixed Base Operator, probably with a big sigh of relief.

For the FBO employee, on the other hand, the issues had just begun. The employee saw the Cessna 310 taxi to the fuel pumps where it came perilously close to an Eclipse jet that was parked nearby. Then it just about ran into the golf cars parked near the FBO building. When it arrived at the self-serve fuel station, it knocked over a ladder with one of its propellers.

The pilot told the FBO employee that he hoped there would be no more clouds and that he wanted 75 gallons of fuel.

He pointed east and said that they had another two hours to their destination. The employee remembers that they said they were flying to Texas, he thought Amarillo but wasn’t sure. He overheard one of them talking about their brand new GPS and that they were having some trouble with it.

The employee showed the pilot how to use the self-serve fuel pump. The pilot handed him the cash for the fuel and the rest of the occupants of the aircraft got out. One of them fuelled up the aircraft while the rest went into the aviation facility.

The pilot called for an abbreviated weather briefing for a visual flight which he described as from Flagstaff to Amarillo, Texas. The general aviation airport in Amarillo is Tradewind Airport, with the identifier TDW. However, the pilot identified his destination airport as L51, which is Heller Farm Airport, in Winifred, Montana. Winifred is 1,100 miles (1,770 km) north of Amarillo.

The weather briefer caught the error and gave the pilot the correct weather for Tradewind Airport in Amarillo, Texas as well as for Amarillo International Airport.

After the Cessna was fuelled and everyone was back on board, the Cessna started up its engines and then began to taxi, without any contact to Air Traffic Control. It taxied past the Flagstaff tower and then turned right onto the main taxiway, continuing directly towards runway 21, where SkyWest flight 2992 was on short final and cleared to land. The tower controller, receiving no reply from the Cessna, issued a go-around to SkyWest 2992. The airliner broke off its approach as the Cessna taxied onto the runway.

The Cessna positioned itself and then started the take-off roll as the pilot made the first call to Air Traffic Control.

The controller at Flagstaff Tower, not surprisingly, was unimpressed. He instructed the Cessna to abort the take off and exit the runway immediately.

(I like to imagine him saying “and don’t come back” at this point but of course he was much too polite to do so)

After the Cessna had vacated the runway and stopped (blocking a ramp entrance in the process), the pilot had a “lengthy conversation” with the controller, in which he explained that he wasn’t aware that there was a problem because his radio had not been turned on.

The controller told him to phone the tower.

SkyWest flight 2992 came in again and landed safely, although the flight crew did make a nervous call to ask what the heck just happened. They were told that it was ‘a case of situational awareness’.

Meanwhile the Flagstaff ATC tower controller spoke to the Cessna pilot on the phone. He said that the pilot didn’t seem to be upset.

The FLG ATC tower controller stated that, during his telephone conversation with the accident pilot following the runway incursion, the pilot “kind of missed the point,” “came up with excuses” for the runway incursion, and did not know there was another airplane “out there” during the runway incursion. The controller stated that, when he told the pilot that there was an airliner on final, and it was at that point that the pilot “realized the gravity of the situation.” The pilot then said that he had been flying for 50 years and nothing like this happened before.

I bet the controller was pretty upset, though.

After this, they entered the runway and took off with no further issue. They remained low as they departed from runway 21 and then after about 1,000 feet, the Cessna went into a climb and entered a left turn, heading northeast.

Amarillo is due east of Flagstaff.

After they departed, radar data showed that the aircraft turned again towards the north, rather than head east towards Amarillo. As they continued to fly towards Montana, the weather began to close in. They would have been flying into rain showers and in instrument meteorological conditions, which no one in the aircraft was qualified for.

The following day, the pilot’s daughter became concerned as she had not heard from her father. The aircraft wreckage, with no survivors, was discovered in Colorado at 11,500 feet… on the side of a mountain. They had flown directly into the rising terrain at high speed: the wreckage path was about 1,050 feet, northbound, travelling up the mountain slope.

The Cessna was destroyed by the impact forces: both engines were separated from the airframe and the propellers were separated from the engines. The instrument panel was destroyed. The destruction was such that it wasn’t possible to test much on the plane but there was no obvious sign of mechanical failure. All the evidence pointed towards a straight-forward controlled flight into terrain, no doubt obscured by the clouds.

The location of the crash was consistent with a northbound flight towards Montana, which the pilot had referenced in his weather briefing when he identified his destination as L51. There was no evidence that he wanted to go to Montana and his daughter said that he did not know anyone in Montana and that he’d specifically told her he was going to Amarillo.

However, on the Amarillo charts, there is one reference to L51: it’s the length of the runway, 5,100 feet. If the pilot and his passengers had misread this as the identifier once, they may well have done so again.

The hand-held GPS was never recovered but the daughter stated that they had hand-held GPS for the flight and the FBO employee recalled the conversation that it was new and something was not quite right. If they entered L51 for their destination, the GPS would have routed them due north to Winifred, Montana. The local weather was much worse, with scattered clouds at 4,700 feet, broken at 6,000 feet, broken at 7,000 feet, wind gusting between 8 and 39 mph (12-63kph) and reports of lightning: not at all good weather for a visual flight over the mountains, let alone the mountains that they didn’t know were there.

PROBABLE CAUSE

The noninstrument-rated pilot’s improper judgment and his failure to maintain situational awareness, which resulted in the flight’s encounter with instrument meteorological conditions and controlled flight into terrain during cruise flight.

Which is sadly what one expects when hearing about a pilot buying and flying an aircraft that he has no experience in and has not been trained for. In the end, though, it wasn’t the aircraft that killed him but the GPS — it could just as easily have happened in the Piper Comanche he kept identifying himself as.

The truth is, I’m simply surprised that he survived that long.