Still Alive and Well Today: Part three of a four-part series that will explore non-military aviation mishaps.
Similar to the accidents discussed in the first two parts of this series, an accident investigation board convened to provide context, factors and recommendations related to the mishap. The National Transportation Safety Board's Aviation Accident Final Report provides insights into the pilot, the aircraft and the circumstances of the mishap flight.
The board's report tells us that 15 months prior to the crash of the Saratoga II aircraft, in April 1998, "The pilot obtained his private pilot certificate for 'airplane single-engine land' ... He did not possess an instrument rating. He received a 'high performance airplane' sign-off in his Cessna 182 in June 1998 and a 'complex airplane' sign-off in the accident airplane in May 1999."
Although the pilot's most recent logbook at the time of the incident could not be located, the investigation board used other documents to estimate the pilot's total experience, excluding simulator time, at around 310 hours. Of those 310 hours, the board estimated around 55 hours were flown at night. The pilot's estimated total time of flying without an instructor on board was a little over 70 hours. As of the day of the accident, the board estimated the pilot's total time in the actual accident aircraft to be "about 36 hours, of which 9.4 hours were at night. About 3 hours of that flight time was without a certified flight instructor (CFI) on board, and about 0.8 hour of that was flown at night and included a night landing."
The pilot's initial training in 1998 was relatively uneventful, and he passed his private pilot flight test April 22. "The designated pilot examiner who administered the checkride stated that as part of the flight test, the pilot conducted two unusual attitude recoveries." About a year later, in March 1999, he took a written Federal Aviation Administration instrument exam and received a score of 78 percent. Soon after, he began his aircraft instrument flight training.
During his instrument training, the pilot progressed at a normal pace; however, about halfway through the program, he displayed considerable difficulty using onboard navigational aids while working with air traffic control. It took the pilot four attempts before he successfully completed that particular instructional lesson. "The CFI stated that the pilot's basic instrument flying skills and simulator work were excellent. However, the CFI stated that the pilot had trouble managing multiple tasks while flying, which he felt was normal for the pilot's level of experience."
The pilot received further instrument instruction in his new aircraft--the one involved in his fatal crash, the Piper Saratoga. One CFI who flew with the pilot in the Saratoga a few times noted that "the pilot's aeronautical abilities and his ability to handle multiple tasks while flying were average for his level of experience." Another CFI who flew with the pilot at night observed that "the pilot used and seemed competent with the autopilot." That said, the instructor also noted that "the pilot had the ability to fly the airplane without a visible horizon but may have had difficulty performing additional tasks under such conditions. He also stated that the pilot was not ready for an instrument evaluation as of July 1, 1999, and needed additional training." Remember: July 1 was 15 days before the crash. A third CFI who had flown the same route flown on the night of the crash on previous occasions and under similar conditions "stated that the pilot had the capability to conduct a night flight to [the destination] as long as a visible horizon existed."
The mishap flight was planned to be flown at night, departing from Essex County Airport in Caldwell, New Jersey, to Martha's Vineyard Airport in Vineyard Haven, Massachusetts, for a passenger drop-off, and concluding at Barnstable Municipal--Boardman/Polando Field in Hyannis, Massachusetts. At 2038:39, Essex Tower cleared the aircraft for takeoff with a right downwind departure. The pilot's acknowledgement of the downwind departure was the last recorded communication between the pilot and air traffic control. The aircraft proceeded northward past White Plains, New York, then eastward toward Bridgeport and New Haven, Connecticut, then past Point Judith, Rhode Island, and across the Rhode Island Sound. The aircraft data recovered for the time after passing Rhode Island paints a picture of erratic altitude, airspeed and heading changes that would indicate a situation of significant confusion, loss of situational awareness and misdirected attention:
The aircraft "began a descent from 5,500 feet about 34 miles west of MVY [Martha's Vineyard], The speed during the descent was calculated to be about 160 knots indicated airspeed (KIAS), and the rate of descent was calculated to have varied between 400 and 800 feet per minute (fpm). About 2138, the target began a right turn in a southerly direction. About 30 seconds later, the target stopped its descent at 2,200 feet and began a climb that lasted another 30 seconds. During this period of time, the target stopped the turn, and the airspeed decreased to about 153 KIAS. About 2139, the target leveled off at 2,500 feet and flew in a southeasterly direction. About 50 seconds later, the target entered a left turn and climbed to 2,600 feet. As the target continued in the left turn, it began a descent that reached a rate of about 900 fpm. When the target reached an easterly direction, it stopped turning; its rate of descent remained about 900 fpm. At 2140:15, while still in the descent, the target entered a right turn. As the target's turn rate increased, its descent rate and airspeed also increased. The target's descent rate eventually exceeded 4,700 fpm. The target's last radar position was recorded at 2140:34 at an altitude of 1,100 feet... On July 20, 1999, about 2240, the airplane's wreckage was located in 120 feet of water, about 1/4 mile north of the target's last recorded radar position."
The investigation board discovered that the pilot made preflight weather observation requests for points along the intended route of flight as late as around 1830 hours on the evening of the crash. However, there was no indication that the pilot asked for the forecasted conditions in the flight area for the actual planned flight time. The observations at the time of the request indicated no less than 4 miles of visibility, with mist or haze, and relatively clear skies. At 1930, a little more than an hour before takeoff, the forecast for Nantucket indicated temporary conditions during the flight time down to 2 miles visibility with mist and scattered clouds down to 500 feet. Similarly, a forecast for Hyannis was issued at the same time that called for temporary conditions of 4 miles visibility with haze.
Another pilot who had flown over Long Island Sound about two hours prior to the crash "... stated that he encountered visibilities of 2 to 3 miles throughout the flight because of haze. He also stated that the lowest visibility was over water, between Cape Cod, Massachusetts, and eastern Long Island." A second pilot operating in the area that night told the investigation board that "... over land, he could see lights on the ground when he looked directly down or slightly forward; however, he stated that, over water, there was no horizon to reference.... He further stated that, between Block Island [Rhode Island] and Martha's Vineyard, there was still no horizon to reference.... He was about 4 miles from Martha's Vineyard when he first observed the airport's rotating beacon."
So, what's the big deal with restrictions to visibility when flying at night and you can't see anything anyway? Technically, if you can't see anything, then the flight should be conducted with extensive references to the onboard flight instruments to ensure the aircraft stays on altitude, on course and on airspeed. However, on a night visual flight, pilots can often use cultural or city lights, moonlight reflections off of terrain and buildings, and other visual cues to stay on track as long as visibility is good enough to see those cues. When visibility distances drop because of rain, snow, fog, mist, haze or other obstructions, continued flight with reference only to those visual cues becomes much more challenging and sometimes impossible. Continued visual-reference flight in those unfavorable conditions puts the pilot or aircrew at an increased risk of spatial disorientation.
The FAA's Instrument Flying Handbook defines spatial disorientation as "The state of confusion due to misleading information being sent to the brain from various sensory organs, resulting in a lack of awareness of the aircraft position in relation to a specific reference point." In other words, what the aircraft is actually doing is mismatched from the pilot's sensory cues--things the pilot sees, hears or the forces felt in turns or other maneuvers. For example, a pilot with no visual cues who executes a rapid level acceleration may actually feel like the aircraft is in a climb due to the forces felt against the back of the seat. The same sensation can be felt by sitting in a car at a stoplight between two larger vehicles like busses or trucks. If one of the vehicles in your peripheral vision starts to roll backward, you may get the sensation that you are actually rolling forward into the intersection and then slam on the brake pedal even if you weren't moving at all!
The FAA Airplane Flying Handbook discusses night flying by stating that "Night flying requires that pilots be aware of, and operate within, their abilities and limitations." Although the handbook has since been updated, at the time of the accident, it also cautioned that "Crossing large bodies of water at night in single-engine airplanes could be potentially hazardous, ... because with little or no lighting the horizon blends with the water, in which case, depth perception and orientation become difficult." A cautionary note from an FAA Advisory Circular (later superseded by an update to the Instrument Flying Handbook) warned aircrews that"... spatial disorientation as a result of continued VFR [Visual Flight Rules] flight into adverse weather conditions is regularly near the top of the cause/factor list in annual statistics on fatal aircraft accidents."
And so, we have collected the building blocks of this fatal aircraft accident:
1. Four months before the crash, the pilot took the FAA's written instrument examination and scored 78 percent. (A passing score is 70 percent.)
2. The pilot was relatively inexperienced in the mishap aircraft, with about 36 hours total and nine flown at night. i
3. Instructors noted the pilot had trouble managing multiple tasks while flying, and he had difficulty performing additional tasks while flying without a visible horizon.
4. An instructor noted 15 days prior to the crash that the pilot was not ready for an instrument evaluation and needed additional training.
5. The pilot was probably unaware of the forecasts for deteriorating visibility conditions during the time of his planned flight.
6. The pilot took off and flew into night darkness in misty, hazy weather and reduced visibility conditions.
7. Radar observed the plane making erratic altitude, heading and airspeed changes indicative of a presumptive loss of situational awareness and aircraft control prior to impacting the ocean and fatally injuring all occupants.
The accident report summarizes this tragic mishap succinctly. "The National Transportation Safety Board determines the probable cause(s) of this accident to be: The pilot's failure to maintain control of the airplane during a descent over water at night, which was a result of spatial disorientation. Factors in the accident were haze, and the dark night."
In our next--and last article of this series, we will revisit the causes and factors of the three mishaps we have now studied in depth. We will then explore whether those factors are still alive and well today by comparing the three mishaps to more recent U.S. Air Force aviation accidents and look for similarities. Finally, we'll discuss mitigation strategies that can hopefully be used to ensure that mishap factors don't continue to be reborn over and over again.
Until then, you may be wondering why this particular spatial disorientation accident was selected to review. This mishap is particularly noteworthy in that the pilot who lost his life along with two passengers that night was John F. Kennedy Jr., the son of the 35th president of the United States, John Fitzgerald Kennedy.
NTSB Accident Report https://app.ntsb.gov/pdfgenerator/ReportGeneratorFile.ashx?EventID=20001212X19354&AKev=1&RType=Final&ITvpe=MA
FAA Instrument Flying Handbook https://www.faa.gov/regulations_policies/handbooksjnanuals/aviation/media/FAA-H-8083-15B.pdf
FAA Airplane Flying Handbook https://www.faa.gov/regulations_policies/handbooks_manuals/aviation/airplane_handbook/
BY COL. BRANDON W.J. DEACON
Caption: Photograph of the accident airplane taken within three months of the accident. (Photograph provided by the previous owner of the accident airplane.)
Caption: Airworthiness--Photo 1. View of the cockpit and cabin area. (NTSB-B2)