Catalina Night Departure: NTSB Preliminary Report Released
On the 8th of October 2024, a Beechcraft Baron crashed shortly after taking off from Catalina Airport at night, killing all five occupants. I wrote about it on the 18th: Night Flight from Catalina: Beechcraft Baron Incident but here’s a quick recap.
Earlier that day, three people from a Santa Monica flight school had flown to the island on an instructional flight, but then were unable to depart again due to a mechanical issue with the aircraft. A retired flight instructor arranged to fly his Beechcraft Baron to Catalina with permission to land after the airport closed, with the agreement that they would leave before sunset. Catalina Island does not have night operations and the table-top runway is unlit. For reasons unknown, they remained on the island for another two hours, departing well after dark at 20:00. The Baron crashed shortly after takeoff from runway 22, descending rapidly from just 75 feet above ground level. The wreckage was found about a mile west of the airport after an SOS notification from a passenger’s mobile phone alerted authorities.
On Wednesday, the NTSB released their preliminary report which sheds more light on what happened that day.
Starting with earlier that day: a flight instructor and two student pilots were stranded at the airport after their rental aircraft had suffered a magneto malfunction during the pre-flight checks. They contacted the flight school, who told them that another aircraft would fly to Catalina Island to take them back to Santa Monica. It is a 30 minute flight from Santa Monica to Catalina Airport.
The rescue flight wasn’t operated by the flight school — the NTSB specifies that the Baron belonged to “an acquaintance of the owner of the flight school.”
Catalina Airport is a table-top runway at 1,601 feet above mean sea level. The concrete runway has steep drop offs on either side. It does not have lighting and night operations are not permitted.
As we know, that was the Beechcraft Baron owned by the retired flight instructor at Santa Monica. However, the early reports, including mine, conflated the names, obscuring the fact that both the Baron’s owner (Ali Safai) and the owner of the flight school (Haris Ali) were on the flight.
They could not get there before the airport closed at 17:00. The airport manager agreed that the second aircraft could come to Catalina and land after closing but told them that they had to depart before sundown at 18:31. The Baron landed at 18:20 with two pilots on board.
Here’s where we start to learn more about what happened.
The rescue flight had just ten minutes to pick up the three stranded pilots and depart Catalina. They shut down the engines and quickly loaded their passengers. However, in what must have been a dismaying moment, when they went to restart the engines, the right engine would not start.
The Beech Baron has one 24 volt battery which offers power to both engines (each engine has a 50 amp alternator). For reasons unknown, the battery did not have enough power to restart the right engine. Everyone piled out of the aircraft. The pilot and owner of the aircraft had a battery charger on board and connected it using an extension cord.
Clearly, there was no way the battery would be charged before sunset. The airport manager was still on site and told them that he would not approve them departing after sunset.
The pilot and owner of the Baron responded that he had to go and made it clear that they would depart anyway once the battery was charged. The airport manager couldn’t stop them from leaving. He made it clear that the departure was unapproved and at the pilot’s own risk. Then, no doubt exasperated and annoyed, he went home.
The situation is complicated by the lack of infrastructure. There are no hotels near the airport. Catalina Taxi & Tours are available for ferry arrivals and departures but any transportation outside of the City of Avalon must have a reservation in advance. It may not have been possible to get any accommodation, leaving them to it at the airport until morning.
Nevertheless, a group of five pilots all appeared to accept flying into the night as a reasonable option. At around 8pm, an hour and a half after sunset, the airport manager heard the sound of an aircraft departing.
This is confirmed by the airport security camera which recorded the Baron coming into view on runway 22 at 20:04. On the video, it is clear that it is dark night conditions during the aircraft’s take-off roll.
The ADS-B data showed that they may have become airborne about halfway down the runway and maintained a low altitude as they continued, but it’s not possible to tell on the video.
As the aircraft passed the departure end of the runway, it descended out of view of the camera. ADS-B data shows a slight descent after take off and a right turn. The data ended at 0.6 miles (965 metres) west of the end of the runway.
The Baron struck the east face of a ridgeline. I’m going to quote the report here because I can’t quite see how the numbers add up (bolding mine).
The ADS-B data showed the airplane continued a slight descent after takeoff followed by a right turn until the data ended about 0.6 miles west of the departure end of runway 22. The airplane impacted the east face of a ridgeline about 0.7 miles west of the last recorded ADS-B target and about .96 miles west-southwest of the departure end of runway 22.
At any rate, they crashed into ridge at 1,230 feet above mean sea level. The ground scars and wreckage shows that they were travelling at a heading of 280° with wings level and the landing gear extended. Then the aircraft slid about 450 feet west, coming to rest in a ravine.
The airport manager said that the sky was clear and there was a slight breeze from the north-northwest. But when he looked out over the departure end of the runway an hour after the crash, he saw cloud tops about 200 feet below.
The wreckage of the aircraft was below the cloud tops.
The preliminary report paints a stark picture of cascading decisions. We start with a simple mechanical issue with a rented aircraft. A second aircraft comes to the rescue with only a ten-minute window in which to pick up the stranded pilots.
A weak battery after the short flight leads to an unavoidable delay and the sun set while the battery was still charging. We don’t know what the conversation was as they watched the sky darken but by the time they boarded the aircraft again, it was completely dark. This might be an example of the Abilene paradox, where a group makes a collective decision that no individual member truly supports. Somehow, at a table-top runway with no lights, the group decided to ignore the airport manager’s warnings and depart at night, towards the sea, with no lights on the horizon. They were likely unaware of the cloud layer below, obscuring even the lights of the cargo ships.
The owner of the flight school, a former flight school owner and Baron pilot and an active instructor accepted the risk of a night departure from a closed airport. I cannot imagine that the two students would have argued. They departed from the airport elevation of 1,601 feet, climbing 50-75 feet above the runway before descending and striking the ridge lurking in the cloud at 1,230 feet. The wings were level and the landing gear was down, suggesting that no one on board had realized they were descending.
Every flight requires a continuous series of risk assessments. That night on Catalina, each decision point pushed the threshold of acceptable risk a little further, until there was no margin left for error.
For those confused by the map scale and wondering if they could walk to a hotel, those are located about 10 miles away in either direction, according to Google Maps.
Still, is it that difficult for the airport to have at least a small lounge area with some fold-out cots for emergency situations like this? I guess they might have, but the “pilot and owner of the Baron responded that he had to go” makes it non-relevant.
As my USAF friends would say “the first indication of approaching terrain was when the pilot’s face hit the rock”
I would have thought with one engine running, its alternator would have enabled the battery to start the second engine? Both engines were warm too so I would have thought restarting would not be an issue. Whatever the reason, lives were unnecessarily lost.
Chris
Is there cross-wiring on this model of Baron to support using the alternator from one engine to start the other engine? It seems like a sensible design, but if so I’d have thought they’d save the weight of a second battery.
Gene’s comments make sense, but the relevant comment is indeed “that he had to go.”. A typical example of “get-home-itis”. Which has killed many a pilot.
Chris makes total sense: Why could the second engine not have started once one engine, running, delivered the necessary power?
I have started the Cessna 310 using cross-over power.
Not very often, but in my case it worked. Maybe the alternator on the already running engine was giving priority to charging the battery?
And maybe the battery itself was in such a poor condition that it sucked up all the available excess power?
I am not familiar with the Baron.
I have flown it only a few times, as safety pilot. It did not have dual controls, When the PIC handed me the controls, there was a throw-over system. The column was mounted centrally, the controls could be moved over rom left to right.
But more to the point: Two instructors. Presumably both very familiar with the Baron; one was even the owner.
Were they instrument rated.?
I have read quite a few accident reports where the pilot apparently DID have an IF rating, but otherwise seemed to be unable to fly on basic instruments. Heavily dependent on the autopilot and the GPS and related gizmos. This seems to be the case especially in General Aviation in the USA. Inevitably, if either the Garmin or the autopilot fails, the pilot is unable to maintain heading, airspeed, altitude, attitude, terrain awareness and in general his or her spatial awareness deteriorates to the point of a crash. A very well known example is the crash of JFK junior. His aircraft probably was in fine fettle, but he was not very experienced, had just recovered from a leg injury and had little recent flying done. He completely lost spatial awareness. Vertigo can manifest very quickly.
In previous comments I have confessed that I have done – and got away with – very stupid things as a pilot. And I hope that whoever reads this will realise that in some cases I have been very lucky. Don’t try my errors, it does not always end well!
But this Beech Baron crash seems to have been totally avoidable.
I have not pulled a stunt like this, but suppose that hypothetically I did,
I would
– discuss the departure and the expected sequence with the other pilot.
In other words: do a pre-departure crew briefing,
– assign duties to this pilot, e.g. call-outs, operating gear, engine power (climb power setting) etc,
– brief him on the weather conditions: pitch dark, cloud cover not known, OAT, wind speed and direction not available.
– check, not assume, that the aircraft, with both engines running, is now in good condition, with the alternators providing the juice to supply all instruments and nav. equipment with power.
In other words: do a thorough pre-departure check.
This would incur two violations already:
1. the unauthorised night time departure,
2. a departure during night / IMC conditions requires a healthy battery. If for some reason all electrical power is lost, the battery is supposed to provide enough emergency power for (standby) instruments for at least half an hour.
But assume that all functioned as it should.
Were these pilots really unable to fly on basic instruments?
The gear was still down. Why?
To continue, if I were to take off under those conditions I would
– make sure before take-off that my instruments and nav aids were properly working and that the artificial horizon, or whatever attitude indicator was fitted, was properly lined up and stable.
– make sure that I would have the QNH set or, if not available, set the altimeter to “zero”: the QFE.
Of course, even if not given (the airport was closed), it is quite possible to set the altimeter to the elevation = QNH.
-I would make certain that my heading was set properly and double-check the runway heading with my compasses.
-I would make sure that my landing lights were working and illuminating a sufficient portion of the runway so that I would not roll off the edge.
– I would keep my eyes outside and brief the other (experienced !) pilot to call out the speeds.
– since I (hypothetically) know the Baron very well, I would raise the nose at the appropriate speed to an angle that would be commensurate with an initial climb. and, once airborne, would keep a gentle climb to a safe attitude using the instruments as my main, even only reference.
– I would raise the undercarriage, or ask the other pilot to do that immediately as soon as a positive climb rate would be established.
Which action should have been briefed by the PF..
– When safely established in a climb, with proper speed and angle of climb (angle of attack), I would ask to set climb power.
All this solely on instruments.
Which should have been well within the ability of two highly experienced pilots.
– I would engage the autopilot once established in a safe climb, to a proper cruise altitude.
– I would continue the climb until I could safely level off and ask the PNF to contact flight advisory services.
This is all a lot of “What action would I have expected from the pilots once they had made the fateful decision to depart.
To experienced pilots, flight instructors even, all this should have been “second nature”.
I spelled out what I hope that I would have done if I had been in a similar situation, and decided to flaunt the rules.
And believe me, even though they had made that decision, they could (and should) have made it.
Great writeup Rudy, thank you.
Rudy — I don’t know which cases you’re thinking of, but John-John definitely did not have an IF rating; see https://en.wikipedia.org/wiki/1999_Martha%27s_Vineyard_plane_crash. He did have enough hours to test for an IF rating if he’d taken the instruction and done the classwork, but it’s not clear he was inclined to take the time (40 hours of instruction when I got mine — don’t know what it is now).
The procedures you describe would have been a good lesson for the student pilots in how to handle an undesirable situation; I doubt any investigation will tell us why they weren’t followed.
Chip,
You are right: I had not mentioned that JFK jr. was not instrument rated and had far too little experience to embark on his ill-fated flight.
Officially he was flying VFR at night.
And I emphasise again that I want to discourage other pilots to try the stunts that I pulled in my career.
I did gain a lot of experience, yes, but at great risk.
In a way, I was a bit like the lottery winner whose numbers all come up. Only, in my case fortunately they did not. Somehow, the holes in the proverbial “Swiss cheese” never aligned.
Maybe I will write a series of stories about the stupid things I got away with; they may fill a book. Maybe I will call it: “Playing Russian Roulette with an airplane”. Or “the toddler who finds a loaded gun in daddy’s drawer, aims at daddy, fires and misses”.
But returning to the article: I was more thinking of these two supposedly very experienced instructors and what they could have done to avoid killing themselves and their students.
Which, of course, would and should have been: accept the inevitable and do not take-off in the first place.
If they had asked the airport manager before he closed down where they could have stayed overnight, he might have been able to suggest something. Even a hay barn. I know of a pilot who slept under the wing of his airplane.
They were in a situation where tunnel vision set in. My own confessions are actually intended to warn all pilots of the dangers of getting too anxious to complete the journey, no matter what. And consequently getting themselves in a death trap of their own making.
What irks me in this saga is what example these two people set. They were supposed to guide their students on the path to become professional (airline) pilots. How they failed to make use of all that they had at their disposal to avoid the accident, once they decided to take off. Even if they had managed to depart successfully, they set a poor example by breaking the rules.
They failed miserably and their poor decision making ended in disaster.
The procedures that I describe are NOT intended to “be a lesson for the student pilots in how to handle an undesirable situation”. Experienced instructors don’t show their students how to break the rules, even if they were getting away with it.
I am only describing in fine detail what in my considered opinion (former captain, over 22000 hours) should have resulted in a successful take-off. A take-off which they should not have attempted in the first place.
In my career, I was Cat 2 qualified and have on many occasions departed in night time conditions and in dense fog. But we did complete pre-departure checks and crew briefings. Which included counting the runway lights, was it a cat 1 or cat 2 runway, getting the official RVR from ATC, etc. But once rotating, especially at night, in fog, all that became irrelevant. Attitude, speed, configuration, rate of climb, heading. All essential information ONLY from the instruments. Looking outside would have led to a crash, for sure.
And we landed, of course,. But here we are discussion a take-off.
To recap: When taking off at night, from a dark runway, no lights, no outside visual references, the take off takes place into a dark hole. Outside visuals become the enemy. Spatial disorientation will follow as night follows day, inevitably no matter the experience level.
Pilots of their experience level should have been aware that trying to orientate themselves by looking outside would be an inevitable one-way ticket to Heaven, on new gossamer wings.
It seems unlikely that they had completed a crew briefing or set out a distribution of tasks: PF / PNF (mind that if the Baron was equipped with the “throw-over” controls, the other pilot had no way of quickly taking over control in the event of the PF getting vertigo. Not enough height, no time. And apparently not or insufficiently relying on their instruments,
Of course, my contribution is based on my own experience and observations and therefore at least partly inaccurate.
But on the other hand, I cannot shake off the feeling that these two pilots in their haste forgot to have even a basic plan of action and paid the price with their, and their students’ lives.
Well said! Also, you definitely should write a book. Most people will remember an exciting human story more readily than a dry theoretical discussion of why you should not do X, Y or Z. A pilot who is about to do something dangerous may have completely forgotten any classroom lessons about why you shouldn’t do that thing, but might suddenly think “wait, one of Rudy’s stories starts just like this”.
“The procedures that I describe are NOT intended to be a lesson for the student pilots …
my contribution is based on my own experience and observations and therefore at least partly inaccurate.”
Agreed; party inaccurate.
Absent general aviation flight experience in the States, above contribution includes irrelevance for BE95 departure from KAVX.
…. abv “experience and observations” appear appropriate for transport category aircraft, departing an island airport nighttime, perhaps in the UK (little of which has ‘procedural’ relevance to … a Baron departing Catalina, under CFR 14, Part 91).
RIP; tragic loss for family and friends.
Classroom lessons?? These two pilots were instructors. They would have given the classroom lessons.
The report makes no mention of a CVR or FDR, which would be unlikely to be installed on this type of aircraft anyway. So that’s probably all the light we’re going to get on this incident, unless the NTSB ferret out some mechanical or electrical failure from the wreckage.
I think a problem might have been that the Baron owner and presumable pilot, as a retired instructor, might not exactly have been current on his instrument rating, but might have felt unable to admit it, and the others would’ve felt it impolite to ask.
Mendel,
At this point we are all guessing. All my comments were based on my own experience, on comparable aircraft: Aircraft with two piston engines.. Mainly the Cessna 310, but also Cessna 340 (essentially a pressurised C310), Piper Aztec, and Partenavia P68 Victor.
Age? Very subjective. Don’t paint yourself in the ageist corner. I had to stop flying because after age 65 my ATPL reverted to PPL status. In Europe we don’t keep the licence and ratings like the FAA does. In the USA the licence is essentially for life. But the only rating that I had in my last JAA licence was the Cessna 500 series. I was not even qualified on single engine aircraft any more. And I had no stomach for doing the exams all over again.
Eventually I became a tourist guide in Ireland and I passed my driving test on coaches. At age 72! In the meantime I became a student of history and got my master’s degree at age 79.The last time I drove a 55 passenger bus (a Scania i6) was after my 80th birthday. Then I had a “heart issue” and the doctor advised me to stop driving large vehicles.
So Mendel, I refuse to accept that the instructor was not capable any more, just because he had reached retirement age.
Procedures, especially those that can be reviewed and briefed before departure, should be second nature to these two ….. (deleted).
I was not there, of course, so my comments must be considered subjective and qualified as such: But in my considered opinion, there was an appalling lack of professionalism from these two EXPERIENCED PILOTS.
And that is something that I find very upsetting.
Doing stunts, showing off,(yes I have confessed), and taking off from a closed runway in pitch dark are never OK.
To do this as an instructor, whose example may determine the entire career of his / her students, is unforgiveable. Worse, in this case their career, and lives, were over.