ERA15LA115

NTSB accident investigation · Piper PA-28R-200 · West Palm Beach, FL · January 28, 2015

Accident · No injuriesLimited investigationFinal report
Date
January 28, 2015, 12:00 local (17:00 UTC)
Place
West Palm Beach, FL
Injuries
4 uninjured
Phase of flight
Approach
Aircraft
N54380Piper PA-28R-200N475ATRobinson Helicopter R22 Beta
Defining events
Approach-VFR pattern final: Midair collisionApproach-VFR pattern final: Midair collision
Weather
Visual (VMC) · Day
Status
Completed · report November 28, 2016
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
Case key
90667

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 failure of the airplane pilots to maintain an adequate visual lookout for known traffic in the traffic pattern, which resulted in a midair collision. Contributing to the accident was the failure of the airplane pilots to announce their intentions before landing, and the helicopter pilots' lack of specificity in their radio communications.

Findings · 5

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.

N54380 · Piper PA-28R-200

Use of equip/info: use of equip/systemPersonnel issues › Task performance · Flight crewPiper PA-28R-200: 4 casesAll aircraft: 1,391 casesProbable cause

N475AT · Robinson Helicopter R22 Beta

Info processing/decision: identification/recognitionPersonnel issues › Action/decision · Pilot of other aircraftRobinson Helicopter R22 BETA: 3 casesAll aircraft: 559 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.

N54380 · Piper PA-28R-200

N475AT · Robinson Helicopter R22 Beta

Analysis

The designated pilot examiner (DPE) and the commercial pilot on board the airplane were performing left traffic patterns during a checkride. A helicopter was simultaneously performing right traffic patterns to the same runway. Throughout the flight, the DPE and pilot had observed the accident helicopter and other helicopters in the right traffic pattern completing their approaches parallel to and to the right side of the runway. The airplane was on the left downwind leg of the traffic pattern, with the commercial pilot preparing for a simulated power-off landing. In light of the previously-observed helicopter operations to the right side of the runway, the DPE advised the pilot that the airplane would remain clear of the helicopters and to continue the approach and landing. The helicopter, however, was established on a shallow, final approach leg of the traffic pattern for a run-on landing. Upon entering the turn from the downwind leg and while on the final approach leg of the traffic pattern for landing, the DPE's view of the accident helicopter was blocked by the cabin and right wing. The airplane overtook the helicopter from above, and the aircraft collided. The helicopter entered a rapid, controlled descent to the runway. The airplane completed a go-around and subsequently landed safely. Review of recorded radio communications revealed that the pilots in the airplane transmitted position reports for the crosswind and downwind legs of the traffic pattern only, but did not announce their intentions to conduct, or the airplane's entry into, the simulated power-off landing maneuver. The helicopter pilots transmitted position reports on the downwind, base, and final legs of the traffic pattern, but before the accident landing approach, announced only that the helicopter was "turning final." The helicopter pilots provided no specificity about the shallow approach or performing a run-on landing to the runway surface. Other helicopters operating in the traffic pattern on the day of the accident had conducted their operations to the grass on the right side of the runway. On the previous approach, the accident helicopter pilots had announced their intention to land the helicopter in the grass abeam the runway. The lack of explicit communication from the helicopter pilots regarding their intentions resulted in the helicopter being in a position that was unexpected to the airplane pilots. In the absence of any information to the contrary, the airplane pilots likely assumed that the accident helicopter would continue to remain clear of the runway and the extended runway centerline, as it and other helicopters had done during previous approaches. This likely lowered the airplane pilots' vigilance in maintaining visual contact with the helicopter throughout the approach for landing.

Factual narrative

On January 28, 2015, about 1200 eastern standard time, a Piper PA-28R-200 airplane, N54380, operated by Palm Beach Flight Training, and a Robinson R22B helicopter, N475AT, operated by Palm Beach Helicopters, collided while maneuvering for landing at Palm Beach County Park Airport (LNA), West Palm Beach, Florida. The helicopter performed a precautionary landing to the runway, while the airplane performed a go-around and subsequently landed uneventfully. The helicopter sustained substantial damage and the airplane sustained minor damage. The flight instructor and private pilot receiving instruction in the helicopter were not injured. The Federal Aviation Administration (FAA) designated pilot examiner (DPE) and commercial pilot on board the airplane were not injured. Visual meteorological conditions prevailed, and no flight plan was filed for either instructional flight, both of which were conducted under the provisions of 14 Code of Federal Regulations Part 91.The pilots in each aircraft provided written statements, and their statements were consistent throughout. The pilot in the airplane was undergoing a flight instructor practical test from the DPE, and the airplane-rated pilot in the helicopter was receiving primary rotary wing instruction. Radar information from the FAA revealed that both aircraft were operating in the traffic pattern for runway 33 at LNA prior to the accident. The airplane was performing left traffic patterns, while the helicopter was performing right traffic patterns. The helicopter maneuvered around the right traffic pattern and was established on a shallow final approach for a run-on landing. About the same time, the airplane was on the left downwind leg of the traffic pattern, with the applicant pilot preparing for a simulated power-off landing. The DPE stated that while the airplane had been conducting left traffic patterns, he and the applicant had observed other helicopters in the right traffic pattern completing their approaches parallel and to the right side of runway 33. In light of these operations, the DPE advised the applicant that the airplane would remain clear of the helicopter, and to continue the approach and landing. Once the airplane entered the turn from the downwind leg and while on the final approach leg of the traffic pattern, the DPE's view of the helicopter was blocked by the cabin and right wing. Witnesses observed the airplane overtake the helicopter from above, heard the contact, and watched the helicopter enter a rapid, controlled descent to the runway. The airplane banked sharply, the engine accelerated, and completed a go-around. A review of the recorded radio communications revealed that the helicopter transmitted position reports on the downwind, base, and final legs of the traffic pattern. The airplane transmitted position reports for the crosswind and downwind legs only, and did not announce its intentions or its entry into the simulated power-off landing. On its previous approach, thehelicopter announced its intention to land in the grass abeam the runway, but prior to the accident; the helicopter announced only that it was "turning final." There was no specificity about a shallow approach or performing a run-on landing to the runway surface. The airplane pilot held a commercial pilot certificate with a rating for airplane single-engine land. His most recent FAA second-class medical certificate was issued September 16, 2014. He reported 677 total hours of flight experience, of which 22 hours were in the accident airplane make and model. The DPE held an airline transport pilot certificate with multiple type ratings, and a flight instructor certificate with multiple ratings. His most recent FAA second-class medical certificate was issued January 16, 2014. The DPE reported 33,164 total hours of flight experience, of which 234 hours were in the accident airplane make and model. The flight instructor in the helicopter held commercial pilot and flight instructor certificates with ratings for airplane single-engine, multiengine, and rotorcraft-helicopter. His most recent FAA second-class medical certificate was issued June 26, 2014, and he reported 1,498 total hours of flight experience, of which 521 hours were in the accident helicopter make and model. The helicopter pilot held a private pilot certificate with ratings for airplane single engine land. His most recent FAA first class medical certificate was issued December 22, 2014. He reported 265 total hours of flight experience, of which 12 hours were in the accident helicopter make and model. LNA was not tower-controlled. Runway 15/33 was 3,421 feet long and 100 feet wide, and was located along the east side of the field. The grass area on the east side of the runway was approximately 200 feet wide. Postaccident examination of the airplane revealed damage to the cabin step. The helicopter displayed substantial damage to the leading edge and spar of one main rotor blade. The pilots of both the airplane and helicopter reported that there were no mechanical issues that would have precluded normal operation of their aircraft. The Federal Aviation Regulations, Part 91.126 states, in part, "Each pilot of a helicopter or powered parachute must avoid the flow of fixed-wing traffic." The FAA Aeronautical Information Manual (AIM), Chapter 4, Section 4-1-9, Traffic Advisory Practices at Airports Without Operating Control Towers, states, "There is no substitute for alertness while in the vicinity of an airport. It is essential that pilots be alert and look for traffic and exchange traffic information when approaching or departing an airport without an operating control tower…To achieve the greatest degree of safety, it is essential that all radio-equipped aircraft transmit/receive on a common frequency identified for the purpose of airport advisories." The AIM recommends that when operating at an airport without a control tower, pilots self-announce their position on the downwind, base, andfinal legs of the traffic pattern.

Aircraft · 2

Registration
N54380
Reported as
Piper PA-28R-200
Category
Airplane
Serial number
28R-7435092
Built
1973
Airframe hours
7,414
Engine
Lycoming I0360 SER, 200 horsepower, reciprocating
Damage
Minor damage
Flight
Instructional · Part 91
Operator
Palm Beach Flight Training Corporation
Registered owner
Wildwood Helicopter Co Inc
Airworthiness certificate
Standard, Normal
Last inspection
Annual · November 14, 2014 · 47 hours before
Departed
LNA · West Palm Beach, FL
Destination
LNA · West Palm Beach, FL
Airport
LNA · Palm Beach County Park, runway 33, 3,421 × 100 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
N475AT
Reported as
Robinson Helicopter R22 Beta
Category
Helicopter
Serial number
2701
Built
1997
Airframe hours
4,570.7
Engine
Lycoming O-360-A1D, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
Palm Beach Helicopters
Registered owner
Llb Enterprises Group Inc
Airworthiness certificate
Standard, Normal
Last inspection
Annual · January 14, 2015 · 219 hours before
Departed
LNA · West Palm Beach, FL
Destination
LNA · West Palm Beach, FL
Airport
LNA · Palm Beach County Park, runway 33, 3,421 × 100 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 · 4

As NTSB recorded them. NTSB leaves out names.

Role
Pilot, aircraft N54380
Age
57
Injuries
None
Certificates
Commercial, Private
Airplane ratings
Single-engine sea, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Seat
Right
Restraint
3-point
Flight hours
677 total · 22 in this make and model
Role
Flight instructor, aircraft N54380
Age
78
Injuries
None
Certificates
Flight engineer, Flight instructor, Airline transport, Commercial
Airplane ratings
Multi-engine sea, Single-engine sea, Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Seat
Left
Restraint
3-point
Flight hours
33,164 total · 234 in this make and model · 33,287 as pilot in command · 36 in the last 90 days · 7 in the last 30 days · 1 in the last 24 hours
Role
Flight instructor, aircraft N475AT
Age
29
Injuries
None
Certificates
Flight instructor, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Helicopter, Airplane
Medical
Class 2, Without waivers/limitations
Seat
Left
Restraint
3-point
Flight hours
1,498 total · 521 in this make and model · 1,394 as pilot in command · 181 in the last 90 days · 74 in the last 30 days · 4 in the last 24 hours
Role
Pilot, aircraft N475AT
Age
27
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 1, With waivers/limitations
Seat
Right
Restraint
3-point
Flight hours
265 total · 12 in this make and model · 77 as pilot in command · 9 in the last 90 days · 9 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
320° at 13 knots, gusting 19
Visibility
10 statute miles
Lowest ceiling
None
Temperature
66 °F, dew point 34 °F
Altimeter
30.15 inHg
Observed at
PBI, 5 nm away

Docket · 8

The files NTSB released with the investigation on September 27, 2016, on NTSB’s docket system: statements, records, photos and specialists’ reports. 10.7 MB in all.

FAA reports on this event · 2

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

Other investigations on N54380 · 1

Matched to the same aircraft by N-number and date.