# NTSB ATL90FA139: Piper PA-38-112, N2409K, Florence, AL, July 1, 1990

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Field investigation · Final report
- Date: July 1, 1990, 17:23 local (22:23 UTC)
- Place: Florence, AL
- Coordinates: 34.820373, -87.659416 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=34.8204&lon=-87.6594&mi=10
- Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping)
- Highest injury: Fatal
- Injuries: 4 fatal
- Status: Completed, report September 21, 1992
- Report: Approved by Office Director
- NTSB case key (mKey): 8138
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ATL90FA139
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/8138/pdf
- Page: https://openairdocs.org/ntsb/ATL90FA139

## Probable cause (aircraft 2)

FAILURE OF THE PILOT-IN-COMMAND OF N2409K TO MAINTAIN SAFE SEPARATION FROM N2437K DURING UNAUTHORIZED FORMATION MANEUVERING.  OVERCONFIDENCE IN PERSONAL ABILITY AND THE EXECUTION OF UNAUTHORIZED FORMATION FLIGHT ON THE PART OF BOTH PILOTS-IN-COMMAND WERE FACTORS IN THE ACCIDENT.  THE LACK OF TOTAL EXPERIENCE OF BOTH PILOTS-IN-COMMAND WAS ALSO A FACTOR IN THE ACCIDENT.

## Probable cause (aircraft 1)

FAILURE OF THE PILOT-IN-COMMAND OF N2409K TO MAINTAIN SAFE SEPARATION FROM N2437K DURING UNAUTHORIZED FORMATION MANEUVERING.  OVERCONFIDENCE IN PERSONAL ABILITY AND THE EXECUTIVE OF UNAUTHORIZED FORMATION FLIGHT ON THE PART OF BOTH PILOTS-IN-COMMAND WERE FACTORS IN THE ACCIDENT.  THE LACK OF TOTAL EXPERIENCE OF BOTH PILOTS-IN-COMMAND WAS ALSO A FACTOR IN THE ACCIDENT.

## Sequence of events

In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf).

- Midair collision, cruise - normal
  - in-flight planning/decision - improper, pilot in command (contributing factor)
  - overconfidence in personal ability, pilot in command (contributing factor)
  - in-flight planning/decision - improper, pilot of other aircraft (contributing factor)
  - overconfidence in personal ability, pilot of other aircraft (contributing factor)
  - procedures/directives - disregarded, pilot in command (contributing factor)
  - lack of total experience, pilot in command (contributing factor)
  - procedures/directives - disregarded, pilot of other aircraft (contributing factor)
  - lack of total experience, pilot of other aircraft (contributing factor)
  - clearance - not maintained, pilot of other aircraft (cause)
  - formation flying - improper, pilot of other aircraft (contributing factor)
- In flight collision with terrain/water, descent - uncontrolled
- Midair collision, maneuvering
  - in-flight planning/decision - improper, pilot in command (contributing factor)
  - overconfidence in personal ability, pilot in command (contributing factor)
  - in-flight planning/decision - improper, pilot of other aircraft (contributing factor)
  - overconfidence in personal ability, pilot of other aircraft (contributing factor)
  - procedures/directives - disregarded, pilot in command (contributing factor)
  - lack of total experience, pilot in command (contributing factor)
  - procedures/directives - disregarded, pilot of other aircraft (contributing factor)
  - lack of total experience, pilot of other aircraft (contributing factor)
  - clearance - not maintained, pilot in command (cause)
  - formation flying - improper, pilot in command (contributing factor)
- In flight collision with terrain/water, descent - uncontrolled

## Analysis (aircraft 2)

THE PILOTS OF TWO SIMILAR PA-38-112 AIRPLANES WERE FILED FOR SEPARATE VFR CROSS COUNTRY FLIGHTS. AFTER AN INTERMEDIATE STOPOVER AT AN AIRPORT AWAY FROM HOME BASE, THE TWO AIRPLANES JOINED UP AND BEGAN FLYING IN FORMATION. ACCORDING TO A WITNESS, THE TRAILING AIRPLANE (N2409K) COLLIDED WITH THE LEADING AIRPLANE (N2437K) FROM THE REAR WHILE MANEUVERING. IMPACT, PAINT AND RUBBER TRANSFER MARKS INDICATED THAT N2409K COLLIDED WITH N2437K FROM THE REAR, RIGHT SIDE. THE FLIGHT SCHOOL FROM WHICH THE PILOTS WERE ENROLLED EXPRESSLY PROHIBITED FORMATION FLYING OF ANY TYPE. THE PIC'S OF EACH AIRPLANE HAD LOGGED ABOUT 118 HOURS EACH PRIOR TO THE ACCIDENT, AND HAD RECEIVED THEIR PILOT CERTIFICATES THE MONTH PRIOR TO THE ACCIDENT. THE PILOTS AND PILOT RATED PASSENGERS WERE ALL SPANISH CITIZENS.

## Analysis (aircraft 1)

THE PILOTS OF TWO SIMILAR PA-38-112 AIRPLANES WERE FILED FOR SEPARATE VFR CROSS COUNTRY FLIGHTS. AFTER AN INTERMEDIATE STOPOVER AT AN AIRPORT AWAY FROM HOME BASE, THE TWO AIRPLANES JOINED UP AND BEGAN FLYING IN FORMATION. ACCORDING TO A WITNESS, THE TRAILING AIRPLANE (N2409K) COLLIDED WITH THE LEADING AIRPLANE (N2437K) FROM THE REAR WHILE MANEUVERING. IMPACT, PAINT AND RUBBER TRANSFER MARKS INDICATED THAT N2409K COLLIDED WITH N2437K FROM THE REAR, RIGHT SIDE. THE FLIGHT SCHOOL FROM WHICH THE PILOTS WERE ENROLLED EXPRESSLY PROHIBITED FORMATION FLYING OF ANY TYPE. THE PIC'S OF EACH AIRPLANE HAD LOGGED ABOUT 118 HOURS EACH PRIOR TO THE ACCIDENT, AND HAD RECEIVED THEIR PILOT CERTIFICATES THE MONTH PRIOR TO THE ACCIDENT. THE PILOTS AND PILOT RATED PASSENGERS WERE ALL SPANISH CITIZENS.

## Aircraft 1

- Registration: [N2409K](https://openairdocs.org/deregistered/N2409K-1991-05-13), registration cancelled 1991-05-13, S/N 3879A0620 (OpenAirDocs)
- Reported make and model: PIPER PA-38-112
- Registry model: [Piper PA-38-112](https://openairdocs.org/model/piper-pa-38-112) (registry code 7103812) (OpenAirDocs)
- Category: Airplane
- Serial number: 38-79A0620
- Airframe hours: 7138
- Engines: LYCOMING O-235-L2C 112 horsepower reciprocating
- Damage: Destroyed
- Flight: Instructional, Part 91
- Registered owner: Bolivar Aircraft Sales, Inc.
- Airworthiness certificate: Standard, Utility; Standard, Normal
- Last inspection: 100 hour, June 14, 1990, 25 hours before
- Departed: HSV, HUNTSVILLE, AL
- Destination: M08, BOLIVAR, TN
- Flight plan: VFR

## Aircraft 2

- Registration: [N2437K](https://openairdocs.org/deregistered/N2437K-2014-09-19), registration cancelled 2014-09-19, S/N 38-79A0634, built 1979 (OpenAirDocs)
- Reported make and model: PIPER PA-38-112
- Registry model: [Piper PA-38-112](https://openairdocs.org/model/piper-pa-38-112) (registry code 7103812) (OpenAirDocs)
- Registry engine: [Lycoming 0-235 series](https://openairdocs.org/engine/lycoming-0-235-series) (registry code 41505, 4 cycle) (OpenAirDocs)
- Category: Airplane
- Serial number: 38-79A0634
- Airframe hours: 6500
- Engines: LYCOMING O-235-L2C 112 horsepower reciprocating
- Damage: Destroyed
- Flight: Instructional, Part 91
- Registered owner: Bolivar Aircrat Sales, Inc.
- Airworthiness certificate: Standard, Utility; Standard, Normal
- Last inspection: 100 hour, June 11, 1990, 20 hours before
- Departed: HSV, HUNTSVILLE, AL
- Destination: M08, BOLIVAR, TN
- Flight plan: VFR

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot, aircraft N2409K; age 27; private; airplane ratings: single-engine land; medical: class 2, valid medical--no waivers/lim.; seat: left; flight hours: 118 total, 5 in this make and model, 42 as pilot in command, 86 in the last 90 days, 50 in the last 30 days, 3 in the last 24 hours
- Pilot, aircraft N2437K; age 22; private; airplane ratings: single-engine land; medical: class 2, valid medical--no waivers/lim.; seat: left; toxicology performed; flight hours: 118 total, 5 in this make and model, 47 as pilot in command, 118 in the last 90 days, 46 in the last 30 days, 3 in the last 24 hours

## Weather

- Conditions: Visual (VMC), Day
- Wind: 290° at 10 knots
- Visibility: 7 statute miles
- Lowest ceiling: 25,000 ft overcast
- Temperature: 91 °F, dew point 68 °F
- Altimeter: 29.89 inHg
- Observed at: MSL, 8 nm away

## FAA reports on this event (2)

The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs).

- [Accident 19900701022981A](https://openairdocs.org/incident/19900701022981A), Jul 1, 1990: Piper PA38112, Florence, AL, Destroyed, 2 fatal. While flying in unauthorized formation collided with N2437K that was changing position. Impact severed empannege.
- [Accident 19900701022982A](https://openairdocs.org/incident/19900701022982A), Jul 1, 1990: Piper PA38112, Florence, AL, Destroyed, 2 fatal. While changing position in unauthorized formation flying collided with N2409K severing its tail. Both crashed.

From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model.

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