DEN02FA105

NTSB accident investigation · Piper PA-24-260 · Rock Springs, WY · September 15, 2002

Accident · No injuriesField investigationFinal report
Date
September 15, 2002, 13:12 local (19:12 UTC)
Place
Rock Springs, WY
Injuries
16 uninjured
Phase of flight
Landing
Aircraft
N8822PPiper PA-24-260N240GLBeech 1900D
Weather
Visual (VMC) · Day
Status
Completed · report May 13, 2003
Report
Approved by Office Director
Parties
Federal Aviation Administration, Great Lakes Aviation, Ltd.
Case key
55720

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 flight crew of the Beech and the pilot of the Piper's failure to attain proper clearance from the other during their respective landings. Factors contributing to the accident were the crew's and the pilot of the other airplane's inadequate visual lookout for each other.

the pilot of the Piper and the flight crew of the Beech's failure to attain proper clearance from each other during their respective landings and the intentional evasive maneuver by the pilot to avoid the other airplane. Factors contributing to the accident were inadequate visual lookout by the pilot and the crew of the other airplane and the inadvertent stall.

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.

Near collision between aircraftLanding - aborted
Clearance - not attainedPilot in commandCause
Clearance - not attainedFlightcrewCause
Visual lookout - inadequatePilot in commandFactor
Visual lookout - inadequateFlightcrewFactor
Radio communications - not successfulFlightcrew
Traffic advisory - not issuedAirport personnel
Abrupt maneuverLanding - aborted
Evasive maneuver - intentionalPilot in commandCause
Loss of control - in flightLanding - aborted
Stall - inadvertentPilot in commandFactor
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - ground
Near collision between aircraftLanding - roll
Visual lookout - inadequateFlightcrewFactor
Visual lookout - inadequatePilot of other aircraftFactor
Clearance - not attainedFlightcrewCause
Clearance - not attainedPilot of other aircraftCause
Radio communications - not successfulFlightcrew
Traffic advisory - not issuedAirport personnel

Analysis

When they were 20 miles west of the airport, the pilot of a Piper PA-24 began making radio calls on Common Traffic Advisory Frequency (CTAF). The pilot reported his position, announced his intentions to land on runway 21, and requested traffic advisories. He heard no response. He made traffic pattern position calls on entering the pattern, on downwind, on base leg, and on final. The pilot said that over the approach end of runway 21 with the wheels just about to touchdown, his wife shouted on the intercom "look at that plane" and threw her arm across the pilot to point at what was at their 8 o'clock position. The pilot said he saw an airplane, a Beech 1900 on runway 27 at a fast roll approaching the runway 21/27 intersection. The pilot said he judged that the two airplanes would meet at the intersection. The pilot applied power to the engine, pulled the nose up into a landing attitude, and veered left so as to pass behind the airplane. "Seconds later we struck the ground in a tail low attitude just past RW27 and to the left of RW21." The airplane sustained substantial damage to the right wing and fuselage. The captain of the Beech said Air Route Traffic Control Center had cleared them for a visual approach to the airport. They briefed the approach for runway 27. They monitored Airport Weather Observing System and made an "in range" call to their station on the ground. The captain said at 20 to 25 miles out, he made a radio call on the CTAF and requested traffic advisories. He said he made advisory calls at 15, 10, and 5 miles from the airport and on short final for runway 27. On short final and approximately 200 feet above ground level, the captain said they received a Terrain Clearance Avoidance System traffic advisory showing "+300 feet," but then it disappeared. The captain said they touched down, rolled out and taxied to the gate. The captain said he heard no other traffic on the CTAF. Witnesses on the ground monitoring the CTAF, said they heard the Piper call inbound for runway 21 and then call three or four more times. An examination of the Piper showed the airplane's radio set to the CTAF. An examination of the radios on the Beech showed no anomalies. Visual meteorological conditions prevailed at the time of the accident.

When they were 20 miles west of the airport, the pilot of a Piper PA-24 began making radio calls on Common Traffic Advisory Frequency (CTAF). The pilot reported his position, announced his intentions to land on runway 21, and requested traffic advisories. He heard no response. He made traffic pattern position calls on entering the pattern, on downwind, on base leg, and on final. The pilot said that over the approach end of runway 21 with the wheels just about to touchdown, his wife shouted on the intercom "look at that plane" and threw her arm across the pilot to point at what was at their 8 o'clock position. The pilot said he saw an airplane, a Beech 1900 on runway 27 at a fast roll approaching the runway 21/27 intersection. The pilot said he judged that the two airplanes would meet at the intersection. The pilot applied power to the engine, pulled the nose up into a landing attitude, and veered left so as to pass behind the airplane. "Seconds later we struck the ground in a tail low attitude just past RW27 and to the left of RW21." The airplane sustained substantial damage to the right wing and fuselage. The captain of the Beech said Air Route Traffic Control Center had cleared them for a visual approach to the airport. They briefed the approach for runway 27. They monitored Airport Weather Observing System and made an "in range" call to their station on the ground. The captain said at 20 to 25 miles out, he made a radio call on the CTAF and requested traffic advisories. He said he made advisory calls at 15, 10, and 5 miles from the airport and on short final for runway 27. On short final and approximately 200 feet above ground level, the captain said they received a Terrain Clearance Avoidance System traffic advisory showing "+300 feet," but then it disappeared. The captain said they touched down, rolled out and taxied to the gate. The captain said he heard no other traffic on the CTAF. Witnesses on the ground monitoring the CTAF, said they heard the Piper call inbound for runway 21 and then call three or four more times. An examination of the Piper showed the airplane's radio set to the CTAF. An examination of the radios on the Beech showed no anomalies. Visual meteorological conditions prevailed at the time of the accident.

Factual narrative

See narrative for DEN01FA105A.

History of flight

On September 15, 2002, at 1312 mountain daylight time, a Piper PA-24-260, N8822P, and a Beech 1900D, N240GL, operating as Great Lakes Airlines Flight 5111 from Denver, Colorado (DEN), to Rock Springs, Wyoming, nearly collided at the intersection of runway 21 and runway 27 at Rock Springs-Sweetwater County Airport (RKS), Rock Springs, Wyoming. Both airplanes were landing on different intersecting runways. The PA-24-260 was landing on runway 21 (5,223 feet by 75 feet, dry asphalt). The Beech 1900D was landing on runway 27 (10,000 feet by 150 feet, dry asphalt). In an effort to avoid a collision, the private pilot of the PA-24-260 initiated a go-around, pitched the airplane nose up, experienced a loss of control, and impacted the terrain. The PA-24-260 was substantially damaged. The Beech 1900D, piloted by an airline transport pilot, continued the landing roll and taxied to parking. The Beech 1900D sustained no damage. Visual meteorological conditions prevailed at the time of the accident. The PA-24-260 was on a personal, cross-country flight from Reno, Nevada, to Rock Springs, Wyoming, and was operating under the provisions of Title 14 CFR Part 91 without a flight plan. The Beech 1900D was operating on an instrument flight rules flight plan as scheduled, domestic passenger service under the provisions of Title 14 CFR Part 121. The pilot and passenger on board the PA-24-260 reported no injuries. The captain, first officer, two flight crew members riding in the cabin, and 10 passengers on board the Beech 1900D sustained no injuries.

In his written statement, the pilot of N8822P said that he began monitoring the "Unicom/CTAF (Common Traffic Advisory Frequency)" for RKS 122.8 Megahertz (MHz) at approximately 75-80 miles from the airport. When they were 20 miles west of the airport, the pilot said he began radioing on Unicom. The pilot said his first transmission was "Rock Springs traffic Comanche 8822 Papa 20 miles west, planning runway 21. Any traffic in the area, please report." The pilot said they heard no response. The pilot said he made similar traffic pattern position calls when entering the pattern on left crosswind, and on downwind, base leg, initial final, and 1 mile final. The pilot said that over the approach end of runway 21 with the wheels just about to touchdown, his wife shouted on the intercom "look at that plane" and threw her arm across the pilot to point at what was at their 8 o'clock position. The pilot said he saw an airplane on runway 27 at a fast roll approaching the runway 21/27 intersection. The pilot said he judged that the two airplanes would meet at the intersection. The pilot said his immediate thought was that he had to take immediate action. He said he applied full power to the engine pulled the nose up into a landing attitude, and veered left so as to pass behind the airplane. "Seconds later we struck the ground in a tail low attitude just past RW27 and to the left of RW21. We bounced tail low, I pulled the power off and we struck the sagebrush and ground in a horizontal attitude. On evacuating the airplane, the pilot said he saw the other airplane arriving at the passenger terminal."

In an interview statement, the captain of N240GL said the first officer was flying the airplane on the leg from DEN to RKS. He said that they were cleared for a visual approach by the Air Route Traffic Control Center (ARTCC). They briefed the visual approach for runway 27 with an instrument landing system approach back up. The captain said they monitored the Airport Weather Observing System (AWOS) frequency, 118.37 MHz, and then made an "in range" call to the Great Lakes Station at RKS on frequency 131.32 MHz, where he provided his estimated time of arrival and put in a request for fuel. The captain said at 20 to 25 miles out, he made his first radio call on the CTAF, 122.8 MHz, and requested any aircraft at Rock Springs please advise. He said he continued to make advisory calls at 15, 10, and 5 miles from the airport and on short final for runway 27. On short final and approximately 200 feet above ground level, the captain said they received a TCAS (Terrain Clearance Avoidance System) traffic advisory showing "+300 feet," but then it disappeared. The captain said he made the advisory call on short final because of the TCAS warning. The captain said they touched down, rolled out and taxied to the gate. The captain said he learned of the accident involving N8822P when they were deplaning. When asked if he requested an airport advisory on the CTAF, the captain said he did not. When asked if he heard any other traffic on the RKS CTAF, the captain said no.

A pilot, deadheading to RKS and sitting in seat 6C on N240GL, said that during rollout she noticed an airplane that appeared to be landing on runway 21 coming directly at the airplane. She said the airplane climbed and flew over the top of N240GL. She said she looked left and saw the airplane impact the ground in a cloud of dust.

A station agent for Great Lakes Airlines said he saw N240GL coming in and a smaller airplane coming in on the left hand side. The agent said they seemed very close. He said as N240GL touched down, the smaller airplane kept "swerving and stalling (until) it hit the ground."

Flight recorders

The cockpit voice recorder (CVR) from N240GL was removed from the airplane and sent to the NTSB CVR Laboratory. On October 9, 2002, the recorder tape was examined. The voice tape indicated that the captain of Flight 5111 made a company in-range radio call to the station at RKS. The voice tape indicates that the crew monitored AWOS for weather information. The voice tape indicates that the crew made five traffic advisory calls to Rock Springs traffic.

Wreckage and impact information

A Federal Aviation Administration inspector examined N8822P at RKS. The airplane rested upright in a field approximately 1,100 feet southwest of the runways intersection. One propeller blade was bent aft. The airplane's right wing was bent upward approximately 10 degrees at mid-span. The upper and lower wing skins were bent and buckled. The fuselage and empennage were bent upward aft of the baggage compartment. Flight control continuity was confirmed. An examination of the cockpit configuration showed the airplane's number 1 communications radio set to a frequency of 122.8 MHz. An examination of the engine, engine controls, and other airplane systems revealed no anomalies.

Tests and research

Air Route Traffic Control Center radar showed N8822P approach RKS from the west-southwest. At 1309:39, N8822P entered a left downwind leg that positioned the airplane east of and parallel to runway 21. At the same time, ARTCC radar showed N240GL on a descending straight in approach to runway 27 approaching from the east. At 1310:08, ARTCC radar showed N240GL approximately 3.5 nautical miles from the approach end of runway 27 at 7,800 feet msl. At the same time, N8822P was over the approach end of runway 27, midway on his downwind leg for runway 21, at 7,600 feet msl, and 2.33 nautical miles west of N240GL at the Beech 1900D's 12 o'clock position. ARTCC radar showed N8822P continue a left-hand traffic pattern that positioned the airplane on a 1 mile final for runway 21. Radar showed both airplanes continued inbound for landings on their respective chosen runways. The data shows both airplane tracks came together at the intersection of both runways at 1311:34.

The three Great Lakes Airlines station agents on duty at RKS recalled that Flight 5111 (N240GL) called "in range" and made a fuel order on the Base Operations Company Frequency, 131.32 MHz, approximately 15 minutes prior to landing. The station agents then went outside to meet the airplane.

Two fire fighters at the RKS fire station, monitoring the CTAF, said they heard N8822P call in bound for landing on runway 21. One of the fire

Aircraft · 2

Registration
N8822P
Reported as
Piper PA-24-260
Category
Airplane
Serial number
24-4278
Airframe hours
2,101
Engine
Lycoming O-540-E4A5, 260 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
John R. Ipson
Registered owner
John R. Ipson, Joan H. Ipson Trustees
Airworthiness certificate
Standard, Normal
Last inspection
Annual · November 2, 2001 · 136 hours before
Departed
RNO · Reno, NV
Destination
RKS · Rock Springs, WY
Airport
RKS · Rock Springs-Sweetwater County, runway 21, 5,223 × 75 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
N240GL
Reported as
Beech 1900D
Category
Airplane
Serial number
UE-240
Airframe hours
955.1
Engines
Pratt & Whitney PT6A-67D, 1,220 horsepower, turbo propPratt & Whitney PT6A-67D, 1,220 horsepower, turbo prop
Damage
No damage
Flight
Part 121
Registered owner
Great Lakes Aviation, Limited
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · September 14, 2002 · 3.3 hours before
Departed
DEN · Denver, CO
Destination
RKS · Rock Springs, WY
Flight plan
IFR
Airport
RKS · Rock Springs-Sweetwater County, runway 27, 10,000 × 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.

Flight crew · 3

As NTSB recorded them. NTSB leaves out names.

Role
Pilot, aircraft N8822P
Age
68
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Valid Medical--w/ waivers/lim
Last flight review
April 26, 2001
Seat
Left
Flight hours
2,557 total · 761 in this make and model · 2,557 as pilot in command · 37 in the last 90 days · 23 in the last 30 days · 3 in the last 24 hours
Role
Pilot, aircraft N240GL
Age
34
Injuries
None
Certificates
Airline transport, Flight instructor
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Last flight review
June 15, 2002
Seat
Left
Flight hours
7,500 total · 3,900 in this make and model · 4,500 as pilot in command · 50 in the last 90 days · 19 in the last 30 days · 6 in the last 24 hours
Role
Co-pilot, aircraft N240GL
Age
33
Injuries
None
Certificates
Flight instructor, Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1
Last flight review
June 22, 2002
Seat
Right
Toxicology
Performed
Flight hours
573 total · 262 in this make and model · 241 as pilot in command · 262 in the last 90 days · 89 in the last 30 days · 6 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
240° at 11 knots, gusting 15
Visibility
10 statute miles
Lowest ceiling
None
Temperature
75 °F, dew point 27 °F
Altimeter
30.32 inHg
Observed at
RKS

FAA reports on this event · 2

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