1959 — Oct 30, Piedmont 349 pilot error crash, Bucks Elbow Mt., ~Charlottesville, VA– 26
— 26 Airdisaster.com. Accident Database. Accident Synopsis 10301959
— 26 CAB. AAR. Piedmont Air…Bucks Elbow Mt…Charlottesville, Virginia, Oct 30, 1959.
— 26 NFPA. “Large Loss of Life Fires of 1959.” Quarterly of the NFPA, V 53, July 1960, p. 28.
Narrative Information
Civil Aeronautics Board Synopsis: “About 2040, October 30, 1959, Piedmont Airlines Flight 349 crashed on Bucks Elbow Mountain located about 13 miles west of the Charlottesville-Albemarle County, Virginia, Airport. The crew of 3 and 23 of 24 passengers were killed; the sole survivor was seriously injured. The aircraft, a DC-3, N 55V, was demolished by impact.
“From the available evidence it is the determination of the Board that this accident occurred during an intended instrument approach. More specifically, it occurred during the inbound portion of the procedure turn which was being flown 6 to 11 miles west of the maneuvering area prescribed by the instrument approach procedure
“The Board concludes that the lateral error resulted from a navigational omission which took place when the pilot did not turn left about 20 degrees in conformity to V-140 airway at the Casanova omni range station. Consequently, when the pilot believed the flight was over the Rochelle intersection it was in fact 13 files northwest of tract position. As a result of this position, when the pilot turned left and flew the heading normally flown from Rochelle intersection, the path of the aircraft over the ground was displaced 8 to 11 miles west of the prescribed track. The Board further concludes that the error was undetected because tracking and other instrument approach requirements were not followed precisely.
“From information regarding the personal background of Captain Lavrinc and expert medical analysis of this information, it is the Board’s opinion that preoccupation resulting from mental stress may have been a contributing factor in the accident cause.
Investigation “Piedmont Airlines Flight 349 was a regularly scheduled flight between Washington, D. C., and Roanoke, Virginia, with intermediate stops at Charlottesville and Lynchburg, Virginia….The aircraft departed Washington at 1949…. When the flight did not land as anticipated a radio search was made, which proved futile.
“A ground search was begun as quickly as possible and supplemented by an air search the next day. Throughout that day both were seriously hampered by bad weather. On November 1, about 0800, the wreckage was sighted from a helicopter on the southern slope of Bucks Elbow Mountain, which is located about 13 miles west of the Charlottesville Airport. It was almost hidden by dense tree cover. Investigation at the scene showed the aircraft crashed where the upslope of the 3,100-foot mountain was nearly 30 degrees. It crashed against the rocky slope…at an elevation of approximately 2,600 feet…. The structural investigation determined that the landing gear was extended at impact and the flaps were fully retracted. Also, although the aircraft sustained great damage, it was reliably determined that there was no malfunction or failure of the aircraft prior to impact.
“…the sole survivor, stated that the flight seemed perfectly normal until the crash….
“The aircraft was heard by the series of witnesses between 2020-2045. The first of the series were located 8-10 miles northeast of the accident location. One of them, located on high terrain near Gibson Mountain, stated the aircraft passed over on a westerly heading and it was so low “it rattled the trees.”
Analysis and Conclusions “Examination of the wreckage of N 55 V revealed no evidence of malfunction or failure of the airframe or powerplants. There was no indication of an inflight fire, all major components of the aircraft were located in the immediate crash zone, and it was clearly evident that both engines and propellers were capable of no operation prior to impact. There was nothing found indicating that an emergency existed before the accident. These findings, reached by examination of the available physical evidence, were substantiated by the observations of Mr. Bradley….
“Based on the work performed and the evidence found, it is the opinion of the Board that this accident occurred for operational reasons. Consequently, the Board sought a determination in this area which would account for the flightpath of the aircraft being parallel to, but 8 to 11 miles west of, the proper track. It sought a situation which could develop easily and, because it is probable that Captain…was flying, one which escaped observation by Copilot Haley. It also sought a situation in which the precarious lateral error would not be readily detected as such by either pilot. Because of a number of unknown elements and the inherent intangibles of the operational situation, it is doubtful that any analysis can determine the sequence of events with complete definitiveness. Nevertheless, the Board believes it reached a determination which best satisfies the aforestated requisites and the known factors.
“To the Board there were numerous factors which were obviously inconsistent with Captain Lavrinc’s record. Some were. The apparent navigational omission, a nonadherence to precise tracking procedures, and a descent below the authorized procedure turn altitude. Others were The failure to note that the time for station passage was in excess of that commensurate with a close-in position, and that ADF indications were not compatible with the normal procedure turn presentation. Still others were a failure to request the latest Charlottesville weather when the communicator did not furnish it, and not using the altimeter setting given in response to the inrange report. The Board believes these factors were not only inconsistent with Captain Lavrinc’s reputation as an exacting pilot but were indicative of a serious departure from the high standard and quality of performance expected during an instrument operation. Because of these factors a comprehensive investigation was made into the personal background of Captain Lavrinc. This was done to search for reasons which could seriously impair his normal piloting ability. During this work reasons were found which could result in his preoccupation.
“Captain Lavrinc had, for several years been under severe emotional strain. The Board considers that disclosure of detailed information relating thereto would adversely affect the interests of certain persons and is not required in the interest of the public. A resume of the Board’s significant findings and certain recommendations, however, are in the public interest and are set forth below.
“Captain Lavrinc received psychotherapy in 1953-1954; he obtained further psychiatric counseling in 1957; intensive psychotherapy was resumed in May 1959, which he underwent several times a week thereafter; his last appointment was the night before the accident. This latter treatment involved the services of two psychiatrists. In the course of this treatment the first psychiatrist prescribed certain psychotropic drugs. After trials on Compazine, Prozine, Sparine, and Thorazine, Prozine was prescribed in August 1959 in a dosage of three or four times daily and was reissued on September 18, 1959. This prescription specified an amount which, if taken as directed, would have been sufficient to last until two days before the accident….
“The Board has evaluated the background and history of Captain Lavrinc, including data set forth above. In addition, it submitted all the available information covering Captain Lavrinc to particularly qualified medical experts for evaluation as to its significance with respect to this accident. The consensus is that Captain Lavrinc was so heavily burdened with mental and emotional problems that he should have been relieved of the strain of flight duty while undergoing treatment for his condition. This condition was such that preoccupation with his problems could well have lowered his standard of performance during instrument flight. Furthermore, with respect to this accident the consensus is that the emotional and mental problems were of far greater importance in causing the preoccupation than…the use of psychotropic medication.
“The Board believes that the facts disclosed by this investigation demonstrate the adverse effects of serious emotional and mental stress on airman proficiency and performance. It further believes that the early recognition and correction of such conditions which might tend to impair an airman’s proficiency and performance would be beneficial to flight safety. Accordingly, the Board recommends that the Federal Aviation Agency, appropriate segments of the aviation industry, and the medical profession initiate exploratory studies in this field.
“The Board also considers that the investigation of this accident demonstrates the need for reexamination of the use of drugs which may affect the faculties of a flight crew member in any manner contrary to safety….
“The basic question which the Board believes must be resolved, therefore, is how does the use of these drugs relate to the safety of flight. For example, within the framework of the present Civil Air Regulation covering the use of drugs, should these drugs be classified as “ . . . drug which affects his (crew member) faculties in any manner contrary to safety . . .” The Board is of the opinion that the answer to the question is a qualified “yes.” In great part this decision is reached from review of military research into the relationship of drugs to the flying profession. The basic conclusion derived from this research can be stated quite simply: If a flight crew member’s personal situation demands tranquilizers he should be removed from flying status while on the drugs.
“The Board determines that the probable cause of this accident was a navigational omission which resulted in a lateral course error that was not detected and corrected through precision instrument flying procedures. A contributing factor to the accident may have been preoccupation of the captain resulting from mental stress.” (Civil Aeronautics Board. AAR. Piedmont Air…Bucks Elbow Mt…Charlottesville, Virginia, Oct 30, 1959.)
Sources
AirDisaster.Com. Accident Database. Accident Synopsis 10301959. Accessed at: http://www.airdisaster.com/cgi-bin/view_details.cgi?date=10301959®=N55V&airline=Piedmont+Airlines
Civil Aeronautics Board. Aircraft Accident Report. Piedmont Airlines, Douglas DC-3, 55V, on Bucks Elbow Mountain, Near Charlottesville, Virginia, October 30, 1959. Washington, DC: CAB (File No. 1-0065), April 24, 1961, 15 pp. Accessed at: http://dotlibrary1.specialcollection.net/scripts/ws.dll?file&fn=8&name=*P%3A%5CDOT%5Cairplane%20accidents%5Cwebsearch%5C103059.pdf
National Fire Protection Association. “Large Loss of Life Fires of 1959.” Quarterly of the National Fire Protection Association, Vol. 53, July 1960, pp. 7-38.