LAX02FA288

A Mooney and a Beech collided in midair on the downwind for right traffic to runway 24. A pilot in the Beech contacted Palomar ground control (GC) at 1247, requesting taxi from its fixed base operator (FBO) to runway 24. The pilot of the Mooney called Palomar tower at 1255:37, reporting 10 miles north of the airport for landing. The local controller (LC) instructed the Mooney pilot to enter right traffic for runway 24 and report downwind. The air traffic control tower had a digital bright radar indicator tower equipment (DBRITE) radar. The LC stated that the DBRITE location in the cab put it out of the line of sight of the majority of the LC's traffic scan, so using the DBRITE for reference required the LC to divert her attention from the traffic in the pattern and on the runway. She observed the Mooney's identity next to its target on the DBRITE. She put the Mooney on the arrival list, and continued working other traffic. Radar data indicated that the Mooney's target followed the coastline from Oceanside to a point about 3 miles northwest of Palomar. The airplane then turned eastbound and tracked toward the right downwind leg for runway 24. At 1258:08, the LC cleared the Beech for takeoff, and the pilot acknowledged. The Beech's first radar target appeared at 1258:39, and the airplane passed the departure end of the runway at 1259:02. The Beech immediately turned right crosswind. At 1259:27, the LC transmitted a traffic advisory to the Mooney, advising of the Beech on right crosswind turning to downwind. In the same transmission, the LC also advised the Beech pilot of the Mooney traffic inbound on the 45-degree entry to downwind. There was no response from either airplane. According to the LC, the airplanes collided immediately after this transmission. At 1259:36, the Mooney radar target crossed the path of the Beech target, at a mode C reported altitude of 1,300 feet mean sea level (msl), and the two targets merged. Measurement on the plot of the radar targets determined that the convergence angle was 124 degrees. One witness observed the Mooney, which was light brown with dark brown accents, bank to the right immediately prior to impact. Another witness reported that both airplanes appeared to turn at the last second, but both turned the same way into each other. Witnesses reported that the two airplanes merged, and then they saw a puff of white smoke. A piece of wing fell from the Mooney, and the airplane immediately went into a nosedive. The Mooney entered a rapid descent, striking the ground at 1259:43, approximately 300 yards from the estimated collision point. The Beech, which was white with blue accents, banked left and maintained that attitude for a few seconds. To some witnesses, the bank angle approached 90 degrees, while to others it appeared to go to an inverted position. Then the airplane's nose down attitude became steeper until it nosed vertically into the ground. The airplane landed about 100 yards from one witness, who did not observe any attempts at recovery. The last radar target, received at 1259:48, showed the airplane descending through a mode C reported altitude of 500 feet. During the period that the airplane was taxiing, the ground controller characterized the LC's workload as light to moderate, with no unusual circumstances in the traffic pattern. There were "a few" clouds west of the airport that were close enough to be a factor for departures. They could cause pilots to turn somewhat earlier than normal if necessary to maintain adequate clearance. Evaluation of all evidence determined that the conflict was detectable both visually and on the tower radar display. When the LC realized that they were in conflict, her actions were too late to provide the pilots with adequate time to maneuver to avoid a collision. The local controller's loss of situational awareness contributed to the accident. FAA order 7110.65 "Air Traffic Control" prescribed ATC procedures and phraseology for use by persons providing air traffic control services. Paragraph 3-1-1 instructed controllers to provide airport traffic control service based only upon observed or known traffic and airport conditions. A note stated that when operating in accordance with the Code of Federal Regulations (CFR's), it was the responsibility of the pilot to avoid collision with other aircraft. It also remarked that, due to the limited space around terminal locations, traffic information could aid pilots in avoiding collisions.

History of flight

On September 17, 2002, about 1300 Pacific daylight time, a Mooney M-20E, N7199U, collided in midair with a Beech 76 (Duchess), N1828A, about 1 mile northwest of McClellan-Palomar Field, Carlsbad, California. The private/pilot owner was operating the Mooney under the provisions of 14 CFR Part 91. The pilot, the sole occupant, sustained fatal injuries; the airplane was destroyed. The personal cross-country flight departed Modesto, California, at 1004, en route to Visalia, California, and departed Visalia at an undetermined time en route to Palomar. Pinnacle Aviation Services, Inc., was operating the Beech under the provisions of 14 CFR Part 91. The certified flight instructor (CFI) pilot and commercial pilot undergoing multiengine instruction (PUI) sustained fatal injuries; the airplane was destroyed. The local training flight departed Palomar at 1258. Visual meteorological conditions prevailed, and no flight plan had been filed for either airplane. The primary wreckage of the Mooney was at 33 degrees 08.223 minutes north latitude and 117 degrees 17.926 minutes west longitude. The primary wreckage of the Beech was at 33 degrees 08.608 minutes north latitude and 117 degrees 18.335 minutes west longitude.

The National Transportation Safety Board investigator-in-charge (IIC) reviewed recorded radio transmissions between air traffic control tower (ATCT) personnel at Palomar and the airplanes. The IIC converted all times to PDT.

A pilot in the Beech contacted Palomar ground control (GC) at 1247, requesting taxi from its fixed base operator (FBO) to runway 24. The ground controller instructed the pilot to taxi to runway 24 via taxiway A.

The pilot of the Mooney called the local controller (LC) at Palomar tower at 1255:37, reporting 10 miles north of the airport, over Oceanside harbor, for landing. There were no other transmissions from the Mooney pilot. The LC instructed the pilot to enter right traffic for runway 24 and report downwind. The pilot of the Beech reported ready for takeoff on runway 24 at 1256:02. The LC instructed the pilot to hold short of the runway. At 1257:32, the LC cleared the Beech to taxi into position and hold. At 1258:08, the LC cleared the Beech for takeoff, and the pilot acknowledged.

At 1259:27, the LC transmitted a traffic advisory to the Mooney, advising of the Duchess on right crosswind turning to downwind. In the same transmission the LC also advised the Duchess pilot of the Mooney traffic inbound on the 45-degree entry to downwind. There was no response from either airplane. According to the LC, the airplanes collided immediately after this transmission. There was no further ATC contact.

One witness observed the Mooney, which was light brown with dark brown accents, bank to the right immediately prior to impact. Another witness reported that both airplanes appeared to turn at the last second, but both turned the same way into each other. Witnesses reported that the two airplanes merged and then they saw a puff of white smoke. A piece of wing fell from the Mooney, which immediately went into a nosedive.

The Beech, which was white with blue accents, banked left and maintained that attitude for a few seconds. To some witnesses the bank angle approached 90 degrees, while to others it appeared to go to an inverted position. Then the airplane's nose down attitude became steeper until it nosed vertically into the ground. The airplane landed about 100 yards from one witness, who did not observe any attempts at recovery.

A Safety Board ATC specialist reviewed recorded radar data and submitted a factual report, which is attached. The following paragraphs summarize his findings.

The Beech's first radar target appeared at 1258:39, and the airplane passed the departure end of the runway at 1259:02. The Beech immediately turned right crosswind and crossed the arrival track of the Mooney at 1259:36, at a mode C reported altitude of 1,400 feet. The Beech continued roughly northbound, then entered a rapid descent and struck the ground east of Cannon Road. The last radar target, received at 1259:48, showed the airplane descending through a mode C reported altitude of 500 feet.

The Mooney followed the coastline from Oceanside to a point about 3 miles northwest of Palomar. The airplane then turned eastbound and tracked toward the right downwind leg for runway 24. At 1259:36, the Mooney crossed the path of the Beech, at a mode C reported altitude of 1,300 feet, and the two targets merged. The Mooney entered a rapid descent, striking the ground approximately 300 yards from the estimated collision point at 1259:43.

Personnel information

Mooney Pilot

A review of Federal Aviation Administration (FAA) airman records revealed that the pilot held a private pilot certificate with an airplane single engine land rating. The pilot held a third-class medical certificate issued on September 15, 2000. It had the limitation that the pilot must wear corrective lenses. The IIC located no personal flight records for the pilot. The aeronautical experience listed in this report came from a review of the airman FAA records on file in the Airman and Medical Records Center located in Oklahoma City, Oklahoma. These records indicated that as of the medical examination, the pilot had a total time of 1,300 hours with 60 hours logged in the previous 6 months.

Beech Duchess Pilots

Certified Flight Instructor (CFI)

A review of FAA airman records revealed that the CFI held a commercial pilot certificate with ratings for airplane single engine and multiengine land, as well as instrument airplane. He held a certified flight instructor certificate with ratings for airplane single engine and multiengine land, as well as instrument airplane. He held a first-class medical certificate issued on March 11, 2002. It had the limitation that the pilot must wear corrective lenses.

The operator submitted a written report. This report indicated that the CFI had a total flight time of 1,700 hours. He accumulated 184 hours in the last 90 days, and 58 in the last 30 days. He had 100 hours in this make and model.

Pilot Undergoing Instruction (PUI)

A review of FAA airman records revealed that the PUI held a commercial pilot certificate with airplane single engine land and instrument airplane ratings. The PUI held a first-class medical certificate issued on December 18, 2000. It had no limitations or waivers.

An examination of the pilot's logbook indicated an estimated total flight time of 325 hours. She logged about 30 hours in the last 90 days, and 15 in the last 30 days. She had an estimated 20 hours in this make and model.

Aircraft information

Mooney

The airplane was a Mooney M20-E, serial number 417. The engine was a Lycoming IO-360-A1A, serial number L-869-51A. The insurance company reported an approximate total airframe time of 4,600 hours, and it had an annual inspection on February 8, 2002.

Beech 76 Duchess

The airplane was a Beech 76 Duchess, serial number ME-422. The operator reported that it had an annual inspection dated April 11, 2002, at a total time of 3,000 hours.

The left engine was a Textron Lycoming O-360-A-1G6D engine, serial number L-2320-36A.

The right engine was a Textron Lycoming LO-360-A-1G6D engine, serial number L-555-71A.

Meteorological information

A routine aviation weather report (METAR) for Palomar (CRQ) was issued at 1253. It stated: skies clear; visibility 10 miles; winds from 220 degrees at 7 knots; temperature 66 degrees Fahrenheit; dew point 59 degrees Fahrenheit; altimeter 29.81 inches of mercury (inHg).

A special observation taken by tower personnel at 1313 reported: skies clear; visibility 8 miles; winds from 230 degrees at 8 knots; temperature 66 degrees Fahrenheit; dew point 59 degrees Fahrenheit; altimeter 29.84 inHg.

Communications

Both airplanes were in contact with the Palomar ATCT on