# NTSB ATL98GA127: Government Aircraft Fact N22S, N6305U, Caribbean Sea, September 18, 1998 - Type: NTSB accident investigation - Classification: Accident · Fatal · Final report - Date: September 18, 1998, 14:28 local (18:28 UTC) - Place: Caribbean Sea - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal, 1 minor, 2 uninjured - Status: Completed, report January 18, 2001 - Report: Approved by Office Director - NTSB case key (mKey): 43952 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ATL98GA127 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/43952/pdf - Page: https://openairdocs.org/ntsb/ATL98GA127 ## Probable cause (aircraft 2) The failure of the pilot-in-command of the other aircraft (N6305U) to maintain physical clearance from N6302W. Contributing factors were the inadequate visual lookout of all four pilots involved. ## Probable cause (aircraft 1) The failure of the pilot-in-command of N6305U to maintain physical clearance from the other aircraft (N6302W). Contributing factors were the inadequate visual lookout of all four pilots involved. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Midair collision, cruise - clearance - not maintained, pilot in command (cause) - visual lookout - inadequate, pilot in command (contributing factor) - visual lookout - inadequate, copilot/second pilot (contributing factor) - visual lookout - inadequate, pilot of other aircraft (contributing factor) - Loss of control - in flight, descent - emergency - aircraft control - reduced - Ditching, emergency descent/landing - terrain condition - water - Midair collision, cruise - clearance - not maintained, pilot of other aircraft (cause) - visual lookout - inadequate, pilot in command (contributing factor) - visual lookout - inadequate, copilot/second pilot (contributing factor) - visual lookout - inadequate, pilot of other aircraft (contributing factor) ## Analysis (aircraft 2) Two U.S. Customs Service airplanes collided in formation cruise flight while being evacuated from Borinquen, Puerto Rico, to Curacao, Dutch Antilles, due to an approaching hurricane. While in cruise flight at 6,500 ft. msl, N6305U maneuvered closer to the lead airplane, N6302W, to take some photographs. Several minutes later, N6305U's right side of the vertical stabilizer collided with the left side of the nose of N6302W. N6305U was ditched while on short final to an airstrip due to a lack of airplane controllability, while N6302W returned to Borinquen and landed without incident. Prior to departure, the crewmembers of both airplanes were directed to fly as a flight of two. Neither of the second-in-commands (SICs) of either airplane had any previous formation flying training, nor was it approved for the flight. Interviews with U.S. Customs personnel revealed that formation flight occurred, as did photographs taken from the SIC aboard N6305U during the accident flight. The U.S. Customs Service required two pilots to operate the airplane due to mission equipment installation. ## Analysis (aircraft 1) Two U.S. Customs Service airplanes collided in formation cruise flight while being evacuated from Borinquen, Puerto Rico, to Curacao, Dutch Antilles, due to an approaching hurricane. While in cruise flight at 6,500 ft. msl, N6305U maneuvered closer to the lead airplane, N6302W, to take some photographs. Several minutes later, N6305U's right side of the vertical stabilizer collided with the left side of the nose of N6302W. N6305U was ditched while on short final to an airstrip due to a lack of airplane controllability, while N6302W returned to Borinquen and landed without incident. Prior to departure, the crewmembers of both airplanes were directed to fly as a flight of two. Neither of the second-in-commands (SICs) of either airplane had any previous formation flying training, nor was it approved for the flight. Interviews with U.S. Customs personnel revealed that formation flight occurred, as did photographs taken from the SIC aboard N6305U during the accident flight. The U.S. Customs Service required two pilots to operate the airplane due to mission equipment installation. ## Factual narrative (aircraft 2) Narrative for this report is contained in ATL98GA127A. ## Factual narrative (aircraft 1) HISTORY OF FLIGHT On September 18, 1998, at 1428 Atlantic Standard Time, two AeroSpace Technologies of Australia (Government Aircraft Factories) N22S Nomad airplanes, N6305U and N6302W, collided in midair during cruise flight over the Caribbean Sea, about 162 miles southwest of Puerto Rico. Both airplanes were operated by the U.S. Customs Service under the provisions of Title 14 CFR Part 91, and visual flight rules. Visual meteorological conditions prevailed, and a visual flight rules (VFR) flight plan was filed for the public use flight operating as a flight of two. The airline transport pilot-in-command (PIC) of N6305U was fatally injured, the airline transport second-in-command (SIC) received minor injures, and the airplane was substantially damaged. N6302W sustained minor damage, and the PIC and SIC, both airline transport certificated, were not injured. Origination of the flight was Borinquen, Puerto Rico, 58 minutes prior to the accident, with a planned destination of Curacao, Dutch Antilles. Approximately 1000 on the day of the accident, the crewmembers of N6302W and N6305U were notified that a hurricane evacuation plan was in effect for Borinquen. Both airplanes needed to be evacuated from Puerto Rico to Curacao, in the Caribbean Sea, due to the approaching hurricane. Prior to departure, the crewmembers of both airplanes were directed to fly as a flight of two. N6302W was directed to be the lead airplane with responsibility for both navigation and radio communications. Due to the fact that neither of the SICs had received any previous ground or flight training in the N22S, the flights were to be used as initial training for both SICs assigned to the flight, as both PICs were instructor pilots. At 1025 on the morning of the accident, the pilot assigned as PIC of N6302W received a weather briefing from the San Juan Automated Flight Service Station (AFSS), and filed a VFR flight plan as a flight of two. According to the PIC of the lead airplane, N6302W, both airplanes departed Borinquen approximately 1330. Five minutes after departure, the PIC of the lead airplane activated the VFR flight plan. According to Federal Aviation Administration (FAA) radio transcripts provided by San Juan Air Route Traffic Control Center (ARTCC), at 1403:17, the lead airplane contacted San Juan ARTCC and reported 17 miles north of DAKES intersection at 6,500 feet mean sea level (msl) en route to Curacao and requested flight following. The lead airplane was issued a transponder code of 0426. The PIC of the lead airplane stated that approximately 10 minutes after departure, both airplanes were flying at an altitude of 6,500 feet above msl on a course of 210 degrees magnetic heading at 140 knots. The SIC of the lead airplane activated the autopilot with the heading and altitude selected. According to the PIC of the lead airplane, the PIC aboard N6305U contacted him over the radio and advised him that he was "on a loose trail" at their seven o'clock position and slightly lower. Approximately 1425, while 120 miles south of Borinquen, the PIC of the trailing airplane, N6305U, advised the PIC of the lead airplane that he was going to "come in closer in order to take a photograph of [N6302W]," to which the PIC of N6302W acknowledged. The PIC of the lead airplane then moved forward in his seat and observed the trailing airplane at his eight o'clock position and slightly lower. At that time, the PIC of the lead airplane considered both airplanes to be at a "safe distance" from each other, and moved back in his seat. According to the SIC aboard the trailing airplane, he recalled the autopilot being engaged. He asked the PIC to disengage the autopilot so that he could hear the alert sound of the autopilot disengagement. The PIC acknowledged his request and disengaged the autopilot. According to the SIC, the autopilot was then re-engaged. He recalled taking several photographs, then asking the PIC a question regarding the airplane's instrumentation. After several minutes, he looked outside the cockpit to the right and realized that their airplane was seconds from colliding with the lead airplane. He stated that the trailing airplane was slightly ahead of N6302W and "closing to the right at a fast pace." He then heard a loud bang. According to the PIC aboard the lead airplane, approximately one to two minutes after moving back in his seat, he "felt an impact on the lower front section" of the airplane. He called the PIC of the trailing airplane over the radio and stated, "Are you crazy? You hit us." Seconds later, he observed the trailing airplane in a nose down position turning toward the northwest. According to the SIC aboard the trailing airplane, N6305U's nose dropped and rolled rapidly to the right. He recalled that the PIC advised the flight crew of the lead airplane that he thought the autopilot was engaged and didn't realize that the two airplanes had gotten so close. At 1427:30, the lead airplane advised San Juan ARTCC, "Ah mayday mayday mayday zero two whiskey oh our second unit had made contact with us going into the wa..." The controller advised him that search and rescue personnel would be notified. At 1433:57, the pilot advised ARTCC that the trailing airplane was attempting to turn north and was having difficulty controlling the airplane. He requested permission to follow his company airplane, which was approved. The controller advised the lead airplane that he did not have their company airplane in radar contact. After the collision, the PIC performed a manual test of N6302W's flight controls, and stated that no operational discrepancies were noted. After verifying that the airplane was still controllable, the crew initiated a search for the trailing airplane. They attempted to contact the crew of N6305U over the radio, and the PIC of the trailing airplane responded that they were flying at an altitude of 1,900 feet msl at 90 knots on a west/northwest heading. The flight crew of the lead airplane was able to establish visual contact with the trailing airplane. The PIC of N6302W provided bearing and range information in an attempt to direct N6305U to the southwest corner of Puerto Rico. Approximately 50 nautical miles southwest of Borinquen, the PIC of the trailing airplane advised that he had visual contact with Mona Island, and that he was going to attempt an emergency landing on the island's airstrip. However, according to the SIC aboard the trailing airplane, the airplane was nearly aligned with the dirt runway when the rate of descent increased and the airplane began to oscillate uncontrollably. Concerned that the airplane might explode on impact with the ground, the PIC considered landing on the shoreline, then made the decision to ditch the airplane in the water approximately one hundred yards south of Mona Island. According to the SIC, they "lost control" of the airplane while approaching the water, and the PIC asked for help in flaring for the landing. Upon impact, the airplane nosed over and submerged under 8 to 10 feet of water. The SIC extricated himself from the airplane; the PIC did not. The PIC of the lead airplane was able to maintain control of the airplane and returned to Borinquen. He circled above the airport for approximately 40 minutes and performed the normal and emergency checklists. He was able to extend all three of the landing gear to the down and locked position. A U.S. Coast Guard helicopter performed an aerial check of N6302W and confirmed that there was minor damage to the airplane's nose and the surface radar housing. N6302W landed on runway 8 without further incident. PERSONNEL INFORMATION The PIC aboard the trailing airplane, N6305U, was found by the rescue swimmers to be seated in the right seat. He held an airline transport pilot's certificate dated January 26, 1995, with airplane single and multiengine ratings. He als ## Aircraft 1 - Registration: [N6305U](https://openairdocs.org/deregistered/N6305U-1998-11-18), registration cancelled 1998-11-18, S/N N22S160 (OpenAirDocs) - Reported make and model: Government Aircraft Fact (GAF) N22S - Registry model: [Government Aircraft Factories N22S](https://openairdocs.org/model/government-aircraft-factories-n22s) (registry code 3880103) (OpenAirDocs) - Category: Airplane - Serial number: F-160 - Airframe hours: 2983 - Engines: Allison 250-B17E 420 horsepower turbo prop - Damage: Destroyed - Flight: Public aircraft, Part 91 - Operator: US Customs Service - Registered owner: US Customs Aviation Opns Div - Airworthiness certificate: Standard, Normal - Last inspection: Continuous airworthiness, June 4, 1998, 61 hours before - Departed: BQN, BORINQUEN, PR - Destination: NCC, CURACAO, OF - Flight plan: VFR - Airport: BQN, Rafael Hernandez Airport, runway 30, 3,000 × 50 ft, dirt ## Aircraft 2 - Registration: [N6302W](https://openairdocs.org/deregistered/N6302W-2018-05-03), registration cancelled 2018-05-03, S/N F-159 (OpenAirDocs) - Reported make and model: Government Aircraft Fact (GAF) N22S - Registry model: [Government Aircraft Factories N22B](https://openairdocs.org/model/government-aircraft-factories-n22b) (registry code 3880102) (OpenAirDocs) - Registry engine: [Allison 250-B17 series](https://openairdocs.org/engine/allison-250-b17-series) (registry code 03017, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: F-159 - Airframe hours: 3126 - Engines: Allison 250-B17E 420 horsepower turbo prop - Damage: Minor damage - Flight: Public aircraft, Part 91 - Operator: U.S. Customs Service - Registered owner: U.S. Customs Aviation Ops Div - Airworthiness certificate: Standard, Normal - Last inspection: Continuous airworthiness, August 10, 1998, 43 hours before - Departed: BQN, BORINQUEN, PR - Destination: NCC, CURACAO, OF - Flight plan: VFR - Airport: BQN, Rafael Hernandez Airport, runway 8, 11,701 × 200 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot, aircraft N6305U; age 43; airline transport; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, valid medical--w/ waivers/lim; seat: right; toxicology performed; flight hours: 4,286 total, 982 in this make and model - Pilot, aircraft N6302W; age 43; airline transport; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, valid medical--w/ waivers/lim; seat: right; toxicology performed; flight hours: 6,908 total, 1,430 in this make and model, 3,500 as pilot in command, 90 in the last 90 days, 60 in the last 30 days, 7 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 15 statute miles - Lowest ceiling: none - Temperature: 77 °F ## 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 19980918034612A](https://openairdocs.org/incident/19980918034612A), Sep 18, 1998: Govt N22S, Aguadilla, Puerto Rico, Destroyed, 1 fatal. Aircraft crashed in the ocean approximately 1 mile south of mona island, p.r. aircraft initially involved ina mid air collision with another customs aircraft… - [Accident 19980918034611A](https://openairdocs.org/incident/19980918034611A), Sep 18, 1998: Govt N22S, Aguadilla, Puerto Rico, Minor damage. Aircraft N6302W collied in flight with company aircraft N6305U (U.S. Customs) 135 NM s/sw of the island of puerto rico. Minor damage was reported in N6302W.… 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. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.