Go Flight Medicine

Menu

JFK Jr Piper Saratoga Mishap

Volanti Subvenimus - We Support the Flyer!

JFK Jr Piper Saratoga Mishap

By In Aerospace Medicine, Aircraft Mishaps, Blog, Flight Medicine On April 15, 2014


JFK Jr Conspiracy Theories

JFK Jr Conspiracy Theories

On 16 July 1999, the son of former President John F. Kennedy took off in his privately-owned Piper Saratoga from New Jersey bound for Martha’s Vineyard. Although he held a private pilot’s license without an instrument rating, he departed in marginal weather at night. Accompanied by his wife, Carolyn Bessette and her sister, they would never be seen again. Due to the mystique surrounding the Kennedy family and the untimely death of another young Kennedy, this mishap continues to consume conspiracy theorists even today.

A simple search for the terms ‘JFK Jr plane crash’ or other similar word combination initially reveals several credible sources in any search engine’s top sites, but then quickly digresses to blogs from conspiracy theorists. Youtube is also teeming with videos of theories alleging the most absurd explanations for John Kennedy’s fatal crash. Although worth reading for a laugh, the reader is soon faced with propositions so ridiculous that I could not with good conscious advertise these sites via links. These ‘alternate’ explanations usually start from a position that the National Transportation Safety Board (NTSB) cannot be trusted because they are a government agency. This belief is typically deeply founded in a greater suspicion that all governments are direct subsidiaries of secret societies or Lucifer himself with the expressed goal of forming a one-world government that will enslave the human race and usher in the preconditions for apocalypse. From these hypotheses, it naturally follows the JFK Jr was assassinated in order for the mafia to ensure that Yale’s Skull & Crossbones would continue to hand pick wall street bankers and Saudi princes in order to dominate the masses.”

This post will tack in a slightly different direction, starting from a hypothesis that the NTSB is what it identifies itself as – “an independent Federal agency charged by Congress with investigating every civil aviation accident the United States and significant accidents in other modes of transportation – railroad, highway, marine and pipeline. The NTSB determines the probable cause of the accidents and issues safety recommendations aimed at preventing future accidents.”1 The unparalleled safety record that the aviation industry has developed over the past few decades lends weight to the effectiveness of the NTSB’s processes.

Using rational thought and empirical evidence, a brief summary of the mishap events followed by a list of contributing and causal factors will be explored.

 

MISHAP NARRATIVE

Kennedy's Flight Path

Kennedy’s Flight Path

On the evening of 16 July 1999, John F. Kennedy, Jr departed from Essex County Airport (CDW) in his privately owned Piper Saratoga with his wife Carolyn Bessette and her sister Lauren. The flight plan was destined for Barnstable Municipal-Boardman/Polando Field (HYA), with a scheduled stop at Martha’s Vineyard Airport (MVY) to drop off Lauren. Because Kennedy filed no official flight plan, the itinerary above was gathered from testimony of friends and family.

Taken directly from the NTSB final report: “The noninstrument-rated pilot obtained weather forecasts for a cross-country flight, which indicated visual flight rules (VFR) conditions with clear skies and visibilities that varied between 4 to 10 miles along his intended route. The pilot then departed on a dark night. According to a performance study of radar data, the airplane proceeded over land at 5,500 feet. About 34 miles west of Martha’s Vineyard Airport, while crossing a 30-mile stretch of water to its destination, the airplane began a descent that varied between 400 to 800 feet per minute (fpm). About 7 miles from the approaching shore, the airplane began a right turn. The airplane stopped its descent at 2,200 feet, then climbed back to 2,600 feet and entered a left turn. While in the left turn, the airplane began another descent that reached about 900 fpm. While still in the descent, the airplane entered a right turn. During this turn, the airplane’s rate of descent and airspeed increased. The airplane’s rate of descent eventually exceeded 4,700 fpm, and the airplane struck the water in a nose-down attitude.” These events unfolded during the last 7 minutes of the mishap flight.1

 

Kennedy's Aircraft - Piper Saratoga

Kennedy’s Aircraft – Piper Saratoga

THE AIRCRAFT

The mishap airplane, N9253N, was a Piper PA-32R-301, Saratoga II, single-engine, low-wing airplane with retractable landing gear. The airplane was originally certificated by Piper Aircraft Corporation on June 9, 1995. After several previous owners, it was eventually purchased by Kennedy on April 28, 1999. According to the maintenance facility employee, “the aircraft was found to be in very good condition, with only a few minor discrepancies.” According to the records and the maintenance facility employee, an annual inspection was completed on June 18, 1999, at a total airframe time of 622.8 hours.

Upon recovery of the wreckage, the tachometer indicated 663.5 hours. There were no significant mechanical failures demonstrated upon analysis of the wreckage and flight data recorder. The aircraft was equipped with a digital voice recorder; when found in the wreckage, it was crushed, its backup battery was missing, and it had retained no data. After the incident, the propeller and engine were examined. Neither revealed evidence of any preexisting failures or conditions that would have prevented engine operation. The aircraft was equipped with an Automatic Flight Control System (autopilot system). Post-mishap investigation did not reveal any evidence of a pre-impact malfunction or jam. The aircraft’s GPS unit was crushed, but the switch was found in the ON position. The flight command indicator displayed a position that indicated a right turn with a bank angle of about 125 degrees and a nose-down pitch attitude of about 30 degrees. The gyro display was captured in a position indicating a steep right turn. The heading indicator was pointing to 339 degrees. On the airspeed indicator, the needle mark was consistent with the maximum mechanical needle travel position for the airspeed indicator design.

INTERPRETATION: The aircraft was documented to be airworthy without any significant discrepancy prior to flight. Examinations on the wreckage indicated there was no failure of the engine, propellers, avionics or other hardware. The flight instruments were essentially frozen in time demonstrating various flight parameters of the aircraft when it impacted the water. All evidence corroborated a scenario in which the aircraft was rapidly descending and engaged in an aggressive right turn upon impact. There was no voice data to evaluate conversations among those in the cockpit or across radio communications during the flight.

 

CONTRIBUTING FACTORS TO MISHAP

Meteorological Conditions (Weather)

These observations indicated that visibilities varied from 10 miles along the route to 4 miles in haze. The lowest cloud ceiling was reported at 20,000 feet. These observations were made about 1800. His takeoff time was 2038 local. It appears that Kennedy made two weather requests prior to flight for a route briefing from TEB to HYA with MVY as an alternate. Preflight weather called for VFR (visual flight rules) conditions.

Three pilots who had flown over the Long Island Sound on the night of the accident were interviewed after the accident. Before departing the city, one of these pilots had obtained current weather observations and forecasts for similar areas traveled by Kennedy’s aircraft. He stated that the visibility was well above VFR minimums. Relating a preflight call to the flight service station (FSS) before departing he stated: ??”I asked if there were any adverse conditions for the route TEB to ACK. I was told emphatically: ‘No adverse conditions. Have a great weekend.’ I queried the briefer about any expected fog and was told none was expected and the conditions would remain VFR with good visibility. Again, I was reassured that tonight was not a problem.” ??This same pilot also provided testimony about weather conditions over MVY that night. When his global positioning system (GPS) receiver indicated that he was over Martha’s Vineyard, he looked down and “…there was nothing to see. There was no horizon and no light….I turned left toward Martha’s Vineyard to see if it was visible but could see no lights of any kind nor any evidence of the island…I thought the island might [have] suffered a power failure.”

Another pilot had flown nearby the same evening at about 1930. This pilot stated that during his preflight weather briefing from an FSS, the specialist indicated VMC (visual meteorological conditions) for his flight. The pilot filed an IFR (instrument flight rules) flight plan and conducted the flight at 6,000 feet. He stated that he encountered visibilities of 2 to 3 miles throughout the flight because of haze. He also stated that the lowest visibility was over water.

A third pilot departed TEB (same airport Kennedy departed) about 2030 destined for Groton, Connecticut, after a stopover at MVY. He stated that the entire flight was conducted under VFR, with a visibility of 3 to 5 miles in haze. He stated that, over land, he could see lights on the ground when he looked directly down or slightly forward; however, he stated that, over water, there was no horizon to reference.

  • INTERPRETATION: Although the weather conditions prior to the flight were expected to be VFR throughout the evening. Based on interviews of other pilots flying in similar locations as the eventual mishap, the weather had deteriorated considerably. The haze seemed especially bad near Martha’s Vineyard. The existence of a persistent visible horizon seems unlikely. In the event of haze and lack of a discernable horizon, spatial disorientation becomes a common and dangerous risk factor. It should also be noted that Kennedy did not make additional weather requests in-flight and that he had programmed the wrong radio frequencies to gain the ATIS (Automatic Terminal Information Service) updates for both Essex County and Martha’s Vineyard.

 

Pilot Experience:

JFK Jr had started his flight instruction almost 17 years before the fatal mishap. He logged 47 hours from 1982-1988, but then did no formal flight instruction until late 1997. He earned his private pilot’s license by April 1998. By 16 July 1999, the night of the mishap, John Kennedy was enrolled in an instrument rating course and had completed 12 of 25 lessons, but did not yet possess an instrument rating. Although Kennedy’s most recent logbook was not located the logbook dated thru 11 November 1998 demonstrated 310 hours of total flight time, 55 of which were at night. In the 15 months prior to the crash, JFK Jr had flown 35 flight legs either to or from the Essex County/Teterboro, New Jersey area and the Martha’s Vineyard/Hyannis, Massachusetts, area (MVY). About half of these flights were without a certified flight instructor (CFI).

One of JFK Jr’s CFI stated to the NTSB that the pilot had the ability to fly the airplane without a visible horizon but may have had difficulty performing additional tasks under such conditions. Another instructor stated that the pilot had the capability to conduct a night flight to MVY as long as a visible horizon existed.

  • INTERPRETATION: Although Kennedy did in fact have a private pilot license, he was relatively inexperienced and his level of experience would be particularly concerning in conditions requiring him to fly exclusively by instruments. 300 hours may seem like a lot to a non-flyer, and actually does meet the 250 hour minimum to acquire a commercial pilot certificate. However, as an indicator of how many hours are considered safe, the FAA passed new pilot qualification standards in July 2013 requiring first officers (co-pilots) to hold an Airline Transport Pilot (ATP) certificate, which requires a minimum of 1,500 hours total flight time as pilot. Kennedy’s lack of solo experience at night was considering more concerning.

 

Pilot Performance

According to New York ATC, an aircraft matching the description and flight path of Kennedy’s plane passed thru its Class B and Class D airspace (both require communication with ATC) alerting the Traffic Alert and Collision Avoidance System (TCAS). This incident provoked ATC to warn a commercial airliner being flown by American Airlines. The entire transcript of the American 1484 pilot and ATC can be found in the NTSB report.

  • INTERPRETATION: This episode in which an aircraft that fit the description and flight path of Kennedy indicates his level of relative inexperience in aviation and may also indicate a lack of situational awareness during these specific flight operations during the night of the mishap.

 

Physical Health

According to medical records, Kennedy fractured his left ankle in a “hang gliding” accident, underwent surgical fixation in June 1999. By the date of the mishap, 6 weeks after his ankle injury, Kennedy had been placed in a Cam-Walker and was using a cane. His medical records noted that he was “full-weight bearing with mild antalgic gait.” JFK Jr’s orthopedic surgeon stated that he felt that, at the time of the accident, the pilot would have been able to apply the type of pressure with the left foot that would normally be required by emergency brake application with the right foot in an automobile.

Toxicological testing was performed on the human remains, which were negative for any presence of drugs or alcohol.

  • INTERPRETATION: According to 14 CFR Section 61.53, “Prohibition On Operations During Medical Deficiency,” in operations that required a medical certificate, a person shall not act as a pilot-in-command while that person, “(1) Knows or has reason to know of any medical condition that would make the person unable to meet the requirements for the medical certificate necessary for the pilot operation.”According to NTSB report, an FAA medical doctor who was interviewed stated that a pilot with the type of ankle injury that the accident pilot had at the time of the accident would not normally be expected to visit and receive approval from an FAA Medical Examiner before resuming flying activities.
  • Based on the above guidance and the testimony from the treating physician, Kennedy likely did possess sufficient strength and range of              motion to pilot his aircraft, but if he was having even minimal pain, this could provide an additional distraction. It is unknown how much if any this fact contributed to the mishap.

 

JFK Jr & Carolyn Bessette

JFK Jr & Carolyn Bessette

Mental Health

Much of the national media focused on the many stressors possibly affecting the pilot in command of this mishap. This was likely due to the profitability of the drama of one of the country’s biggest socialite, but psychological stress should not be fully ignored.

  • INTERPRETATION: John Kennedy owned a magazine, George, which was having significant financial troubles. Additionally, the original flight plan had been to take off at 1800 local. Due to Kennedy’s sister-in law’s delay and heavy traffic, the flight was also delayed over 2.5 hours. Lastly, there is some evidence that Kennedy and his wife, Carolyn Bessette, had an unstable marriage. Although, it is possible that his wife’s presence proved a distraction for the pilot or that they were engaged in an argument during flight, but this theory is only speculation. Regardless of these two more unlikely proposed theories, it is probable that underlying stress could manifest by diminishing situational awareness during flight, increasing the risk for minor errors that can easily compile.

 

Spatial Disorientation (SD)

Spatial disorientation (commonly referred to as Spatial-D) is the inability to determine or incorrect perception of one’s location and motion relative to their environment. The general term, spatial disorientation can be further divided into a variety of unique categories that can affect aviators.

DATED, SLIGHTLY BORING, BUT INSTRUCTIVE FAA VIDEO DESCRIBING SPATIAL DISORIENTATION:

Graveyard Spin & Spiral

Graveyard Spin & Spiral

  • INTERPRETATION: There are a number of factors that suggest that JFK Jr experienced spatial disorientation [LINK], which directly led to the fatal crash in the Atlantic Ocean. Many of the textbook risk factors for SD were present. A lack of visual references and the absence of a discernable horizon are major risk factors for SD. Flying over a large featureless body of water at night can cause a black hole effect, making visual references difficult to find. Additionally, an inexperienced pilot will not only be at more risk of developing SD, but his ability to recognize and correct the problem quickly is very limited.
  • Analysis by specialists during the investigation evaluated airplane performance data for the final 7 minutes of the flight using radar, aircraft, and weather data. The aircraft’s movements and the pilot’s inputs all but sealed the case. John F. Kennedy Jr was victim of a well-known and highly dangerous specific type of Spatial Disorientation – The Graveyard Spiral.

 

CAUSAL FACTORS TO MISHAP

The NTSB’s final conclusion for the direct cause of this aircraft mishap was “The pilot’s failure to maintain control of the airplane during a descent over water at night, which was a result of spatial disorientation. Factors in the accident were haze and the dark night.”1

Mishaps are never simple, nor are they often due to one specific decision, input, or mechanical failure. An aircraft mishap is usually a result of compounding factors that go unnoticed, eventually lining up in such a way to result in actual catastrophe. For every actual mishap, there are a much greater number of potential mishaps that are first noticed and avoided. The fact that the party was running late may have pressured Kennedy to fly over a patch of featureless ocean as it was the fastest way to cross, but this increased his risk for developing SD.

Although many of the other factors listed above may have contributed to this mishap, ultimately pilot error directly led to this fatal crash. The relative limited experience and training by Kennedy increased his chances of experiencing SD and decreased his likelihood of accurately identifying and correcting it. It is quite possible that Kennedy was experiencing the most dangerous type of SD, type 1 or unrecognized SD and did not know he was disoriented until he hit the water. His physical and mental health, along with several other factors noted above may have led to a state of decreased attention and increased distraction, which also are risk factors for vestibular illusions.

There is no hidden agenda or conspiracy in this story, just another sad and tragic chapter in the Kennedy Story.

 

REFERENCES:

  1. National Transportation Safety Board, About Us. Accessed 10 Mar 2014. https://www.ntsb.gov/about/index.html.
  2. Full NTSB Report
  3. AOPA – Landmark Accidents: Vineyard Spiral