Crash sequence
13 min read

This is a chronicle of events of a search operation requested by a worried family when their loved one did not arrive from a short instrument flight.

I got up on October 6, 2015, to a gloomy, overcast morning. After lunch my cell phone started to vibrate and when I answered it was Jim from the FBO office at the Chadron Airport. He explained that a V-tail Beechcraft had left Chadron for Alliance midmorning and had not arrived. There were concerned individuals at the Alliance airport who were asking for someone to look for the plane; would I have time and want to fly our Cessna 175 to check the route between Chadron and Alliance?

I told Jim I could do this and would contact Charlie to see if he could come with me. Charlie is also a partner in the Cessna 175. I called Charlie at his office and said, “We have a request to look for a plane.” Charlie could come with me so I picked him up on the way to the airport. Neither of us were overly concerned; we have had this happen before. There was a good chance that the plane and pilot would be located at some other airport before we could pull our plane from the hangar.

When we arrived at the airport, Jim and Scott gave us more information. The pilot had had not spent much time at the airport and, after taking off, had radioed he was turning around and returning to Chadron, but that had not happened. We “assumed” the radio call had been to Chadron Unicom. We also learned that Flight Service was calling airports in the area to determine if he had landed elsewhere. Our concern level ratcheted up considerably based on this information. We checked the weather over the Pine Ridge south of the Chadron airport and on to Alliance, rolled our Cessna 175 out of the hangar, performed the preflight procedures, then taxied out and took off.

Ridges

Finding an airplane in this terrain is incredibly difficult.

We departed south and a little east out of the pattern, with the intention of intersecting the route to Alliance out of Chadron over Highway 385 and going at least to the Niobrara River, which should have covered the route flown before the pilot turned around. As we were crossing the Pine Ridge, we were contacted by Jim from the Chadron Airport and informed us that new information indicated the plane was west of Highway 385. We flew to the area where the aircraft should have crossed 385 and turned to go back to the northwest toward the Chadron Airport.

As we were approaching the Pine Ridge from the south, Jim contacted us again and said they had information the plane might be near a small sawmill on Dead Horse Road, which runs north and south up and over the Pine Ridge. We were not sure exactly where that was located and were told it was about three miles north of the intersection of Dead Horse and Table Road at the top of the ridge. This was narrowing the search to somewhere north of Table Road, near Dead Horse Road, and back to the vicinity of the Chadron Airport.

We began a creeping line search north and south about three miles east of Dead Horse Road, creeping west. With the information we had, turning around may have put him several miles east or west of Dead Horse Road. We learned later that our second pass to the north took us directly over the crash site and neither of us saw it under our 175. After another pass we heard Jeff of Heartland Aviation from Alliance and his passenger were in the air to east, beginning their search for the plane. We decided to make a few more passes creeping west, which would keep the two search planes apart and check if the missing pilot had turned west to intercept the VOR approach to the Chadron Airport.

Jim contacted us again on the radio with more information. The pilot of the missing plane had filed an IFR flight plan and they were looking at part of his radar track on their computer using Flightware.com. The radar track ended over Dead Horse Road near the north side of the Pine Ridge. We flew east back to Dead Horse Road as we now had good information narrowing the possible location of the aircraft. We contacted the other aircraft and decided to fly north toward the airport on the west side of Dead Horse Road. Since we had been told the pilot made a radio call about returning to the Chadron Airport, he might have crashed into the Pine Ridge or crashed on the return to the airport. There are creeks, draws, and badlands in places between the Pine Ridge and just south of the Chadron Airport. We searched the west side of Dead Horse Road back to the Chadron Airport. Since we were at the airport, we landed to take a look at the information on Flightaware.com and check on the exact exchange the pilot made about returning to the Chadron Airport.

When we entered the FBO office, Jim showed us the radar track on the computer screen. We were just about to call Denver Center to get the exact radio transmissions when we received a radio call from the other aircraft. They had spotted the wreckage in a canyon about two miles east of Dead Horse Road, on the north edge of the Pine Ridge and it didn’t look like the pilot could have survived. That radio call changed everything in an instant; we now had a confirmed crash site, a location, and probably a recovery, not a rescue.

Reporting this tragedy was the next step; after a brief discussion, Charlie called the Dawes County Sheriff’s Office and informed the deputy on duty that we had a confirmed plane crash with only the pilot on board and the approximate location. That triggered the recovery response, starting with the deputy confirming who was making the report, getting name, address, phone number, etc.; then confirming as many details as possible about location and determining how to communicate with the aircraft. Communication was a problem because we were informed the Sheriff’s Department did not have a radio to communicate on FAA frequencies, so it seemed the quickest way to establish communication with the aircraft in the air was to radio the deputy’s cell number to the aircraft circling the crash site.

Crash site

A crash site that suggests a rescue mission had changed to a recovery mission.

With the response activated, we were standing in the FBO office deciding what we should do next. We decided to fly to the crash site and determine why we had not spotted it. After taking off, we contacted the other aircraft and determined a 500-foot altitude separation between us to look at the crash site. When we flew over the area east of Dead Horse Road and the north edge of the Pine Ridge, we located and contacted the other aircraft below us. We then set up a follow-the-leader pass over the crash site. We descended behind the other plane and flew north over a deep box canyon where we observed a black, burned patch with pieces of something in it; nothing in that black patch looked much like an airplane.

After this maneuver, we returned to our different altitudes. The other plane informed us the emergency response team was coming south on Dead Horse Road with a ground team of Sheriff’s vehicles as well as the Chadron Fire Department, which included rural fire fighting equipment, ambulance, and their volunteer staff. As it was getting late in the afternoon, the plane from Alliance asked that we guide the ground teams to the crash site as they wanted to return to Alliance. We got the cell number the other aircraft was using to communicate with the sheriff’s deputy and immediately made contact. This was fortunate as the cell signal in this area is often accessible only on high points of the landscape. As long as the team on the ground could contact a cell tower, we could communicate.

The deputy said they had left Dead Horse Road and were going east on a trail across a pasture. This information indicated we needed to look north as we had seen no vehicles yet on Dead Horse Road and they could not drive a vehicle close to the crash site, as this part of the Pine Ridge consisted of buttes and deep box canyons with steep or vertical walls and only wide enough to walk on the bottom or on top.

We saw three vehicles about three miles directly north of the crash site headed east. We told them to turn south on a trail coming up in front of them and follow it south to a fork and then take the southwest trail. We advised them to go southwest because driving the south trail led up the side of a deep canyon that did not look passable from the air. One pickup tried it and was still trying to escape the canyon when we left the scene. The other two pickups drove to a ridge that stretched south toward the crash site and found they could drive no further. We still had cell communication and told the deputy we could see no way into the crash site from any direction, not even with a four-wheeler. We then described, as best we could, how to climb the steep ridge that stopped them in their vehicles and follow that ridge along a series of branching ridges south to the crash. There was no way in but to walk and climb for about a mile. We saw four-wheelers and rescue vehicles approaching from different directions now and all being stopped by the steep terrain.

We continued circling, flying from the south over the canyon to the north, wagging our wings over the crash site, then flying back to the south and repeating this pattern. When the deputy got on top of the ridge, we could slowly guide him down the ridgelines. He passed our directions by radio to other ground parties. Finally, we could see a group of about five people standing on the ridge to the northwest of the crash amid debris on that ridge and they could see the final crash area far below in the canyon. We made one more pass from the south and determined our part of this mission was complete; we returned to the airport and put the plane away. This had turned into a tragic day.

The next morning, the deputy called me and described how difficult that hike to the crash site had been. He said it was late into the night before they got the body back to an ambulance. It had been a difficult recovery.

On Saturday, October 31, Charlie and I (with some friends) made arrangements to visit the crash site. By that time, the official inspection of the crash site was complete and the aircraft wreckage had been removed using a helicopter. The area was cleaned up better than we expected. We contacted a rancher in the area who had helped guide the ground team vehicles as close as possible to the crash site and made arrangements for him to guide us to the same location. We left our vehicles at the start of the ridges leading to the crash. We could understand the stress and difficulty finding the crash after hiking and climbing along these ridges with canyons dropping away to the north and south. Finally, we came to a narrow saddle in the ridge line and saw plastic bags in the trees on the saddle, some treetops broken off, debris from a windscreen, and a black area where the plane finally crashed and burned in the deep box canyon to the south.

Crash sequence

The crash sequence shows the final seconds of the flight.

We climbed down to the burned area and then explored the ridges to the north of the saddle; we could determine the sequence of the crash. We knew from the Flight Aware site that the plane was on course, how high, and the rate of descent for the short period it appeared on radar. It had been descending about one hundred feet a minute before it disappeared from radar. After disappearing from radar, the plane had remained on course, not turned back. The rate of descent was not steep; it struck the top of a butte a few hundred feet north of the saddle above the deep box canyon. This impact broke out the windscreen—there were shards scattered along the crash trajectory—and broke open the plane, spilling pet supplies in plastic bags from south of the butte to the saddle. It broke off tree tops on the saddle, spilling more debris, and then crashed into the vertical wall of the box canyon. The rancher showed us the location on the south edge of the burn area in the canyon where the pilot, still in his seat, had been thrown from the crash. The body was not burned.

As we viewed the crash scene and speculated about this crash, the following questions were discussed:

  • Why did the pilot descend on course into high, rough terrain on an instrument flight plan? Engine or instrument trouble, incapacitated pilot, lack of planning?
  • Why was the smoke and fire not seen by local ranchers? Our rancher guide said there was a dense fog that morning, the ground was wet, and the canyon was deep and enclosed. The fire was probably out when the fog lifted, the grass too wet to burn, and the sound muffled by the canyon walls.
  • How do we quickly set up radio communications with other agencies such as the sheriff’s personnel? We discussed this with the sheriff later and were told that each of the sheriff’s vehicles had a handheld radio that can be tuned to almost any frequency. He lent us one to try out on FAA frequencies; after we charged the battery, we found it worked fine. We did not know about about this option and the sheriff’s deputy did not know about it either.
  • Why didn’t we check Flightware.com or a similar app to get information about an aircraft on a flight plan? We just didn’t think about that option.
  • Why did this pilot crash? The NTSB report describes in detail the pilot’s currency and experience, the currency and condition of the plane, the weather, and the transmissions with Denver Center. The pilot flew in from North Platte on an instrument flight plan, dropped off a passenger at CDR and a short time later took off and then filed an instrument flight plan in the air. He was waiting for Denver Center to activate this flight plan as he started flying the route to Alliance. My guess is that flying on instruments, the pilot was not aware of the sharp rise in the geography just a few miles south of the airport. As he descended under the cloud deck waiting for his instrument flight plan to be activated, he suddenly found himself ricocheting off the top of a butte.

The reader may find this book of interest when wondering why an experienced pilot crashes in conditions they were trained to manage.

Roger Wess
Latest posts by Roger Wess (see all)
9 replies
  1. Steve Green
    Steve Green says:

    Roger, this is an excellant description of what these tragedies look like and how they unfold. I’ll add a plug for my article a few years ago, because there are a set of accidents in which the pilot and/or passengers DO survive, and yet the crash site is no easier to locate or gain access to than this one. Often they are even more challenging. Time is critical, and you have to be able to survive until people such as yourself can get there.

    https://airfactsjournal.com/2016/07/survived-airplane-crash-heres-learned/

    Reply
  2. Timothy Vaughan
    Timothy Vaughan says:

    A word of caution, flying a solo search, or a search with multiple aircraft is dangerous without proper training and coordination.

    The Civil Air Patrol trains extensively for this type of mission. An earlier call to the Sheriff’s Office would trigger a request to state emergency managers, who would call the Air Force Rescue Coordination Center. The AFRCC would alert CAP state incident commanders who would then initiate an airborne search.

    Reply
  3. David
    David says:

    I wish I had a dime for every sad story I’ve heard involving box canyons. Stay away from them, even if you’re sure you can get out.

    Reply
  4. Christopher Fowler
    Christopher Fowler says:

    As a Senior Member officer/Emergency services officer and ground team member with Civil Air Patrol, I had to share this with my squadron to highlight the issues that ALL search teams run across when an aircraft goes down in a remote location. Excellent article. It’s never good when a rescue turns into a recovery.

    Reply
  5. Bob
    Bob says:

    This is clearly a case of CFIT — Controlled flight into terrain. The WHY is obvious. This pilot did exactly what so many other pilots do every day of the week: Try to kill two birds (not including himself) with one stone by launching VFR and gambling on running the SCUD until ATC issues a clearance into the soup. It is a vulgar way to satisfy the get-there-itis for which we are all vulnerable.

    Reviewing the NTSB report for N877DM and this pilot’s qualifications to whom this airplane was registered indicate to me a particular susceptibility that Airline Pilots flying GA aircraft can not escape. When you fly for an airline, you are spoon-fed all of the information you need to conduct your flight in the flight levels from a professional and well organized Dispatch Department. This form of ‘assistance’ fosters the detrimental effect of causing that pilot to lose the fundamental skills of preflight planning and preparation. A student pilot working on his cross-country phase of training will be far more proficient at 91.103 compliance than a 19,000-hour Airline Pilot with SEVEN big-iron type ratings and only 195 hours in make & model.

    This pilot probably filed his routing based upon a suggestion from ForeFlight. The NTSB report indicates he had no contact with Flight Service for a Standard Weather briefing. He probably never looked at the Cheyenne Sectional to get some idea of the terrain. Furthermore, it appears he did not look at the Chart Supplement to get Denver Center’s telephone number or consult the Non-Standard Takeoff minimums and Departure Procedures for CDR if only for prudent guidance and perspective. All of these omissions, if correct, fail to satisfy the obligation every pilot has to comply with what 91.103 says in the simplest words possible: “Each pilot in command shall, BEFORE beginning a flight, become familiar with all available information concerning that flight.” The keyword is BEFORE. Aeronautical Decision Making CAN and for the most part DOES occur on the ground, BEFORE walking out to the airplane to depart and BEFORE assuming the responsibilities and pressures of commanding a flight.

    The sad fact is that this scenario has played itself out too many times in the past and will continue to do so in the future because the pilot community willfully chooses NOT to learn from the mistakes of others and our own past experiences. We had better take notice while we can because none of us will live long enough to make ALL of those mistakes ourselves.

    Any pilot so foolish as to ring a bell that cannot be unrung (as in running the SCUD) had better be prepared for the only practical escape maneuver available after that pilot gets swallowed up by the soup: CLIMB. Forget about attempting a 180. Any maneuvering at low altitude in the blind while in the throws of a wet-your-pants panic will usually result in Loss of Control. The likelihood of smacking into another airplane is minuscule compared to smacking into a rock. It may not be legal but it is certainly preferable to CFIT. It is far better to be alive and survive to answer for our poor ADM than it is to dictate our own epitaph.

    It was very gracious of you to go looking for this wayward pilot. It is also gratifying to know there are still people in this world with that sense of goodness in their hearts to do so. Nevertheless, I hope that MY sense of 91.103 compliance will be far more than minimally sufficient to protect ME from getting slightly killed and by extension, you as well in the aftermath of any careless, reckless and entirely preventable aeronautical decisions.

    Reply
    • Carlos
      Carlos says:

      Right on Bob. As a student pilot about to do his checkride I have learned valuable lessons from both the article and your response. Keep sharing and together we learn. Appreciated!

      Reply
  6. Mike Sheetz
    Mike Sheetz says:

    Thank you for sharing this! So much information provided both in the article and the comments to follow. I doubt if I will ever be called on to assist in a search SS the majority of my flights are behind me. I also am only a fair weather pilot with little need to get anywhere in a hurry and challenge the weather. Having said that, this story was tragic, and my condolences go out to the family if this pilot. To those that choose to respond to these event types I commend you for answering the call.

    Reply
  7. MICHAEL J PAYNE
    MICHAEL J PAYNE says:

    …will continue to do so in the future because the pilot community willfully chooses NOT to learn from the mistakes of others… Great Point Bob.

    One of my mentors, LTC Dick Sparks said if he was Kiing of Army Aviation for the day, he would pass a unrevoccable regulation that every pilot be required to read EVERY FlightFax ever written. FlightFax is the Army’s monthly safety newsletter, listing all current accidents. Mr. Sparks (He reverted to Warrant Officer) said that we stopped coming up with news to kill ourselves a long time ago. If you wanted to know about the next accident, just know what had happened in the past.

    My Son is getting his Stuck wing, excuse me, Fixed wing rating. Your comment reminded me to send him this link;

    https://safety.army.mil/ON-DUTY/Aviation/Flightfax

    The Army is open with sharing it’s dirty Aviation laundry. I hope some of you will take advantage of this as one more source of information on the path of becoming life long Safe Pilot.

    Flying is wonderful, but it’s more wonderful if all successful landing = takeoffs.

    Reply

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