Earlier this week the NTSB released its final report on the crash of N5225J, a Cessna 310R that crashed into East Palo Alto in February of 2010 when on an instrument departure from KPAO.
Unfortunately for those of us waiting, the NTSB has offered no additional insights into the cause of this accident. Their final report simply states that the pilot failed to fly the departure procedure as charted and directed, and thus impacted terrestrial objects. This information was fairly obvious as had the pilot flown the procedure as directed, the accident would have never occurred.
In fairness to the NTSB, they did report that no mechanical reasons for the pilot not flying the intended course were identified. No indication of mechanical failure was found in the wreckage.
At this point, we can only speculate as to what actually occurred, and are left with the burning question: Why did Doug Bourn (the pilot) not execute the procedure as planned? Was he incapacitated? Was he severely disoriented? Did someone else other than him manipulate the controls or prevent him from doing so?
To those who said he took off despite the tower warning him not to do so, this simply wasn’t the case. When the controller said, “I cannot clear you for takeoff because I don’t have visibility on the runway, so ah, the release is all yours and it’s at your own risk sir.”, he was not warning the pilot not to take off. He was warning the pilot he could not confirm that the runway was in sight (by the controller), and the pilot would be responsible for ensuring the runway was clear. This is standard FAA phraseology. This is a common situation with fog that is close to the ground since the controller is quite high off the ground and some distance away from the runway.
What I will add to the story is that he had flown that departure dozens of times, and many times in conditions such as were the case that morning. I personally have flown that departure as well, and have even flown it in that aircraft with Doug at the controls. The point is, this is a procedure the pilot knew like the proverbial back of his hand.
This is likely to forever remain a mystery, one that only the Davy Jones of the air will ever know.
We will all forever miss Doug. A great pilot, a great electrical engineer, and simply a great man.