Jersey Inferno

Instrument failure in IMC leads to loss of control and a fiery finish on the streets below


Confidence is a double-edged sword. On the one hand, confidence eliminates the uncertainties that make decisions harder. On the other, confidence can lead you into believing bad things only happen to other people.

Sometimes, bad things happen to skilled people. Confidence can be a magic cloak that wards off disaster, but it can also be an inviting smell that brings misfortune in for a closer look.

On a relatively balmy November morning last year, a pilot and two members of his family said goodbye to a fourth family member. It was the Friday after Thanksgiving, and the family had been together for the holiday.

The pilot had flown his 1964 Bonanza S35 from his home in Bethesda, Md., to Linden, N.J., on Wednesday evening. The pilot, his wife and 13-year-old daughter stayed at a motel in Linden and, early Thanksgiving Day, went to the Brooklyn home of his 25-year-old daughter. After a holiday together, the three travelers returned to the motel about 11:45 p.m.

Although the weather was warm, low clouds raised the prospect that the family would have to drive to Washington, D.C., the next day instead of fly.

The pilots credentials were impressive. He had been flying for about 40 years, including a stint in the Israeli Air Force.

He obtained a U.S. medical certificate and license in 1988 and held an ATP certificate and was a well-known Washington-area CFI. He was also a core instructor of the American Bonanza Societys Bonanza Pilot Proficiency Program, where he earned notoriety among his student pilots for his emphasis on partial panel operations in IFR conditions.

He was also rated to instruct in gliders and multi-engine airplanes and had a single-engine seaplane rating.

His total flight time was ambiguous. Although he reported 5,800 hours when he renewed his Class II medical three weeks earlier, his logbooks showed a total of 4,172, of which about 1,300 were reported to be in actual IMC.

He called for weather briefings four times. Thursday morning he obtained an outlook briefing and filed an IFR flight plan for the next morning. They planned to leave about 7 a.m.

Although the NTSB file did not give any details about the weather briefings, the family apparently discussed the potential for having to drive to Washington the next day instead of fly.

Friday morning, a few minutes before 6 a.m., he was back on the phone to the Flight Service Station, updating his weather information. At 8 a.m. he called again, updating his weather information and amending his proposed departure time.

At 9:23 he called the final time and obtained another abbreviated weather report. Apparently he didnt mind what he heard. At around 10 a.m. he called his son-in-law in Brooklyn and said theyd fly to Washington after all, his daughter later told police.

As the plane was preparing to depart, the pilot had trouble communicating with controllers because the remote frequency normally used to issue clearances to Linden departures was inoperative. For the next half hour, the pilots communications with controllers were by cell phone as the Bonanza waited for its IFR clearance to be issued. At one point, he called asking for help finding one of the fixes in the clearance he was given.

Into the Crud
Finally, about 10:46, the pilot was given his IFR release and the Bonanza rolled onto runway 9.

Weather at the time in nearby Newark was a scattered layer at 600 feet, broken layer at 1,300. Visibility was 2 miles with light rain and mist. The temperature was 61 and the dewpoint 59. Witnesses on the ground when the airplane took off at Linden said the ceiling was 50 to 100 feet.

Climbing out of 500 feet for 2,000, the pilot contacted Departure. He was identified on radar, told to turn left to a heading of 010 and climb to 5,000 feet. Barely had he acknowledged the clearance when the controller was back, amending his altitude to the 2,000 he had initially been given. Thirty seconds later, the controller called him again.

92M, turn left, left turn heading 270, the controller said. The airplanes ground track was due north.

92M, New York.

92M, New York.

Yes, 92M. I have a problem, the pilot finally responded. Despite the instruction to turn left to 270, the airplane had actually turned right and was headed due east.

92M, whats your problem, sir.

I had a gyro problem momentarily. It looks straightening now. I must have had water in the system.

For roughly the next 30 seconds, controllers scrambled to get a USAir jet on approach to Newark out of the way of the wayward Bonanza. That done, the controller went back to work on the V-tailed airplane.

92M, continue the right turn all the way around now, heading of, uh, correction, youre in a left turn now.

The radar track showed that, as the controller was issuing the instructions, the airplane began a gentle turn to the left, straightening out on a heading of roughly due north. Over the next minute, the following exchange took place:

92M, stop your climb at 2,000, turn left, left turn heading 270.

270, 92M

92M, youre able, youre OK to, uh, navigate now?

92M. I think I have a problem. Can you try to give me a climb?

92M, maintain 2,000. Stop. What is your heading?

92M. Looks like 030.

92M. I have a problem.

During that exchange, the airplane followed a path that was roughly north, oscillating left and right four times with larger deviations each time. Over the next several minutes, Departure tried calling the pilot numerous times, but were not able to get an answer.

During the last 10 seconds of radar data, the airspeed jumped from about 130 knots to nearly 240 knots in a final, agonizing descent that reached what investigators calculated to be 10,000 feet per minute.

Nevertheless, the pilot apparently was trying to regain control. The airplane came out of the clouds nearly wings-level, but it was then that the pilots time ran out.

The airplane struck the corner of the roof of an abandoned three-story brick building. From there, the debris extended about 760 feet down a street in a densely populated neighborhood.

Urban Chaos
The crash ignited the abandoned building and destroyed another building. All told, 18 buildings, including six houses, and eight cars were damaged or destroyed. The pilot and his passengers were killed. On the ground 24 people were hurt, suffering injuries from minor cuts to third-degree burns. Seven weeks later, one of the burn victims died from his injuries, bringing the death toll to four.

Several of the people interviewed by police immediately after the crash, including a police officer, said the engine sounded abnormal. There was no evidence that an engine malfunction had occurred, however. The witnesses may have thought the sound abnormal because the high rate of descent may have overspeeded the engine. In addition, most people dont know the sound of airplane engines close-up.

The witnesses described a frightening scene of burning houses, debris-strewn roads and downed power lines. Bleeding people walked the streets crying. Several cars exploded.

Within days of the accident, the city of Newark filed a lawsuit against the estate of the pilot, seeking compensation for the cost of the cleanup and overtime for police officers and firefighters. The city put the price tag on the accident at $3.275 million – part of which was loss of rental income for the owners of buildings that were damaged.

The NTSB, meanwhile, was sifting through the wreckage trying to determine the cause of the accident. The investigators latched on to the pilots report of a gyro problem. Because the airplane disintegrated during the accident sequence, verifying the integrity of the system was impossible. However, they were able to locate several smoking guns.

Upon examining the airplanes gyroscopic instruments, they determined that the attitude indicator gyro was spinning at the time of the crash. Both the gyro and the housing showed marks consistent with the gyro rotating at the time of impact. Furthermore, when investigators supplied low-pressure air to the rotor, it spun freely.

The HSI was another story. Both the gyro rotor and the housing showed the rotor was not spinning when the crash occurred. Because of the extent of the damage to the airplane, investigators were unable to examine the plumbing of the airplanes gyro pressure system to determine why the HSI was not operating.

Next the investigators looked at the electrically powered turn coordinator gyro. It also showed no evidence that it was rotating at the time of impact. The housing was not recovered and the cause of the instruments failure was undetermined.

The inescapable conclusion was that the pilot had suffered the failure of two gyros powered by two different systems. The improbability of such a failure initially led to speculation that the pilot was flying with a known deficiency in that one of the instruments was inoperative from the start.

The NTSB interviewed several people familiar with the pilots flying habits, all of whom said he was meticulous about maintenance and cautious in his decision-making.

One, a Baltimore-area pilot examiner who had made several instrument flights in the previous months and had issued the pilot his ATP certificate in February 1999, described the pilot as a very competent pilot [who] tried diligently to maintain his proficiency in both VFR and IFR flying.

The pilots reputation was tarnished, however, when investigators discovered a major problem the pilot had concealed from the FAA for more than a decade.

FAA records showed the pilots first FAA medical was issued in 1988. At that time, and at every exam afterward, the pilot said he had no medical conditions that would be disqualifying and that he was not taking any prescription medication.

In fact, the pilots personal medical records, maintained by his HMO, showed a long-standing history of migraine headaches. A 1976 entry, the first described in the NTSB report, noted he had a history of migraines and was taking Fiorinal (which contains a barbiturate) up to two times per week.

Entries over the next 13 years continued to outline the problems he was having with migraines and the use of Fiorinal to combat them. The references to migraines in his medical file ended in 1989. The use of the drug, however, did not.

Pharmacy records showed the pilot had been dispensed more than 6,000 tablets in the seven years leading up to the crash – including 800 in the previous 11 months.

Migraines are specifically addressed in the medical application, with a question directly asking whether the applicant has ever in his or her life had frequent or severe headaches. It also specifically asks if the applicant is taking any medication. The pilot answered negatively to each question.

The FAA Guide for Aviation Medical Examiners specifically states that migraine sufferers are ineligible for any class of medical certificate. The guide has this to say:

Pain, in some cases, may be acutely incapacitating. Chronic recurring headaches … often require medications for relief or prophylaxis and in most cases the use of such medications is disqualifying because they may interfere with a pilots alertness and functioning.

Fiorinal is a combination of butalbital, aspirin and caffeine. Butalbital is a barbiturate and can be habit forming. One of the most common side effects of taking the drug is dizziness or drowsiness.

Although the NTSB concluded that the pilots use of inappropriate medication was a contributing factor in the crash, others are not so quick to point the finger.

Michael Palmen, a physician at the Mayo Clinic in Rochester, Minn., and an expert on addiction and drug tolerance, says its possible that the pilot had built up a tolerance to the drug over the years such that his performance was not impaired at all. The key to deciding whether the drug represented a danger at the time would be how consistently he took it and in what quantities.

The prescriptions filled represent an average of fewer than 2.5 tablets a day. If someone took 2.5 tablets a day for years, Palmen says, the patient would build up a tolerance to the depressant effects of butalbital such that their performance may be hurt more by not taking the drug than by taking it. On the other hand, someone who took 35 tablets over three days every two weeks would not develop nearly the same tolerance to the depressant effects.

There would be relative safety when someone was consistently taking small doses, Palmen says. But it would be difficult to say [this accident] was due to his drug usage, from an intoxication standpoint, without knowing how often he took it and in what dosages. Obviously he flew for years while taking the drug, so maybe that tells you something.

The pilot, however, was also a physician, which further clouds the issue of whether the use of Fiorinal was appropriate and whether flying with the potential for migraines was dangerous, regardless of the regulatory point of view. He was also affiliated with the Uniformed Services University of Health Sciences, where military physicians are trained. Research into migraines and Fiorinal, it appears, should have been amply available to him.

Uncovering the Truth
Like many general aviation accidents, not enough evidence remained to find a truly definitive answer as to what went wrong. One can, however, do some Monday-morning quarterbacking and come up with some plausible theories.

The primary lesson is that, even with systems redundancy, the pilot is charged with the task of determining which system is malfunctioning. Shortly after takeoff into IMC in crowded airspace is a difficult time to face one instrument failure, much less two. Because theres no way of knowing how the failed instruments presented themselves to the pilot, its impossible to know whether he misdiagnosed the problem or was merely overwhelmed by the attempt.

The pilots he instructed say he emphasized partial-panel work among his students, which implies he should also have held his own performance on partial panel in high regard. His knowledge of the Bonanza and its systems was thorough, and he had attended and instructed in a Bonanza Pilot Proficiency Program weekend seminar in North Carolina a few weeks earlier.

His logbook, however, yielded another clue of something that may have played a psychological role in the accident.

Of the 271 hours he logged in 1998, more than three-quarters of them were as an instructor. He flew 67.5 hours as his own man. His 1999 logbook information was not broken out in the NTSB report.

This is not to say the pilot wasnt proficient, for no one can assess that now with any certainty. But instructors are not immune to human nature, and self-confidence and rusty skills have combined to cause grief countless times in all pursuits.

The tragic crash, mysterious though it may be given the pilots qualifications and accomplishments, is not made any less so by the medical skeletons he hid in his closet. Many pilots are guilty of looking after their health with one doctor and their medical certificate with another. As a physician himself, he was qualified to tell whether his dont ask, dont tell relationship with his AME was appropriate or dangerous.

In the cold, hard light of the accident aftermath, its easy to conclude that the warning signs were there. But in fact, this pilot took off in weather that was poor but not overwhelmingly so, on a mission he was qualified to fly and in an airplane he had owned for a decade and trusted with his life more than once. The airplane let him down, to be sure. And the issue of whether he let himself down, too, well, thats a moot point – but one to ponder.

-by Ken Ibold


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