# NTSB DEN02FA105: Piper PA-24-260, N8822P, Rock Springs, WY, September 15, 2002 - Type: NTSB accident investigation - Classification: Accident · No injuries · Field investigation · Final report - Date: September 15, 2002, 13:12 local (19:12 UTC) - Place: Rock Springs, WY - Coordinates: 41.59, -109.059165 - Nearby events: https://openairdocs.org/map.md?lat=41.5900&lon=-109.0592&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 16 uninjured - Status: Completed, report May 13, 2003 - Report: Approved by Office Director - Parties: Federal Aviation Administration, Great Lakes Aviation, Ltd. - NTSB case key (mKey): 55720 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=DEN02FA105 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/55720/pdf - Page: https://openairdocs.org/ntsb/DEN02FA105 ## Probable cause (aircraft 2) 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. ## Probable cause (aircraft 1) 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Near collision between aircraft, landing - aborted - clearance - not attained, pilot in command (cause) - clearance - not attained, flightcrew (cause) - visual lookout - inadequate, pilot in command (contributing factor) - visual lookout - inadequate, flightcrew (contributing factor) - radio communications - not successful, flightcrew - traffic advisory - not issued, airport personnel - Abrupt maneuver, landing - aborted - evasive maneuver - intentional, pilot in command (cause) - Loss of control - in flight, landing - aborted - stall - inadvertent, pilot in command (contributing factor) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - ground - Near collision between aircraft, landing - roll - visual lookout - inadequate, flightcrew (contributing factor) - visual lookout - inadequate, pilot of other aircraft (contributing factor) - clearance - not attained, flightcrew (cause) - clearance - not attained, pilot of other aircraft (cause) - radio communications - not successful, flightcrew - traffic advisory - not issued, airport personnel ## Analysis (aircraft 2) 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. ## Analysis (aircraft 1) 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 (aircraft 2) SEE NARRATIVE FOR DEN01FA105A. ## Factual narrative (aircraft 1) 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 1 - Registration: [N8822P](https://openairdocs.org/aircraft/N8822P), registered now, S/N 24-4278, built 1965 (OpenAirDocs) - Reported make and model: Piper PA-24-260 - Registry model: [Piper PA-24-260](https://openairdocs.org/model/piper-pa-24-260) (registry code 7102406) (OpenAirDocs) - Registry engine: [Lycoming 0-540 series](https://openairdocs.org/engine/lycoming-0-540-series) (registry code 41532, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 24-4278 - Airframe hours: 2101 - Engines: 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 ## Aircraft 2 - Registration: [N240GL](https://openairdocs.org/aircraft/N240GL), registered now, S/N UE-240, built 1996 (OpenAirDocs) - Reported make and model: Beech 1900D - Registry model: [Beech 1900D](https://openairdocs.org/model/beech-1900d) (registry code 1154162) (OpenAirDocs) - Registry engine: [Pratt & Whitney PT6A series](https://openairdocs.org/engine/pratt-whitney-pt6a-series) (registry code 52032, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: UE-240 - Airframe hours: 955.1 - Engines: Pratt & Whitney PT6A-67D 1220 horsepower turbo prop; Pratt & Whitney PT6A-67D 1220 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot, aircraft N8822P; age 68; injuries: none; 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 - Pilot, aircraft N240GL; age 34; injuries: none; 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 - Co-pilot, aircraft N240GL; age 33; injuries: none; 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 (OpenAirDocs). - [Accident 20020915025519A](https://openairdocs.org/incident/20020915025519A), Sep 15, 2002: Piper PA24260, Rock Springs, WY, Substantial damage. (-23) The pilot was about to touch down on runway 21 when the passenger alerted him to a BE-1900 airliner rolling out after touch down on runway 27. To avoid… - [Incident 20020915025429I](https://openairdocs.org/incident/20020915025429I), Sep 15, 2002: Beech 1900D, Rock Springs, WY. (-23) On 9/15/02, at 1:10 pm lakes air 5111, a BE-1900-D airliner operated by great lakes aviation ltd., was in the landing roll after landing on runway 27 at… 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.