ERA09MA447

NTSB accident investigation · Piper PA-32R-300 · Hoboken, NJ · August 8, 2009

Accident · FatalClass 1 · MajorFinal report
Date
August 8, 2009, 11:53 local (15:53 UTC)
Place
Hoboken, NJ
Injuries
9 fatal
Phase of flight
Enroute
Aircraft
N71MCPiper PA-32R-300N401LHEurocopter AS 350 BA
Defining events
Enroute-cruise: Midair collisionEnroute-cruise: Midair collision
Weather
Visual (VMC) · Day
Status
Completed · report October 25, 2010
Report
Board-adopted at Board Meeting
Investigation class
Class 1
NTSB office
Eastern Region Aviation
Parties
Liberty Helicopters, Piper, FAA AAI-100
Safety recommendations
Yes
Case key
74473

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

(1) the inherent limitations of the see-and-avoid concept, which made it difficult for the airplane pilot to see the helicopter until the final seconds before the collision, and (2) the Teterboro Airport local controller’s nonpertinent telephone conversation, which distracted him from his air traffic control (ATC) duties, including correcting the airplane pilot’s read back of the Newark Liberty International Airport (EWR) tower frequency and the timely transfer of communications for the accident airplane to the EWR tower. Contributing to this accident were (1) both pilots’ ineffective use of available information from their aircraft’s electronic traffic advisory system to maintain awareness of nearby aircraft, (2) inadequate Federal Aviation Administration (FAA) procedures for transfer of communications among ATC facilities near the Hudson River Class B exclusion area; and (3) FAA regulations that did not provide adequate vertical separation for aircraft operating in the Hudson River Class B exclusion area.

Findings · 10

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

N71MC · Piper PA-32R-300

Attention/monitoring: monitoring other aircraftPersonnel issues › Psychological · Not specifiedPiper PA-32R-300: 1 caseAll aircraft: 231 casesProbable cause
Attention/monitoring: attentionPersonnel issues › Psychological · ATC personnelPiper PA-32R-300: 2 casesAll aircraft: 226 casesProbable cause
Use of equip/info: use of equip/systemPersonnel issues › Task performance · PilotPiper PA-32R-300: 4 casesAll aircraft: 1,391 casesProbable cause
Policy/procedure: adequacy of policy/procOrganizational issues › Management · FAA/RegulatorPiper PA-32R-300: 1 caseAll aircraft: 106 casesProbable cause

N401LH · Eurocopter AS 350 BA

Attention/monitoring: attentionPersonnel issues › Psychological · ATC personnelEurocopter AS 350 BA: 1 caseAll aircraft: 226 casesProbable cause
Policy/procedure: adequacy of policy/procOrganizational issues › Management · FAA/RegulatorEurocopter AS 350 BA: 1 caseAll aircraft: 106 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

N71MC · Piper PA-32R-300

N401LH · Eurocopter AS 350 BA

Analysis

The Safety Board’s full report is available at http://www.ntsb.gov/publictn/2010/AAR1005.htm The Aircraft Accident Report number is NTSB/AAR-10/05. On August 8, 2009, at 1153:14 eastern daylight time, a Piper PA-32R-300 airplane, N71MC, and a Eurocopter AS350BA helicopter, N401LH, operated by Liberty Helicopters, collided over the Hudson River near Hoboken, New Jersey. The pilot and two passengers aboard the airplane and the pilot and five passengers aboard the helicopter were killed, and both aircraft received substantial damage from the impact. The airplane flight was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 91, and the helicopter flight was operating under the provisions of 14 CFR Parts 135 and 136. No flight plans were filed or were required for either flight, and visual meteorological conditions prevailed at the time of the accident.

Factual narrative

The Safety Board’s full report is available at http://www.ntsb.gov/publictn/2010/AAR1005.htm The Aircraft Accident Report number is NTSB/AAR-10/05. On August 8, 2009, at 1153:14 eastern daylight time, a Piper PA-32R-300 airplane, N71MC, and a Eurocopter AS350BA helicopter, N401LH, operated by Liberty Helicopters, collided over the Hudson River near Hoboken, New Jersey. The pilot and two passengers aboard the airplane and the pilot and five passengers aboard the helicopter were killed, and both aircraft received substantial damage from the impact. The airplane flight was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 91, and the helicopter flight was operating under the provisions of 14 CFR Parts 135 and 136. No flight plans were filed or were required for either flight, and visual meteorological conditions prevailed at the time of the accident.

Aircraft · 2

Registration
N71MC
Reported as
Piper PA-32R-300
Category
Airplane
Serial number
32R-7680172
Airframe hours
4,505
Engine
Lycoming TIO-540, 300 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Steven M Altman
Registered owner
Lca Partnership
Airworthiness certificate
Standard, Normal
Last inspection
Annual · April 2, 2009
Departed
TEB · Teterboro, NJ
Destination
26N · Ocean City, NJ

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
N401LH
Reported as
Eurocopter AS 350 BA
Category
Helicopter
Serial number
3059
Airframe hours
13,095
Engine
Turbomeca ARRIEL 1B, 681 horsepower, turbo shaft
Damage
Substantial damage
Flight
Part 135
Operator
Liberty Helicopters
Registered owner
Meridian Consulting I Corp Inc
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · August 2, 2009 · 23 hours before
Departed
JRA · New York, NY
Destination
JRA · New York, NY

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 N71MC
Age
60
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
November 12, 2008
Seat
Left
Toxicology
Performed
Flight hours
1,121 total · 834 in this make and model · 1,041 as pilot in command · 18 in the last 90 days · 1 in the last 30 days · 1 in the last 24 hours
Role
Pilot, aircraft N401LH
Age
32
Injuries
Fatal
Certificates
Commercial, Flight instructor
Instrument ratings
Helicopter
Medical
Class 2, With waivers/limitations
Last flight review
March 24, 2009
Seat
Left
Toxicology
Performed
Flight hours
3,150 total · 1,198 in this make and model · 2,728 as pilot in command · 189 in the last 90 days · 76 in the last 30 days · 8 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
Variable at 3 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
75 °F, dew point 45 °F
Altimeter
30.22 inHg
Observed at
TEB, 7 nm away

Docket · 41

The files NTSB released with the investigation on April 28, 2010, on NTSB’s docket system: statements, records, photos and specialists’ reports. 35.3 MB in all.

Airworthiness Factual Report of Group ChairmanItem 1 · .PDF · 113 KBAirworthiness - Attachment 1 - Photos & FiguresItem 2 · .PDF · 839 KBAirworthiness - Attachment 2 - Helicopter Maintenance RecordsItem 3 · .PDF · 2.3 MBAirworthiness - Attachment 3 - Airplane Maintenance RecordsItem 4 · .PDF · 1.7 MBAirworthiness - Addendum 1Item 5 · .PDF · 35 KBOperations/Human Performance 2 - Factual Report of Group Chairman (see errata dated 6/2/10)Item 6 · .PDF · 203 KBOperations/Human Performance 2 - Errata 1 to the Factual Report dated 06/02/10Item 7 · .PDF · 13 KBOperations/Human Performance 2 - Attachment 1: Interview SummariesItem 8 · .PDF · 241 KBOperations/Human Performance 2 - Attachment 2: Air Tour Safety Program LOAItem 9 · .PDF · 151 KBOperations/Human Performance 2 - Attachment 3: Air Tour Safety Program Tour AlphaItem 10 · .PDF · 816 KBOperations/Human Performance 2 - Attachment 4: New York Terminal Area ChartItem 11 · .PDF · 1.9 MBOperations/Human Performance 2 - Attachment 5: New York Helicopter Route ChartItem 12 · .PDF · 1.1 MBOperations/Human Performance 2 - Attachment 6: Record of FAA Enforcement DataItem 13 · .PDF · 163 KBOperations/Human Performance 2 - Attachment 7: Record of FAA Accident/Incident DataItem 14 · .PDF · 250 KBOperations/Human Performance 2 - Attachment 8: IHST ChecklistItem 15 · .PDF · 244 KBATC 3 - Factual Report of Group ChairmanItem 16 · .PDF · 1.4 MBATC 3 - Attachment 1 - N71MC - Arrival Flight Progress Strip - TEBItem 17 · .PDF · 15 KBATC 3 - Attachment 2 - N71MC - Departure Flight Progress Strip - TEBItem 18 · .PDF · 16 KBATC 3 - Attachment 3 - ATCT Tower Log - TEB - 08-08-09Item 19 · .PDF · 89 KBATC 3 - Attachment 4 - EWR-TEB ATCT Letter Of AgreementItem 20 · .PDF · 420 KBATC 3 - Attachment 5 -EWR ATCT Daily Record of Facility OperationItem 21 · .PDF · 181 KBATC 3 - Attachment 6 TEB ATCT Local Control TranscriptItem 22 · .PDF · 341 KBATC 3 - Attachment 7 TEB ATCT Clearance Delivery TranscriptItem 23 · .PDF · 50 KBATC 3 - Attachment 8 TEB ATCT Position LogsItem 24 · .PDF · 147 KBATC 3 - Attachment 9 EWR CBA ATC TranscriptItem 25 · .PDF · 57 KBATC 3 - Attachment 10 - TEB ATCT Controller StatementsItem 26 · .PDF · 121 KBATC 3 - Attachment 11 - EWR ATCT Controller StatementsItem 27 · .PDF · 97 KBATC 3 - Attachment 12 - N71MC TEB FBO Meridian Ramp ReceiptItem 28 · .PDF · 64 KBATC 3 - Attachment 13 - TEB ATCT LC Transcript from a 1129 to 1136 EDT recordingItem 29 · .PDF · 12 KBSurvival Factors 6 - Factual Report of Group ChairmanItem 30 · .PDF · 379 KBAircraft Performance 13 - Radar & Cockpit Visibility StudyItem 31 · .PDF · 6.0 MBAircraft Performance 13 - ERRATA #1 to the Radar and Cockpit Visibility StudyItem 32 · .PDF · 5.9 MBPilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 33 · .PDF · 487 KBWitness Statements and InterviewsItem 34 · .PDF · 8.0 MBWeather ReportItem 35 · .PDF · 65 KBToxicological ReportsItem 36 · .PDF · 155 KBRelease of Aircraft Wreckage, NTSB Form 6120.15 (N71MC)Item 37 · .PDF · 102 KBRelease of Aircraft Wreckage, NTSB Form 6120.15 (N401LH)Item 38 · .PDF · 93 KBStatement of Party Representatives to NTSB InvestigationItem 39 · .PDF · 430 KBStatement of Party Representatives to NTSB InvestigationItem 40 · .PDF · 693 KBAnimation Description and DisclaimerItem 41 · .PDF · 26 KB

FAA reports on this event · 2

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