CHI00MA066

NTSB accident investigation · Moravan Z242L · Zion, IL · February 8, 2000

Accident · FatalMajor investigationFinal report
Date
February 8, 2000, 15:04 local (21:04 UTC)
Place
Zion, IL
Injuries
3 fatal
Phase of flight
Approach
Aircraft
N5ZAMoravan Z242LN99063Cessna 172P
Weather
Visual (VMC) · Day
Status
Completed · report May 3, 2001
Report
Approved by Office Director
Safety recommendations
Yes
Case key
48624

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

Clearance not maintained by the pilot of the other airplane. A factor relating to the accident was the airport control tower's local controller's failure to provide effective sequencing.

The pilot's failure to maintain clearance from the other airplane. Factors relating to the accident were the pilot's poor visual lookout, and the airport control tower local controller's failure to provide effective sequencing.

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
Clearance - not maintainedPilot in commandCause
Visual lookout - poorPilot in commandFactor
Visual separation - not maintainedAtc personnel(lcl/gnd/clnc)Factor
Loss of control - in flightApproach
Wing - bent
Flight control,aileron - jammed
Propeller system/accessories,blade - sheared
In flight collision with objectDescent - uncontrolled
Object - building(nonresidential)
Midair collisionApproach
Clearance - not maintainedPilot of other aircraftCause
Visual separation - not maintainedAtc personnel(lcl/gnd/clnc)Factor
Loss of control - in flightApproach
In flight collision with objectDescent - uncontrolled
Object - tree(s)
In flight collision with terrain/waterDescent - uncontrolled

Analysis

At 1455:29, the pilot of N5ZA, a Moravan Z242L, called the Waukegan Regional Airport (UGN) air traffic control tower (ATCT) and reported 15 miles northeast for landing. The local controller (LC) acknowledged and queried N5ZA, 'are you coming down the shoreline?' N5ZA responded, 'That's affirmative.' (Radar data showed that N5ZA was actually 4.5 miles east of the shoreline). The LC instructed the pilot to 'report turning final at the shoreline for the straight in [to] runway two three.' The pilot responded, 'ok, straight in for two three, thanks.' At 1457:57, the LC instructed N99063, a Cessna 172P, to taxi into position and hold,' and, 10 seconds later, he cleared N99063 for takeoff. At 1459:48, the LC asked the pilot of N5ZA for his position. The pilot replied that he was 'just about a mile or two off the lake...off the shoreline.' (However, radar data showed that N5ZA was actually 3.75 miles off the shore along the runway 23 extended centerline and 2.7 miles from shore with the shoreline being abeam to the right side of the aircraft.) At 1459:53, the LC asked the pilot, 'are you straight in still?' The pilot responded, 'ah, yes sir.' The LC instructed the pilot to 'keep your speed up as much as feasible cleared to land.' The pilot acknowledged and stated, 'peddling as fast as I can.' At 1500:38, the LC instructed N99063 to 'continue on the downwind, advise when you see a red low wing aircraft straight in on final.' The pilot of N99063 responded, 'looking for traffic.' (Radar data showed that N99063 was established on the downwind leg, approximately 0.7 miles due north of the approach end of runway 23. The radar also showed that N5ZA was 2.3 miles northeast of the shoreline, 6.3 miles from the approach end of runway 23.) At 1500:50, the pilot stated, 'zulu alpha's the white zlin.' The LC acknowledged and transmitted to N99063, 'it'll be a white low wing aircraft.' The pilot of N99063 acknowledged. At 1501:16, the pilot of N99063 stated, 'negative traffic,' and asked the LC to advise her when to turn for her base leg. The LC acknowledged. (Radar data showed that N99063 was 1.75 miles northeast of the approach end of runway 23 and that N5ZA was 1.4 miles northeast of the shoreline, 5.3 miles from the approach end of runway 23.) At 1501:41, the LC asked the pilot of N5ZA how far out he was from the shoreline; the pilot responded that he was 'just crossing the shoreline.' (Radar data showed that N5ZA was 0.8 miles from the shoreline, approximately 4.8 miles from the approach end of runway 23.) At 1502:09, the LC asked the pilot of N99063 if she saw N5ZA yet. The pilot of N99063 responded, 'negative.' The LC asked the pilot of N99063, 'have you passed the shoreline?' The pilot of N99063 replied, 'gettin there.' (Radar data showed that N99063 was 1.6 miles from the shore along the extended downwind leg for runway 23's right-hand traffic pattern.) At 1502:16, the LC instructed N99063 to 'start your base leg now.' The pilot of N99063 acknowledged. (Radar data showed N5ZA crossing the shoreline, 4 miles from the approach end of the runway 23. As the pilot of N99063 turned onto base leg, then final approach, the airplane was slightly in front of N5ZA.) At 1503:19, the pilot of N5ZA reported, 'negative contact with the cessna in front of us.' (Radar data showed that N5ZA was approximately 2.6 miles from the approach end of runway 23.) The LC replied, 'you should be number one, Bob.' At 1503:27, the pilot of N5ZA stated, 'then we have the traffic in sight, thanks.' (Radar data showed that N99063 established on final 2.5 miles from the approach end of runway 23.) At 1503:38, the LC instructed the pilot of N99063 to 'advise when you turn final.' The pilot of N99063 reported that she was on final approach. The LC said, 'thank you.' At 1503:53, the LC asked N5ZA, 'do you see a cessna in front of you?' At 1504:00, the pilot of N5ZA responded, '[N5ZA] just had a midair.' The LC responded, 'we just saw that.' (The last radar target from N5ZA was received at 1503:59 and showed that N5ZA was 2 miles from the approach end of runway 23.) Both airplanes came down in the city of Zion, Illinois. N5ZA impacted into the roof of a hospital, and subsequently exploded. N99063 struck a tree and a sidewalk before coming to rest on a residential street. Examinations of the wreckage of both airplanes revealed no anomalies.

At 1455:29, the pilot of N5ZA, a Moravan Z242L, called the Waukegan Regional Airport (UGN) air traffic control tower (ATCT) and reported 15 miles northeast for landing. The local controller (LC) acknowledged and queried N5ZA, "are you coming down the shoreline?" N5ZA responded, "That's affirmative." (Radar data showed that N5ZA was actually 4.5 miles east of the shoreline). The LC instructed the pilot to "report turning final at the shoreline for the straight in [to] runway two three." The pilot responded, "ok, straight in for two three, thanks." At 1457:57, the LC instructed N99063, a Cessna 172P, to taxi into position and hold," and, 10 seconds later, he cleared N99063 for takeoff. At 1459:48, the LC asked the pilot of N5ZA for his position. The pilot replied that he was "just about a mile or two off the lake...off the shoreline." (However, radar data showed that N5ZA was actually 3.75 miles off the shore along the runway 23 extended centerline and 2.7 miles from shore with the shoreline being abeam to the right side of the aircraft.) At 1459:53, the LC asked the pilot, "are you straight in still?" The pilot responded, "ah, yes sir." The LC instructed the pilot to "keep your speed up as much as feasible cleared to land." The pilot acknowledged and stated, "peddling as fast as I can." At 1500:38, the LC instructed N99063 to "continue on the downwind, advise when you see a red low wing aircraft straight in on final." The pilot of N99063 responded, "looking for traffic." (Radar data showed that N99063 was established on the downwind leg, approximately 0.7 miles due north of the approach end of runway 23. The radar also showed that N5ZA was 2.3 miles northeast of the shoreline, 6.3 miles from the approach end of runway 23.) At 1500:50, the pilot stated, "zulu alpha's the white zlin." The LC acknowledged and transmitted to N99063, "it'll be a white low wing aircraft." The pilot of N99063 acknowledged. At 1501:16, the pilot of N99063 stated, "negative traffic," and asked the LC to advise her when to turn for her base leg. The LC acknowledged. (Radar data showed that N99063 was 1.75 miles northeast of the approach end of runway 23 and that N5ZA was 1.4 miles northeast of the shoreline, 5.3 miles from the approach end of runway 23.) At 1501:41, the LC asked the pilot of N5ZA how far out he was from the shoreline; the pilot responded that he was "just crossing the shoreline." (Radar data showed that N5ZA was 0.8 miles from the shoreline, approximately 4.8 miles from the approach end of runway 23.) At 1502:09, the LC asked the pilot of N99063 if she saw N5ZA yet. The pilot of N99063 responded, "negative." The LC asked the pilot of N99063, "have you passed the shoreline?" The pilot of N99063 replied, "gettin there." (Radar data showed that N99063 was 1.6 miles from the shore along the extended downwind leg for runway 23's right-hand traffic pattern.) At 1502:16, the LC instructed N99063 to "start your base leg now." The pilot of N99063 acknowledged. (Radar data showed N5ZA crossing the shoreline, 4 miles from the approach end of the runway 23. As the pilot of N99063 turned onto base leg, then final approach, the airplane was slightly in front of N5ZA.) At 1503:19, the pilot of N5ZA reported, "negative contact with the cessna in front of us." (Radar data showed that N5ZA was approximately 2.6 miles from the approach end of runway 23.) The LC replied, "you should be number one, Bob." At 1503:27, the pilot of N5ZA stated, "then we have the traffic in sight, thanks." (Radar data showed that N99063 established on final 2.5 miles from the approach end of runway 23.) At 1503:38, the LC instructed the pilot of N99063 to "advise when you turn final." The pilot of N99063 reported that she was on final approach. The LC said, "thank you." At 1503:53, the LC asked N5ZA, "do you see a cessna in front of you?" At 1504:00, the pilot of N5ZA responded, "[N5ZA] just had a midair." The LC responded, "we just saw that." (The last radar target from N5ZA was received at 1503:59 and showed that N5ZA was 2 miles from the approach end of runway 23.) Both airplanes came down in the city of Zion, Illinois. N5ZA impacted into the roof of a hospital, and subsequently exploded. N99063 struck a tree and a sidewalk before coming to rest on a residential street. Examinations of the wreckage of both airplanes revealed no anomalies.

Factual narrative

See narrative CHI99MA066A.

History of flight

On February 8, 2000, about 1504 central standard time, a Moravan Z242L, N5ZA, and a Cessna 172P, N99063, collided in flight over a residential area of Zion, Illinois, approximately 2 miles from the approach end of runway 23 at the Waukegan Regional Airport (UGN), Waukegan, Illinois. N5ZA impacted the roof of a hospital, and N99063 came to rest on a residential street after striking a tree and a sidewalk. Both airplanes were destroyed on impact. The pilot and passenger on board N5ZA were fatally injured. The student pilot of N99063 was also fatally injured. Both airplanes were operating under the provisions of 14 Code of Federal Regulations (CFR) Part 91 without flight plans. Daytime visual meteorological conditions prevailed at the time of the accident. N5ZA's cross-country flight originated at Sheboygan, Wisconsin, at 1400.

At 1338:34, the pilot of N99063 contacted the UGN air traffic control tower (UGN ATCT). The pilot reported that she was 7 miles south of the airport, confirmed having the automatic terminal information service information, and requested permission to perform practice takeoffs and landings. At 1342:18, the UGN ATCT local controller (LC) cleared N99063 for touch and go, and instructed the pilot to make a right hand traffic pattern. Over the next 45 minutes, the pilot of N99063 operated in the closed traffic pattern and performed nine practice takeoffs and landings. At 1426:26, the pilot of N99063 requested clearance for the option and performed a full stop landing.

At 1455:25, the pilot of N5ZA made his initial call to UGN ATCT. Approximately 6 seconds later, the pilot reported that he was 15 miles northeast of the airport. The LC acknowledged the call and asked the pilot, "are you coming down the shoreline?" The pilot responded, "That's affirmative." (Radar data provided by the Federal Aviation Administration [FAA] from its Chicago terminal radar approach control [TRACON], which covers the traffic pattern altitude at UGN, showed that N5ZA was 4.5 miles east of the shoreline). The LC instructed the pilot to "report turning final at the shoreline for the straight in [to] runway two three." The pilot responded, "ok straight in for two three thanks."

At 1457:42, the pilot of N99063 reported to UGN ATCT that she was holding short of runway 23 and was "ready for departure." The LC instructed N99063 to "hold short." The pilot acknowledged. At 1457:57, the LC instructed N99063 to "taxi into position and hold," and, 10 seconds later, he cleared N99063 for takeoff.

At 1459:48, the LC asked the pilot of N5ZA for his position. The pilot replied that he was "just about a mile or two off the lake...off the shoreline." (However radar data from Chicago TRACON showed that N5ZA was actually 3.75 miles northeast of the shore along the runway 23 extended centerline [approximately 7.75 miles from the end of the runway] and 2.7 miles from shore, with the shoreline being abeam to the right side of the aircraft.) At 1459:53, the LC asked the pilot, "are you straight in still?" The pilot responded, "ah yes sir." The LC instructed the pilot to "keep your speed up as much as feasible cleared to land." The pilot acknowledged and stated, "peddling as fast as I can."

At 1500:38, the LC instructed N99063 to "continue on the downwind advise when you see a red low wing aircraft straight in on final." The pilot of N99063 responded, "looking for the traffic." (Radar data from Chicago TRACON revealed that N99063 was established on the downwind leg, approximately 0.7 mile due north of the approach end of runway 23. The radar also revealed that N5ZA was 2.3 miles northeast of the shoreline, 6.3 miles from the approach end of runway 23.) At 1500:50, the pilot of N5ZA stated, "zulu alpha's the white zlin." The LC acknowledged and transmitted to N99063, "it'll be a white low wing aircraft." The pilot of N99063 acknowledged. At 1501:16, the pilot of N99063 stated, "negative traffic," and asked the LC to advise her when to turn for her base leg. The LC acknowledged. (Radar data from Chicago TRACON showed that N99063 was approximately 1.75 miles northeast of the approach end of runway 23 and that N5ZA was 1.4 miles northeast of the shoreline, 5.3 miles from the approach end of runway 23.) In a post accident interview, the LC stated that at this point he could not see N99063 and that he had lost sight of the aircraft about 1.5 miles northeast of the field. The LC also stated that he could not see N5ZA at that time. He added that weather conditions "got hazy near the water."

At 1501:41, the LC asked the pilot of N5ZA how far out he was from the shoreline; the pilot responded that he was "just crossing the shoreline." (Radar data from Chicago TRACON showed that N5ZA was 0.8 miles from the shoreline, approximately 4.8 miles from the approach end of runway 23.) At 1502:09, the LC asked the pilot of N99063 if she saw N5ZA yet. The pilot of N99063 responded, "negative." At 1502:12, the LC asked the pilot of N99063, "have you passed the shoreline?" The pilot replied, "gettin there." (Radar data from Chicago TRACON showed that N99063 was approximately 1.6 miles from the shore along the extended downwind leg for runway 23's right-hand traffic pattern.) At 1502:16, the LC instructed N99063 to "start your base leg now." At 1502:18, the pilot acknowledged. (About the same time, radar showed N5ZA crossing the shoreline, 4 miles from the approach end of the runway 23. As the pilot of N99063 turned onto base leg, then final approach, the airplane was slightly in front of N5ZA.) In a post accident interview, the LC stated that his decision to instruct N99063 to turn was based on his estimate of the elapsed time between losing sight of N99063 and N5ZA pilot's verbal report that he had crossed the shoreline.

At 1502:47, a Cessna 172, N52048 reported, "we have the cessna." The LC transmitted, "whoever advised they have the cessna in sight you were covered." N52048 stated, "we're back on the downwind and we have the landing traffic in sight." The LC asked N52048, "is it the low wing or cessna?" N52048 replied, "it's the cessna." At 1503:04, the LC responded, "follow in behind the cessna you're number three." The pilot of N52048 acknowledged. Chicago TRACON radar showed that, at 1503:05, N52048 was 2.5 miles northeast of the approach end of runway 23 on left downwind and that N5ZA was 3 miles from the approach end of runway 23 on the extended centerline. The radar also revealed that, at 1503:08, N99063 had completed her base leg and turned to final, at a point approximately 2.7 miles from the approach end of runway 23.

At 1503:19, the pilot of N5ZA reported, "negative contact with the cessna in front of us." (Chicago TRACON radar showed that N5ZA was approximately 2.6 miles from the approach end of runway 23.) The LC replied, "you should be number one Bob." At 1503:27, the pilot of N5ZA stated, "then we have the traffic in sight, thanks." (Chicago TRACON radar showed that N99063 was established on final 2.5 miles from the approach end of runway 23 and that N52048 was on left base 3.1 miles from the approach end of runway 23.) In a post accident interview, the LC stated that at this point, "something started to click [that] something was wrong" and that he used binoculars to try to get the aircraft in sight. The LC stated that he saw N5ZA at this time but that he did not see N99063.

At 1503:38, the LC instructed the pilot of N99063 to "advise when you turn final." At 1503:40, the pilot of N99063 reported that she was on final approach. The LC stated, "thank you." At 1503:53, the LC asked N5ZA, "do you see a cessna in front of you?" At 1504:00, the pilot of N5ZA responded, "[N5ZA] just had a midair." The LC responded, "we just saw that." (Chicago TRACON's last radar target from N5ZA was received at 1503:59 and showed that N5ZA was 2 miles from the approach end of runway 23

Aircraft · 2

Registration
N5ZA
Reported as
Moravan Z242L
Category
Airplane
Serial number
0695
Airframe hours
100
Engine
Lycoming AEIO-360-A1B6, 200 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Registered owner
Daniel Bitton & Robert Collins
Airworthiness certificate
Standard, Normal
Last inspection
Annual · November 3, 1999 · 4 hours before
Departed
SBM · Sheboygan, WI
Destination
UGN · Waukegan, IL
Airport
UGN · Waukegan Regional Airport, runway 23, 6,000 × 150 ft, concrete

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
N99063
Reported as
Cessna 172P
Category
Airplane
Serial number
17276398
Airframe hours
12,160
Engine
Lycoming O-320-D2J, 160 horsepower, reciprocating
Damage
Destroyed
Flight
Instructional · Part 91
Operator
American Flyers, doing business as American Flyers, Inc.
Registered owner
Ate Of New York, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · January 10, 2000 · 60 hours before
Departed
UGN · Waukegan, IL
Airport
UGN · Waukegan Regional Airport, runway 23, 6,000 × 150 ft, concrete

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 N5ZA
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
1,200 total · 15 in this make and model · 2 in the last 24 hours
Role
Pilot, aircraft N99063
Certificate
Student
Medical
Class 3, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
36 total · 36 in this make and model · 1 as pilot in command · 36 in the last 90 days · 10 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
220° at 17 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
91 °F, dew point 73 °F
Altimeter
30.00 inHg
Observed at
UGN, 2 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.