# NTSB ERA15LA115: Piper PA-28R-200, N54380, West Palm Beach, FL, January 28, 2015 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: January 28, 2015, 12:00 local (17:00 UTC) - Place: West Palm Beach, FL - Coordinates: 26.593055, -80.084999 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=26.5931&lon=-80.0850&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: No injuries - Injuries: 4 uninjured - Status: Completed, report November 28, 2016 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 90667 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA15LA115 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/90667/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=90667 - Page: https://openairdocs.org/ntsb/ERA15LA115 ## Probable cause (aircraft 2) 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 NTSB's coded findings; those marked are part of the probable cause. - [Info processing/decision: identification/recognition](https://openairdocs.org/ntsb-findings/02041510): Personnel issues › Action/decision · Flight crew (probable cause), aircraft 1; cases with it: [Piper PA-28R-200, 2 cases](https://openairdocs.org/ntsb-findings/02041510/cases.md?model=7102811), [All aircraft, 559 cases](https://openairdocs.org/ntsb-findings/02041510/cases.md) - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Flight crew (probable cause), aircraft 1; cases with it: [Piper PA-28R-200, 4 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=7102811), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) - [Info processing/decision: identification/recognition](https://openairdocs.org/ntsb-findings/02041510): Personnel issues › Action/decision · Pilot of other aircraft (probable cause), aircraft 2; cases with it: [Robinson Helicopter R22 BETA, 3 cases](https://openairdocs.org/ntsb-findings/02041510/cases.md?model=7640110), [All aircraft, 559 cases](https://openairdocs.org/ntsb-findings/02041510/cases.md) - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Flight crew (probable cause), aircraft 2; cases with it: [Robinson Helicopter R22 BETA, 16 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=7640110), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) - [Main rotor system: main rotor blade system](https://openairdocs.org/ntsb-findings/01046210): Aircraft › Aircraft propeller/rotor · Damaged/degraded, aircraft 2; cases with it: [Robinson Helicopter R22 BETA, 6 cases](https://openairdocs.org/ntsb-findings/01046210/cases.md?model=7640110), [All aircraft, 60 cases](https://openairdocs.org/ntsb-findings/01046210/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: [Piper PA-28R-200, 4 cases](https://openairdocs.org/ntsb-events/250/sequence.md?model=7102811), [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: [Robinson Helicopter R22 BETA, 4 cases](https://openairdocs.org/ntsb-events/250/sequence.md?model=7640110), [All aircraft, 196 cases](https://openairdocs.org/ntsb-events/250/sequence.md) ## Analysis (aircraft 2) 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 (aircraft 2) 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 1 - Registration: [N54380](https://openairdocs.org/deregistered/N54380-2018-03-15), registration cancelled 2018-03-15, S/N 28R-7435092, built 1973 (OpenAirDocs) - Reported make and model: PIPER PA-28R-200 - Registry model: [Piper PA-28R-200](https://openairdocs.org/model/piper-pa-28r-200) (registry code 7102811) (OpenAirDocs) - Registry engine: [Lycoming I0360 series](https://openairdocs.org/engine/lycoming-i0360-series) (registry code 41515, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28R-7435092 - Year built: 1973 - Airframe hours: 7414 - Engines: 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 ## Aircraft 2 - Registration: [N475AT](https://openairdocs.org/aircraft/N475AT), registered now, S/N 2701, built 1997 (OpenAirDocs) - Reported make and model: ROBINSON HELICOPTER R22 BETA - Registry model: [Robinson Helicopter R22 BETA](https://openairdocs.org/model/robinson-helicopter-r22-beta) (registry code 7640110) (OpenAirDocs) - Registry engine: [Lycoming 0-360-A1D](https://openairdocs.org/engine/lycoming-0-360-a1d) (registry code 41504, reciprocating) (OpenAirDocs) - Category: Helicopter - Serial number: 2701 - Year built: 1997 - Airframe hours: 4570.7 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot, aircraft N54380; age 57; injuries: none; 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 - Flight instructor, aircraft N54380; age 78; injuries: none; 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 - Flight instructor, aircraft N475AT; age 29; injuries: none; 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 - Pilot, aircraft N475AT; age 27; injuries: none; 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 ## FAA reports on this event (2) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20150128001512A](https://openairdocs.org/incident/20150128001512A), Jan 28, 2015: Piper PA-28R-200, Lantana, FL, Minor damage. [privacy data omitted] Was flying as applicant for a flight instructor certificate in Piper arrow N54380. He and DPE [privacy data omitted] were conducting a… - [Accident 20150128001521A](https://openairdocs.org/incident/20150128001521A), Jan 28, 2015: Robinson Helicopter R22 BETA, Lantana, FL, Substantial damage. [privacy data omitted] Was flying as applicant for a flight instructor certificate in Piper arrow N54380. He and DPE [privacy data omitted] were conducting a… ## Other investigations on N54380 (1) From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. - [NTSB ERA15FA299](https://openairdocs.org/ntsb/ERA15FA299), Aug 10, 2015: Piper PA-28R (N54380), Marathon, FL, destroyed, 1 fatal. Probable cause: The pilot's failure to maintain a positive climb rate after takeoff due to spatial disorientation while turning after takeoff in dark night conditions in a sparsely populated area, which resulted in… ## Docket (8 files) The files NTSB released with the investigation on September 27, 2016, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=90667. 10.7 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 321 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40444758&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 Airplane PIC (item 2, .PDF, 8.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40444759&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1%20Airplane%20PIC-Master.PDF - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 Helicopter (item 3, .PDF, 722 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40444760&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1%20Helicopter-Master.PDF - Pilot's and Witness Statement (item 4, .PDF, 269 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40444761&FileExtension=.PDF&FileName=Pilot%27s%20and%20Witness%20Statement-Master.PDF - Memorandum for Record – DPE Statement to FAA (item 5, .PDF, 57 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40444762&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20%E2%80%93%20DPE%20Statement%20to%20FAA-Master.PDF - Memorandum for Record – Telephone Interview, Pilot (item 6, .PDF, 54 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40444763&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20%E2%80%93%20Telephone%20Interview,%20Pilot-Master.PDF - Pilot's Statement and Witness Statement (item 7, .PDF, 165 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40444764&FileExtension=.PDF&FileName=Pilot%27s%20Statement%20and%20Witness%20Statement-Master.PDF - Photo Array (Courtesy of FAA) (item 8, .PDF, 3 photos, 719 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40444765&FileExtension=.PDF&FileName=Photo%20Array%20(Courtesy%20of%20FAA)-Master.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.