ATL98FA060

NTSB accident investigation · Cessna 525 · Marietta, GA · April 4, 1998

Accident · FatalField investigationFinal report
Date
April 4, 1998, 10:32 local (15:32 UTC)
Place
Marietta, GA
Injuries
5 fatal
Phase of flight
Enroute
Aircraft
N111LRCessna 525N737WDCessna 172N
Weather
Visual (VMC) · Day
Status
Completed · report September 7, 2000
Report
Approved by Office Director
Safety recommendations
Yes
Case key
3930

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

The failure of both pilots to see and avoid conflicting traffic, and the failure of the 172 pilot to operate the transponder as required by current regulations. Factors were the controller's failure to observe the traffic conflict, the lack of radar conflict capability, and the training emphasis on maximum autopilot usage with the autopilot controller placed at the rear of the cockpit center mounted pedestal.

The failure of both pilots to see and avoid conflicting traffic, and the failure of the 172 pilot to operate the transponder as required by current regulations. Factors were the controller's failure to observe the traffic conflict, the lack of radar conflict alert capability, and the training emphasis on maximum autopilot usage with the autopilot controller placed at the rear of the cockpit center mounted pedestal.

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 collisionClimb - to cruise
Visual lookout - inadequatePilot in commandCause
Acft/equip,inadequate control locationManufacturerFactor
Inadequate certification/approval,aircraftFaa(organization)
Loss of control - in flightClimb - to cruise
Empennage - separation
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - residential area
Midair collisionCruise
Visual lookout - inadequatePilot in commandCause
Procedures/directives - not followedPilot in commandCause
Identification of aircraft on radar - not identifiedAtc personnel(dep/apch)Factor
Facility inadequateAtc personnel(dep/apch)Factor
Insuff standards/requirements,airways/airspaceFaa(organization)Factor
Loss of control - in flightCruise
Fuselage - loss,partial
In flight collision with objectDescent - emergency
Object - tree(s)
In flight collision with terrain/waterDescent - uncontrolled
FireDescent - uncontrolled

Analysis

A Cessna 525 and a Cessna 172 collided in flight about 3,400 feet mean sea level on converging courses, with the 525 heading north and the 172 heading southwest. The converging speed was about 300 knots. The 525 departed under instrument flight rules, received vectors, and was initiating a climb on course. Training in the 525 emphasizes maximum use of the autopilot to afford greater outside scanning by the single pilot. The 525 was in radio contact with terminal approach control and the pilot's acknowledgement of the climb clearance was interrupted by the collision. The 172 had departed a local airfield, located just outside the 30 mile Mode C veil airspace of a terminal airport, and proceeded southwest. The collision occurred as the 172 was approaching Class D airspace of a military tower, and the pilot was initiating radio contact with the military tower. The terminal approach controller in contact with the 525 stated he did not observe the primary target of the 172, and conflict alert software was not installed. The 172 did not display a transponder signal and the transponder switch was subsequently found in the 'off' position. A cockpit visibility study indicated that from a fixed eye position the 172 was essentially hidden behind aircraft structure of the 525 for the 125 seconds before impact. The 172 could be seen by shifting the pilot's eye position. The 525 was viewable in the left lower section of the 172's windscreen. Both airplanes were operating in visual flight conditions.

A Cessna 525 and a Cessna 172 collided in flight about 3,400 feet mean sea level on converging courses, with the 525 heading north and the 172 heading southwest. The converging speed was about 300 knots. The 525 departed under instrument flight rules, received vectors, and was initiating a climb on course. Training in the 525 emphasizes maximum use of the autopilot to afford greater outside scanning by the single pilot. The 525 was in radio contact with terminal approach control and the pilot's acknowledgement of the climb clearance was interrupted by the collision. The 172 had departed a local airfield, located just outside the 30 mile Mode C veil airspace of a terminal airport, and proceeded southwest. The collision occurred as the 172 was approaching Class D airspace of a military tower, and the pilot was initiating radio contact with the military tower. The terminal approach controller in contact with the 525 stated he did not observe the primary target of the 172, and conflict alert software was not installed. The 172 did not display a transponder signal and the transponder switch was subsequently found in the 'off' position. A cockpit visibility study indicated that from a fixed eye position the 172 was essentially hidden behind aircraft structure of the 525 for the 125 seconds before impact. The 172 could be seen by shifting the pilot's eye position. The 525 was viewable in the left lower section of the 172's windscreen. Both airplanes were operating in visual flight conditions.

Factual narrative

History of flight

On April 4, 1998, about 1034 eastern standard time, a Cessna 525 (CitationJet), N111LR and a Cessna 172N, N737WD, collided in flight over a residential area in Marietta, Georgia. Both airplanes were operated by the respective pilots, under the provisions of Title 14 CFR Part 91. Visual meteorological conditions prevailed at the time of the accident. The commercial certificated pilot of the 172, the airline transport pilot of the CitationJet, and the three passengers in the CitationJet, were all fatally injured. Both airplanes were destroyed. The CitationJet departed from the Dekalb-Peachtree Airport about 1030, with an instrument flight plan to Harrisburg, Pennsylvania. According to radar data, the 172 departed Mathis Airfield, near Cumming, Georgia, about 1025. A flight plan was not filed for the 172 flight, reported as a flight to inspect power lines for Georgia Power Co.

After takeoff, the CitationJet was initially assigned 3,000 feet mean sea level (msl) and a heading of 280 degrees by Atlanta Terminal Radar Control (TRACON). Subsequently, it was assigned a heading of 360 degrees and cleared to climb to 14,000 feet msl. According to radar data the CitationJet had vacated 3,000 feet msl and was at 3,400 feet msl, at 1034, when a primary target merged with the radar target of the CitationJet. In addition to the loss of radio contact with the CitationJet, the radar data block on the controller's display depicted "coast" indicating that radar contact was lost.

At 1033:01, a clearance to climb from 3,000 feet msl was issued to the CitationJet. Radar data indicated that N111LR was at 2,900 feet msl at that time. About 23 seconds later, at 1033:26, radar data depicted the airplane at 3,000 feet, indicating a climb had commenced. The CitationJet pilot's acknowledgement of the climb clearance was interrupted about 1034.

Recorded radar data provided by the Atlanta TRACON depicted a trail of primary targets (a primary target is radar energy reflected from the skin of the airplane without electronic enhancement) that began at 1025:07, approximately two miles southwest of the Mathis Airport, and extended to the southwest in a curving path that intersected the flight path of the CitationJet, over the collision site. The operator of Mathis Airfield reported that he believed the pilot of the 172 departed Mathis Airfield about 1015, on the day of the accident.

About 1034, the Cessna 172 initiated radio contact with Dobbins Air Force Base Air Traffic Control Tower (ATCT), and identified itself as seven Whiskey Delta. The controller responded "7WD, Dobbins Tower." The aircraft responded "Good morning , sir, 7WD Cessna one seventy." The controller stated "seven whiskey delta you were cut out." No further transmissions were received from the airplane, and the controller was unable to re-establish contact.

The CitationJet came to rest inverted in the rear of a residence at 1922 Fields Pond Glen, Marietta, Georgia. The 172 was observed to collide with trees and come to rest inverted in a residential yard at 5125 Timber Ridge Road, Marietta, Georgia.

Personnel information

CitationJet Pilot

The pilot of the CitationJet held airline transport pilot certificate number 253663704, with a CE-525S (Cessna 525 CitationJet) type rating. (The "S" suffix denotes that this type rating allows the holder to operate the CitationJet as a single piloted airplane.) Additionally, he held an airline transport pilot multiengine rating and a private airplane single engine land rating. The airline transport pilot certificate was issued to the pilot on January 9, 1998. His last medical certificate, a first class, was issued March 28, 1997, with the limitation that the airman must wear corrective lenses. As of the date of his last medical examination, the pilot had 1,510 total flight hours, according to Federal Aviation Administration records.

A pilot log was obtained that contained the CitationJet pilot's name on a preprinted label indicating he had completed a pilot-in-command and instrument proficiency check on February 28, 1998, at Wichita, KS. The last entry in the log was dated March 29, 1998. According to entries in the log the pilot had 1,824.6 total flight hours, with 81.4 and 4.5 flight hours within 90 and 30 days, respectively, prior to the accident. All of the flights listed in the log book within the 90 days prior to the accident were in the accident airplane. According to the log book, the pilot had 86.3 total hours in the CitationJet. The pilot recorded a total of 4.2 actual instrument flight hours, and 0.7 simulated instrument flight hours in the CitationJet. His total instrument flight hours were recorded in the log book as 180.1 actual instrument and 104.6 simulated instrument. There were entries in the log book that indicated the pilot regularly flew a Beech 90, turbopropeller airplane, prior to his operation of the CitationJet. The log book contained an entry dated August 29, 1997, that indicated an "ATP checkride" in the CE-525 simulator. The log book reflected two periods of CE 525 training at Flight Safety during August, 1997 and February, 1998.

A local flight instructor was interviewed who stated he provided the pilot's initial flight instruction in 1994, as well as through several ratings. He assisted the pilot to purchase his first airplane, a Beech 60 Duke, a high performance, pressurized, reciprocating engine twin. The pilot later moved to a Beech 90 King Air, high performance, pressurized, "T" tail, turbine powered twin. He then assisted the pilot select and purchase the CitationJet, and attended Flight Safety International training with him. The instructor described the pilot as highly qualified, competent, and detail oriented. It was his understanding that the pilot bought the airplane to be used for business travel. He also stated that the pilot enrolled in the CitationJet proficiency course that required attendance every three months. The instructor reported that the Flight Safety training course instructed the student to use the auto-pilot as soon as possible, after takeoff, to reduce the work load on the pilot (wheels up, flaps up, auto-pilot on). The instructor stated that the use of the auto-pilot to initiate a climb involved looking down, locating and turning the altitude select knob, checking the readout on the Electronic Attitude Director Indicator, then rotating the Pitch Wheel to initiate the climb.

Cessna 172 Pilot

The pilot of the Cessna 172 held commercial pilot certificate number 216623423 with airplane single engine, multiengine, and instrument airplane ratings. Additionally, he was a certificated flight instructor with airplane single and multiengine ratings. The pilot also held a mechanics certificate with airframe and powerplant ratings. His second class medical certificate was last issued on April 2, 1998, with no waivers or limitations.

A total of five pilot logbooks, numbered 2-6, were located for the pilot. Logbook number 1 was not found, however, an entry at the beginning of Logbook number 2 stated the student had lost his logbook, and his flight hours had been reconstructed from invoices. Entries in the logbooks indicated the pilot obtained his instrument rating, multiengine rating, and commercial pilot certificate in early 1982. Logbook entries indicated he received his flight instructor certificate and multiengine flight instructor rating about July 21, 1989. The logbook numbered 6 had a beginning date of May 22, 1997. An entry in logbook number 6, dated August 13, 1997, indicated the pilot had received a flight review. A corresponding entry indicated the flight review was accomplished in N737WD, the accident airplane. According to the entries in logbook number 6 the 172 pilot had 13,958.8 total flight hours, as of the last entry dated March 31, 1998. Within the last 90 and 30 days, the pilot's log indicated he had flown a total of 67.8 and 13.8 hours respectively. His

History of flight

On April 4, 1998, about 1034 eastern standard time, a Cessna 525 (CitationJet), N111LR and a Cessna 172N, N737WD, collided in flight over a residential area in Marietta, Georgia. Both airplanes were operated by the respective pilots, under the provisions of Title 14 CFR Part 91. Visual meteorological conditions prevailed at the time of the accident. The commercial certificated pilot of the 172, the airline transport pilot of the CitationJet, and the three passengers in the CitationJet, were all fatally injured. Both airplanes were destroyed. The CitationJet departed from the Dekalb-Peachtree Airport about 1030, with an instrument flight plan to Harrisburg, Pennsylvania. According to radar data, the 172 departed Mathis Airfield, near Cumming, Georgia, about 1025. A flight plan was not filed for the 172 flight, reported as a flight to inspect power lines for Georgia Power Co.

After takeoff, the CitationJet was initially assigned 3,000 feet mean sea level (msl) and a heading of 280 degrees by Atlanta Terminal Radar Control (TRACON). Subsequently, it was assigned a heading of 360 degrees and cleared to climb to 14,000 feet msl. According to radar data the CitationJet had vacated 3,000 feet msl and was at 3,400 feet msl, at 1034, when a primary target merged with the radar target of the CitationJet. In addition to the loss of radio contact with the CitationJet, the radar data block on the controller's display depicted "coast" indicating that radar contact was lost.

At 1033:01, a clearance to climb from 3,000 feet msl was issued to the CitationJet. Radar data indicated that N111LR was at 2,900 feet msl at that time. About 23 seconds later, at 1033:26, radar data depicted the airplane at 3,000 feet, indicating a climb had commenced. The CitationJet pilot's acknowledgement of the climb clearance was interrupted about 1034.

Recorded radar data provided by the Atlanta TRACON depicted a trail of primary targets (a primary target is radar energy reflected from the skin of the airplane without electronic enhancement) that began at 1025:07, approximately two miles southwest of the Mathis Airport, and extended to the southwest in a curving path that intersected the flight path of the CitationJet, over the collision site. The operator of Mathis Airfield reported that he believed the pilot of the 172 departed Mathis Airfield about 1015, on the day of the accident.

About 1034, the Cessna 172 initiated radio contact with Dobbins Air Force Base Air Traffic Control Tower (ATCT), and identified itself as seven Whiskey Delta. The controller responded "7WD, Dobbins Tower." The aircraft responded "Good morning , sir, 7WD Cessna one seventy." The controller stated "seven whiskey delta you were cut out." No further transmissions were received from the airplane, and the controller was unable to re-establish contact.

The CitationJet came to rest inverted in the rear of a residence at 1922 Fields Pond Glen, Marietta, Georgia. The 172 was observed to collide with trees and come to rest inverted in a residential yard at 5125 Timber Ridge Road, Marietta, Georgia.

Personnel information

CitationJet Pilot

The pilot of the CitationJet held airline transport pilot certificate number 253663704, with a CE-525S (Cessna 525 CitationJet) type rating. (The "S" suffix denotes that this type rating allows the holder to operate the CitationJet as a single piloted airplane.) Additionally, he held an airline transport pilot multiengine rating and a private airplane single engine land rating. The airline transport pilot certificate was issued to the pilot on January 9, 1998. His last medical certificate, a first class, was issued March 28, 1997, with the limitation that the airman must wear corrective lenses. As of the date of his last medical examination, the pilot had 1,510 total flight hours, according to Federal Aviation Administration records.

A pilot log was obtained that contained the CitationJet pilot's name on a preprinted label indicating he had completed a pilot-in-command and instrument proficiency check on February 28, 1998, at Wichita, KS. The last entry in the log was dated March 29, 1998. According to entries in the log the pilot had 1,824.6 total flight hours, with 81.4 and 4.5 flight hours within 90 and 30 days, respectively, prior to the accident. All of the flights listed in the log book within the 90 days prior to the accident were in the accident airplane. According to the log book, the pilot had 86.3 total hours in the CitationJet. The pilot recorded a total of 4.2 actual instrument flight hours, and 0.7 simulated instrument flight hours in the CitationJet. His total instrument flight hours were recorded in the log book as 180.1 actual instrument and 104.6 simulated instrument. There were entries in the log book that indicated the pilot regularly flew a Beech 90, turbopropeller airplane, prior to his operation of the CitationJet. The log book contained an entry dated August 29, 1997, that indicated an "ATP checkride" in the CE-525 simulator. The log book reflected two periods of CE 525 training at Flight Safety during August, 1997 and February, 1998.

A local flight instructor was interviewed who stated he provided the pilot's initial flight instruction in 1994, as well as through several ratings. He assisted the pilot to purchase his first airplane, a Beech 60 Duke, a high performance, pressurized, reciprocating engine twin. The pilot later moved to a Beech 90 King Air, high performance, pressurized, "T" tail, turbine powered twin. He then assisted the pilot select and purchase the CitationJet, and attended Flight Safety International training with him. The instructor described the pilot as highly qualified, competent, and detail oriented. It was his understanding that the pilot bought the airplane to be used for business travel. He also stated that the pilot enrolled in the CitationJet proficiency course that required attendance every three months. The instructor reported that the Flight Safety training course instructed the student to use the auto-pilot as soon as possible, after takeoff, to reduce the work load on the pilot (wheels up, flaps up, auto-pilot on). The instructor stated that the use of the auto-pilot to initiate a climb involved looking down, locating and turning the altitude select knob, checking the readout on the Electronic Attitude Director Indicator, then rotating the Pitch Wheel to initiate the climb.

Cessna 172 Pilot

The pilot of the Cessna 172 held commercial pilot certificate number 216623423 with airplane single engine, multiengine, and instrument airplane ratings. Additionally, he was a certificated flight instructor with airplane single and multiengine ratings. The pilot also held a mechanics certificate with airframe and powerplant ratings. His second class medical certificate was last issued on April 2, 1998, with no waivers or limitations.

A total of five pilot logbooks, numbered 2-6, were located for the pilot. Logbook number 1 was not found, however, an entry at the beginning of Logbook number 2 stated the student had lost his logbook, and his flight hours had been reconstructed from invoices. Entries in the logbooks indicated the pilot obtained his instrument rating, multiengine rating, and commercial pilot certificate in early 1982. Logbook entries indicated he received his flight instructor certificate and multiengine flight instructor rating about July 21, 1989. The logbook numbered 6 had a beginning date of May 22, 1997. An entry in logbook number 6, dated August 13, 1997, indicated the pilot had received a flight review. A corresponding entry indicated the flight review was accomplished in N737WD, the accident airplane. According to the entries in logbook number 6 the 172 pilot had 13,958.8 total flight hours, as of the last entry dated March 31, 1998. Within the last 90 and 30 days, the pilot's log indicated he had flown a total of 67.8 and 13.8 hours respectively. His

Aircraft · 2

Registration
N111LR
Reported as
Cessna 525
Category
Airplane
Serial number
525-0222
Airframe hours
181
Engine
Williams Intl FJ44-1A, 1,900 lbs thrust, turbo jet
Damage
Destroyed
Flight
Business · Part 91
Operator
Marion H. Allen
Registered owner
Alpha Wolf Enterprises LLC
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · March 29, 1998
Departed
PDK · Chamblee, GA
Destination
MDT · Harrisburg, PA
Flight plan
IFR

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
N737WD
Reported as
Cessna 172N
Category
Airplane
Serial number
17269724
Airframe hours
13,744
Engine
Lycoming O-320-H2AD, 160 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Business · Part 91
Registered owner
Rudolf H. Duncan
Airworthiness certificate
Standard, Normal
Last inspection
Annual · March 28, 1998
Departed
84A · Cumming, GA

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 N111LR
Age
53
Certificates
Private, Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
1,824 total · 86 in this make and model · 1,772 as pilot in command · 81 in the last 90 days · 4 in the last 30 days
Role
Pilot, aircraft N737WD
Age
44
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--no waivers/lim.
Seat
Left
Toxicology
Performed
Flight hours
13,958 total · 67 in the last 90 days · 13 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
320° at 12 knots, gusting 20
Visibility
10 statute miles
Lowest ceiling
3,300 ft overcast
Temperature
54 °F, dew point 46 °F
Altimeter
29.00 inHg
Observed at
PDK, 9 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.