Why do pilots continue to press on into instrument conditions while flying by visual references?

If it’s not a puzzle as old as aviation itself, it’s at least as old as the introduction of gyroscopic attitude instruments to light civilian aircraft: Why do pilots continue to press on into instrument meteorological conditions (IMC) while flying by visual references? And why do pilots who’ve learned how to fly by instrument references continue to succumb to spatial disorientation once they lose sight of the ground?

The Flight

At about 8:10 pm local time on Thursday, Apr. 22, 2021—13 minutes after sunset—a Robinson R44 lifted off from the Queen City Municipal Airport (KXLL) in Allentown, Pennsylvania. The pilot requested flight following to the Bradford County Airport in Towanda, Pennsylvania, a straight-line distance of 82 nautical miles (nm) to the northwest, at a cruising altitude of 3,000 ft. He did not contact Leidos Flight Service for a weather briefing or consult ForeFlight weather software, and there is no record of him checking weather information from any other source. The route was a familiar one, as he had been using the helicopter to commute to work since buying it the previous summer. According to his wife, his departure that evening was later than usual, but “flying at night was not an issue” for him. Conditions were dark, with the moon obscured by a higher overcast layer.

At 8:28 pm, five minutes after the end of evening civil twilight, the air traffic control (ATC) tower at KXLL handed him off to ATC at Wilkes-Barre/Scranton International Airport (KAPV). Thirty-five minutes later, radar tracking data showed that the helicopter began an initially gradual right turn that tightened into a descending spiral. Radar contact was lost at 9:04 pm. ATC did not receive any distress calls.

Initial press reports suggested that an air medical helicopter crew passing overhead first spotted the burning wreckage. Emergency responders included the Pennsylvania State Police, the Pennsylvania Game Commission, and volunteer firefighters. Reaching the “remote, wooded” area required them to hike in from the point that the landscape became impassable for all-terrain vehicles; one state trooper estimated that it was a two-hour to two-and-a-half-hour round trip from the nearest road. By the time responders arrived, most of the helicopter’s fuselage and tail cone had been consumed by the fire. The pilot’s remains were later recovered from the wreckage.

The Weather

The National Transportation Safety Board (NTSB) final report noted that while there were no high- or low-­pressure systems near the accident site, a trough running from north central to southwest Pennsylvania provided lifting action for whatever moisture was in the vicinity. While KAPV, 23 miles to the southeast, reported 10 miles visibility under a 7,500-ft. overcast, the Greater Binghamton Airport (KBGM) in East Maine, New York, 44 miles north, recorded just 1.5 miles visibility in light snow and mist, with broken ceilings descending from 4,300 ft. 10 minutes before the accident to 2,900 ft. 18 minutes later.

At 7:53 pm, more than 15 minutes before the pilot took off, the National Weather Service office in Binghamton, New York, had issued an area forecast that included lake-effect snow showers moving through the area, and AIRMETs (AIRman’s METeorological Information) for mountain obscuration, moderate icing, and moderate turbulence were in effect across the route. Archived Doppler radar data showed snow showers moving across the accident site at the time of the crash.

The Pilot

The 54-year-old private pilot was an anesthesiologist who routinely flew to his practice in Sayre, Pennsylvania, after buying the R44 less than a year earlier. He was rated for single-engine airplanes and seaplanes and held an instrument airplane rating. He had not obtained an instrument helicopter rating. Of his total 2,278 hours of flight experience, 2,070 were in airplanes. His 208 hours of helicopter time were equally divided between the Robinson R22, in which he’d completed his initial training, and the R44 he had bought in June 2020 to commute to work. His logbooks showed 30 of the 104 R44 hours in the preceding 90 days, with 19 of them recorded in the previous month.

The Helicopter

NTSB investigators noted that the 2020-model helicopter “was not approved for flight in instrument meteorological conditions.” The NTSB’s probable-­cause report and supporting documentation didn’t specify the exact panel layout of the helicopter; however, R44s of that vintage are equipped with the minimal set of basic attitude instruments (including either electronic or gyroscopic attitude and heading indicators), enabling an instrument pilot to maintain altitude and heading or execute a level 180-degree turn to escape from an inadvertent entry into IMC.

The post-crash fire consumed not only the cabin and fuselage, including the flight-control tubes, but also most of the tail cone and empennage. Although the crash destroyed the bladders and outer shells of the fuel tanks, the caps were secure and the finger strainers were clean and unobstructed. The main-rotor hub remained attached to its driveshaft, and damage to the main- and tail-rotor blades was ascribed to either initial impact during descent or first responders’ efforts during recovery operations.

Damage to the engine, chiefly a sheared crankshaft-gear dowel pin, was attributed to impact forces. The NTSB concluded that “there was no evidence of any pre-impact mechanical malfunctions or failures that would have precluded normal operation” of the airframe or the engine.

The Takeaway

Not surprisingly, the NTSB attributed the accident to … the pilot’s inadequate preflight weather planning, which resulted in an inadvertent encounter with instrument meteorological conditions at night, spatial disorientation, and collision with terrain.

“VFR-into-IMC” accidents—those resulting from attempts to continue flying by visual references in instrument meteorological conditions—plagued aviation even before the first attempts to institute airmail services in the 1920s. It was a major reason life expectancy among those first airmail pilots was measured in weeks. VFR-into-IMC accidents typically end with flight into terrain, either controlled (think collision with a ridgeline) or uncontrolled (think graveyard spiral). The chances of a lethal result are high either way.

The invention of reliable attitude instruments and training programs to use them effectively have broadened the options available to both professional and non­occupational pilots, but these efforts ­haven’t begun to solve the problem. Combined across all aircraft categories and types of operations, about one-third of pilots involved in VFR-into-IMC accidents earned an instrument rating at some point but failed to use those skills effectively when they were most urgently needed. Two-thirds of VFR-into-IMC accidents are fatal, a figure that hasn’t changed much in at least the past 70 years.

As a first cut, these accidents can be sorted into three distinct categories: those in which the pilots never learned to fly by instrument references, those in which the pilot was qualified but the aircraft wasn’t appropriately equipped, and those in which an instrument-rated pilot failed to use those instruments to avoid catastrophe.

Because relatively few helicopters are certificated for flight in instrument conditions and, consequently, relatively few helicopter pilots pursue the instrument rating, spatial disorientation accidents in rotorcraft largely fall into the first category. The present case is less straightforward: the pilot had enough instrument training to have successfully passed that checkride—in an airplane—and the helicopter had enough instrumentation to enable him to maintain airspeed, altitude, and heading while requesting assistance from ATC. But instrument flight is a highly perishable skill dependent on consistent, recurrent practice. The pages of the pilot’s logbook recorded in the NTSB’s docket file begin in August 2020 and show no instrument (or fixed-wing) flights during the eight months preceding the accident.

It is therefore fair to suggest that he was not only no longer legally current in, but also out of practice at instrument flight while also still relatively new to flying helicopters. The combination of lost visibility in snow squalls and a dark, overcast night would have challenged both his instrument and his cyclic-and-collective skills in a low-altitude setting that left little margin for error either way.

Dark-night conditions are most prudently treated as effectively IMC, regardless of reported ceilings or visibilities. In the end, this pilot’s crucial mistakes began with his failure to recognize and appreciate that the evening’s weather posed potentially lethal hazards. Neglecting to consider alternative routes or prepare for escape from unfavorable conditions left him with no options beyond hope once things began to go wrong.


  • David Jack Kenny

    David Jack Kenny is a fixed-wing ATP with commercial privileges for helicopter. He also holds degrees in statistics. From 2008 through 2017, he worked for AOPA’s Air Safety Institute, where he authored eight editions of its Joseph T. Nall Report and nearly 500 articles. He’d rather be flying.

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David Jack Kenny

David Jack Kenny

David Jack Kenny is a fixed-wing ATP with commercial privileges for helicopter. He also holds degrees in statistics. From 2008 through 2017, he worked for AOPA’s Air Safety Institute, where he authored eight editions of its Joseph T. Nall Report and nearly 500 articles. He’d rather be flying.