ANC15LA033

NTSB accident investigation · Cessna 185 · Talkeetna, AK · June 1, 2015

Accident · Serious injuriesLimited investigationFinal report
Date
May 31, 2015, 17:20 local (Jun 1, 2015, 01:20 UTC)
Place
Talkeetna, AK
Injuries
1 serious, 1 minor, 4 uninjured
Phase of flight
Approach
Aircraft
N1694MCessna 185N8525UCessna 172
Defining events
Approach-VFR pattern final: Midair collisionApproach-VFR pattern final: Midair collision
Weather
Visual (VMC) · Day
Status
Completed · report July 11, 2016
Report
Approved by Office Director
NTSB office
Alaska Regional Office
Parties
FAA
Case key
91276

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The other pilot’s failure to maintain an adequate visual lookout, which resulted in a midair collision. Contributing to the accident was the other pilot’s failure to follow Federal Aviation Administration-recommended traffic pattern procedures.

The pilot’s failure to maintain an adequate visual lookout, which resulted in a midair collision. Contributing to the accident was the pilot's failure to follow Federal Aviation Administration-recommended traffic pattern procedures.

Findings · 4

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

N1694M · Cessna 185

Use of equip/info: use of policy/procedurePersonnel issues › Task performance · PilotCessna A185E: 1 caseAll aircraft: 191 casesProbable cause

N8525U · Cessna 172

Attention/monitoring: monitoring other aircraftPersonnel issues › Psychological · Pilot of other aircraftCessna 172F: 4 casesAll aircraft: 231 casesProbable cause
Use of equip/info: use of policy/procedurePersonnel issues › Task performance · Pilot of other aircraftCessna 172F: 1 caseAll aircraft: 191 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

N1694M · Cessna 185

Midair collisionApproach-VFR pattern finalCessna A185E: 1 caseAll aircraft: 196 casesDefining event

N8525U · Cessna 172

Midair collisionApproach-VFR pattern finalCessna 172F: 1 caseAll aircraft: 196 casesDefining event

Analysis

A Cessna 185 airplane was operating as a commercial air tour flight with five passengers on board in day, visual meteorological conditions. A student pilot was operating a Cessna 172 as a solo cross-country flight; both aircraft were landing on the same runway. The Cessna 185 entered the traffic pattern on an extended right base about 2.5 miles from the end of the runway, and the pilot was following procedures established by local commercial air tour operators, which did not include information about reporting points or describe nonstandard traffic pattern entry procedures; this information is contained in Federal Aviation Administration (FAA) publications. The other airplane was also in the right traffic pattern for the same runway, and the student pilot was following the prescribed, FAA-recommended right traffic pattern procedures. A review of recorded radio communications from the common traffic advisory frequency revealed that the student pilot made position reports 10 miles from the airport, 5 miles from the airport, directly over midfield, on the right downwind leg, and when turning from the base to final leg. The commercial pilot made two position reports: one at a visual flight rules reporting point and a second one during which he stated that he was No. 2 on the base leg for the runway even though he was actually No. 3. The student pilot turned his airplane onto the final approach leg behind the airplane that was No. 2 on the base leg for the runway. While on short final, the Cessna 185 impacted the Cessna 172 from behind, above, and slightly to the right, which resulted in the Cessna 185 straddling the Cessna 172. The two airplanes remained conjoined until ground impact. The commercial pilot reported that he never saw the other airplane. If the commercial pilot had followed the FAA-recommended traffic pattern procedures, he might have been able to see the Cessna 172 and avoid hitting it.

A Cessna 185 airplane was operating as a commercial air tour flight with five passengers on board in day, visual meteorological conditions. A student pilot was operating a Cessna 172 as a solo cross-country flight; both aircraft were landing on the same runway. The Cessna 185 entered the traffic pattern on an extended right base about 2.5 miles from the end of the runway, and the pilot was following procedures established by local commercial air tour operators, which did not include information about reporting points or describe nonstandard traffic pattern entry procedures; this information is contained in Federal Aviation Administration (FAA) publications. The other airplane was also in the right traffic pattern for the same runway, and the student pilot was following the prescribed, FAA-recommended right traffic pattern procedures. A review of recorded radio communications from the common traffic advisory frequency revealed that the student pilot made position reports 10 miles from the airport, 5 miles from the airport, directly over midfield, on the right downwind leg, and when turning from the base to final leg. The commercial pilot made two position reports: one at a visual flight rules reporting point and a second one during which he stated that he was No. 2 on the base leg for the runway even though he was actually No. 3. The student pilot turned his airplane onto the final approach leg behind the airplane that was No. 2 on the base leg for the runway. While on short final, the Cessna 185 impacted the Cessna 172 from behind, above, and slightly to the right, which resulted in the Cessna 185 straddling the Cessna 172. The two airplanes remained conjoined until ground impact. The commercial pilot reported that he never saw the other airplane. If the commercial pilot had followed the FAA-recommended traffic pattern procedures, he might have been able to see the Cessna 172 and avoid hitting it.

Factual narrative

On May 31, 2015, about 1720 Alaska daylight time (AKD), a wheel-ski equipped Cessna 185 airplane, N1694M, and tricycle gear equipped Cessna 172 airplane, N8525U, collided midair while landing at Talkeetna Airport, Talkeetna, Alaska. The Cessna 185 was registered to, and operated by, Talkeetna Air Taxi, Inc., Talkeetna, as a visual flight rules (VFR) on-demand commercial air tour under the provisions of Title 14 Code of Federal Regulation (CFR) Part 135 when the accident occurred. The commercial pilot and three of the four passengers sustained no injuries, with the fourth passenger sustaining minor injuries. The Cessna 172 was registered to Artic's Air Academy, LLC, Palmer, Alaska, and operated by the student pilot as a VFR cross-country flight under the provisions of Title 14 CFR Part 91. The student pilot, and sole occupant of the airplane, sustained serious injuries. Visual meteorological conditions prevailed in the area at the time of the accident. The Cessna 185 departed Talkeetna Airport about 1456 for a flight seeing tour around Denali National Park, and a VFR flight plan was on file. The Cessna 172 departed Palmer Airport, Palmer, about 1625, destined for Talkeetna airport with no flight plan on file. During a telephone conversation with the National Transportation Safety Board (NTSB) investigator-in-charge (IIC) on June 1, 2015, the pilot of the Cessna 185 stated that while approaching Talkeetna (TKA), he was the fifth commercial air tour airplane in sequence for landing. He remembered hearing the Cessna 172 make a radio transmission stating his position as 10 miles south of the airport, but did not remember any other transmissions. He also stated that he did not see the Cessna 172. In an interview with the NTSB IIC and an FAA air safety inspector on June 4, 2015, the pilot of the Cessna 172 stated that he was conducting a solo cross-country flight from Palmer to Talkeetna when the accident occurred. As he approached the traffic pattern, he saw two airplanes operated by another commercial operator and heard them make a radio transmission that they were on final approach. After watching the two airplanes pass, the pilot turned onto the final approach segment of the traffic pattern. When he was in a position to land, he reduced power and added full flaps. Just before starting to flare, about 20-30 feet above the ground, he heard what he described as a loud "unworldly" sound. He felt the airplane get hit and pushed forward. At that point, the airplane descended at an estimated 45-degree angle until impact with the ground. After the collision, both airplanes remained joined together during and after impact with the ground. The debris field was about 460 feet long with the initial fragments located about 62 feet prior to the runway threshold. The main wreckage came to rest about 5 feet off of the left side of the runway with the Cessna 185 on top of the Cessna 172. Talkeetna Airport (TKA) is a public airport in Class E airspace between thehours of 1700-0500 universal coordinated time (UTC), and Class G airspace all other times. It is not served by an operating control tower. There are two main runways, 18 and 36, with 18 having a right traffic pattern and 36 having a left traffic pattern. An FAA Flight Service Station (FSS) is located on the airport property and provides local airport advisories to aircraft operating in the area. It was staffed with one air traffic control specialist at the time of the accident. During a review of FAA FSS recordings of the common traffic advisory frequency (CTAF) 123.6, both airplanes can be heard transmitting position reports in relation to the airport traffic pattern. At 1706, AKD [0106:44 universal coordinated time (UTC)], the pilot of the Cessna 172 reported his position as 10 miles south of TKA and requested traffic advisories. The FSS replied advising pilot of four arrivals, three from the northwest and one from the west that was landing at the village strip. The three arrivals from the northwest were using the callsigns 5FK, 44Q, and 424KT. About 1708:56, the pilot of N727KT reported being over "Chase," which is a visual flight rules (VFR) reporting point for TKA. At 1709:50, the Cessna 185 pilot said "Talkeetna radio one six niner four mike is uh chase two thousand with kilo one eight and the traffic." FSS replied "November one six niner four mike Talkeetna radio thank you." "Chase" is a VFR reporting point located about 8 miles northwest of TKA. At 1710:01, the Cessna 172 pilot reported his location as about 5 miles south with intentions to overfly the airport midfield at 2,500 feet and enter a right downwind traffic pattern leg for runway 18. About 1710:39, the pilot of N320KT reported being over "chase." At 1711:34, the Cessna 172 pilot stated that he was flying over midfield at 2,200 feet and would be entering the traffic pattern on a right downwind for runway 18. At 1713:01, the Cessna 172 pilot reported that he was right downwind for runway 18. At 1713:08, the Cessna 185 pilot reported "niner four mike's right base number two one eight," when actually he was number three in the sequence behind N727KT and N320KT. About 1713:15, the pilot of N727KT reported clear of runway 18. At 1714:15, the Cessna 172 pilot reported that he was "on base to final runway 18." About 1714:22, the pilot of N320KT reported clear of runway 18. At 1715:18, the FSS air traffic control specialist asks if the Cessna 185 is okay, after witnessing the collision between the Cessna 185 and the Cessna 172. A transcript of the CTAF recording is located in the public docket for this accident. A Garmin 296 handheld GPS was located in the wreckage of the Cessna 185. The unit was sent to the NTSB Vehicle Recorders Laboratory in Washington D.C. for examination. A NTSB electrical engineer was able to extract the GPS data for the accident flight, which included, in part: time, latitude, longitude, and GPS altitude. Groundspeed and course information were derived from theextracted parameters. The GPS data logs for May 31, 2015, revealed that the airplane entered the traffic pattern on a right base leg about 2.5 miles from the end of the runway. The Alaska Supplement in effect on the day of the accident contained a statement for the Talkeetna Airport "See Section C notices for tfc pattern information." The Section C notice contained only a pictorial display of a right traffic pattern, but no reference to reporting points, including "Chase" or written description of non-standard traffic pattern entry procedures. The Anchorage Sectional Aeronautical Chart with an effective date of May 28, 2015, displayed "Chase" and one other VFR waypoint for TKA. The sectional chart located in the aircraft of the Cessna 172 was the previous edition and was no longer current. This previous chart did not contain the VFR waypoints. The FAA Aeronautical Information Manual (AIM) recommends inbound pilots to non-towered airports announce their position 10 miles from the airport, entering the downwind leg, base leg, final approach leg and when exiting the runway. 14 CFR 91.113(g) states, in part: "When two or more aircraft are approaching an airport for the purpose of landing, the aircraft at the lower altitude has the right-of-way, but it shall not take advantage of this rule to cut in front of another which is on final approach to land or to overtake that aircraft." The FAA Airplane Flying Handbook (FAA-H-8083-3A) states "Compliance with the basic rectangular traffic pattern reduces the possibility of conflicts at airports without an operating control tower." It further states "When entering the traffic pattern at an airport without an operating control tower, inbound pilots are expected to observe other aircraft already in the pattern and to conform to the traffic pattern in use." The Handbook recommends entering the traffic pattern at a 45° angle to the downwind leg of the runway to be utilized. A flight track map overlay, and tabular data corresponding to the accident flight are available in the public docket for this accident. The closest weather reporting facility is Talkeetna Airport, Talkeetna. At 1653, an aviation routine weather report (METAR) at Talkeetna, reported in part: wind 350 at 4 knots; visibility 10 statute miles; sky condition, clear; temperature, 78 degrees F; dew point 39 degrees F; altimeter 29.76 inHg.

On May 31, 2015, about 1720 Alaska daylight time (AKD), a wheel-ski equipped Cessna 185 airplane, N1694M, and a tricycle gear equipped Cessna 172 airplane, N8525U, collided midair while landing at Talkeetna Airport, Talkeetna, Alaska. The Cessna 185 was registered to, and operated by, Talkeetna Air Taxi, Inc., Talkeetna, as a visual flight rules (VFR) on-demand commercial air tour, under the provisions of Title 14 Code of Federal Regulation (CFR) Part 135, when the accident occurred. The commercial pilot and three of the four passengers sustained no injuries, with the fourth passenger sustaining minor injuries. The Cessna 172 was registered to Artic's Air Academy, LLC, Palmer, Alaska, and operated by the student pilot as a VFR cross-country flight under the provisions of Title 14 CFR Part 91. The student pilot, and sole occupant of the airplane, sustained serious injuries. Visual meteorological conditions prevailed in the area at the time of the accident. The Cessna 185 departed Talkeetna Airport about 1456 for a flight seeing tour around Denali National Park, and a VFR flight plan was on file. The Cessna 172 departed Palmer Airport, Palmer, about 1625, destined for Talkeetna airport with no flight plan on file. During a telephone conversation with the National Transportation Safety Board (NTSB) investigator-in-charge (IIC) on June 1, 2015, the pilot of the Cessna 185 stated that while approaching Talkeetna (TKA), he was the fifth commercial air tour airplane in sequence for landing. He remembered hearing the Cessna 172 make a radio transmission stating his position as 10 miles south of the airport, but did not remember any other transmissions. He also stated that he did not see the Cessna 172. In an interview with the NTSB IIC and an FAA air safety inspector on June 4, 2015, the pilot of the Cessna 172 stated that he was conducting a solo cross-country flight from Palmer to Talkeetna when the accident occurred. As he approached the traffic pattern, he saw two airplanes operated by another commercial operator and heard them make a radio transmission that they were on final approach. After watching the two airplanes pass, the pilot turned onto the final approach segment of the traffic pattern. When he was in a position to land, he reduced power and added full flaps. Just before starting to flare, about 20-30 feet above the ground, he heard what he described as a loud "unworldly" sound. He felt the airplane get hit and pushed forward. At that point, the airplane descended at an estimated 45-degree angle until impact with the ground. After the collision, both airplanes remained joined together during and after impact with the ground. The debris field was about 460 feet long with the initial fragments located about 62 feet prior to the runway threshold. The main wreckage came to rest about 5 feet off of the left side of the runway with the Cessna 185 on top of the Cessna 172. Talkeetna Airport (TKA) is a public airport in Class E airspace betweenthe hours of 1700-0500 universal coordinated time (UTC), and Class G airspace all other times. It is not served by an operating control tower. There are two main runways, 18 and 36, with 18 having a right traffic pattern and 36 having a left traffic pattern. An FAA Flight Service Station (FSS) is located on the airport property and provides local airport advisories to aircraft operating in the area. It was staffed with one air traffic control specialist at the time of the accident. During a review of FAA FSS recordings of the common traffic advisory frequency (CTAF) 123.6, both airplanes can be heard transmitting position reports in relation to the airport traffic pattern. At 1706, AKD [0106:44 universal coordinated time (UTC)], the pilot of the Cessna 172 reported his position as 10 miles south of TKA and requested traffic advisories. The FSS replied advising pilot of four arrivals, three from the northwest and one from the west that was landing at the village strip. The three arrivals from the northwest were using the callsigns 5FK, 44Q, and 424KT. About 1708:56, the pilot of N727KT reported being over "Chase," which is a visual flight rules (VFR) reporting point for TKA. At 1709:50, the Cessna 185 pilot said "Talkeetna radio one six niner four mike is uh chase two thousand with kilo one eight and the traffic." FSS replied "November one six niner four mike Talkeetna radio thank you." "Chase" is a VFR reporting point located about 8 miles northwest of TKA. At 1710:01, the Cessna 172 pilot reported his location as about 5 miles south with intentions to overfly the airport midfield at 2,500 feet and enter a right downwind traffic pattern leg for runway 18. About 1710:39, the pilot of N320KT reported being over "chase." At 1711:34, the Cessna 172 pilot stated that he was flying over midfield at 2,200 feet and would be entering the traffic pattern on a right downwind for runway 18. At 1713:01, the Cessna 172 pilot reported that he was right downwind for runway 18. At 1713:08, the Cessna 185 pilot reported "niner four mike's right base number two one eight," when actually he was number three in the sequence behind N727KT and N320KT. About 1713:15, the pilot of N727KT reported clear of runway 18. At 1714:15, the Cessna 172 pilot reported that he was "on base to final runway 18." About 1714:22, the pilot of N320KT reported clear of runway 18. At 1715:18, the FSS air traffic control specialist asks if the Cessna 185 is okay, after witnessing the collision between the Cessna 185 and the Cessna 172. A transcript of the CTAF recording is located in the public docket for this accident. A Garmin 296 handheld GPS was located in the wreckage of the Cessna 185. The unit was sent to the NTSB Vehicle Recorders Laboratory in Washington D.C. for examination. A NTSB electrical engineer was able to extract the GPS data for the accident flight, which included, in part: time, latitude, longitude, and GPS altitude. Groundspeed and course information were derived fromthe extracted parameters. The GPS data logs for May 31, 2015, revealed that the airplane entered the traffic pattern on a right base leg about 2.5 miles from the end of the runway. The Alaska Supplement in effect on the day of the accident contained a statement for the Talkeetna Airport "See Section C notices for tfc pattern information." The Section C notice contained only a pictorial display of a right traffic pattern, but no reference to reporting points, including "Chase" or written description of non-standard traffic pattern entry procedures. The Anchorage Sectional Aeronautical Chart with an effective date of May 28, 2015, displayed "Chase" and one other VFR waypoint for TKA. The sectional chart located in the aircraft of the Cessna 172 was the previous edition and was no longer current. This previous chart did not contain the VFR waypoints. The FAA Aeronautical Information Manual (AIM) recommends inbound pilots to non-towered airports announce their position 10 miles from the airport, entering the downwind leg, base leg, final approach leg and when exiting the runway. 14 CFR 91.113(g) states, in part: "When two or more aircraft are approaching an airport for the purpose of landing, the aircraft at the lower altitude has the right-of-way, but it shall not take advantage of this rule to cut in front of another which is on final approach to land or to overtake that aircraft." The FAA Airplane Flying Handbook (FAA-H-8083-3A) states "Compliance with the basic rectangular traffic pattern reduces the possibility of conflicts at airports without an operating control tower." It further states "When entering the traffic pattern at an airport without an operating control tower, inbound pilots are expected to observe other aircraft already in the pattern and to conform to the traffic pattern in use." The Handbook recommends entering the traffic pattern at a 45° angle to the downwind leg of the runway to be utilized. A flight track map overlay, and tabular data corresponding to the accident flight are available in the public docket for this accident. The closest weather reporting facility is Talkeetna Airport, Talkeetna. At 1653, an aviation routine weather report (METAR) at Talkeetna reported in part: wind 350 at 4 knots; visibility 10 statute miles; sky condition clear; temperature 78 degrees F; dew point 39 degrees F; altimeter 29.76 inHg.

Aircraft · 2

Registration
N1694M
Reported as
Cessna 185
Category
Airplane
Serial number
18501879
Built
1971
Airframe hours
9,267
Engine
Continental IO-550D, 300 horsepower, reciprocating
Damage
Substantial damage
Flight
Part 135
Operator
Talkeetna Air Taxi Inc
Registered owner
Talkeetna Air Taxi Inc
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · May 18, 2015 · 38 hours before
Departed
TKA · Talkeetna, AK
Destination
TKA · Talkeetna, AK
Flight plan
VFR
Airport
TKA · Talkeetna, runway 18, 3,500 × 75 ft, asphalt
Equipment
Handheld GPS

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Registration
N8525U
Reported as
Cessna 172
Category
Airplane
Serial number
17252425
Built
1964
Engine
Lycoming O-320-E2D, 150 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Airworthiness certificate
Standard, Normal
Departed
PAQ · Palmer, AK
Destination
TKA · Talkeetna, AK
Airport
TKA · Talkeetna, runway 18, 3,500 × 75 ft, asphalt
Equipment
Stall warning system

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot, aircraft N1694M
Age
32
Injuries
None
Certificate
Commercial
Airplane ratings
Single-engine sea, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
May 14, 2015
Seat
Left
Restraint
4-point
Flight hours
731.9 total · 28.1 in this make and model · 641.2 as pilot in command · 73.6 in the last 90 days · 37.4 in the last 30 days · 4.8 in the last 24 hours
Role
Pilot, aircraft N8525U
Age
27
Injuries
Serious
Certificate
Student
Medical
Class 3, With waivers/limitations
Seat
Left
Flight hours
38.9 total

Weather

Conditions
Visual (VMC) · Day
Wind
350° at 4 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
79 °F, dew point 25 °F
Altimeter
29.76 inHg
Observed at
PATK

Docket · 10

The files NTSB released with the investigation on May 23, 2016, on NTSB’s docket system: statements, records, photos and specialists’ reports. 5.7 MB in all.

FAA reports on this event · 2

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.

Other investigations on N1694M · 3

Matched to the same aircraft by N-number and date.