Investigation Summary
On the evening of November 15, 1964, Flight 114 was conducting a VOR/DME-3 approach to McCarran International Airport's Runway 25. The weather at the time was poor, characterized by light snow, an obscured sky, and a ceiling of approximately 500 feet. The approach procedure being used had only become effective on October 3, 1964, and this was the first time it had been flown by a crew under these conditions. The aircraft struck a hill at an elevation of 3,575 feet MSL, approximately 9.7 miles from the VOR station. At this point in the approach, the flight should have maintained an altitude of 4,300 feet MSL. The impact occurred only 10 feet below the ridge line, and the aircraft exploded instantly. All 29 aboard—26 passengers and a crew of three—died in the crash. Recovery efforts were severely hampered by snowdrifts and rugged terrain, requiring the use of helicopters and the eventual construction of a temporary road to the site. While the Civil Aeronautics Board (CAB) officially cited the captain's misinterpretation of the chart as the cause, subsequent litigation highlighted that the Jeppesen approach chart was non-standard. The profile section of the chart showed a solid horizontal line labeled 'Flight Path' at 3,100 feet, which could be interpreted as the cleared altitude once the initial fix was reached, despite the presence of higher terrain in the intermediate segment.
Final Conclusions
The Civil Aeronautics Board (CAB) concluded that the probable cause was the misinterpretation of the approach chart by the captain, which resulted in a premature descent below obstructing terrain. The investigation noted that the chart's profile section lacked specific descent information for the segment between the 15-mile and 6-mile fixes, potentially misleading the crew into descending to 3,100 feet too early.
Video Analysis
No video analysis linked for this case file yet.
Airframe & Maintenance
Crew Experience
Captain
Henry Fitzpatrick
First Officer
Systems & Failure Modes
Jeppesen Approach Chart
The navigational chart used by the crew for the VOR/DME-3 approach, which was later found to have confusing profile depictions regarding minimum altitudes.
VOR/DME
VHF Omnidirectional Range with Distance Measuring Equipment, the primary navigation system used for the instrument approach into McCarran.
Interesting Facts
- 01The aircraft struck the mountain only 10 feet below the ridge crest.
- 02The VOR/DME-3 approach procedure used had been in effect for less than six weeks.
- 03This was the only fatal accident in the 23-year history of Bonanza Air Lines.
- 04The captain was a veteran pilot with over 11,000 hours of flight experience.
- 05Initial media reports stated 28 fatalities based on the flight manifest, but the official count was revised to 29 after the body of a young girl was discovered in the wreckage.
- 06The aircraft's Manufacturer Serial Number (MSN) was 29.
- 07The aircraft was formerly registered as N145L.
Safety Actions & Advisories
Chart Standardization
The accident highlighted the need for standardized and unambiguous depictions of descent profiles on instrument approach charts to prevent misinterpretation of minimum altitudes.
Known Controversies & Unanswered Questions
Approach Chart Liability
Reference ↗While the CAB blamed the pilot, a wrongful death lawsuit against Jeppesen (the chart publisher) resulted in a $490,000 out-of-court settlement, acknowledging the chart's confusing and non-standard layout.