DEN99LA048

NTSB accident investigation · Piper PA-28-235 · Provo, UT · March 6, 1999

Accident · Serious injuriesLimited investigationFinal report
Date
March 6, 1999, 13:30 local (20:30 UTC)
Place
Provo, UT
Injuries
1 serious, 1 minor, 3 uninjured
Phase of flight
Takeoff
Aircraft
N4312APiper PA-28-235N189DADiamond Aircraft Industries DA 20-A1
Weather
Visual (VMC) · Day
Status
Completed · report October 13, 2000
Report
Approved by Office Director
Case key
45889

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The pilot exercising poor judgment by ignoring proper procedures/directives, his intentional selection of the wrong runway for takeoff, and his failure to maintain an adequate visual lookout. Factors were his ostentatious display, the other airplane moving on the ground, and the other pilot's failure to maintain an adequate visual lookout.

The pilot exercising poor judgment by ignoring proper procedures/directives, his intentional selection of the wrong runway for takeoff, and his failure to maintain an adequate visual lookout. Factors were his ostentatious display, the other airplane moving on the ground, and the other pilot's failure to maintain an adequate visual lookout.

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.

On ground/water collision with objectTakeoff - roll/run
Object - aircraft moving on groundFactor
Judgment - poorPilot in commandCause
Ostentatious displayPilot in commandFactor
Procedures/directives - not followedPilot in commandCause
Wrong runway - intentionalPilot in commandCause
Visual lookout - not maintainedPilot in commandCause
Visual lookout - not maintainedPilot of other aircraftFactor
On ground/water collision with objectTakeoff - roll/run
Object - aircraft moving on groundFactor
Visual lookout - not maintainedPilot in commandFactor
Judgment - poorPilot of other aircraftCause
Ostentatious displayPilot of other aircraftFactor
Procedures/directives - not followedPilot of other aircraftCause
Wrong runway - intentionalPilot of other aircraftCause
Visual lookout - not maintainedPilot of other aircraftCause

Analysis

N189DA, a Diamond-DA 20-A1 was one of several airplanes in the traffic pattern for runway 31, which was the active runway. The airplane landed and was on landing rollout when it was struck by N4312A, a Piper PA-28-235 that was on takeoff roll on runway 18. The collision occurred at the intersection of runways 31 and 18. The pilot of the piper said he saw two airplanes in the traffic pattern, and heard both pilots advise of their positions and intentions. The pilot of the piper announced that he would be taxiing onto runway 18 for departure because he had 'plenty of time to depart before either of the two aircraft were in position to land.' He did not see the diamond, which was ahead of the other two airplanes. Two other pilots reported having near collisions with the piper earlier that day, and one pilot reported having a near collision with the piper two months earlier.

N189DA, a Diamond-DA 20-A1 was one of several airplanes in the traffic pattern for runway 31, which was the active runway. The airplane landed and was on landing rollout when it was struck by N4312A, a Piper PA-28-235 that was on takeoff roll on runway 18. The collision occurred at the intersection of runways 31 and 18. The pilot of the piper said he saw two airplanes in the traffic pattern, and heard both pilots advise of their positions and intentions. The pilot of the piper announced that he would be taxiing onto runway 18 for departure because he had 'plenty of time to depart before either of the two aircraft were in position to land.' He did not see the diamond, which was ahead of the other two airplanes. Two other pilots reported having near collisions with the piper earlier that day, and one pilot reported having a near collision with the piper two months earlier.

Factual narrative

See NARRATIVE for DEN 99-L-A048A.

On March 6, 1999, approximately 1330 mountain standard time, a Piper PA-28-235, N4312A, and a Diamond DA 20-A1, N189DA, were destroyed when they collided on the ground at the Provo Municipal Airport, Provo, Utah. N4312A was on takeoff roll on runway 18, and N189DA was on landing rollout on runway 31. The private pilot and two passengers aboard N4312A escaped injury. The flight instructor aboard N189DA was seriously injured, and his student pilot received minor injuries. Visual meteorological conditions prevailed at the time, and flight plans had not been filed by either pilot. Both flights were being conducted under Title 14 CFR Part 91. The flight of N4312A was for business and was originating at the time of the accident. The flight of N189DA was for instruction and had originated at Provo approximately 30 minutes before the accident.

The following is based on the accident report submitted by the pilot of N4312A, Larry M. Jones, and a telephone conversation he had with this investigator a few days after the accident. Mr. Jones wrote that he conducted his pre-takeoff check with the radio on (but told this investigator that it was after he had completed his pre-takeoff check that he put his earphones on). There were two airplanes in the traffic pattern. He heard the first pilot advise he was turning onto base leg for runway 31. The second pilot said he was going to follow the first airplane in for landing. With both airplanes in sight, Mr. Jones radioed that he would be taxiing onto runway 18 for departure because he had "plenty of time to depart before either of the two aircraft were in position to land." As he approached the intersection, his brother called his attention to a third airplane, N189DA. Mr. Jones said he closed the throttle, pulled the hand brake (locking the brakes), applied left rudder (in an attempt to go behind N189DA), then applied back elevator pressure and full left aileron (in an attempt to raise the right wing over the top of N189DA). N4312A collided with N189DA and caught fire. All three occupants of N4312A evacuated the airplane. The two occupants of N189DA were extricated by CFR personnel and taken to a local hospital.

Stan Jones, the right front seat passenger and brother of the pilot, submitted a statement which corroborated Larry Jones' report. He made no reference, however, to the near midair collision that had occurred earlier that morning as they were landing at Provo.

In his accident report, the flight instructor aboard N189DA, Steven Hill, said he and his student were landing on runway 31. "There was another airplane close in behind [us] on base, and there was another airplane also behind him," he said. He said they intentionally landed long to give the trailing traffic additional landing clearance. He could not remember anything else.

The student aboard N189DA, Derek Hansen, said that after practicing flight maneuvers, he made several touch and go landings. "The airport was busy," Mr. Hansen wrote. "I don't recall a time from the time we entered the traffic pattern until the time of the accident when there was not at least one other airplane in the pattern. Transmissions were brief, pertinent, and frequent. . ." Mr. Hansen landed the airplane under the supervision of Mr. Hill. As he started to turn the airplane off the runway, Mr. Hill yelled and kicked hard left rudder. Mr. Hansen said he caught a glimpse of an airplane just before the collision.

The Provo Police Department also investigated the accident and collected 12 witness statements (attached). The witnesses corroborated reports that runway 31 was the active runway, that N189DA had landed long on runway 31, that N4312A was taking off on runway 18, and that the collision occurred at the intersection of the two runways (two witnesses mistakenly thought N189DA was taking off and N4312A was landing).

During the course of this investigation, it was learned that the pilot of N4312A had another near collision earlier in the day as he approached Provo Airport for landing after a flight from Richfield, Utah. In a written statement, Christopher Harger said he had been giving flight instruction to a student, and they were returning to Provo for landing. At an altitude of 5,500 feet, they made a 45 degree entry into the traffic pattern, then turned onto a left downwind leg for runway 13 and announced their position on the radio. He heard the pilot of N4312A announce over the radio that he was "over the lake" and downwind for runway 18. When he heard the pilot say he was "over the numbers for three one," Mr. Harger made an immediate 360 degree turn to the right because he was in the general area. Nearing completion of the turn, he found himself on a collision course with the Cherokee (N4312A). He pulled up and the Cherokee passed 200 to 300 feet below him.

According to a written statement submitted by Heather Heslington, the airport Unicom operator, N4312A had also nearly collided with an airplane piloted by Mr. Stan Shaw, a flight instructor at Advantage Aviation (attempts to contact Mr. Shaw to obtain a statement were unsuccessful).

Flight Instructor Gerald Maass submitted a written statement about a near midair collision he had with N4312A three months earlier, on December 21, 1998. He was administering a private pilot practical examination to an applicant, and they were doing touch and go landings on runway 18. He heard the pilot of N4312A announce that he was downwind for runway 18. After takeoff and while climbing out, Mr. Maass observed N4312A pass him off to the right. The airplane was about 10 feet above him, and its left wing was over his right wing 3 to 4 feet. N4312A then turned abruptly to the left and passed in front and over the top "by not more than 20 feet." Mr. Jones later explained that he had been going through the "Before Landing" checklist in preparation for landing, and he inadvertently moved the fuel selector to the OFF position. The engine lost power and he immediately turned towards runway 18 (he made no announcement over the radio). When he observed Mr. Maass' airplane on the runway, he moved the fuel selector switch to a tank and regained engine power. The remedial action brought the two airplanes in close proximity to each other.

Brian Wortham, a flight instructor with Great Western Aviation in West Bountiful, Utah, said he gave Mr. Jones Class B (airspace) flight instruction shortly after the near collision. "I found his ability to maneuver the aircraft within the standards of the private pilot certificate," Mr. Wortham wrote. "I did express to him some concerns that I had about his decisions and judgments even with me in the aircraft. . .I was concerned about the ambivalence or lack of understanding of the seriousness of his situation. . ."

Mr. Jones' attitude was variously described as "flippant" by Ms. Heslington, "very nonchalant" by Mr. Maass, and "cavalier" by Mr. Wortham.

The wind, recorded 25 minutes after the accident, was from 280 degrees at 6 knots.

On April 22, 1999, Mr. Jones appeared at FAA's Flight Standards District Office in Salt Lake City to have his competency as a private pilot reexamined in accordance with Section 44709 of the U.S. Code, Title 49. He failed the oral portion of the reexamination. Because of the failure, no flight test was administered.

Aircraft · 2

Registration
N4312A
Reported as
Piper PA-28-235
Category
Airplane
Serial number
28-10249
Airframe hours
4,815
Engine
Lycoming O-540-B4B5, 235 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Business · Part 91
Registered owner
Larry M. & Stanley H. Jones
Airworthiness certificate
Standard, Normal
Last inspection
Annual · October 24, 1998 · 30 hours before
Departed
PVU
Destination
RIF · Richfield, UT
Airport
PVU · Provo Municipal, runway 18, 6,937 × 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.

Registration
N189DA
Reported as
Diamond Aircraft Industries DA 20-A1
Category
Airplane
Serial number
10189
Airframe hours
2,799
Engine
Rotax 912-F3, 81 horsepower, reciprocating
Damage
Destroyed
Flight
Instructional · Part 91
Registered owner
Utah Valley State College
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · February 17, 1999 · 67 hours before
Departed
PVU
Airport
PVU · Provo Municipal, runway 31, 7,091 × 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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot, aircraft N4312A
Age
47
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Valid Medical--w/ waivers/lim
Seat
Left
Flight hours
90 total · 30 in this make and model · 55 as pilot in command · 26 in the last 90 days · 10 in the last 30 days · 1 in the last 24 hours
Role
Pilot, aircraft N189DA
Age
28
Certificates
Commercial, Flight instructor
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Seat
Right
Flight hours
249 total · 173 in this make and model · 224 as pilot in command · 53 in the last 90 days · 40 in the last 30 days · 4 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
280° at 6 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
50 °F, dew point 27 °F
Altimeter
29.00 inHg
Observed at
PVU

FAA reports on this event · 2

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