DEN03MA035

NTSB accident investigation · Piper PA-31T · Denver, CO · January 25, 2003

Accident · FatalMajor investigationFinal report
Date
January 24, 2003, 17:21 local (Jan 25, 2003, 00:21 UTC)
Place
Denver, CO
Injuries
5 fatal, 6 minor; on the ground: 6 minor
Phase of flight
Enroute
Aircraft
N360LLPiper PA-31TN52241Cessna 172P
Weather
Visual (VMC) · Dusk
Status
Completed · report November 25, 2003
Report
Approved by Office Director
Parties
Pratt & Whitney, Cessna Aircraft Company, FAA Flight Standards District Office, The New Piper Aircraft Corporation, National Air Traffic Controllers Association
Case key
56404

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 NTSB’s determination of the probable cause, and any contributing factors.

Both pilots' inadequate visual lookout. A contributing factor was the Cheyenne pilot operating the airplane with a known transponder deficiency.

Both pilots' inadequate visual lookout. A contributing factor was the Cheyenne pilot operating the airplane with a known transponder deficiency.

Analysis

A Piper PA-31T "Cheyenne" and a Cessna 172P "Skyhawk" collided in midair during cruise flight at dusk and in visual meteorological conditions. The Cheyenne departed under visual flight rules (VFR) from a local airport northwest of Denver, and was proceeding direct at 7,800 feet to another local airport south of Denver. Radar indicated its ground speed was 230 knots. Its altitude encoder was transmitting intermittently. The Skyhawk departed VFR from the south airport and was en route to Cheyenne, Wyoming, at 7,300 feet. The pilot requested and was cleared to climb to 8,500 feet and penetrate class B airspace. Radar indicated its ground speed was 110 knots. The Skyhawk was flying in the suggested "VFR flyway"; the Cheyenne was not. When the controller observed the two airplanes converging, he asked the pilot of the Cheyenne for his altitude. He replied he was at 7,600 feet. The controller immediately issued a traffic advisory, but the pilot did not acknowledge. Both airplanes departed controlled flight: the Skyhawk struck a house, and the Cheyenne fell inverted into the backyard of a residence. Wreckage was scattered over a 24 square block area in west Denver. At the time of the accident, the controller was handling low altitude en route, arrival and departure traffic for both airports. Wreckage examination disclosed four slashes, consistent with propeller strikes, on top of the Cheyenne's right engine nacelle, the cabin above the right wing trailing edge, the empennage at the root of the dorsal fin, and at the tail cone. The Cheyenne was on a similar flight three days before the collision when the pilot was informed by air traffic control that the transponder was operating intermittently. According to recorded radar and voice communications from that flight, the transponder/encoder operated intermittently and the pilot was so advised. Examination of the Cheyenne's altimeter/encoder revealed a cold solder connection on pin 8 of the 15-pin altimeter connector. When the wire was resoldered to the pin, the information from the altimeters, encoder, and altitude serializer was normal.

A Piper PA-31T "Cheyenne" and a Cessna 172P "Skyhawk" collided in midair during cruise flight at dusk and in visual meteorological conditions. The Cheyenne departed under visual flight rules (VFR) from a local airport northwest of Denver, and was proceeding direct at 7,800 feet to another local airport south of Denver. Radar indicated its ground speed was 230 knots. Its altitude encoder was transmitting intermittently. The Skyhawk departed VFR from the south airport and was en route to Cheyenne, Wyoming, at 7,300 feet. The pilot requested and was cleared to climb to 8,500 feet and penetrate class B airspace. Radar indicated its ground speed was 110 knots. The Skyhawk was flying in the suggested "VFR flyway"; the Cheyenne was not. When the controller observed the two airplanes converging, he asked the pilot of the Cheyenne for his altitude. He replied he was at 7,600 feet. The controller immediately issued a traffic advisory, but the pilot did not acknowledge. Both airplanes departed controlled flight: the Skyhawk struck a house, and the Cheyenne fell inverted into the backyard of a residence. Wreckage was scattered over a 24 square block area in west Denver. At the time of the accident, the controller was handling low altitude en route, arrival and departure traffic for both airports. Wreckage examination disclosed four slashes, consistent with propeller strikes, on top of the Cheyenne's right engine nacelle, the cabin above the right wing trailing edge, the empennage at the root of the dorsal fin, and at the tail cone. The Cheyenne was on a similar flight three days before the collision when the pilot was informed by air traffic control that the transponder was operating intermittently. According to recorded radar and voice communications from that flight, the transponder/encoder operated intermittently and the pilot was so advised. Examination of the Cheyenne's altimeter/encoder revealed a cold solder connection on pin 8 of the 15-pin altimeter connector. When the wire was resoldered to the pin, the information from the altimeters, encoder, and altitude serializer was normal.

Factual narrative

The factual narrative1,280 words

History of flight

On January 24, 2003, at 1720:36 mountain standard time, a Piper PA-31T, N360LL, registered to and operated by Lee Larson Aircraft Sales of Northglenn, Colorado, and a Cessna 172P, N52241, registered to EDB Air, Inc., and doing business as Key Lime Flights of Englewood, Colorado, collided in midair over Denver, Colorado. The commercial pilot-in-command and the commercial certificated pilot-passenger aboard N360LL and the private pilot and two passengers aboard N52241 were fatally injured. The Denver Police Department (DPD) reported that six persons on the ground, including a 15-year old boy and a 2-year old girl, received minor injuries from falling debris. Visual meteorological conditions prevailed, and neither pilot had filed flight plans. Both flights were being operated under Title 14 CFR Part 91. N5224's flight originated at Centennial Airport, Englewood, Colorado, at 1708, and was en route to Cheyenne, Wyoming. N360LL's flight originated at Jeffco Airport, Broomfield, Colorado, at 1716, and was en route to Centennial Airport.

At 1708, the pilot of N52241 was cleared for takeoff from Centennial Airport's runway 17L, and to proceed VFR (visual flight rules) "on course." At 1716, the pilot of N360LL was cleared for takeoff from Jeffco Airport's runway 29R, VFR, with a southbound departure. At 1717:52, the pilot of N360LL contacted Denver Terminal Radar Control (TRACON) and advised "We're just off Jeffco, down to Centennial." [At this point, radar data indicated N52241 was about 10 miles northwest of Centennial, its transponder transmitting a beacon code of 1200 (VFR)]. At 1718:04, the controller assigned the pilot a transponder beacon code of 5250. At 1718:26, he identified the airplane on radar: "Cheyenne Zero Lima Lima, radar contact, four (miles) south of Jeffco. Proceed as requested. [Note: According to NTSB's Operational Factors Division (AS-30), "proceed as requested" does not constitute an ATC clearance, which requires an aircraft to proceed under conditions specified by ATC, nor was one required because the pilot was operating in Class E airspace under visual flight rules.] I'm not getting any mode C on you. You squawking altitude?" The pilot replied, "Ah, yes, sir, we are." [At this point, radar data indicated N360LL was 10.73 miles from N52241]. At 1718:34, the controller asked the pilot for his altitude. He replied he was at 7,800 feet. [Radar data indicated the N360LL's mode C was still inoperative and it remained so throughout the flight. The radar-computed ground speed indicated "23," or 230 knots.]

At 1718:58, the pilot of N52241 contacted Denver Terminal Radar Control (TRACON): "Denver, Cessna Five Two Two Four One is over Denver at seven thousand, three hundred feet, with a request." The controller issued the pilot a transponder beacon code of 5251. The pilot acknowledged the instruction and requested clearance to climb to 8,500 feet, which would place the airplane in Class B airspace. He also advised he was en route to Cheyenne. [At this point, Centennial tower called the controller with a request for another aircraft's IFR departure release. The controller issued the release and assigned a departure heading of 050 degrees, then coordinated the departure with the south sector controller]. At 1720:04, the controller identified the airplane on radar when it was 15 miles southeast of Jeffco Airport, and asked the pilot to repeat his requested altitude. He repeated his request for 8,500 feet. [At this point, separation between N360LL and N52241 had closed to 2.91 miles. N52241's radar-computed ground indicated "11," or 110 knots. At about this time, the controller made a transmission to an aircraft that was on the downwind leg at Centennial Airport. He then vectored another airplane onto the NDB (nondirectional beacon) approach to Centennial Airport. The controller was also monitoring other aircraft that were getting close to a restricted area and the airport traffic area]. At 1720:16, the controller cleared N52241 to enter class B airspace and climb to 8,500 feet. Two seconds later, radar showed target separation as 1.64 miles. At 1720:22, target separation was 1.20 miles. At 1720:27, target separation was 0.80 miles.

At 1720:28, the controller asked the pilot of N360LL to report his altitude. The pilot replied, "(Unintelligible) six." The controller said, "Say again." At 1720:31, target separation had reduced to 0.29 miles. The pilot said, "Seven thousand, six hundred." At 1720:33, the controller issued the pilot a traffic advisory: "Traffic is at twelve o'clock and a mile at seventy seven hundred, a Cessna." The pilot did not acknowledge this transmission. At 1720:36, the two airplanes were 0.06 miles apart. Immediately thereafter, radar data indicated both targets had entered "coast" mode (i.e. computer-generated projection of targets' tracks and positions). At 1720:47, the controller advised N360LL that the previously reported traffic was no longer a factor and issued another advisory for traffic 4 miles away. Receiving no reply from the pilot, the controller attempted several times to contact both airplanes. The controller then contacted a traffic patrol pilot and asked him to fly over the area where radar contact was lost. Shortly thereafter, the traffic patrol pilot reported that it appeared there had been an accident. The TRACON controller initiated search and rescue procedures.

The collision occurred 2 minutes, 43 seconds and 1 minute, 35 seconds after the pilots of N360LL and N52241 made initial contact with Denver TRACON, respectively.

DPD took written statements from 113 witnesses, three of whom were pilots. Of those witnesses, 32 were interviewed and those interviews were videotaped. The majority of the witnesses reported hearing a loud noise, variously described as a bang, pop, or explosion. Looking up into the sky, they saw a wing(s) falling to the ground and a twin engine airplane enter an inverted flat spin and fall straight down. A small, single-engine airplane was seen to nosedive into a house, trailing debris. Five witnesses made note of the light conditions: either the sun was setting or had gone below the horizon. "There was still light out," wrote one witness. There was "no trouble seeing," said another. Seventeen witnesses reported hearing an engine "stalling" or "sputtering." Some described it as "revving up." Three witnesses said the engine restarted. Several witnesses noted that the twin engine airplane was traveling "quite fast." One witness said he saw "white streak in the sky." Another said one airplane was on fire, and 12 other witnesses said one or both airplanes trailed smoke as they plummeted to the ground.

Of the 113 known witnesses, NTSB contacted 17 who actually saw the airplanes prior to or at the time of the collision. One witness saw "both airplanes heading toward each other" at "low altitude." He wrote, "...the two planes were trying to avoid each other, both in a heavy right bank." Then, "the smaller plane hit the left wing of the twin engine, severing it from the fuselage." Through an interpreter, another witness wrote: "I see two planes doing a hard right turn...and they hit." A third witness wrote, "I see the two planes coming together. The plane heading south started to bank turn away when it clip the wing" (sic). Two witnesses reported seeing the Cessna at about 1,000 feet and banking to the right at the last instant. Still another witness said the Piper pulled up and banked to the right just before the collision. One witness said he saw the "two planes veering away from each other and the wings clipped each other...The planes seemed to be coming from the north and south and when they hit, they seemed to hit wing to wing at a 45 degree angle." Two other witnesses who claim to have seen the actual collision said that neither airplane made any evasive maneuver.

Of those witnesses who saw the collision, most did not notice any lights on either

The factual narrative1,280 words

History of flight

On January 24, 2003, at 1720:36 mountain standard time, a Piper PA-31T, N360LL, registered to and operated by Lee Larson Aircraft Sales of Northglenn, Colorado, and a Cessna 172P, N52241, registered to EDB Air, Inc., and doing business as Key Lime Flights of Englewood, Colorado, collided in midair over Denver, Colorado. The commercial pilot-in-command and the commercial certificated pilot-passenger aboard N360LL and the private pilot and two passengers aboard N52241 were fatally injured. The Denver Police Department (DPD) reported that six persons on the ground, including a 15-year old boy and a 2-year old girl, received minor injuries from falling debris. Visual meteorological conditions prevailed, and neither pilot had filed flight plans. Both flights were being operated under Title 14 CFR Part 91. N5224's flight originated at Centennial Airport, Englewood, Colorado, at 1708, and was en route to Cheyenne, Wyoming. N360LL's flight originated at Jeffco Airport, Broomfield, Colorado, at 1716, and was en route to Centennial Airport.

At 1708, the pilot of N52241 was cleared for takeoff from Centennial Airport's runway 17L, and to proceed VFR (visual flight rules) "on course." At 1716, the pilot of N360LL was cleared for takeoff from Jeffco Airport's runway 29R, VFR, with a southbound departure. At 1717:52, the pilot of N360LL contacted Denver Terminal Radar Control (TRACON) and advised "We're just off Jeffco, down to Centennial." [At this point, radar data indicated N52241 was about 10 miles northwest of Centennial, its transponder transmitting a beacon code of 1200 (VFR)]. At 1718:04, the controller assigned the pilot a transponder beacon code of 5250. At 1718:26, he identified the airplane on radar: "Cheyenne Zero Lima Lima, radar contact, four (miles) south of Jeffco. Proceed as requested. [Note: According to NTSB's Operational Factors Division (AS-30), "proceed as requested" does not constitute an ATC clearance, which requires an aircraft to proceed under conditions specified by ATC, nor was one required because the pilot was operating in Class E airspace under visual flight rules.] I'm not getting any mode C on you. You squawking altitude?" The pilot replied, "Ah, yes, sir, we are." [At this point, radar data indicated N360LL was 10.73 miles from N52241]. At 1718:34, the controller asked the pilot for his altitude. He replied he was at 7,800 feet. [Radar data indicated the N360LL's mode C was still inoperative and it remained so throughout the flight. The radar-computed ground speed indicated "23," or 230 knots.]

At 1718:58, the pilot of N52241 contacted Denver Terminal Radar Control (TRACON): "Denver, Cessna Five Two Two Four One is over Denver at seven thousand, three hundred feet, with a request." The controller issued the pilot a transponder beacon code of 5251. The pilot acknowledged the instruction and requested clearance to climb to 8,500 feet, which would place the airplane in Class B airspace. He also advised he was en route to Cheyenne. [At this point, Centennial tower called the controller with a request for another aircraft's IFR departure release. The controller issued the release and assigned a departure heading of 050 degrees, then coordinated the departure with the south sector controller]. At 1720:04, the controller identified the airplane on radar when it was 15 miles southeast of Jeffco Airport, and asked the pilot to repeat his requested altitude. He repeated his request for 8,500 feet. [At this point, separation between N360LL and N52241 had closed to 2.91 miles. N52241's radar-computed ground indicated "11," or 110 knots. At about this time, the controller made a transmission to an aircraft that was on the downwind leg at Centennial Airport. He then vectored another airplane onto the NDB (nondirectional beacon) approach to Centennial Airport. The controller was also monitoring other aircraft that were getting close to a restricted area and the airport traffic area]. At 1720:16, the controller cleared N52241 to enter class B airspace and climb to 8,500 feet. Two seconds later, radar showed target separation as 1.64 miles. At 1720:22, target separation was 1.20 miles. At 1720:27, target separation was 0.80 miles.

At 1720:28, the controller asked the pilot of N360LL to report his altitude. The pilot replied, "(Unintelligible) six." The controller said, "Say again." At 1720:31, target separation had reduced to 0.29 miles. The pilot said, "Seven thousand, six hundred." At 1720:33, the controller issued the pilot a traffic advisory: "Traffic is at twelve o'clock and a mile at seventy seven hundred, a Cessna." The pilot did not acknowledge this transmission. At 1720:36, the two airplanes were 0.06 miles apart. Immediately thereafter, radar data indicated both targets had entered "coast" mode (i.e. computer-generated projection of targets' tracks and positions). At 1720:47, the controller advised N360LL that the previously reported traffic was no longer a factor and issued another advisory for traffic 4 miles away. Receiving no reply from the pilot, the controller attempted several times to contact both airplanes. The controller then contacted a traffic patrol pilot and asked him to fly over the area where radar contact was lost. Shortly thereafter, the traffic patrol pilot reported that it appeared there had been an accident. The TRACON controller initiated search and rescue procedures.

The collision occurred 2 minutes, 43 seconds and 1 minute, 35 seconds after the pilots of N360LL and N52241 made initial contact with Denver TRACON, respectively.

DPD took written statements from 113 witnesses, three of whom were pilots. Of those witnesses, 32 were interviewed and those interviews were videotaped. The majority of the witnesses reported hearing a loud noise, variously described as a bang, pop, or explosion. Looking up into the sky, they saw a wing(s) falling to the ground and a twin engine airplane enter an inverted flat spin and fall straight down. A small, single-engine airplane was seen to nosedive into a house, trailing debris. Five witnesses made note of the light conditions: either the sun was setting or had gone below the horizon. "There was still light out," wrote one witness. There was "no trouble seeing," said another. Seventeen witnesses reported hearing an engine "stalling" or "sputtering." Some described it as "revving up." Three witnesses said the engine restarted. Several witnesses noted that the twin engine airplane was traveling "quite fast." One witness said he saw "white streak in the sky." Another said one airplane was on fire, and 12 other witnesses said one or both airplanes trailed smoke as they plummeted to the ground.

Of the 113 known witnesses, NTSB contacted 17 who actually saw the airplanes prior to or at the time of the collision. One witness saw "both airplanes heading toward each other" at "low altitude." He wrote, "...the two planes were trying to avoid each other, both in a heavy right bank." Then, "the smaller plane hit the left wing of the twin engine, severing it from the fuselage." Through an interpreter, another witness wrote: "I see two planes doing a hard right turn...and they hit." A third witness wrote, "I see the two planes coming together. The plane heading south started to bank turn away when it clip the wing" (sic). Two witnesses reported seeing the Cessna at about 1,000 feet and banking to the right at the last instant. Still another witness said the Piper pulled up and banked to the right just before the collision. One witness said he saw the "two planes veering away from each other and the wings clipped each other...The planes seemed to be coming from the north and south and when they hit, they seemed to hit wing to wing at a 45 degree angle." Two other witnesses who claim to have seen the actual collision said that neither airplane made any evasive maneuver.

Of those witnesses who saw the collision, most did not notice any lights on either

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 collisionCruise - normal
Visual lookout - inadequatePilot in commandCause
Visual lookout - inadequatePilot of other aircraftCause
Comm/nav equipment,transponder - erratic
Operation with known deficiencies in equipment - intentionalPilot in commandFactor
Flight advisories - issuedAtc personnel(dep/apch)
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - residential area
Midair collisionClimb - to cruise
Visual lookout - inadequatePilot in commandCause
Visual lookout - inadequatePilot of other aircraftCause
In flight collision with objectDescent - uncontrolled
Object - residence

Aircraft · 2

Registration
N360LL
Reported as
Piper PA-31T
Category
Airplane
Serial number
31T-7520036
Airframe hours
6,478
Engine
Pratt & Whitney Canada PT6A-28, 620 horsepower, turbo prop
Damage
Destroyed
Flight
Personal · Part 91
Registered owner
Lee Larson
Airworthiness certificate
Standard, Normal
Departed
BJC · Broomfield, CO
Destination
APA · Englewood, CO

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
N52241
Reported as
Cessna 172P
Category
Airplane
Serial number
17274452
Airframe hours
12,873
Engine
Lycoming O-360-A4M, 180 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Registered owner
EDB Air, Inc.
Airworthiness certificate
Standard, Utility; Standard, Normal
Last inspection
100 hour · January 8, 2003
Departed
APA · Englewood, CO
Destination
CYS · Cheyenne, WY

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 N360LL
Age
57
Injuries
Fatal
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Last flight review
May 9, 2001
Seat
Left
Toxicology
Performed
Flight hours
9,365 total · 9,067 as pilot in command
Role
Pilot, aircraft N360LL
Age
51
Injuries
Fatal
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Last flight review
January 21, 2002
Seat
Right
Toxicology
Performed
Flight hours
1,944 total · 1,697 as pilot in command
Role
Pilot, aircraft N52241
Age
20
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
128 total · 124 in this make and model · 59 as pilot in command · 26 in the last 90 days · 8 in the last 30 days

Weather

Conditions
Visual (VMC) · Dusk
Wind
130° at 14 knots
Visibility
10 statute miles
Lowest ceiling
22,000 ft broken
Temperature
39 °F, dew point 23 °F
Altimeter
30.12 inHg
Observed at
DEN, 23 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.