ATL00FA091

NTSB accident investigation · Piper PA-28-161 · Ft. Pierce, FL · September 11, 2000

Accident · FatalField investigationFinal report
Date
September 11, 2000, 12:46 local (16:46 UTC)
Place
Ft. Pierce, FL
Injuries
2 fatal
Phase of flight
Approach
Aircraft
N9208NPiper PA-28-161N54325Piper PA-23-250
Weather
Visual (VMC) · Not reported
Status
Completed · report December 4, 2001
Report
Approved by Office Director
FAA report
20000911016289A
Case key
50240

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

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Probable cause

Failure of local controller to provide adequate spacing between two airplanes that resulted in a midair collision. Contributing Factors: the local controller declined receiving a formal brief before relieving the controller on duty. The controller who was relieved failed to ensure proper briefing of local traffic.

Failure of local controller to provide adequate spacing between two airplanes that resulted in a midair collision. Contributing Factors: the local controller declined receiving a formal brief before relieving the controller on duty. The controller who was relieved failed to ensure proper briefing of local traffic.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Midair collisionApproach - vfr pattern - final approach
Visual separation - not maintainedAtc personnel(lcl/gnd/clnc)Cause
Crew/group briefing - disregardedAtc personnel(lcl/gnd/clnc)Factor
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - ground
Midair collisionApproach - vfr pattern - final approach
Visual separation - not maintainedAtc personnel(lcl/gnd/clnc)Cause
Crew/group briefing - disregardedAtc personnel(lcl/gnd/clnc)Cause
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - ground

Analysis

A Cherokee was in the traffic pattern executing touch and go landing, and the Aztec was inbound to the airport. The Cherokee and the Aztec collided in-flight in controlled airspace, while under the control of the local controller. There was a shift change at the control tower a few minutes prior to the midair collision. The relieving local controller declined a formal briefing of the location of traffic because he was busy. .

A Cherokee was in the traffic pattern executing touch and go landing, and the Aztec was inbound to the airport. The Cherokee and the Aztec collided in-flight in controlled airspace, while under the control of the local controller. There was a shift change at the control tower a few minutes prior to the midair collision. The relieving local controller declined a formal briefing of the location of traffic because he was busy.

Factual narrative

History of flight

On September 11, 2000, at 1246 eastern daylight time, a PA-28-161 (Cherokee), N9208N, and a PA-23-250 (Aztec), N54235, collided on final approach to land on runway 09 at the Saint Lucie International Airport in Fort Pierce, Florida. The Cherokee was operated by Flight Safety International and the Aztec was operated by the airline transport pilot under the provisions of Title 14 CFR Part 91 with no flight plans filed. Visual weather conditions prevailed at the time of the collision. The air transport pilot onboard the Aztec, and the private pilot, a Saudi Arabian citizen, onboard the Cherokee, both received fatal injuries. Both airplanes were destroyed. The Cherokee instructional flight departed Vero Beach, Florida, on a solo training flight at approximately 1220, and the Aztec departed Okeechobee, Florida, after refueling, at approximately 1230.

According to the information recovered from the Saint Lucie County Airport Air Traffic Control Tower recordings, at 1227:50, the pilot of the Cherokee radioed the tower that he was seven miles northeast of the airport inbound for touch and go landings. The pilot was instructed to report two miles northeast for a left downwind for runway 09. At 1235:29, the Cherokee was cleared for the first touch and go landing. After the landing, and as the Cherokee had reentered the traffic pattern, at 1240:16, the tower controller instructed the pilot of the Cherokee to execute a 360 degree right turn on downwind for spacing.

At 1242:06, the pilot of the Aztec, radioed the tower controller and reported 10 miles west of the airport inbound for landing. The pilot was instructed to continue straight-in and to report over the interstate. At 1245:25, the pilot of the Aztec, reported over the interstate for runway 09. The tower controller instructed the pilot of the Aztec to follow the Cherokee, who was turning base to a three mile final to runway 09. The pilot of the Aztec reported "we're looking for the Cherokee." At 1246:19, the tower controller asked the pilot of the Aztec "do you have the Cherokee off of your left wing?" The pilot of the Aztec report, "no contact." At 1646:34, the controller asked the Cherokee if he had "an Aztec alongside of ya out there?" The pilot of the Cherokee replied, "ah negative sir." The controller then told the Cherokee to "over fly runway niner, make left traffic." No response was noted from the Cherokee pilot.

At 1247, another airplane flying above the airport reported that they had just witnessed an in-flight collision three miles from the end of runway 09.

Personnel information

The pilot of the PA-28-161 (Cherokee) held a student pilot certificate. His total flight time in the Cherokee was 17.6 hours, but his total flight time in all aircraft was undetermined. The pilot also had a foreign based private pilot license from the Philippines. The pilot held a current first class medical certificate, dated May 16, 2000, with no limitations or waivers.

The pilot of the PA-23-250 (Aztec) held an airline transport pilot multi-engine land, a type rating in EMB-120, commercial pilot single-engine land, and instrument ratings. Included also were certified flight instructor single and multi-engine instrument airplane ratings. His total flight time was 7438 hours and the approximate flying time in the PA-23-250 was not determined. The pilot held a current second-class medical certificate, dated September 14, 1999, with no limitations or waivers.

Aircraft information

The PA-28-161, N9208N, was owned and operated by Flight Safety International, of Vero Beach, Florida. N9208N was a low-wing airplane powered by a Lycoming O-320-D36 engine. A review of the airplane maintenance logbooks showed that the last maintenance inspection was on September 8, 2000.

The PA-23-250, N54235, was owned by St. Lucia Petroleum, of Port St. Lucia, Florida. The airplane was operated by Roger M. Boromei of Okeechobee, Florida. N7317A was a low-wing multi-engine airplane powered by two Lycoming IO-540-C4B5 engines. A review of the airplane maintenance logbooks showed that the last maintenance inspection was September 1, 1999.

Meteorological information

Ft. Pierces St. Lucie County International Airport, in Florida, 1053, weather observation reported a scattered cloud layer, visibility 10 miles, wind 090 degrees at nine knots.

Airport information

Ft. Pierces St. Lucie County International Airport, in Florida, has two runways: 14/32 and 09/27. At the time of the accident, runway 09 was in use.

The Ft. Pierce air traffic control tower is operated by Federal Aviation Administration. The facility operates from 0700 to 2100 daily. There is no radar at the airport, nor does the tower have any type of radar display to augment airport operations.

Wreckage and impact information

Examination of the accident site disclosed that both airplanes were 2.7 miles west of runway 09, and were within several feet of the extended centerline of the landing runway. The Cherokee was found inverted orientated on an easterly magnetic heading, and the Aztec was found in a near vertical nose down attitude orientated on a northeasterly magnetic heading. Both airplanes were located approximately 75 feet apart in a citrus fruit grove. Further examination of the damaged airplanes showed two diagonal slashes on the bottom-side of the Cherokee at a position near the right wing root, and at another position several inches inboard of the right wing tip. Chordwise damage was observed on both of the propeller blades on the Aztec.

Cherokee

The right wing remained attached to the Cherokee. The mid portion of the aileron, approximately five feet, was attached to the center hinge. Inboard ten feet of the aileron was separated, but remained attached to the inboard hinge. The flap was bent in a "V" shape, 35 inches outboard of the flap root, and the lower wing skin aft of the main spar between the wing root and the main gear was destroyed with exposed aileron cables.

The right flap had a prop strike measuring nine inches starting at the root of the flap, the second prop strike is forward of the flap and is 15 inches in length.

The right stabilator, starting at the root and trailing edge has a semi circular indention approximately 16 inches wide, and is bent downward 15 inches. There is black smearing apparent at the outboard edge of the anti servo trim tab.

The left wing remained attached to the fuselage. The fuel tank separated at the leading edge, and 27 rivets sheared. The stall strips were attached, and bent in a "V" shape. Outboard eight feet of the wings' leading edge was deformed. There were black smear marks 13 inches apart.

The vertical stabilator was flattened even with the tail cone. The rudder is separated from the vertical stabilator, but remained attached to the torque tube. The left stabilator has blue paint transfer starting at the leading edge root extending out 17 inches.

The right stabilator leading edge was deformed. A tear was noted on the stabilator skin, and the inboard trailing edge skin is crushed and wrinkled.

The right anti-servo was bent downward and had heavy black smearing. The left anti-servo tab was bent downward with black smearing. There is heavy black smearing aft of the forward tail cone rivet line which extends to the rear bulkhead.

Aztec

The left tail cone is crushed inboard approximately three inches located at the dorsal fin. The right tail cone is crushed inboard approximately 17 inches located at the dorsal fin.

The left wing is separated at the wing root, and the entire leading edge is crushed aft to the main spar outboard to the nacelle. The leading edge material nacelle to the tip is separated and destroyed. The aileron remained attached to three hinges, the outboard 12 inches of aileron is crushed up and aft a few inches. Aileron connecting rod is separated at t

History of flight

On September 11, 2000, at 1246 eastern daylight time, a PA-28-161 (Cherokee), N9208N, and a PA-23-250 (Aztec), N54235, collided on final approach to land on runway 09 at the Saint Lucie International Airport in Fort Pierce, Florida. The Cherokee was operated by Flight Safety International and the Aztec was operated by the airline transport pilot under the provisions of Title 14 CFR Part 91 with no flight plans filed. Visual weather conditions prevailed at the time of the collision. The air transport pilot onboard the Aztec, and the private pilot, a Saudi Arabian citizen, onboard the Cherokee, both received fatal injuries. Both airplanes were destroyed. The Cherokee instructional flight departed Vero Beach, Florida, on a solo training flight at approximately 1220, and the Aztec departed Okeechobee, Florida, after refueling, at approximately 1230.

According to the information recovered from the Saint Lucie County Airport Air Traffic Control Tower recordings, at 1227:50, the pilot of the Cherokee radioed the tower that he was seven miles northeast of the airport inbound for touch and go landings. The pilot was instructed to report two miles northeast for a left downwind for runway 09. At 1235:29, the Cherokee was cleared for the first touch and go landing. After the landing, and as the Cherokee had reentered the traffic pattern, at 1240:16, the tower controller instructed the pilot of the Cherokee to execute a 360 degree right turn on downwind for spacing.

At 1242:06, the pilot of the Aztec, radioed the tower controller and reported 10 miles west of the airport inbound for landing. The pilot was instructed to continue straight-in and to report over the interstate. At 1245:25, the pilot of the Aztec, reported over the interstate for runway 09. The tower controller instructed the pilot of the Aztec to follow the Cherokee, who was turning base to a three mile final to runway 09. The pilot of the Aztec reported "we're looking for the Cherokee." At 1246:19, the tower controller asked the pilot of the Aztec "do you have the Cherokee off of your left wing?" The pilot of the Aztec report, "no contact." At 1646:34, the controller asked the Cherokee if he had "an Aztec alongside of ya out there?" The pilot of the Cherokee replied, "ah negative sir." The controller then told the Cherokee to "over fly runway niner, make left traffic." No response was noted from the Cherokee pilot.

At 1247, another airplane flying above the airport reported that they had just witnessed an in-flight collision three miles from the end of runway 09.

Personnel information

The pilot of the PA-28-161 (Cherokee) held a student pilot certificate. His total flight time in the Cherokee was 17.6 hours, but his total flight time in all aircraft was undetermined. The pilot also had a foreign based private pilot license from the Philippines. The pilot held a current first class medical certificate, dated May 16, 2000, with no limitations or waivers.

The pilot of the PA-23-250 (Aztec) held an airline transport pilot multi-engine land, a type rating in EMB-120, commercial pilot single-engine land, and instrument ratings. Included also were certified flight instructor single and multi-engine instrument airplane ratings. His total flight time was 7438 hours and the approximate flying time in the PA-23-250 was not determined. The pilot held a current second-class medical certificate, dated September 14, 1999, with no limitations or waivers.

Aircraft information

The PA-28-161, N9208N, was owned and operated by Flight Safety International, of Vero Beach, Florida. N9208N was a low-wing airplane powered by a Lycoming O-320-D36 engine. A review of the airplane maintenance logbooks showed that the last maintenance inspection was on September 8, 2000.

The PA-23-250, N54235, was owned by St. Lucia Petroleum, of Port St. Lucia, Florida. The airplane was operated by Roger M. Boromei of Okeechobee, Florida. N7317A was a low-wing multi-engine airplane powered by two Lycoming IO-540-C4B5 engines. A review of the airplane maintenance logbooks showed that the last maintenance inspection was September 1, 1999.

Meteorological information

Ft. Pierces St. Lucie County International Airport, in Florida, 1053, weather observation reported a scattered cloud layer, visibility 10 miles, wind 090 degrees at nine knots.

Airport information

Ft. Pierces St. Lucie County International Airport, in Florida, has two runways: 14/32 and 09/27. At the time of the accident, runway 09 was in use.

The Ft. Pierce air traffic control tower is operated by Federal Aviation Administration. The facility operates from 0700 to 2100 daily. There is no radar at the airport, nor does the tower have any type of radar display to augment airport operations.

Wreckage and impact information

Examination of the accident site disclosed that both airplanes were 2.7 miles west of runway 09, and were within several feet of the extended centerline of the landing runway. The Cherokee was found inverted orientated on an easterly magnetic heading, and the Aztec was found in a near vertical nose down attitude orientated on a northeasterly magnetic heading. Both airplanes were located approximately 75 feet apart in a citrus fruit grove. Further examination of the damaged airplanes showed two diagonal slashes on the bottom-side of the Cherokee at a position near the right wing root, and at another position several inches inboard of the right wing tip. Chordwise damage was observed on both of the propeller blades on the Aztec.

Cherokee

The right wing remained attached to the Cherokee. The mid portion of the aileron, approximately five feet, was attached to the center hinge. Inboard ten feet of the aileron was separated, but remained attached to the inboard hinge. The flap was bent in a "V" shape, 35 inches outboard of the flap root, and the lower wing skin aft of the main spar between the wing root and the main gear was destroyed with exposed aileron cables.

The right flap had a prop strike measuring nine inches starting at the root of the flap, the second prop strike is forward of the flap and is 15 inches in length.

The right stabilator, starting at the root and trailing edge has a semi circular indention approximately 16 inches wide, and is bent downward 15 inches. There is black smearing apparent at the outboard edge of the anti servo trim tab.

The left wing remained attached to the fuselage. The fuel tank separated at the leading edge, and 27 rivets sheared. The stall strips were attached, and bent in a "V" shape. Outboard eight feet of the wings' leading edge was deformed. There were black smear marks 13 inches apart.

The vertical stabilator was flattened even with the tail cone. The rudder is separated from the vertical stabilator, but remained attached to the torque tube. The left stabilator has blue paint transfer starting at the leading edge root extending out 17 inches.

The right stabilator leading edge was deformed. A tear was noted on the stabilator skin, and the inboard trailing edge skin is crushed and wrinkled.

The right anti-servo was bent downward and had heavy black smearing. The left anti-servo tab was bent downward with black smearing. There is heavy black smearing aft of the forward tail cone rivet line which extends to the rear bulkhead.

Aztec

The left tail cone is crushed inboard approximately three inches located at the dorsal fin. The right tail cone is crushed inboard approximately 17 inches located at the dorsal fin.

The left wing is separated at the wing root, and the entire leading edge is crushed aft to the main spar outboard to the nacelle. The leading edge material nacelle to the tip is separated and destroyed. The aileron remained attached to three hinges, the outboard 12 inches of aileron is crushed up and aft a few inches. Aileron connecting rod is separated at t

Aircraft · 2

Registration
N9208N
Reported as
Piper PA-28-161
Category
Airplane
Serial number
28-41008
Airframe hours
8,369
Engine
Lycoming O-320-D36, 160 horsepower, reciprocating
Damage
Destroyed
Flight
Instructional · Part 91
Registered owner
Flight Safety International
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · September 8, 2000
Departed
VRB · Vero Beach, FL
Airport
FPR · St. Lucie International, runway 9, 6,492 × 150 ft, asphalt

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
N54325
Reported as
Piper PA-23-250
Category
Airplane
Serial number
27-7554029
Airframe hours
8,381
Engine
Lycoming IO-540-C4B5, 250 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Operator
Roger M. Boromei
Registered owner
St. Lucie Petroleum
Airworthiness certificate
Standard, Normal
Last inspection
Annual · September 1, 1999 · 116 hours before
Departed
OBE · Okeechobee, FL
Destination
FPR
Airport
FPR · St. Lucie International, runway 9, 6,492 × 150 ft, asphalt

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot, aircraft N9208N
Age
39
Certificates
Private, Flight engineer
Airplane ratings
Single-engine land
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Toxicology
Performed
Flight hours
18 in this make and model · 18 in the last 30 days
Role
Pilot, aircraft N54325
Age
32
Certificates
Flight engineer, Commercial, Airline transport
Airplane ratings
Single-engine land, Single-engine sea, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
7,438 total

Weather

Conditions
Visual (VMC) · Not reported
Wind
90° at 9 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
187 °F, dew point 158 °F
Altimeter
30.00 inHg
Observed at
FPR, 3 nm away

FAA reports on this event · 1

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