Investigation Summary
The flight departed Washington at 19:49, approximately 20 minutes behind schedule due to ground delays. While navigating airway V-140 at 4,000 feet, the crew reported passing the Casanova omni range station at 20:10. According to the flight plan, the aircraft should have turned left from a 260 degree radial to a 239 degree radial at Casanova. Instead, the aircraft maintained its previous heading. This navigational omission resulted in a massive lateral error. When the crew reported passing the Rochelle intersection at 20:25, they were actually 13 miles off their intended position. Believing they were on the correct track, the crew initiated a procedure turn for the Charlottesville-Albemarle Airport. Because of their displaced starting position, this turn placed them directly over the Blue Ridge Mountains. At 20:40, the aircraft's right wing struck trees on the 3,100 foot Bucks Elbow Mountain at an elevation of 2,600 feet. The aircraft was configured for the approach with the landing gear extended, but the flaps remained fully retracted at the time of impact. The sole survivor, Ernest P. Bradley, lay seriously injured near the wreckage for nearly 36 hours before being discovered by search teams on November 1.
Final Conclusions
The Civil Aeronautics Board (CAB) concluded that the probable cause was a navigational omission resulting in a lateral course error that went undetected due to a lack of precision instrument flying procedures. A landmark aspect of the report was the focus on Captain George Lavrinc's mental health. The investigation revealed Lavrinc had been undergoing psychotherapy for severe emotional stress related to a difficult divorce and religious preoccupation. He had been prescribed Prozine, an antipsychotic/tranquilizer, and had seen his psychiatrist the night before the accident. The CAB stated that any crew member requiring such medication should be removed from flight status, marking one of the first times mental health and pharmacological factors were officially cited as contributing to a major commercial air disaster.
Photographic Evidence (1)
Video Analysis
The Crash of Piedmont Flight 349 — A detailed look at the 1959 crash of a Piedmont Airlines DC-3 into Bucks Elbow Mountain and the subsequent investigation into the captain's mental state.
If playback is blocked, the owner has disabled embedding — use the link above.
Airframe & Maintenance
Crew Experience
Captain
Captain George Lavrinc was undergoing psychotherapy for severe emotional stress and had been prescribed Prozine.
First Officer
First Officer Bascom Haley.
Systems & Failure Modes
Casanova VOR
A Very High Frequency Omnidirectional Range station used for navigation; the crew failed to track the correct radial outbound from this station.
Instrument Landing System (ILS)
The crew was attempting an ILS approach to Charlottesville, but the lateral error placed them outside the system's reliable coverage area.
Interesting Facts
- 01The aircraft was a Douglas DC-3 named 'Buckeye Pacemaker', construction number 20447.
- 02The aircraft previously flew with Meteor Air Transport as N53593 before being sold to Piedmont in 1956.
- 03The sole survivor was found still strapped into his seat, which had been thrown clear of the fuselage.
- 04The captain was under the care of a psychiatrist and had been prescribed the tranquilizer Prozine.
- 05The crash site was located 13 miles west of the Charlottesville-Albemarle County Airport.
- 06The aircraft was at its maximum allowable takeoff weight of 25,346 pounds.
Safety Actions & Advisories
Drug Use Regulation Re-examination
The CAB recommended a re-examination of Civil Air Regulations regarding the use of psychopharmacological drugs by flight crew members, stating pilots requiring tranquilizers should be grounded.
Known Controversies & Unanswered Questions
ALPA Navigational Beacon Theory
Reference ↗The Air Line Pilots Association disputed the pilot error finding, suggesting that faulty radio beacons or interference from a private beacon in Hagerstown, Maryland, could have led the crew off course.