# NTSB ERA15LA084: Aerotek Pitts Special S-1S, N49294, Westminster, MD, December 27, 2014 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: December 27, 2014, 15:45 local (20:45 UTC) - Place: Westminster, MD - Coordinates: 39.608333, -77.007774 - Nearby events: https://openairdocs.org/map.md?lat=39.6083&lon=-77.0078&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining events: [Approach-VFR pattern final: Midair collision](https://openairdocs.org/ntsb-events/250); [Approach-VFR pattern final: Midair collision](https://openairdocs.org/ntsb-events/250) - Highest injury: Serious injuries - Injuries: 1 serious, 2 uninjured - Status: Completed, report September 8, 2015 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 90538 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA15LA084 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/90538/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=90538 - Page: https://openairdocs.org/ntsb/ERA15LA084 ## Probable cause (aircraft 1) The pilot’s failure to see and avoid the other airplane, which resulted in a midair collision while both airplanes were on final approach to land. ## Probable cause (aircraft 2) The other pilot’s failure to see and avoid the airplane, which resulted in a midair collision while both airplanes were on final approach to land. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Attention/monitoring: monitoring other aircraft](https://openairdocs.org/ntsb-findings/02021540): Personnel issues › Psychological · Pilot (probable cause), aircraft 1; cases with it: [Aerotek PITTS SPECIAL S-1S, 1 case](https://openairdocs.org/ntsb-findings/02021540/cases.md?model=0110301), [All aircraft, 231 cases](https://openairdocs.org/ntsb-findings/02021540/cases.md) - [Attention/monitoring: monitoring other aircraft](https://openairdocs.org/ntsb-findings/02021540): Personnel issues › Psychological · Pilot of other aircraft (probable cause), aircraft 2; cases with it: [All aircraft, 231 cases](https://openairdocs.org/ntsb-findings/02021540/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach-VFR pattern final: Midair collision](https://openairdocs.org/ntsb-events/250) (defining event), aircraft 1; cases with it: [Aerotek PITTS SPECIAL S-1S, 1 case](https://openairdocs.org/ntsb-events/250/sequence.md?model=0110301), [All aircraft, 196 cases](https://openairdocs.org/ntsb-events/250/sequence.md) - [Approach-VFR pattern final: Midair collision](https://openairdocs.org/ntsb-events/250) (defining event), aircraft 2; cases with it: [All aircraft, 196 cases](https://openairdocs.org/ntsb-events/250/sequence.md) ## Analysis (aircraft 1) A Piper PA-28-140 and a Pitts Special S-1S collided in midair while both airplanes were on final approach to land. The Piper was equipped with a two-way radio and the Pitts was not. Both pilots were flying their airplanes on a visual approach to the same runway; the Piper entered the traffic pattern on the downwind leg, and the Pitts entered the traffic pattern on the crosswind leg. According to the Piper pilot, he made radio calls during each leg of the traffic pattern to announce his position, and, after beginning the final approach about 1.5 nautical miles from the runway threshold, he observed the Pitts on the downwind leg. The Pitts pilot reported that he flew a tighter traffic pattern and that he did not see the Piper. Witnesses reported that, as the airplanes were on short final, the Pitts converged on the Piper from behind and above. The Pitts' tailwheel struck the top of the Piper's fuselage, and the right main landing gear struck the cowling and was subsequently separated by the Piper's propeller. After the collision, the Pitts entered a dive and then impacted the ground, which resulted in substantial damage to the wings and elevator. The Piper pilot landed the airplane on the runway; the airplane sustained substantial damage to the fuselage from the collision. ## Analysis (aircraft 2) A Piper PA-28-140 and a Pitts Special S-1S collided in midair while both airplanes were on final approach to land. The Piper was equipped with a two-way radio and the Pitts was not. Both pilots were flying their airplanes on a visual approach to the same runway; the Piper entered the traffic pattern on the downwind leg, and the Pitts entered the traffic pattern on the crosswind leg. According to the Piper pilot, he made radio calls during each leg of the traffic pattern to announce his position, and, after beginning the final approach about 1.5 nautical miles from the runway threshold, he observed the Pitts on the downwind leg. The Pitts pilot reported that he flew a tighter traffic pattern and that he did not see the Piper. Witnesses reported that, as the airplanes were on short final, the Pitts converged on the Piper from behind and above. The Pitts' tailwheel struck the top of the Piper's fuselage, and the right main landing gear struck the cowling and was subsequently separated by the Piper's propeller. After the collision, the Pitts entered a dive and then impacted the ground, which resulted in substantial damage to the wings and elevator. The Piper pilot landed the airplane on the runway; the airplane sustained substantial damage to the fuselage from the collision. ## Factual narrative (aircraft 1) On December 27, 2014, about 1545 eastern standard time, a Pitts Special S-1S, N49294 and a Piper PA-28-140, N95297, were substantially damaged when they collided during an approach to land near Carroll County Regional Airport (DMW), Westminster, Maryland. The private pilot and passenger of the Piper were not injured. The private pilot of the Pitts received serious injuries. Visual meteorological conditions prevailed and no flight plan was filed for either local flight. The Piper departed Lancaster Airport (LNS), Lancaster, Pennsylvania about 1500 and the Pitts departed DMW about 1545. Both personal flights were conducted under the provisions of Title 14 Code of Federal Regulations Part 91. According to the accident pilots, the Piper was equipped with two-way radio communication and the Pitts was not. Upon returning to the airport the Piper entered the downwind leg for runway 16 and made left traffic. The pilot of the Piper stated that he announced his position over the Common Traffic Advisory Frequency during each leg of the traffic pattern. During a long final approach leg at about 75 knots, the pilot of the Piper observed a "small red aircraft" on the downwind leg about midfield. Witnesses reported that while on the final approach leg the Pitts came from behind and above the Piper and converged on top of the airplane about 100 yards from the approach end of runway 16 about 100 ft. above ground level. The Piper landed on the runway and the Pitts entered a steep dive and subsequently impacted the ground. The pilot of the Pitts reported that he was not aware that he was involved in a mid-air collision until he spoke with witnesses; however, he did recall that he flew a "tight" airport traffic pattern. In a follow-up written statement, the pilot of the Pitts reported that he entered the traffic pattern parallel to the runway 16 upwind leg at 1,600 feet and 100 mph. He flew both the crosswind and downwind legs at the same altitude and airspeed, but flew a "descending base and final" at 90 mph. The pilot of the Pitts also provided a hand drawing of his approach to runway 16. The illustration showed that the pilot established himself on the final approach leg about 1,000 feet from the runway threshold. The operators of both airplanes reported that there were no preimpact mechanical malfunctions or failures with the airplanes that would have precluded normal operation. Carroll County Regional Airport was a publicly owned, non-towered airport with an elevation of about 789 feet mean sea level (msl) and a traffic pattern attitude of 1,599 feet msl. The recorded weather at DMW, about the time of the accident, included clear skies, visibility of 10 miles, and wind from 260 degrees at 4 knots. Examination of the airplanes by a Federal Aviation Administration inspector revealed that the Pitts top and bottom right wings had separated at the wing spar. The airplane also sustained substantial damage to the right outboard section of the elevator. The right mainlanding gear of the Pitts had completely separated at the airplane's right main landing gear strut. Examination of the Piper revealed a tire mark and compression damage on the fuselage and left cockpit window, above the pilot's seat, and another tire mark on the cowling, just aft of the propeller. The damage and tire mark on the Piper fuselage matched the width of the Pitts' tailwheel landing gear. The Piper cowling tire marking was similar in width and tread as the Pitts airplane's main landing gear tire. The Piper's propeller also exhibited a black mark with similar dimensions to the Pitts' main landing gear. There was one witness at the fixed base operator who was operating the Unicom/CTAF frequency and recalled hearing some "chatter"; however, he could not recall any of the specific frequency communications. The accident was not captured on radar; however, both pilot reported that they were utilizing navigational aid devices. The pilot of the Piper used an Adventure Pilot iFly 700 GPS receiver and the internet application Foreflight on his iPad. The Pitts pilot used an earlier version of the internet application Foreflight on his iPhone, which was not equipped with recording capabilities. The iPad and Adventure Pilot GPS were forwarded to the NTSB Vehicle Recorders Laboratory, Washington, D.C., for data download. According to the recorder laboratory factual report, the iPAD foreflight internet application was not recording at the time of the accident and, thus, did not retain any pertinent information. The Adventure Pilot iFly 700 GPS captured the accident flight and revealed that the Piper approached the airport from the east at a GPS altitude of about 1,600 feet msl and entered the downwind leg of the traffic pattern for runway 16 about 1539. The Piper entered the final approach leg for runway 16 about 1.5 nm from the runway threshold at a GPS altitude of about 1,237 feet msl. The last recorded GPS data showed the airplane at an approximate distance of 1,600 feet from the runway threshold, at a GPS altitude of about 919 feet msl. ## Factual narrative (aircraft 2) On December 27, 2014, about 1545 eastern standard time, a Pitts Special S-1S, N49294 and a Piper PA-28-140, N95297, were substantially damaged when they collided during an approach to land near Carroll County Regional Airport (DMW), Westminster, Maryland. The private pilot and passenger of the Piper were not injured. The private pilot of the Pitts received serious injuries. Visual meteorological conditions prevailed and no flight plan was filed for either local flight. The Piper departed Lancaster Airport (LNS), Lancaster, Pennsylvania about 1500 and the Pitts departed DMW about 1545. Both personal flights were conducted under the provisions of Title 14 Code of Federal Regulations Part 91. According to the accident pilots, the Piper was equipped with two-way radio communication and the Pitts was not. Upon returning to the airport the Piper entered the downwind leg for runway 16 and made left traffic. The pilot of the Piper stated that he announced his position over the Common Traffic Advisory Frequency during each leg of the traffic pattern. During a long final approach leg at about 75 knots, the pilot of the Piper observed a "small red aircraft" on the downwind leg about midfield. Witnesses reported that while on the final approach leg the Pitts came from behind and above the Piper and converged on top of the airplane about 100 yards from the approach end of runway 16 about 100 ft. above ground level. The Piper landed on the runway and the Pitts entered a steep dive and subsequently impacted the ground. The pilot of the Pitts reported that he was not aware that he was involved in a mid-air collision until he spoke with witnesses; however, he did recall that he flew a "tight" airport traffic pattern. In a follow-up written statement, the pilot of the Pitts reported that he entered the traffic pattern parallel to the runway 16 upwind leg at 1,600 feet and 100 mph. He flew both the crosswind and downwind legs at the same altitude and airspeed, but flew a "descending base and final" at 90 mph. The pilot of the Pitts also provided a hand drawing of his approach to runway 16. The illustration showed that the pilot established himself on the final approach leg about 1,000 feet from the runway threshold. The operators of both airplanes reported that there were no preimpact mechanical malfunctions or failures with the airplanes that would have precluded normal operation. Carroll County Regional Airport was a publicly owned, non-towered airport with an elevation of about 789 feet mean sea level (msl) and a traffic pattern attitude of 1,599 feet msl. The recorded weather at DMW, about the time of the accident, included clear skies, visibility of 10 miles, and wind from 260 degrees at 4 knots. Examination of the airplanes by a Federal Aviation Administration inspector revealed that the Pitts top and bottom right wings had separated at the wing spar. The airplane also sustained substantial damage to the right outboard section of the elevator. The right mainlanding gear of the Pitts had completely separated at the airplane's right main landing gear strut. Examination of the Piper revealed a tire mark and compression damage on the fuselage and left cockpit window, above the pilot's seat, and another tire mark on the cowling, just aft of the propeller. The damage and tire mark on the Piper fuselage matched the width of the Pitts' tailwheel landing gear. The Piper cowling tire marking was similar in width and tread as the Pitts airplane's main landing gear tire. The Piper's propeller also exhibited a black mark with similar dimensions to the Pitts' main landing gear. There was one witness at the fixed base operator who was operating the Unicom/CTAF frequency and recalled hearing some "chatter"; however, he could not recall any of the specific frequency communications. The accident was not captured on radar; however, both pilot reported that they were utilizing navigational aid devices. The pilot of the Piper used an Adventure Pilot iFly 700 GPS receiver and the internet application Foreflight on his iPad. The Pitts pilot used an earlier version of the internet application Foreflight on his iPhone, which was not equipped with recording capabilities. The iPad and Adventure Pilot GPS were forwarded to the NTSB Vehicle Recorders Laboratory, Washington, D.C., for data download. According to the recorder laboratory factual report, the iPAD foreflight internet application was not recording at the time of the accident and, thus, did not retain any pertinent information. The Adventure Pilot iFly 700 GPS captured the accident flight and revealed that the Piper approached the airport from the east at a GPS altitude of about 1,600 feet msl and entered the downwind leg of the traffic pattern for runway 16 about 1539. The Piper entered the final approach leg for runway 16 about 1.5 nm from the runway threshold at a GPS altitude of about 1,237 feet msl. The last recorded GPS data showed the airplane at an approximate distance of 1,600 feet from the runway threshold, at a GPS altitude of about 919 feet msl. ## Aircraft 1 - Registration: [N49294](https://openairdocs.org/deregistered/N49294-2019-04-19), registration cancelled 2019-04-19, S/N 1-0060, built 1978 (OpenAirDocs) - Reported make and model: AEROTEK PITTS SPECIAL S-1S - Registry model: [Aerotek PITTS SPECIAL S-1S](https://openairdocs.org/model/aerotek-pitts-special-s-1s) (registry code 0110301) (OpenAirDocs) - Registry engine: [Lycoming AEIO-360 series](https://openairdocs.org/engine/lycoming-aeio-360-series) (registry code 41522, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 1-0060 - Year built: 1978 - Airframe hours: 22.6 - Engines: Lycoming IO-360-B4A 180 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Bob Gillespie - Registered owner: Bob Gillespie - Airworthiness certificate: Standard, Aerobatic - Last inspection: Annual, April 18, 2014, 432 hours before - Departed: DMW, WESTMINSTER, MD - Destination: DMW, WESTMINSTER, MD - Airport: DMW, Carroll County Airport, runway 16, 5,100 × 100 ft, asphalt - Equipment: Stall warning system, Handheld GPS ## Aircraft 2 - Registration: N95297 (not matched to a registry record) - Reported make and model: PIPER PA-28-140 - Category: Airplane - Serial number: 28-25877 - Year built: 1969 - Airframe hours: 2626.64 - Engines: LYCOMING O-320 SERIES 150 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Robert Graham - Registered owner: Robert Graham - Airworthiness certificate: Standard, Normal - Last inspection: Annual, July 4, 2014 - Departed: LNS, LANCASTER, PA - Destination: DMW, WESTMINSTER, MD - Airport: DMW, Carroll County Airport, runway 16, 5,100 × 100 ft, asphalt - Equipment: Electronic flight bag or handheld device, Onboard weather ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot, aircraft N49294; age 53; injuries: serious; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; last flight review July 19, 2013; seat: single; restraint: 5-point; flight hours: 1,068.5 total, 59.5 in this make and model, 985 as pilot in command, 8 in the last 90 days, 2.9 in the last 30 days, 0.4 in the last 24 hours - Pilot, aircraft N95297; age 55; injuries: none; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; last flight review April 13, 2014; seat: left; restraint: lap only; flight hours: 305.2 total, 256.7 as pilot in command ## Weather - Conditions: Visual (VMC), Day - Wind: 170° at 4 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 57 °F, dew point 19 °F - Altimeter: 30.13 inHg - Observed at: DMW ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20141227023042A](https://openairdocs.org/incident/20141227023042A), Dec 27, 2014: Aerotek PITTS SPECIAL S-1S, Westminster, MD, Destroyed. Piper cherokee, N95297 was inbound runway 16 approx 100FT MSL. The pitts, N49294 struck the left side pilots compartment roof area, the right main landing gear… ## Docket (10 files) The files NTSB released with the investigation on August 4, 2015, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=90538. 11.5 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 - N95297 (item 1, .PDF, 5.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40430453&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1%20-%20N95297-Redacted.PDF - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 - N49294 (item 2, .PDF, 603 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40430454&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1%20-%20N49294-Redacted.PDF - Electronic Devices – Specialists Factual Report (item 3, .PDF, 6 photos, 3.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40430452&FileExtension=.PDF&FileName=Electronic%20Devices%20%E2%80%93%20Specialists%20Factual%20Report-Master.PDF - Record of Conversations (item 4, .PDF, 684 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40430455&FileExtension=.PDF&FileName=Record%20of%20Conversations-Redacted.PDF - NTSB Release of Wreckage N95297 (item 5, .PDF, 293 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40430456&FileExtension=.PDF&FileName=NTSB%20Release%20of%20Wreckage%20N95297-Redacted.PDF - NTSB Release of Wreckage N49294 (item 6, .PDF, 213 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40430457&FileExtension=.PDF&FileName=NTSB%20Release%20of%20Wreckage%20N49294-Redacted.PDF - Weather Report and Record (item 7, .PDF, 206 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40430458&FileExtension=.PDF&FileName=Weather%20Report%20and%20Record-Master.PDF - Photo 1 - Airplane at Accident Site (Photo Courtesy of FAA) (item 8, .PDF, 123 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40430459&FileExtension=.PDF&FileName=Photo%201%20-%20Airplane%20at%20Accident%20Site%20(Photo%20Courtesy%20of%20FAA)-Master.PDF - Photo 2 - Fuselage (Photo Courtesy of FAA) (item 9, .PDF, 343 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40430460&FileExtension=.PDF&FileName=Photo%202%20-%20Fuselage%20(Photo%20Courtesy%20of%20FAA)-Master.PDF - Photo 3 - Cowling (Photo Courtesy of FAA) (item 10, .PDF, 246 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40430461&FileExtension=.PDF&FileName=Photo%203%20-%20Cowling%20(Photo%20Courtesy%20of%20FAA)-Master.PDF From the NTSB's public API. 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