Paradise Airlines Flight 901A

Cloudy skies over Lake Tahoe showing the high mountains around the lake acting as a barrier in overcast conditions.

The flight, flying as Paradise Airlines Flight 901A, was one of two daily passenger flights operated by the airline between San Jose and Lake Tahoe.[1] It left the company's base at the Oakland International Airport on the morning of March 1 with only the four crew members aboard, and stopped at nearby Salinas Airport to pick up a group of 18 passengers before proceeding to San Jose Airport where the aircraft was filled to capacity with the final 63 passengers.[2][3] Fifteen additional passengers were turned away because the flight was full.[4] The 81 passengers and 4 crew members departed San Jose at 10:39 a.m. for the 50-minute flight to Lake Tahoe.[4] The passengers who had been turned away were bussed to Oakland to catch a later flight but that second flight was eventually cancelled because of poor weather in the mountains.[4]

The U.S. Weather Bureau forecast for Lake Tahoe anticipated poor conditions for aircraft, but after evaluating the data, the Paradise Airlines dispatcher predicted that weather conditions would improve by the time the flight would arrive, so he approved the departure.[5]^(p2) En route, the crew of Flight 901A communicated by radio with the crew of the company's other plane, operating as Paradise Airlines Flight 802, which had just left the Tahoe Airport.[5]^(p4) Flight 802's crew said they had encountered icing conditions at 12,000 feet, snow showers over Lake Tahoe, and that clouds obscured the tops of mountains in the vicinity.[5]^(p4) At 11:21 am, the pilot of Flight 901A, in the vicinity of Lake Tahoe, reported that he had located a break in the cloud cover, that he could see the airport on the south shore of the lake, and that he was going to proceed with a visual approach.[4][6] At 11:27 am, the pilots contacted the passenger agent for Paradise Airlines at Tahoe Valley Airport to let him know they were approaching. The agent informed the pilots that the 11:00 a.m. Weather Bureau report listed the weather conditions as overcast, 2,000 ft. estimated ceiling, with 3 miles visibility.[5]^(p5) FAA regulations required a minimum ceiling of 4,000 feet and 10 miles visibility in order to proceed with an approach, so a landing would not have been allowed.[7]

A witness on the ground reported that she saw the plane flying toward the airport, on the south end of Lake Tahoe, operating normally.[5]^(p6) She watched the aircraft approach the airport until it disappeared behind thin clouds, then heard the engines add power.[5]^(p6) Other witnesses a mile north heard a low flying plane, and later saw the aircraft flying north back towards the lake at approximately 500 feet altitude with the landing gear up, but the landing gear doors still open.[5]^(p6) Another witness further north saw the plane with its gear up and the gear doors closed, flying towards the lake.[5]^(p7) A different witness further north reported seeing the plane flying at around 500 feet altitude on a northwesterly heading, with the gear up.[5]^(p7) Shortly afterward, the weather deteriorated into blizzard conditions.[5]^(p7) At 11:30 am, three witnesses on the east shore of Lake Tahoe reported hearing a "large aircraft" flying overhead, heading in an easterly or northeasterly direction.[5]^(p7) It was snowing heavily and none of the witnesses saw the aircraft.[5]^(p7) Some witnesses said the engine sounds abruptly stopped but they had not heard an explosion or crash.[5]^(p7)

The aircraft struck the ground near the crest of a ridge on Genoa Peak, Nevada.[5]^(p7) The ridge, with a maximum height of 8,900 feet above sea level, forms the north shoulder of Daggett Pass, a pass several miles across which has an average elevation of 7,300 feet above sea level.[5]^(p7) At impact, the plane first struck several trees on the ridge's west slope, and the damage to those trees showed that the aircraft was in an almost level flight attitude.[5]^(p8) The ground impact occurred just 25 to 30 feet below the top of the ridge, leaving a trail of wreckage approximately 900 feet long and no survivors.[6] At the altitude the aircraft was flying when it crashed, it would have cleared the ridge if it had been only 100 feet more to the right.[7]

Paradise Airlines had been operating as an intrastate airline in California since 1962, and had not had any accidents in its history before this flight.[8][9] It is the worst accident involving the Lockheed L-049 Constellation,[10] and at the time was the second worst single-plane accident in United States history.[11][4]

2015 aerial view of Lake Tahoe from the east, with Daggett Pass in the foreground

Because of heavy snowstorms in the Tahoe area, only limited search efforts for the missing aircraft were possible on the first day.[4] Two small boats searched along a 10-mile stretch of the lake's shore, but found no traces of the missing aircraft by nightfall. Meanwhile, experienced ski rescue crews and mountaineers waited for a break in the weather before they could join the search.[4] By dawn the next morning, the weather had cleared enough to start a large-scale search.[12] Air Force Lt. Col Alexander Sherry headed the operation, involving more than 50 planes and hundreds of people.[9] At 7:36 am, an Air Force helicopter spotted the wreckage of the aircraft on the ridge.[12] A second helicopter landed at the site and confirmed that the wreckage was from the missing flight, and that there were no survivors.[12]

Douglas County Sheriff deputies led a group of off-road vehicles to the crash scene and left two deputies to guard the wreckage through the night.[2] A bulldozer cleared a 3 ¹⁄₂-mile (6 km) road to the site along an old logging track.[2][13] Civil Aeronautics Board (CAB) investigators arrived at the scene of the crash to sift through the wreckage of the aircraft for clues to why it crashed.[2] Portions of the four engines had burned, and there was evidence that a small area of the crash site had burned for four or five hours.[2] Most of the wreckage was shattered into tiny pieces, with only a few recognizable parts.[14] The impact site was so close to the top of the ridge that the aircraft's nose wheel was found on the other side of the mountain.[6]

Rescuers predicted that because of the rugged terrain and the deep snow, it would take several days or possibly even after the Spring thaw before all the victims could be recovered.[2] The first seven victims were brought to a makeshift morgue in the CVIC hall in Minden, Nevada, on March 3, where technicians from the Federal Bureau of Investigation (FBI) began the process of identification.[13] An additional 43 were brought the next day, with officials hurrying to recover bodies before an incoming snowstorm made them inaccessible.[15] Recovery efforts were aided by the use of an Air Force Helicopter to lift the bodies down from the ridge.[16] Two large Army jet helicopters airlifted three 600-pound (270 kg) mobile hot air furnaces to the site to help clear away the snow.[17] By March 6, searchers had located and recovered all but two of the victims.[18] They were eventually located, but by March 9, officials had only been able to recover one of the bodies before poor weather forced them to halt recovery operations.[19] The final victim was removed from the site on March 30.[20] Douglas County District Attorney John Chrislaw reported that Paradise Airlines refused to pay the $300 (equivalent to $2,500 in 2019) per victim mortuary expenses of handling the remains, leaving the victims' relatives to bear the cost, but company president Herman Jones disputed that, saying that the expenses would be paid by the airline's insurance company.[15][21]

Airline grounded

Diagram showing different types of de-icing systems used on aircraft, including electric (1) on pitot tubes, windshields, and propeller blades, and air-inflated (2) systems on the leading edges of flight surfaces fed by hot exhaust (4) from the engines.

After cancelling flights in the aftermath of the crash, Paradise Airlines resumed flights to Lake Tahoe on the morning of March 3.[22] The FAA immediately ordered an emergency suspension of all flights by the airline, which took effect at noon that same day.[17] The suspension order said that the airline showed "a lack of ability and qualifications to conduct a safe intrastate common carrier passenger operation".[17] The FAA said that the airline could appeal the suspension, but that it would have to remain grounded until a decision was made on the appeal.[17] FAA regional Director Joseph H. Tippets said that the reason for the strict restriction was that Paradise Airlines Flight 901A had taken off on its flight while the weather conditions at the destination airport were below the minimum allowable conditions.[23] He also said the airline had also authorized its other aircraft, Flight 802, to depart Lake Tahoe Airport that same day, when weather conditions were below the minimum.[23] Both planes were flying in conditions where icing might be expected, but neither of the planes were equipped with wing de-icing equipment.[23][24] The aircraft's wing edges were painted black to give the appearance that de-icing equipment was present.[25] Company president Herman Jones told reporters that he was puzzled by the FAA's action, saying that his understanding was that the FAA had found no problems with the company's operations or its paperwork.[26] In days following the suspension, he said that he believed that the FAA's "over-restrictive rules" about flying in adverse weather conditions was to blame for the accident.[7] He said that the flight was only three or four miles from the Tahoe Airport and that the pilot might have already had had the airport in sight by the time the Tahoe Airport agent informed them of the reported weather conditions with only a 2,000-foot ceiling. Jones said the pilot probably decided to divert to Reno in order to avoid receiving an FAA violation for landing below minimums, even though it would have been safe to land.[7]

At the outset of the appeal hearing before the CAB, Paradise Airlines unsuccessfully argued that the FAA had no jurisdiction over the company because it was an intrastate airline that operated only within state boundaries.[27] Once the hearing had commenced, attention was given to the company's inexperienced 25-year-old dispatcher that had cleared the flight for takeoff. He had been employed by the company for only one month, had limited fluency in the English language, and in response to questioning by the FAA, was unable to identify critical weather terms that were present in that day's forecast.[28] He testified that he had used his own judgment in predicting that weather conditions at Tahoe Airport would be safe enough for the flight to land, but under questioning, when he was given sample weather observations, he was unable to predict how those conditions could affect flight safety.[29] In later testimony at the hearing, it was revealed that the company's Tahoe Valley operations manager had altered a 10:10 a.m. weather observation report made by the airport's official weather observer on the morning of the flight.[30] 24-year-old Raymond Rickard testified that he had added a minus sign in front of a meteorological symbol on the report, changing the meaning from "broken cloud ceiling" to "thin, broken clouds".[30] He said, "I knew [the observer] would not let us dispatch an airplane under the conditions he'd written, so I just inserted the minus sign."[30] He said he did this after hearing the observer tell a pilot that it was all right to take off, so he thought that the observer had just made a mistake on the report.[31] On the other hand, the observer testified that he had definitely seen weather conditions well below minimum operating conditions that morning.[31] An FAA investigator testified that Paradise Airlines had violated civil air regulations several times in the three months before the accident, mostly involving weather conditions.[32] On April 6, the company lost its appeal of the FAA order grounding the company's aircraft.[33] Paradise Airlines president Herman Jones characterized the hearings as "a great miscarriage of justice" and vowed to keep the company's planes flying, with or without an air operator's certificate.[34] FAA representatives countered that if the company attempted to fly without a certificate, U.S. marshals would seize the aircraft involved.[35] After the ruling, the airline closed its operation at the Oakland airport.[36]

Lockheed L-049 Constellation

The aircraft was a Lockheed L-049 Constellation, serial number 2025 and registered with tail number N86504. It had been manufactured in December 1945 and had a total of 45,629 flight hours.[5]^(p25) It was equipped with four Wright R-3350 Duplex-Cyclone propeller engines that had undergone a total overhaul within the past 1,300 flight hours.[5]^(p26)

The plane was owned by Nevada Airmotive Corporation of Las Vegas, and had been leased to Paradise Airlines since June 1963.[33] In its past, it had been operated by Trans World Airlines before it was retired.[3] Paradise Airlines had flown it a total of 551 hours.[5]^(p25) The FAA reported that the type of aircraft was well suited for operation in high altitude, mountainous airports, due to its relatively slow speed and high maneuverability.[37]

Paradise Airlines Flight 901A carried 81 passengers and 4 crew on its final flight.[4] Nearly all of the passengers were from the Salinas and San Jose areas.[6] 16 of the 18 passengers that the airline had picked up at its Salinas stop were employees of the same company, the Monte Mar Development company of Salinas and Monterey.[4]

The pilot of the flight was Henry Norris, age 43, who had been employed with the airline since November 1963.[5]^(p24)[38] He had 15,391 hours of flight time, including 3,266 hours in Lockheed Constellation type aircraft.[5]^(p24) He had served in the Air Transport Command during World War II and had flown as a pilot for Modern Air Transport and World Airways and served as the director of training for Alaska Airlines.[38][39] He was unmarried and a resident of Alameda, California.[9][38]

The first officer, 28-year-old Donald A. Watson, of San Francisco, had been employed with the company since March 1963.[5]^(p24)[9] He had 3,553 flight hours of experience, including 149 hours instrument time and 1,353 hours in the Lockheed Constellation.[5]^(p24) Before joining Paradise Airlines, he had served as a mechanic with Pan American Airways and a pilot with Flying Tiger Line.[38]

The flight engineer, Jack C. Worthley, 33, of Fremont, California, had been employed with the company since October 1963.[5]^(p25)[9] He had 3,700 flight hours as a flight engineer, including 912 hours on the Lockheed Constellation.[5]^(p25) He was the father of three small children and was a native of Seattle.[38]

Investigators from the CAB, headed by George R. Baker, arrived at the headquarters of Paradise Airlines on the day the plane went missing, even before the crash site had been located.[9] Just as company president Herman Jones was about to meet with officials from the CAB and the FAA the next morning, word came in that the crash site had been located.[9] After the meeting, investigators impounded all of the company's records.[6] More than thirty CAB investigators were involved in the probe, studying the maintenance records of the plane, interviewing witnesses, studying the weather reports, and examining pieces of the wreckage for indications of the cause of the crash.[40] The aircraft was not equipped with a pilot voice recorder.[40] All four propeller hub assemblies were located and shipped, with the broken propeller blades, to a shop in Hayward, California, to determine how much power the engines were generating when the plane crashed.[18] By May 1, investigators had recovered the key instruments and the radio equipment of the crashed plane.[36] A salvage operator began removing the rest of the plane, taking the pieces to a warehouse at Reid–Hillview Airport near San Jose and storing them there in case they were needed by CAB investigators.[36]

The CAB held a probable cause hearing in Oakland between June 2 and 5.[41] The investigative team learned that pilots had made 11 reports of problems with the plane's directional instruments in the months before the crash.[41] Testimony from the Tahoe Airport's weather observer repeated some of what was said during the appeal of the FAA's suspension of Paradise Airlines' operating certificate.[41] The pilot of the Paradise Airlines flight that left Lake Tahoe an hour before the crash testified that he took off because he was verbally assured by the weather observer that the weather was clear enough, but the observer said that he did not recall such a conversation.[42] The pilot was asked about the company's procedures for operating in bad weather, and the company's financial arrangements with its pilots, and he revealed that the pilots were paid a flat fee of $35 (equivalent to $300 in 2019) per flight.[42] The CAB hinted that the flat fee payment arrangements gave an incentive to pilots to avoid diversions due to bad weather because they would not be paid for their additional time.[42] Investigators learned that neither of the company's aircraft operating at the Tahoe Airport had been equipped with de-icing equipment, and that Flight 802 had picked up rime ice half an inch thick when it was flying out of the Tahoe Valley earlier that day.[24] They also learned that the maintenance records of the company's aircraft had several discrepancies, but that the FAA had no enforcement actions pending at the time of the crash.[24] Previous flight crews had noted minor errors in the altimeters aboard the aircraft, and instrument repairmen had worked on both altimeters on the day before the crash.[24] The right-hand fluxgate compass was known to be faulty on the day of the crash, with crews reporting that it was "completely unreliable in any kind of banking turn".[24] Instrument technicians had worked on it just two days earlier.[24] Investigators learned that there had been gaps in the cloud cover when the flight had arrived, but a snow squall hit the north end of the airport just as the aircraft was approaching from the north for landing.[24]

On July 15, 1965, the CAB released its final report.[43] The report stated that the crash was caused by pilot error, a falsified weather report, and illegal maintenance practices.[43] The accident report stated:

The Board Determines that the probable cause of this accident was the pilot's deviation from prescribed VFR flight procedures in attempting a visual landing approach in adverse weather conditions. This resulted in an abandoned approach and geographical disorientation while flying below the minimum altitude prescribed for operations in mountainous areas.

— Synopsis, CAB Final Report[5]^(p1)

The CAB report stated that maintenance had been performed on both altimeters and the No. 2 fluxgate compass transmitter on the evening before the accident.[5]^(p9) The maintenance personnel who had performed the work had also inspected and signed off on their own work.[5]^(p1) The report stated the mechanic who had worked on the compass had never worked on that type of transmitter, and did not refer to any technical publications for guidance.[5]^(pp9–10) He failed to check the entire system and did not perform all of the actions outlined in the maintenance manual.[5]^(p10) The technician who performed the work on the altimeters could not remember whether or not he had secured the barometric adjusting screw that he had unscrewed during the adjustments he had made.[5]^(p10) The reinstallation of the unit had been performed by a mechanic who had never performed that type of work before, and who did not perform all of the checks required by the manual.[5]^(p10) The captain's altimeter that was recovered from the wreckage showed a pre-impact discrepancy that would have caused the pilot to believe the aircraft was flying 280 feet higher than its true altitude.[5]^(p17) In addition, the compass had an error of 15 degrees or more, which would have meant that the aircraft's actual course could have been more to the north than what the instruments were indicating to the pilots.[5]^(p18)

Weather reports that were available to the company dispatcher included warnings of icing conditions in the Tahoe Airport area and that clouds and snow showers would be obscuring mountains in western Nevada.[5]^(p12) None of this information was communicated to the captain of Flight 901A before or during the flight, and it was possible that ice accumulation on the aircraft may have affected its ability to gain sufficient altitude to clear the mountains.[5]^{(pp13, 20)}

The report concluded that when the crew abandoned the approach to Tahoe Valley Airport, they decided to proceed through Daggett Pass for unknown reasons, possibly to avoid an area of known icing that they had passed through during their descent, or possibly because icing was preventing the aircraft from being able to climb higher.[5]^(p20) The pilots would have been aware that an altitude of 9,000 feet would have given the aircraft 1,500 feet of terrain clearance through the pass's center, and an easterly heading from the southern end of the lake would have taken the aircraft through the pass's center, an opening several miles wide.[5]^(p19) The aircraft leveled off at 9,000 feet, either because the pilots believed that they had sufficient clearance, or because icing prevented further altitude gains.[5]^(p19) The report concluded that it was possible that the crew was unaware that its course, altitude, or both, were not being accurately shown on the aircraft's instruments, and that undetected tail winds might also have affected the flight's course.[5]^(p21)