By Robert N. Rossier, EAA 472091
This piece originally ran in Robert’s Stick and Rudder column in the October 2024 issue of EAA Sport Aviation magazine.
Every now and then we read an accident report that makes us shake our head and wonder. The NTSB report on the fatal crash of a Sikorsky S-76B helicopter was just such a report, and it was a chilling reminder of how things can go wrong when we attempt to push the limits.
In this case, a highly experienced and qualified pilot flying a day-VFR charter under Part 135 suddenly went missing. He was found to have crashed on a hillside. Nobody would have guessed that a professional pilot would allow himself to get caught in the continued VFR flight into IMC trap, but that’s pretty much how it went according to the NTSB report.
The NTSB report noted the 50-year-old pilot had more than 8,500 hours of flight time, including 1,250 in the S-76B. He was the charter company’s chief pilot and a check airman for this aircraft, so we can only assume he was knowledgeable, well trained, and qualified. Yet he got himself into a bind when he lost visibility and attempted to climb above the clouds that had enveloped him. The situation quickly spun out of control, and the helicopter slammed into terrain at a high rate of speed.
Why would an experienced pilot continue such a flight in the prevailing conditions? Why would he make such a bad choice? It likely wasn’t because he didn’t know about spatial disorientation, how to fly by reference to instruments, or that the terrain and circumstances were potentially dangerous. So, what might have been the underlying reason this tragedy occurred?
Decades ago, when I was learning to fly by instruments, my instructor gave me a good lesson on the dangers of attempting to fly by visual reference when flying among the clouds. We were on an IFR flight, but flying in and out of the clouds. We were within what can only be described as canyons among the clouds. At one point, he asked me to revert to visual flight and just look around and fly by visual references, so I did.
My eyes quickly picked up visual cues that suggested where the horizon should be. I maintained orientation to those visual references. Less than a minute later, he asked me if I was flying straight and level, which I was certain I was. But when he had me cross-check my instruments, I quickly saw the disconnect. I was in a near 30-degree bank and losing altitude. His point was well made.
Sometimes we get good lessons, but then it’s a good long time before we get to put those lessons into practice. Years later, I was completing a VFR flight to my home airport. About 4 miles out over the water, the bright sunshine and blue skies gave way to scattered cumulus clouds. I knew it would take some time to contact approach, get a pop-up IFR clearance, and then fly the localizer in for a landing. I would have to copy a clearance, pull out my approach plates, set up the radios, brief the approach, and then get vectors for the approach. And some delays might be expected before I would be cleared for the approach.
Thinking it would be more expeditious to continue the flight under VFR, I began maneuvering around the puffy clouds as I worked my way to the nontowered airport. After all, the automated weather observing system was still reporting VFR, and it seemed like it shouldn’t be too difficult to complete the flight under VFR.
At some point in my maneuvering, clouds were below me — and it seemed like déjà vu. Just like that instructional flight years before, I began to recognize that things were amiss. I cross-checked my instruments and realized I had made a bad choice. I had once again become the victim of spatial disorientation and fooled by visual cues that were clearly amiss.
Fortunately, I recognized the error before the situation got out of control. I transitioned to instruments, turned around, and headed back into clear conditions where I would make some better choices.
Perhaps the reason I had chosen not to open an IFR flight plan was because of a subtle form of time pressure. It wasn’t like I had some important meeting or pressing event to attend. It wasn’t that I didn’t have enough fuel to complete an instrument approach. It wasn’t that I was not “equipped and qualified for IFR,” as surely the controller would ask. And it wasn’t that I didn’t know better. It was simply inconvenient, and besides, I was in familiar terrain. It looked like I could safely continue under VFR.
From this frame of reference, I reflected on the decisions that may have been made by the helicopter pilot on that fatal flight. I’m sure he knew what the conditions were — for the most part. It wasn’t that he wasn’t instrument rated, although IFR operations were not allowed for the company’s charter operations. Investigators suggest it was because he was under some type of self-induced pressure that he made the choice he made. Being intimately familiar with the local terrain and prevailing conditions, he too might have been confident that he could complete the flight safely under VFR. Perhaps it was concern about his reputation or self-image as a competent, reliable pilot that steered him into a bad choice.
Other subtle factors might have been involved. Perhaps he became briefly distracted by a cockpit task and momentarily lost his visual references. When he realized he was in trouble, he decided to climb through the clouds to get on top. The pilot clearly would have had his hands full as he made the decision to climb to 4,000 feet and alerted controllers. The controller asked him to ident on his transponder, which investigators suggested might have been enough of a distraction to undo the pilot. Just turning his head to comply with the ATC request could induce a somatogravic illusion. Whatever the cause, the pilot lost control, and the rest was over in seconds.
Any way we look at it, we need to recognize that we are at risk during flight at low altitude, especially in poor or marginal visibility conditions. While we might easily convince ourselves that we know what we’re doing, that we can complete the flight safely, it doesn’t take much to find out that we’re wrong. When that happens at low altitude in low visibility, it doesn’t take much time to lose control and slam into the terrain. Spatial disorientation can snatch us from the sky just that quickly.
We need to recognize that no matter how good or well trained we might be, we are not invincible. We can make mistakes. The regulations that have been put in place by the FAA are there for a good reason — to help prevent us from making bad choices.
So, as we focus on maintaining currency, flight skills, and aeronautical knowledge, it might be a good idea to focus also on the insidious factors and circumstances through which we put subtle pressure on ourselves — pressure that could lead us to make a bad choice. We need to closely evaluate our personal decision-making and examine that gray area where clouds and circumstances collide.
Robert N. Rossier, EAA 472091, has been flying for more than 40 years and has worked as a flight instructor, commercial pilot, chief pilot, and FAA flight check airman.