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ASN Wikibase Occurrence # 35346
Last updated: 7 April 2021
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Type:Silhouette image of generic P28A model; specific model in this crash may look slightly different
Piper PA-28-181
Owner/operator:Gordon Bergman
Registration: N9703C
C/n / msn: 28-7890438
Fatalities:Fatalities: 2 / Occupants: 2
Other fatalities:0
Aircraft damage: Written off (damaged beyond repair)
Location:Bangor, CA -   United States of America
Phase: Unknown
Departure airport:Lincoln, CA (LHM)
Destination airport:Sunriver, OR (S21)
Investigating agency: NTSB
The pilot had logged 1,600 total flight hours, of which 1,100 hours were flown in his autopilot equipped airplane. The pilot and his passenger/wife, also a pilot with over 300 flight hours, planned to fly northward from Lincoln, California, to Bend, Oregon. Neither pilot was instrument rated. FSS provided the pilot with a weather briefing indicating flight precautions for mountain obscurement and thunderstorms. Weather conditions along the planned route included multiple cloud layers at 2,000 and 4,000 feet msl, and light rain showers. The pilot informed the FSS briefer that he could fly in IMC. After a 0740 takeoff the pilot requested and received VFR radar flight following service, encountered the clouds, and commenced flight in IMC while continuing toward his intended destination. At 0759:28, the pilot advised the Oakland ARTCC controller that he was in the clouds and on autopilot. The controller advised the pilot to 'use caution and maintain VFR.' The pilot again informed the controller that he was in the clouds and VFR flight was not possible, to which the controller responded at 0800:51 by stating 'maintain VFR.' Then, the controller provided the pilot with directions to an airport ahead with unknown weather conditions. The controller observed the airplane's 2,400-foot altitude and was aware that the minimum instrument altitude for the area was at least 5,000 feet. Contrary to requirements specified in the FAA's Air Traffic Control Order 7110.65, the controller failed to perform his first duty priority by not properly assisting the pilot in an emergency. The controller provided the pilot with a bearing to an airport south of his position necessitating a course reversal turn while proceeding in IMC, and he neglected to issue a safety alert for terrain proximity or give climb instructions to an area where flight under VFR was likely possible. Seconds after the pilot received the turn instructions he became disoriented, lost control of the airplane, and in an inverted attitude impacted the underlying hilly terrain. About 8 months prior to the accident flight the 78-year-old pilot's high blood pressure (180/90) was reduced with prescription drug treatment. Insufficient specimens remained for definitive autopsies or toxicological tests. No mechanical malfunctions were found with the airplane. CAUSE: The pilot's attempted flight into instrument meteorological conditions, loss of spatial orientation, and the resultant loss of airplane control. Contributing factors were his improper preflight and in-flight decisions, overconfidence in his personal ability, and the low ceiling. An additional factor was the radar controller's substantial deviation from prescribed procedures for handling VFR aircraft in weather difficulty.



Revision history:

24-Oct-2008 10:30 ASN archive Added
21-Dec-2016 19:22 ASN Update Bot Updated [Time, Damage, Category, Investigating agency]

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