HISTORY OF FLIGHT Use your browsers 'back' function to return to synopsisReturn to Query Page
On November 14, 2009, about 1050 eastern standard time, a Piper PA-28R-200, N4499T, was substantially damaged when it impacted terrain about 10 minutes after takeoff from Woodbine Airport (OBI), Woodbine, New Jersey. The certificated, non-instrument-rated private pilot/owner, and the passenger were fatally injured. The personal flight was operated under the provisions of 14 Code of Federal Regulations Part 91. Instrument meteorological conditions (IMC) prevailed, and no flight plan was filed for the flight to Monroe County Airport (BMG), Bloomington, Indiana.
According to several witnesses, the pilot originally planned to depart for BMG on Thursday, November 12, but weather conditions caused him to delay his departure. The following day, he came to the airport, and again due to inclement weather, the pilot decided not to depart for BMG. While at the airport, the pilot requested assistance from the airport manager, who also had conducted the pilot's most recent flight review, in using an Internet-based flight planning tool. Later that day, the pilot met a flying companion in a local restaurant; the two spoke of the pilot's planned flight, and how the existing weather conditions had again delayed the flight. During that conversation, the companion cautioned the pilot "not to take any chances," and to wait for the weather to improve.
On the morning of the accident, IMC prevailed, but the forecast called for conditions to improve as the day progressed. The recorded weather conditions at OBI reported an overcast ceiling at 300 feet above ground level (agl) for the period from 1000 to 1200; that ceiling was below the minimum values for the published instrument approach procedures into OBI. Several other pilots, including some who were instrument-rated, were either in the airport office, or elsewhere on the airport, waiting for conditions to improve so that they could fly. About 1015, those witnesses observed the pilot and the passenger at the fuel dock, fueling the airplane. The witnesses universally reported that a solid overcast ceiling was present at approximately 200 to 300 feet agl, that "there were no holes" in the ceiling, and that "there was no sun" shining anywhere that they could see. All witnesses who observed the pilot fueling the airplane stated that they "assumed," due to the low ceiling, that the pilot would return his airplane to the hangar after fueling was completed. The OBI fueling records indicated that the pilot completed the purchase of 20.7 gallons of fuel at 1030. Shortly thereafter, several witnesses saw and/or heard the airplane operating on the ground near the threshold of runway 31.
About 1040, the pilot utilized the Unicom frequency to broadcast his intention to depart, and he began his takeoff roll on runway 31. Several persons, some of whom knew the pilot, and who also knew that he was not instrument-rated, watched the airplane take off, and climb into the overcast. One witness stated that the airplane entered the overcast "between the end of the runway and the railroad tracks," which crossed the extended runway centerline approximately 1/3 mile beyond the runway end. Three witnesses in a maintenance hangar at OBI had access to a radio that could receive aviation frequencies, and after the airplane took off, they changed the frequency on the radio to 124.6 megahertz (MHz), which was the frequency for Atlantic City approach control. They heard the pilot request traffic "advisories," and although they could not hear the controller, understood that the controller had assigned the airplane a discrete transponder code.
Witnesses on and near the airport reported that they heard, and occasionally saw, for a period of between 5 and 10 minutes, an airplane flying in their vicinity. All witnesses reported that the sound varied in a way that gave them the impression that the airplane was continuously changing speed and direction, as if it was climbing, descending and circling. One witness, who was in his backyard with his daughter, stated that he was familiar with how airplanes typically sounded, but "this one was different." The continued variation in sound gave him the impression that the airplane was performing aerobatics, and he questioned the pilot's judgment for performing aerobatics in the clouds. He then saw the airplane fly over his neighbor's house. He said that he "never saw a plane that low before," and he sent his daughter inside for her safety. Another witness at the airport saw the airplane emerge from the overcast, headed away from him to the west, and disappear below the treeline. He then saw the airplane re-emerge, and climb back up into the overcast. All witnesses reported that their sightings of the airplane were very brief, each lasting only a few seconds.
Another witness and his wife were sitting in their kitchen, and heard the airplane apparently circling. They then heard a "bang" or a "clunk," which was followed by a "hard thud." Another witness heard the airplane strike tree branches. Most witnesses only reported a single sound of impact, which some described as a "thump." Two residents, who lived in separate homes approximately 1/2 mile from the accident site, ran into the woods behind their homes in search of the airplane. They located the main wreckage, checked the airplane occupants for vital signs, found none, and notified authorities via a mobile telephone. According to the New Jersey State Police, the first 911 call was placed at 1059.
Federal Aviation Administration (FAA) records indicated that the pilot held a private pilot certificate, with an airplane single engine land rating, that was obtained in 2004. His most recent FAA third-class medical certificate was issued in September 2007, and was valid through September 2009. On that application he reported 300 total hours of flight experience. Examination of the pilot's personal flight time log indicated that as of the date of the accident, he had approximately 395 total hours of flight experience, including 308 hours in the accident airplane. His most recent flight review was completed in December 2008.
According to FAA and Piper Aircraft documentation, the airplane was a four-place, low-wing monoplane of all-metal construction, with retractable, tricycle-style landing gear. The design utilized an all-moving tailplane known as a stabilator. Each wing was equipped with an integral "wet wing" fuel tank that had a usable fuel capacity of 24 gallons. The three-bladed constant-speed propeller was driven by a Lycoming IO-360 series piston engine.
The airplane was manufactured in 1972, and was registered to the pilot in 2005. A review of maintenance records indicated that the most recent annual inspection was completed on September 12, 2009, and at that time, the airplane had accumulated a total time in service of 2,378 hours. The engine had the same amount of time in service, and at the time the inspection was completed, it had accumulated 887 hours since its most recent major overhaul. The propeller had accumulated a total time in service of 335 hours at the time of the annual inspection.
The airplane maintenance records indicated that Piper Service Bulletin (SB) "1181" was complied with in 2006. Review of Piper Service Letter (SL) and SB information revealed that no such SL or SB was applicable to the accident airplane model. Piper SB 1161, issued in March 2006, did apply to the airplane. That SB specified inspection of a wing rib located at wing span station 49.25 for cracking, with 100-hour visual, and 500-hour dye penetrant repetitive inspection intervals. That SB was considered mandatory by Piper, but there was no corresponding FAA Airworthiness Directive (AD). The 2006 maintenance records entry stated "no cracks found." No subsequent maintenance entries that referenced either SB 1161 or SB "1181" were located.
A review of maintenance records indicated that the vacuum pump and the artificial horizon in the airplane at the time of the accident had been installed in the airplane since at least 2006. An FAA inspector's review of the maintenance records indicated that there was "no evidence that a current inspection of the Altimeter and Transponder was accomplished" in accordance with applicable regulations.
The OBI recorded weather observations at 5 minute intervals during the period from 1000 to 1200 reported an overcast ceiling at 300 feet agl. During that same period, the reported visibility ranged from 1 3/4 miles to 3 miles, and the temperature and dew point remained constant at 14 degrees C, with the exception of the first two dew point readings of 13 degrees C. Examination of other weather data indicated that the region was blanketed by a layer of stratus clouds that was approximately 3,000 feet thick, and pilot reports (PIREPs) corroborated those observations.
Review of the FAA Atlantic City air traffic control (ATC) audio and radar tracking data indicated that the pilot first contacted Atlantic City approach about 1046. At that point the airplane had just taken off from OBI, was turning to the west, and was broadcasting the visual flight rules (VFR) code of 1200 on its transponder. The controller acknowledged the radio call, and the pilot then stated "nine nine tango is departing OBI. Destination is bravo gulf bravo mike gulf Indiana Bloomington. Request advisories inflight please." The controller assigned a discrete transponder code to the flight, and the pilot acknowledged. About 1 minute later, the controller broadcast "Cherokee nine nine tango you're radar contact a mile west of the Woodbine airport. Atlantic City altimeter is 29.95, maintain VFR at all times, proceed on course," and the pilot responded with only "nine tango." About 1053, the controller queried the pilot "how do you read?" and then stated "radar contact lost." The controller repeated those calls about 20 seconds later. Finally, about 1056, the controller asked the pilot of another aircraft to try to contact the flight; that pilot made two radio calls but did not elicit a response from the pilot of N4499T. No other radio transmissions from the airplane were recorded.
The departure airport (OBI) was a non-towered airport equipped with two runways. Runway 1/19 was 3,304 feet long, runway 13/31 was 3,073 feet long, and the two runways intersected near the approach ends of 13 and 19.
A fuel sample was obtained from the OBI pump where the pre-accident refueling of the airplane was accomplished. The sample was free of contaminants.
WRECKAGE AND IMPACT INFORMATION
The accident site and wreckage were examined in detail beginning the day after the accident. The wreckage consisted of two basic groups of debris; left wing and left stabilator fragments in a loose cluster, and the remainder of the airplane at the main wreckage site. The overall debris field was oriented on a magnetic heading of about 015 degrees, and measured about 1260 feet in length. The left wingtip was the first item in the debris field. The outboard 7-foot section (approximate parting stations WS100 at leading edge, WS130 at trailing edge) of the left wing was next; it was located about 160 feet beyond the wingtip. The outboard 3-foot segment of the left stabilator was located about 400 feet beyond the left wingtip, and was the last item in that grouping, which also included portions of the left aileron. The main wreckage was situated about 3,500 feet southwest of the OBI runway 1 threshold.
The outboard wing section skin and spar damage was consistent with deflection of the wing in the positive (with respect to the airplane axis system) direction, and the aileron displayed similar deformation. No corrosion, fretting, or other indications of pre-separation or pre-impact failure were observed on the spar cap or web fracture surfaces of the wing or aileron. The only crush or impact damage to the wing section was near the wingtip, primarily in a spanwise direction from outboard to inboard. The damage to the left outboard stabilator was consistent with deflection in the positive direction.
The main wreckage was tightly contained, and consisted of the entire airplane, with the exception of the outboard portions of the left wing and left stabilator. The ground impact point was demarcated by a 2-foot-deep crater with an east-west dimension of approximately 10 feet, and a north-south dimension of 5 feet. Most of the main wreckage was adjacent to the northern and eastern boundaries of the crater. Most structural components exhibited significant disruption and deformation. The upper-aft fuselage and tailcone/empennage was separated from the rest of the airplane. The lower fuselage and cockpit area were found inverted. The aft seats had been removed prior to the flight, and were subsequently found in the pilot's hangar.
Most of the cockpit instruments were damaged and unreadable. The tachometer registered a time of 2,387.15 hours. The artificial horizon and the directional gyro were removed and retained for further examination. The frequencies set into the top-most navigation/communication radio could not be determined. The communication radio below that radio was set to 122.00 MHz. The autopilot mode selector was set to "HDG," but the operational status of the unit could not be determined. The engine controls were all found in their full forward positions. The flap handle was impact damaged and displaced upward, and the pre-impact flap position could not be determined. The remainder of the switch and control positions were deemed to be unreliable. The landing gear was found in the retracted position. Both wing fuel tanks were highly fragmented, and were devoid of fuel.
The entire right wing was located with the main wreckage, and exhibited extensive crush and deformation damage. The outboard section of the right wing was fracture-separated outboard of the main landing gear. The forward and aft wing-to-fuselage attach points were fractured. The aileron and flap remained attached to the right wing. The aileron balance weight was separated from the aileron, but was found adjacent to the wing. The inboard section of the left wing, including the left flap, was also located with the main wreckage, and exhibited extensive crush and deformation damage. No corrosion, fretting or other indications of pre-impact failure were observed on the spar cap or web fracture surfaces of the inboard section of the left wing.
The main portion of the empennage, including the vertical stabilizer and rudder, was entangled with the left inboard wing section. The center section of the stabilator remained attached at both hinge points. The balance tube remained attached to the stabilator, but was displaced aft of its design location. The right outboard end of the stabilator was separated and found adjacent to the rest of the empennage. All four stabilator stop bolts were undamaged and secure, with head heights of approximately 3/8 inch above their mounting pad surface. All rudder hinges remained securely attached and undamaged. Both rudder stop bolts were undamaged and secure, with head heights of approximately 3/8 inch above the hinge plate.
All aerodynamic control surfaces were found at the accident site, and control continuity from the cockpit controls to the aerodynamic surfaces was confirmed. The stabilator pitch trim drum showed 16 threads of extension, which was consistent with a full airplane nose up setting, and a tab deflection of 12 degrees tab down. According to a representative of the airplane manufacturer, the as-found position "may not reflect the actual trim setting prior to impact."
The engine remained partially attached to the engine mount and firewall. The lower engine case was cracked. The intake and exhaust tubes were partially crushed and bent. The muffler, one magneto and some other components were separated from the engine. The internal surfaces of the muffler and other exhaust tubing were light gray/white, which was consistent with normal operation. The fuel distribution block and the engine-driven fuel pump contained fuel that appeared uncontaminated. The vacuum pump was removed and retained for further examination. Visual examination of the engine did not reveal indications of any pre-impact failures that would have precluded normal operation.
All three propeller blades remained attached to the hub, which remained attached to the engine. One blade was straight, and the other two were twisted and bent aft nearly 90 degrees. All blades displayed some chordwise scratching. A 5-inch diameter tree was cut through at an angle of about 60 degrees to the tree axis; the cut was 143 inches above the ground, and 134 inches from the center of the ground impact crater.
The vacuum pump and artificial horizon were examined for indications of functionality and damage. The vacuum pump was essentially undamaged, but no dataplate or manufacturer's identification markings were observed. An aftermarket dataplate affixed to the pump indicated that the pump was "overhauled" by Warrior Enterprises in Mesa, Arizona. There was no date on the tag, but it identified the part number as 211CC, and a serial number of 07201.The pump cover was removed and the internal components were examined. All the rotor blades were present, undamaged, and free to move/slide in the rotor per the design. There was no abnormal scoring on internal chamber wall or blade edges, and when the rotor was manually rotated, normal resistance was felt, and all blades moved in and out of their respective slots in the rotor per design.
The artificial horizon was damaged by impact forces; the case was absent. The presentation plates and gimbal assemblies remained attached to the instrument. The rotor housing showed no external damage, but the bearings and pivots were damaged. The rotor housing was removed from the yoke and opened to extract the rotor. The rotor was free to rotate in the housing, and no scoring or other internal damage was detected.
MEDICAL AND PATHOLOGICAL INFORMATION
The New Jersey Office of the State Medical Examiner autopsy report indicated that the pilot's cause of death was "multiple blunt trauma." With the exception of "mild steatosis" of the liver, the autopsy did not report any pre-accident abnormalities. The FAA Civil Aeromedical Institute conducted forensic toxicology examinations on specimens from the pilot, and reported that no carbon monoxide, cyanide, ethanol, or any screened drugs were detected.
Airplane Weight and Balance
The contents of the airplane, and their estimated weights, were documented. Those results (153 pounds) were used in combination with the known pilot and passenger weights (320 pounds), estimated fuel load (288 pounds), the removed rear seats (minus 27 pounds), and nominal airplane empty weight data to calculate a gross weight and center of gravity (CG) for the departure. The calculated gross weight of the airplane was 2,326 pounds, and the calculated CG was 87.53 inches aft of the datum. Those values were below the maximum certificated takeoff weight (2,650 pounds), and within the allowable CG range (82.5 to 93.0 inches) for that weight.
Weather History and Pilot's Flight Planning
According to Lockheed Martin (LM), the pilot contacted Lansing FAA Contract Facility / Automated Flight Service Station on November 13 (the night before the accident flight), and obtained an abbreviated weather briefing. The pilot told the briefer that he was planning a VFR flight to Bloomington Indiana, with a departure time of 0900 on November 14. The briefer responded that the pilot could expect "a lot of clouds associated with the low pressure system," and "generally IFR conditions throughout the entire morning," with rain showers and ceilings of 700 to 800 feet from New Jersey, through Virginia and into the eastern edge of West Virginia. Progressing west from there, the ceilings were forecast to increase in height, with good VFR conditions predicted near the West Virginia-Ohio border. The pilot asked the briefer to repeat the specifics of the improved conditions, and then asked when the forecast would next be updated. The briefer told him that the forecast would be updated the following day at 0100 and again at 0700, and the pilot told the briefer that he would call again in the morning.
LM personnel checked with the Direct Access User Terminals (DUATS) vendors, and the vendors' records indicated that no services were provided to the pilot, but that the pilot attempted to utilize the system four times on November 13, and once (at 0752) on the morning of the accident.
A damaged, printed copy of a "CSC DUATS on the Web" flight planning sheet from OBI to BMG was found in the wreckage. The sheet listed a departure time of "1300 UTC" (Universal Time Coordinated, or 0800 Eastern) on November 14, 2009, and an enroute altitude of 6,000 feet. The listed waypoints were OBI; Elkton Maryland (Cecil County); Morgantown, West Virginia; Franklin, Indiana (Franklin Flying Field) and BMG. The flight plan was printed on November 13, 2009.
FAA Ground-Based Radar Tracking
The FAA ground-based radar tracking system first acquired the airplane about 1045, shortly after it departed OBI, at a mode C altitude of 200 feet, while it was still broadcasting the VFR 1200 code on its transponder. About 1 minute and 45 seconds later later, the tracking data block associated with the assigned discrete transponder code appeared in the radar data. About 1049 the target disappeared, and then re-appeared about 30 seconds later. The final radar target associated with the airplane radar was acquired about 1052. All radar returns indicated that the airplane remained about 1-2 miles southwest of OBI. The mode C altitude data ranged between 200 feet and 1,600 feet, and varied irregularly; the airplane never stabilized in a climb, descent, or fixed altitude.
Ground Track Recovered from GPS Unit
Data downloaded from the Lowrance AIRMAP 1000 GPS unit by National Transportation Safety Board (NTSB) Vehicle Recorder Laboratory personnel yielded a total of sixteen flight tracks; track data included latitude and longitude position only, with no altitude information or timestamp data. The details of the data recovery were documented in a separate report that can be found in the accident docket. The last track contained data located in the immediate vicinity of the accident site, and ended between the airport and the wreckage location. That track was determined to be from the accident flight. The overlay of the track on a local area map revealed that the airplane flew over or very close to the locations of several ear- or eye-witnesses.
The GPS track data indicated that the airplane departed from runway 31, and then made 180-degree, 3,000- foot radius turn to the left. The airplane then made four consecutive 360-degree turns of continually-decreasing radii; the radius of first turn was about 1,000 feet, and the radius of the fourth turn was about 500 feet. The airplane then tracked generally southeast, via a 90-degree, 1,000-foot radius turn to the left, followed by a 180-degree, 1,500-foot radius turn to the right. The track continued with three acute, angular directional changes which totaled about 270 degrees, and resulted in a south-southeast track. At this point the airplane was about 1 1/2 miles south of the airport. The track then depicted a 180-degree, 400-foot radius turn to the left, closely followed by two 360-degree, 1,000-foot radius right turns. The airplane then tracked south-southeast for about 1 mile before it reversed course with a 1,000-foot radius turn to the left. The track then depicted a 180-degree, 1,000- foot radius turn to the right, where the data ended. The end of the track data was located about 4,000 feet north-northeast of the left wing, and about 3,000 feet northeast of the main wreckage.
Others' Observations Regarding Previous Pilot Actions
A technician from the maintenance provider at OBI, where the three most recent annual inspections on the airplane had been accomplished, stated that the pilot was diligent about making sure the airplane's maintenance needs were met. Others who were acquainted with the pilot had similar opinions about his attention to maintenance requirements.
The airport manager conducted the pilot's most recent flight review, about 10 months prior to the accident. At that time, the pilot stated that he was interested in pursuing his instrument rating. However, that conversation was the last time that the pilot mentioned an instrument rating to the airport manager, and to the manager's knowledge, the pilot did not subsequently begin any instrument training. Examination of the pilot's logbook did not reveal any entries for instructional flights subsequent to the flight review.
An individual who called the pilot his "closest pilot friend" had flown with the pilot several times. He stated that as a pilot, "the guy was competent," and "pretty meticulous." He was of the opinion that the pilot did not intentionally fly into clouds, or intentionally put himself in danger. He understood that the pilot had been planning this trip for "at least one month," but given the weather conditions at the time of the departure, he was "surprised" that the pilot decided to take off.
Another individual who was a certificated airline transport pilot and a flight instructor flew with the pilot several times, but no more recently than about 4 years prior to the accident. He stated that the pilot was "meticulous" and "safety conscious." He opined that the pilot's intentional departure into the low overcast was "totally against the character" of the pilot, and that the pilot "knew better" than to intentionally depart in those conditions. He stated that he had "no doubt" that the pilot "knew the rules" concerning a VFR departure into IMC.
The wife of the pilot relayed observations that tended to differ from the above-cited observations, and that occasionally appeared to contradict prior statements she had made. In one of her earliest conversations with the NTSB, she stated that the pilot was going to "pop above the clouds" for the trip; he occasionally flew in the clouds, but he was "very cautious," and was working on his instrument rating.
In a subsequent conversation with the NTSB, the wife said that the trip had been planned for 6 months, the original departure had already been delayed for 2 days due to weather, and that departing "Sunday [the day after the accident] was not an option." She was aware that the pilot was not instrument rated, but stated that he "had all the books" and he understood the concepts of instrument flight. In a telephone conversation just before the departure, the pilot told his wife that he "saw a sunbeam where the clouds were thinner." He told her "there's a break, I'm leaving now," and that "if I'm not in blue [sky] right away, I'm coming back."
Both the pilot's wife and their son had flown with the pilot on multiple occasions, and she made the following statements about the pilot's previous flight activities:
• The pilot would only fly in clouds if "he could get out of the clouds immediately"
• He sometimes flew through clouds "1,000 to 2,000" feet thick.
• "Sometimes you can't help it, you're flying from point A to point B" and "you have to fly through clouds"
• "He never kept me in clouds more than 2 minutes"
• Their son thought flying in the clouds was "cool," but she did not particularly care for it
• "If the weather was coming in, sometimes you had to go through the clouds"
When the pilot's wife was asked by investigators if the autopilot was functional, and whether the pilot used it, she replied that it was functional, but that he "rarely, rarely" used it. When she was asked if the pilot would use the autopilot to fly through clouds, she responded that he would hand fly the airplane through the clouds. She also stated that for the accident flight, she was "confused why he would have trouble in the clouds."
VFR Flight into IMC
Chapter 16 ("Emergency "Procedures") of the FAA publication Airplane Flying Handbook (AFH, FAA-H-8083-) contained a section entitled "Inadvertent VFR Flight into IMC," which stated that "Accident statistics show that the pilot who has not been trained in attitude instrument flying, or one whose instrument skills have eroded, will lose control of the airplane in about 10 minutes once forced to rely solely on instrument reference." The stated purpose of the AFH was "to provide guidance on practical emergency measures to maintain airplane control for a limited period of time in the event a VFR pilot encounters IMC conditions...to help the VFR pilot keep the airplane under adequate control until suitable visual references are regained."
The AFH stated that the first steps necessary for a VFR pilot to survive an encounter with IMC included "recognition and acceptance of the seriousness of the situation and the need for immediate remedial action, maintaining control of the airplane, and obtaining the appropriate assistance." It stated that "Attempts to control the airplane partially by reference to flight instruments while searching outside the cockpit for visual confirmation of the information provided by those instruments will result in inadequate airplane control," which "may be followed by spatial disorientation and complete control loss." The AFH emphasized that the pilot "must understand the most important concern-in fact the only concern at this point-is to keep the wings level. An uncontrolled turn or bank usually leads to difficulty in achieving the objectives of any desired flight condition."
The guidance then discussed emergency airplane attitude control, and how to achieve and maintain it. It instructed pilots to use elevator trim to "maintain hands-off level flight at cruise airspeed, ...resist the tendency to over control the airplane," and cautioned that
"no attitude changes should be made unless the flight instruments indicate a definite need" for those changes. Finally it advised pilots to "make use of any available aid in attitude control such as autopilot or wing leveler."
An FAA-contracted study and report (ARL-00-15/FAA-00-8) by the Aviation Research Lab (Institute of Aviation, University of Illinois) examined the factors that affected pilots' decision-making for cases of VFR flight into IMC. The study noted that NTSB accident data indicated that between 1990 and 1997, 2.5 percent of the accidents involved VFR into IMC, and those events accounted for 11 percent of all the fatalities for the same period. It was also noted that the issue was not unique to the United States.
The study identified four factors that contributed to those cases; they were situation assessment, risk perception, motivation, and decision framing. Situation assessment concerned pilots' evaluation of the meteorological conditions, risk assessment concerned pilots' evaluation of the likelihood of suffering a loss due to a hazard, motivation concerned the pilots' reasons for conducting the flight, and decision framing concerned the pilots' determination of the possible gains or losses associated with a particular course of action (i.e. conducting the flight or postponing/cancelling it). The study noted that each of the four factors influenced the final decision of any pilot to conduct or avoid a VFR flight into IMC; no factor was a sole influence, although the weight of each factor would vary as a function of pilots and circumstances, and even for a given pilot in varying circumstances.
One conclusion of the study was that "pilots who continued VFR flight into IMC made errors early in the decision making process in the form of inaccurate assessments of visibility, and this was compounded by other factors such as their greater willingness to take risks, greater confidence in their flight skills, and a reduced sense of vulnerability to weather hazards and pilot error." Another conclusion was that the "pilots' decisions were influenced more by factors that were related to tangible gains and losses for themselves, as well as their self-approval and [self-]disapproval," as opposed to peer or other social pressures. The overall conclusion of the study was that the individual factors, and their interplay, require additional examination in order to develop more effective intervention strategies.