Hazardous Attitudes: A 10,000-Hour Pilot Departs VFR Into a Warning

Experience is supposed to protect you. Sometimes it does the opposite: it gives you a long record of getting away with things. The FAA teaches five hazardous attitudes because they show up in pilots of every experience level, and they're hardest to see in yourself.

The AOPA Air Safety Institute (ASI) re-creates this flight in its video "Accident Case Study: Hazardous Attitudes," which you can watch below. The summary that follows is ours and is based on the NTSB final report (WPR19FA079), which also gives the official probable cause. Watch the full case study for ASI's own analysis.

Loads YouTube when you press play

The flight, in short

On February 3, 2019, a 75-year-old commercial pilot with an instrument rating and about 10,235 hours departed Fullerton Municipal Airport (FUL) in Southern California in a Cessna 414, headed VFR to Minden, Nevada (MEV). He filed no flight plan, and the NTSB found no evidence that he got a weather briefing. AIRMETs for moderate turbulence below 12,000 feet and mountain obscuration were in effect for the area.

The weather at Fullerton was VFR. With the takeoff clearance, the tower controller cautioned the pilot about deteriorating weather about 4 miles east of the airport. He departed about 1339 and made a climbing left turn to the east, into an area where conditions had turned to IMC with rain showers and a microburst.

About 5½ minutes after takeoff, the airplane was about 7,800 feet above the ground when it entered a rapid descending right turn. Data from a portable ADS-B receiver aboard showed that in the last 15 seconds the pitch swung between 45° nose down and 75° nose up, and the bank between 170° left and 150° right. Witnesses saw the airplane come out of the clouds and break apart. Pieces of the airplane came down on a street and a house in Yorba Linda, and the house burned. The pilot and four people on the ground were killed, and two more on the ground were seriously injured.

The NTSB determined the probable cause to be: “The pilot’s failure to maintain airplane control after entering instrument meteorological conditions (IMC) while climbing due to spatial disorientation, which resulted in the exceedance of the airplane’s design stress limits and subsequent in-flight break-up. Contributing to accident was the pilot's improper decision to conduct the flight under visual flight rules and to continue the flight when conditions deteriorated.”

The five hazardous attitudes

The NTSB report doesn't name an attitude, and we won't guess at what this pilot was thinking. ASI's video covers how hazardous attitudes can betray pilots who don't heed warnings. Here are the five the FAA teaches, with the antidote for each, and a question this flight raises.

• Anti-authority (“Don't tell me.”) Antidote: Follow the rules. They are usually right. Question: when a controller warns you about weather ahead, do you treat it as information or as an opinion?
• Impulsivity (“Do it quickly.”) Antidote: Not so fast. Think first. Question: did you get a briefing for this flight, or just look out the window?
• Invulnerability (“It won't happen to me.”) Antidote: It could happen to me. Question: would you let a student make this departure?
• Macho (“I can do it.”) Antidote: Taking chances is foolish. Question: why go VFR toward weather when you hold an instrument rating and the airplane is IFR equipped?
• Resignation (“What's the use?”) Antidote: I'm not helpless. I can make a difference. Question: once you're in it, do you still believe a turn back or a call to ATC can change the outcome?

An instrument rating only protects you when you use it. Flying VFR into weather means flying without a clearance, an altitude assignment or a plan for the clouds, which is exactly when an instrument pilot is easiest to catch off guard.