# NTSB FTW92FA025: Beech B19, N9343S, Forth Worth, TX, November 20, 1991 - Type: NTSB accident investigation - Classification: Accident · No injuries · Field investigation · Final report - Date: November 20, 1991, 12:18 local (18:18 UTC) - Place: Forth Worth, TX - Coordinates: 32.820049, -97.359077 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=32.8200&lon=-97.3591&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 4 uninjured - Status: Completed, report September 11, 1992 - Report: Approved by Office Director - NTSB case key (mKey): 18342 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=FTW92FA025 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/18342/pdf - Page: https://openairdocs.org/ntsb/FTW92FA025 ## Probable cause (aircraft 2) INADEQUATE VISUAL LOOKOUT BY THE PILOTS-IN-COMMAND OF BOTH AIRCRAFT, WHICH RESULTED IN THEIR FAILURE TO SEE-AND-AVOID THE OTHER AIRCRAFT. A FACTOR RELATED TO THE ACCIDENT WAS: FAILURE OF THE DEVELOPMENTAL CONTROLLER OR THE SUPERVISOR TO PROVIDE ADEQUATE CONTROL TOWER SERVICE. ## Probable cause (aircraft 1) INADEQUATE VISUAL LOOKOUT BY THE PILOTS-IN-COMMAND OF BOTH AIRCRAFT, WHICH RESULTED IN THEIR FAILURE TO SEE-AND-AVOID THE OTHER AIRCRAFT. A FACTOR RELATED TO THE ACCIDENT WAS: FAILURE OF THE DEVELOPMENTAL CONTROLLER OR THE SUPERVISOR TO PROVIDE ADEQUATE CONTROL TOWER SERVICE. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Midair collision, cruise - control tower service - inadequate, atc personnel(lcl/gnd/clnc) (contributing factor) - visual lookout - inadequate, pilot in command (cause) - visual lookout - inadequate, pilot of other aircraft (cause) - Forced landing, descent - emergency - In flight collision with terrain/water, landing - terrain condition - rough/uneven (contributing factor) - Midair collision, approach - vfr pattern - base leg/base to final - control tower service - inadequate, atc personnel(lcl/gnd/clnc) (contributing factor) - visual lookout - inadequate, pilot in command(cfi) (cause) - visual lookout - inadequate, pilot of other aircraft (cause) - precautionary landing ## Analysis (aircraft 2) CONVAIR 600, N94258, WAS ON A FLT WITH A COML PLT IN THE L SEAT & A CFI IN THE RGT SEAT. THEY ENTERED VFR TFC FOR ILS APCHS TO RWY 34. THE COML PLT WAS USING A HOOD; THE CFI WAS PROVIDING SIMULATED ATC VCTRS FOR AN APCH. A DEVELOPMENTAL CTLR (D/C) WAS CTLG TFC AT THE ARPT UNDER SUPVN OF AN INSTRUCTOR. THE D/C HAD ADZD THE PLTS TO MAINT VFR & THAT SEPN SVCS WOULD NOT BE PROVIDED. AS THE CONVAIR WAS IN A CLOSED/RGT PATTERN, THE PLT OF BEECH B19, N9343S, CTCD THE TWR FOR APPROVAL TO TRANSIT THE AREA FM SE TO NE. THE B19 PLT WAS CLRD THRU THE AREA AT OR BLO 2400' MSL. SUBSEQUENTLY, THE 2 ACFT CONVERGED & COLLIDED AT AN ALT OF ABT 2000' MSL. IMPACT OCCURRED AS THE B19 WAS ON A HDG OF 060 DEG & THE CONVAIR WAS IN A RGT TURN TO INTERCEPT THE ILS FINAL APCH COURSE. THE B19 PLT SAW THE CONVAIR JUST BFR IMPACT & TRIED TO AVOID A COLLISION; THE CONVAIR PLTS DID NOT SEE THE B19. AFTER IMPACT, THE CONVAIR WAS LNDD WITH A DMGD HRZNTL STBLZR. THE B19 PLT WAS FORCED TO LNDG ON ROUGH TRRN. THE ATC CTLRS HAD NOT NOTIFIED EITHER CREW OF THE OTHER ACFT'S PSN. ## Analysis (aircraft 1) CONVAIR 600, N94258, WAS ON A FLT WITH A COML PLT IN THE L SEAT & A CFI IN THE RGT SEAT. THEY ENTERED VFR TFC FOR ILS APCHS TO RWY 34. THE COML PLT WAS USING A HOOD; THE CFI WAS PROVIDING SIMULATED ATC VCTRS FOR AN APCH. A DEVELOPMENTAL CTLR (D/C) WAS CTLG TFC AT THE FTW ALLIANCE ARPT UNDER SUPVN OF AN INSTRUCTOR. D/C ADZD THE PLTS TO MAINT VFR & THAT SEPN SVCS WOULD NOT BE PROVIDED. AS THE CONVAIR WAS IN A CLOSED/RGT PATTERN, THE PLT OF BEECH B19, N9343S, CTCD THE TWR FOR APPROVAL TO TRANSIT THE AREA FM SE TO NE. THE B19 PLT WAS CLRD THRU THE AREA AT OR BLO 2400' MSL. SUBSEQUENTLY, THE 2 ACFT CONVERGED & COLLIDED AT AN ALT OF ABT 2000' MSL. IMPACT OCCURRED AS THE B19 WAS ON A HDG OF 060 DEG & THE CONVAIR WAS IN A RGT TURN TO INTERCEPT THE ILS FINAL APCH COURSE. THE B19 PLT SAW THE CONVAIR JUST BFR IMPACT & TRIED TO AVOID A COLLISION; THE CONVAIR PLTS DID NOT SEE THE B19. AFTER IMPACT, THE CONVAIR WAS LNDD WITH A DMGD HRZNTL STBLZR. THE B19 PLT WAS FORCED TO LNDG ON ROUGH TRRN. THE ATC CTLRS HAD NOT NOTIFIED EITHER CREW OF THE OTR ACFT'S PSN. ## Aircraft 1 - Registration: [N9343S](https://openairdocs.org/deregistered/N9343S-1993-01-25), registration cancelled 1993-01-25, S/N MB777 (OpenAirDocs) - Reported make and model: BEECH B19 - Registry model: [Beech B19](https://openairdocs.org/model/beech-b19) (registry code 1151215) (OpenAirDocs) - Category: Airplane - Serial number: MB-777 - Engines: LYCOMING O-320-E3D 150 horsepower reciprocating - Damage: Substantial damage - Flight: Business, Part 91 - Registered owner: Michael Cohen - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, October 9, 1991, 55 hours before - Departed: FTW, FT WORTH, TX - Destination: ADS, DALLAS, TX - Airport: AFW, Ft Worth Alliance ## Aircraft 2 - Registration: [N94258](https://openairdocs.org/deregistered/N94258-2004-03-08), registration cancelled 2004-03-08, S/N 119, built 1948 (OpenAirDocs) - Reported make and model: CONVAIR 600 - Registry model: [Convair 600-240D](https://openairdocs.org/model/convair-600-240d) (registry code 2422660) (OpenAirDocs) - Registry engine: [Rolls-Royce DART-542 series](https://openairdocs.org/engine/rolls-royce-dart-542-series) (registry code 54522, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: 119 - Airframe hours: 61707 - Engines: Rolls-Royce RDA-10 3060 horsepower turbo prop - Damage: Substantial damage - Flight: Instructional, Part 91 - Registered owner: Aircraft Leasing Inc. - Airworthiness certificate: Standard, Transport - Last inspection: Continuous airworthiness, November 11, 1991, 1 hours before - Departed: AWF, FORT WORTH, TX - Airport: AFW, Ft Worth Alliance, runway 34, 9,600 × 150 ft, concrete ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot, aircraft N9343S; age 21; commercial, flight instructor; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; seat: left; flight hours: 690 total, 200 in this make and model, 580 as pilot in command, 180 in the last 90 days, 42 in the last 30 days, 3 in the last 24 hours - Pilot, aircraft N94258; age 36; flight instructor, airline transport; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; seat: right; flight hours: 7,200 total, 5,100 in this make and model, 4,700 as pilot in command, 88 in the last 90 days, 48 in the last 30 days, 2 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 360° at 20 knots - Visibility: 20 statute miles - Lowest ceiling: none - Temperature: 57 °F - Altimeter: 30.00 inHg - Observed at: AFW, 2 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 19911120062711A](https://openairdocs.org/incident/19911120062711A), Nov 20, 1991: Beech B19, Fort Worth, TX, Substantial damage. Cleared through area VFR saw N94258.last minutes tried to miss but struck tail of convair. Forced landed off airport - [Accident 19911120062712A](https://openairdocs.org/incident/19911120062712A), Nov 20, 1991: Cvac 340D, Ft Worth, TX, Substantial damage. Cleared for approach saw N9343S brifly prior collision. Landed on afw with part of horizontal stabilizer missing. 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.