LAX06FA106

NTSB accident investigation · Cessna 172RG · El Cajon, CA · February 9, 2006

Accident · FatalField investigationFinal report
Date
February 8, 2006, 16:42 local (Feb 9, 2006, 00:42 UTC)
Place
El Cajon, CA
Injuries
3 fatal
Phase of flight
Enroute
Aircraft
N9531BCessna 172RGN759KECessna 182Q
Weather
Visual (VMC) · Day
Status
Completed · report March 26, 2007
Report
Approved by Office Director
Parties
National Air Traffic Controllers Association, Federal Aviation Administration, Cessna Aircraft Company
Case key
63211

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The pilots of both airplanes failure to maintain an adequate visual lookout due to their relative flight paths, which limited the available visual cues. Factors were the failure of the air traffic controller(s) to issue a conflict alert to the Cessna 172RG after repeated visual and aural warnings of an impending collision and the task load of the certified flight instructor in the other airplane.

The pilots of both airplanes failure to maintain an adequate visual lookout due to their relative flight paths, which limited the available visual cues. Factors were the failure of the air traffic controller(s) to issue a conflict alert to the Cessna 172RG after repeated visual and aural warnings of an impending collision and the task load of the certified flight instructor.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Midair collisionClimb - to cruise
Visual lookout - inadequatePilot in command(cfi)Cause
Excessive workload (task overload)Pilot in command(cfi)Factor
Visual lookout - inadequatePilot of other aircraftCause
Ifr separation standards - not complied withAtc personnel(artcc)Factor
Traffic advisory - not issuedAtc personnel(artcc)Factor
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - ground
Midair collisionClimb - to cruise
Visual lookout - inadequatePilot in commandCause
Visual lookout - inadequatePilot of other aircraftCause
Excessive workload (task overload)Pilot of other aircraftFactor
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - ground

Analysis

A Cessna 182Q and a Cessna 172RG, were operating in class D airspace and departed from the same airport. The Cessna 172RG was operating under instrument flight rules as an instructional flight (IFR) and receiving radar service from an approach control facility, while the Cessna 182 was operating under visual flight rules (VFR) and had been released from communication with air traffic control. The pilot undergoing instruction in the Cessna 172RG was most likely wearing a view limiting device which tasked the certified flight instructor seated in the right seat to serve as both an instructor and a safety pilot. The Cessna 172RG departed first, performing a right 260-degree turn over the airport and was assigned a southwest heading by the controller. The Cessna 182Q departed to the west and made a left turn, while climbing in a southeasterly direction. The heading assigned to the Cessna 172RG put it on a direct collision course with the Cessna 182Q, with a collision angle of 40 degrees. Following a discussion with the controller about the pilot's intentions upon completion of an approach, the controller instructed the Cessna 172RG to fly heading 190. The pilot read back, "One nine" and no further transmissions were received from the Cessna 172RG. In class D airspace, there is no specified separation requirement between VFR and IFR aircraft. However, controllers still have a responsibility to be vigilant for potential collisions between aircraft under these circumstances. This accident occurred after the controllers in communication with the Cessna 172RG had received a sustained conflict alert involving the Cessna 172RG and Cessna 182Q (operating on a VFR transponder code), but failed to recognize or resolve the conflict. Comparisons of the calculated convergence angles of the two airplanes showed that for an 85th percentile male seated in the left seat (Cessna did not create pilot view angles for pilots seated in the front right seat), the Cessna 172RG pilot was about 15 degrees outside of the right view angle and the Cessna 182Q pilot was within about 6 degrees of the left view angle.

A Cessna 182Q and a Cessna 172RG, were operating in class D airspace and departed from the same airport. The Cessna 172RG was operating under instrument flight rules as an instructional flight (IFR) and receiving radar service from an approach control facility, while the Cessna 182 was operating under visual flight rules (VFR) and had been released from communication with air traffic control. The pilot undergoing instruction in the Cessna 172RG was most likely wearing a view limiting device which tasked the certified flight instructor seated in the right seat to serve as both an instructor and a safety pilot. The Cessna 172RG departed first, performing a right 260-degree turn over the airport and was assigned a southwest heading by the controller. The Cessna 182Q departed to the west and made a left turn, while climbing in a southeasterly direction. The heading assigned to the Cessna 172RG put it on a direct collision course with the Cessna 182Q, with a collision angle of 40 degrees. Following a discussion with the controller about the pilot's intentions upon completion of an approach, the controller instructed the Cessna 172RG to fly heading 190. The pilot read back, "One nine" and no further transmissions were received from the Cessna 172RG. In class D airspace, there is no specified separation requirement between VFR and IFR aircraft. However, controllers still have a responsibility to be vigilant for potential collisions between aircraft under these circumstances. This accident occurred after the controllers in communication with the Cessna 172RG had received a sustained conflict alert involving the Cessna 172RG and Cessna 182Q (operating on a VFR transponder code), but failed to recognize or resolve the conflict. Comparisons of the calculated convergence angles of the two airplanes showed that for an 85th percentile male seated in the left seat (Cessna did not create pilot view angles for pilots seated in the front right seat), the Cessna 172RG pilot was about 15 degrees outside of the right view angle and the Cessna 182Q pilot was within about 6 degrees of the left view angle.

Factual narrative

1.1 History of the Flight

On February 8, 2006, at 1642 Pacific standard time, a Cessna 172RG, N9531B, and a Cessna 182Q, N759KE, collided in flight approximately 3 miles south of the Gillespie Field Airport in El Cajon, California. Both airplanes were destroyed in the collision sequence and post impact fires. The two occupants of the Cessna 172RG and the sole occupant of the Cessna 182Q were fatally injured. The collision occurred over a densely populated residential area and multiple homes sustained damage from the falling debris; there were no reported ground injuries. Both airplanes were operated under 14 CFR Part 91, the Cessna 172RG by Scandinavian Flight Academy, Inc. as an instructional flight and the Cessna 182Q, by a private pilot, as a personal flight. The Cessna 172RG was registered to the operator and the Cessna 182Q was registered to a private company. The Cessna 172RG departed from Gillespie Field, at 1637 on an instrument flight rules (IFR) clearance and was destined for Brown Field Municipal Airport, San Diego, California, located 15 miles south of Gillespie Field. The Cessna 182Q departed from Gillespie Field at 1638 on a local visual flight rules flight (VFR) to the Brown Field Municipal Airport. Visual meteorological conditions prevailed, and included high broken cloud cover with visibility of 25 miles.

1.1.1 Air Traffic Control History

The Cessna 172RG contacted Gillespie Field ground control (also working clearance delivery) at 1620:08, initially requesting a tower en route IFR clearance to McClellan-Palomar Airport, Carlsbad, California, located 24 nautical miles northwest of Gillespie Field. At 1620:31, a different voice changed the destination airport to Brown Field. The controller issued a clearance to depart via the published Gillespie Field departure procedure to Mission Bay (MZB) which was as follows: maintain 3,000 feet, expect 4,000 feet 10 minutes after departure. The pilot was given a discrete transponder code of 5276. The pilot read back the altitude clearance correctly.

The Cessna 172RG requested taxi clearance at 1622 and was instructed to taxi to runway 27R. The Cessna 182Q had been engaged in VFR pattern work at Gillespie Field, executing several full stop landings and taxiing back for departure after each one. At 1633:45, the Cessna 182Q reported ready for departure at runway 27R. At 1635:52, the local controller instructed the Cessna 172RG to stand by for IFR release, and then cleared the flight for takeoff at 1637:12. The Cessna 182Q was cleared for takeoff at 1638:31.

The Cessna 172RG departed to the west and then executed a right 270-degree turn in accordance with the published instrument departure procedure, crossing overhead runways 27L and 27R southbound climbing through about 1,400 feet. The pilot was instructed to contact SCT at 1638:48.

The Cessna 182Q departed runway 27R at 1638:31, proceeded straight out to state highway 125 and then turned southbound. At 1640:38, the pilot requested and received permission to go off frequency. At that time, the Cessna 182Q was about 1.6 nm west of the Cessna 172RG, climbing through 1,700 feet.

There was no further Gillespie Field ATCT contact with either aircraft.

The Cessna 172RG contacted the SCT East Radar sector at 1639:41, climbing through 1,300 feet to 3,000 feet. The controller acknowledged. At 1640:24, the radar controller radar identified the Cessna 172RG one half mile south of Gillespie Field, instructing the pilot to maintain 2,600 feet and fly a heading of 200 degrees and expect vectors to the POGGI 336 radial. The pilot read back the wrong radial, and the controller corrected him. At 1640:54, the controller read the Brown Field weather to the pilot and told the pilot to expect the VOR-A approach. An aural alarm consistent with a conflict alert warning was audible in the background of this ATC transmission and no action was taken by ATC.

Between 1641:08 and 1641:31, the Cessna 172RG pilot and controller discussed the pilot's intentions following completion of the VOR-A approach. At 1641:34, the controller instructed the Cessna 172RG to fly heading 190. The pilot read back "One nine" At 1641:43, the controller repeats the heading instruction. At 1641:46, static is heard on the frequency. The controller called the Cessna 172RG at 1641:49 and at 1641:59 with no response. At 1642:12, a pilot of Eagle Flight 87 reported, "…two uh targets just ahead of us uh down a couple thousand they were just two fireballs and uh both look like they hit the ground." The controller acknowledged, and at 1642:24 another pilot confirmed the report.

1.1.2 Radar Information

Recorded radar data was obtained from the Southern California Terminal Radar Approach Control (SCT) facility using data from the airport surveillance radar (ASR-9) located near Miramar, California. The radar data was analyzed for time frame and proximity to the anticipated flight tracks of the airplanes en route from Gillespie. Based on the information, two radar tracks were located that were consistent with the respective paths of flight.

The Cessna 172RG was directly overhead the airport at 1639:55 at an elevation of 1,300 feet mean sea level (msl) and its path of travel was generally southbound. At 1640:51, the Cessna 172RG was climbing through 1,900 feet msl and the flight path changed to a south-southwest direction while it was overhead of Interstate 8.

At 1640:00, the Cessna 182 was west-southwest bound at an elevation of 1,200 feet msl. The Cessna 182 climbed through 1,900 feet at 1640:51 and was established in a south-southeast direction of flight after transitioning from the upwind leg.

The respective airplanes' courses continued in the aforementioned directions with the Cessna 172RG slightly ahead and higher than the Cessna 182, until the collision, at approximately 1642 and at an elevation of 2,300 feet msl.

1.1.3 Witness Information

A witness, who was a professional airline pilot, observed the accident while located at a private residence in the Mount Helix area. He noted two airplanes flying approximately 1,800 feet mean sea level (msl), with one flying southwest bound and the other moving eastward. They were both high-wing airplanes and one appeared to be larger than the other, with a size differentiation similar to a Cessna 152 in comparison to a Cessna 172. The airplanes appeared to be in the Gillespie Field class D airspace when the eastbound airplane impacted the right side of the southwest bound airplane. Upon impact, there was an instant ball of fire and the wings separated from the fuselages of the airplanes as they descended to the ground.

Another witness was driving her car westbound, approaching Interstate 8 (I-8). She looked upward to the sky and noticed an airplane following I-8 in an eastward direction. She subsequently observed another airplane flying westbound, which appeared at a slightly lower altitude. If the airplanes continued on their present paths, it appeared that their respective paths would intersect. The airplanes did not appear to be in distress. As she continued to watch the airplanes, the airplane flying east impacted the airplane flying west at its approximate 3-o'clock position. The eastbound airplane appeared to impact the westbound airplane on the right side from its front to middle section. The witness did not see an immediate fire but soon after the collision, pieces fell from the airplanes in an arc-like pattern.

1.2 Other Damage

Debris was scattered from the airplanes across a 6-block area consisting of a residential neighborhood and a park. As the right wing of the Cessna 182Q landed in front of a residence, fuel sprayed from the fuel bladder onto the front of the residence, which subsequently sustained considerable fire damage. The left wing of the Cessna 172RG landed on a residence, penetrating the structure; the right wing landed in a

1.1 History of the Flight

On February 8, 2006, at 1642 Pacific standard time, a Cessna 172RG, N9531B, and a Cessna 182Q, N759KE, collided in flight approximately 3 miles south of the Gillespie Field Airport in El Cajon, California. Both airplanes were destroyed in the collision sequence and post impact fires. The two occupants of the Cessna 172RG and the sole occupant of the Cessna 182Q were fatally injured. The collision occurred over a densely populated residential area and multiple homes sustained damage from the falling debris; there were no reported ground injuries. Both airplanes were operated under 14 CFR Part 91, the Cessna 172RG by Scandinavian Flight Academy, Inc. as an instructional flight and the Cessna 182Q, by a private pilot, as a personal flight. The Cessna 172RG was registered to the operator and the Cessna 182Q was registered to a private company. The Cessna 172RG departed from Gillespie Field, at 1637 on an instrument flight rules (IFR) clearance and was destined for Brown Field Municipal Airport, San Diego, California, located 15 miles south of Gillespie Field. The Cessna 182Q departed from Gillespie Field at 1638 on a local visual flight rules flight (VFR) to the Brown Field Municipal Airport. Visual meteorological conditions prevailed, and included high broken cloud cover with visibility of 25 miles.

1.1.1 Air Traffic Control History

The Cessna 172RG contacted Gillespie Field ground control (also working clearance delivery) at 1620:08, initially requesting a tower en route IFR clearance to McClellan-Palomar Airport, Carlsbad, California, located 24 nautical miles northwest of Gillespie Field. At 1620:31, a different voice changed the destination airport to Brown Field. The controller issued a clearance to depart via the published Gillespie Field departure procedure to Mission Bay (MZB) which was as follows: maintain 3,000 feet, expect 4,000 feet 10 minutes after departure. The pilot was given a discrete transponder code of 5276. The pilot read back the altitude clearance correctly.

The Cessna 172RG requested taxi clearance at 1622 and was instructed to taxi to runway 27R. The Cessna 182Q had been engaged in VFR pattern work at Gillespie Field, executing several full stop landings and taxiing back for departure after each one. At 1633:45, the Cessna 182Q reported ready for departure at runway 27R. At 1635:52, the local controller instructed the Cessna 172RG to stand by for IFR release, and then cleared the flight for takeoff at 1637:12. The Cessna 182Q was cleared for takeoff at 1638:31.

The Cessna 172RG departed to the west and then executed a right 270-degree turn in accordance with the published instrument departure procedure, crossing overhead runways 27L and 27R southbound climbing through about 1,400 feet. The pilot was instructed to contact SCT at 1638:48.

The Cessna 182Q departed runway 27R at 1638:31, proceeded straight out to state highway 125 and then turned southbound. At 1640:38, the pilot requested and received permission to go off frequency. At that time, the Cessna 182Q was about 1.6 nm west of the Cessna 172RG, climbing through 1,700 feet.

There was no further Gillespie Field ATCT contact with either aircraft.

The Cessna 172RG contacted the SCT East Radar sector at 1639:41, climbing through 1,300 feet to 3,000 feet. The controller acknowledged. At 1640:24, the radar controller radar identified the Cessna 172RG one half mile south of Gillespie Field, instructing the pilot to maintain 2,600 feet and fly a heading of 200 degrees and expect vectors to the POGGI 336 radial. The pilot read back the wrong radial, and the controller corrected him. At 1640:54, the controller read the Brown Field weather to the pilot and told the pilot to expect the VOR-A approach. An aural alarm consistent with a conflict alert warning was audible in the background of this ATC transmission and no action was taken by ATC.

Between 1641:08 and 1641:31, the Cessna 172RG pilot and controller discussed the pilot's intentions following completion of the VOR-A approach. At 1641:34, the controller instructed the Cessna 172RG to fly heading 190. The pilot read back "One nine" At 1641:43, the controller repeats the heading instruction. At 1641:46, static is heard on the frequency. The controller called the Cessna 172RG at 1641:49 and at 1641:59 with no response. At 1642:12, a pilot of Eagle Flight 87 reported, "…two uh targets just ahead of us uh down a couple thousand they were just two fireballs and uh both look like they hit the ground." The controller acknowledged, and at 1642:24 another pilot confirmed the report.

1.1.2 Radar Information

Recorded radar data was obtained from the Southern California Terminal Radar Approach Control (SCT) facility using data from the airport surveillance radar (ASR-9) located near Miramar, California. The radar data was analyzed for time frame and proximity to the anticipated flight tracks of the airplanes en route from Gillespie. Based on the information, two radar tracks were located that were consistent with the respective paths of flight.

The Cessna 172RG was directly overhead the airport at 1639:55 at an elevation of 1,300 feet mean sea level (msl) and its path of travel was generally southbound. At 1640:51, the Cessna 172RG was climbing through 1,900 feet msl and the flight path changed to a south-southwest direction while it was overhead of Interstate 8.

At 1640:00, the Cessna 182 was west-southwest bound at an elevation of 1,200 feet msl. The Cessna 182 climbed through 1,900 feet at 1640:51 and was established in a south-southeast direction of flight after transitioning from the upwind leg.

The respective airplanes' courses continued in the aforementioned directions with the Cessna 172RG slightly ahead and higher than the Cessna 182, until the collision, at approximately 1642 and at an elevation of 2,300 feet msl.

1.1.3 Witness Information

A witness, who was a professional airline pilot, observed the accident while located at a private residence in the Mount Helix area. He noted two airplanes flying approximately 1,800 feet mean sea level (msl), with one flying southwest bound and the other moving eastward. They were both high-wing airplanes and one appeared to be larger than the other, with a size differentiation similar to a Cessna 152 in comparison to a Cessna 172. The airplanes appeared to be in the Gillespie Field class D airspace when the eastbound airplane impacted the right side of the southwest bound airplane. Upon impact, there was an instant ball of fire and the wings separated from the fuselages of the airplanes as they descended to the ground.

Another witness was driving her car westbound, approaching Interstate 8 (I-8). She looked upward to the sky and noticed an airplane following I-8 in an eastward direction. She subsequently observed another airplane flying westbound, which appeared at a slightly lower altitude. If the airplanes continued on their present paths, it appeared that their respective paths would intersect. The airplanes did not appear to be in distress. As she continued to watch the airplanes, the airplane flying east impacted the airplane flying west at its approximate 3-o'clock position. The eastbound airplane appeared to impact the westbound airplane on the right side from its front to middle section. The witness did not see an immediate fire but soon after the collision, pieces fell from the airplanes in an arc-like pattern.

1.2 Other Damage

Debris was scattered from the airplanes across a 6-block area consisting of a residential neighborhood and a park. As the right wing of the Cessna 182Q landed in front of a residence, fuel sprayed from the fuel bladder onto the front of the residence, which subsequently sustained considerable fire damage. The left wing of the Cessna 172RG landed on a residence, penetrating the structure; the right wing landed in a pa

Aircraft · 2

Registration
N9531B
Reported as
Cessna 172RG
Category
Airplane
Serial number
172RG0859
Airframe hours
5,429
Engine
Textron Lycoming O-360-F1A6, 180 hp, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Instructional · Part 91
Registered owner
Scandinavian Aviation Academy, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · November 1, 2005 · 66 hours before
Departed
KSEE · El Cajon, CA
Destination
KSDM · Brown Field, CA
Flight plan
IFR

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
N759KE
Reported as
Cessna 182Q
Category
Airplane
Serial number
18266048
Airframe hours
2,958.87
Engine
Teledyne Continental O-470-U, 230 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Operator
William Kupiec
Registered owner
Signal Mountain Aviation, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
Annual · February 1, 2006 · 3 hours before
Departed
KSEE · El Cajon, CA
Destination
KSDM · San Diego, CA

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 · 3

As NTSB recorded them. NTSB leaves out names.

Role
Flight instructor, aircraft N9531B
Age
22
Injuries
Fatal
Certificates
Commercial, Flight instructor
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
January 1, 2006
Seat
Right
Toxicology
Performed
Flight hours
570 total · 435 as pilot in command · 45 in the last 90 days · 27 in the last 30 days
Role
Other flight crew, aircraft N9531B
Age
23
Injuries
Fatal
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Seat
Left
Toxicology
Performed
Flight hours
305 total
Role
Pilot, aircraft N759KE
Age
68
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Without waivers/limitations
Last flight review
March 1, 2005
Seat
Right
Toxicology
Performed
Flight hours
322 total · 233 in this make and model · 145 as pilot in command · 36 in the last 90 days · 20 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
260° at 8 knots
Visibility
25 statute miles
Lowest ceiling
20,000 ft broken
Temperature
73 °F
Altimeter
29.93 inHg
Observed at
KSEE, 3 nm away

Docket · 32

The files NTSB released with the investigation on February 12, 2007, on NTSB’s docket system: statements, records, photos and specialists’ reports. 21.3 MB in all.

ATC 3 - Factual Report of Group ChairmanItem 1 · .PDF · 294 KBPilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 2 · .PDF · 505 KBWitness Statement Summary- AdamsItem 3 · .PDF · 14 KBWitness Statement Summary- IsaakItem 4 · .PDF · 14 KBPolice Witness Statements5Item 5 · .PDF · 275 KB172RG - Rangeby LogbookItem 6 · .PDF · 342 KB172RG- SAA EmailItem 7 · .PDF · 16 KB172RG- Sigurdson Flight TimeItem 8 · .PDF · 75 KB172RG - Maintenance Logbook ExcerptsItem 9 · .PDF · 155 KB182- GPS DownloadItem 10 · .PDF · 70 KB182- Kupiec Record of ConversationItem 11 · .PDF · 15 KB182 - Kupiec Flight Time LogbookItem 12 · .PDF · 1.8 MB182- Fueling RecordItem 13 · .PDF · 13 KB182- Maintenance Logbook ExcerptsItem 14 · .PDF · 418 KBCessna Visibility StudyItem 15 · .PDF · 17 KBSun DataItem 16 · .PDF · 11 KBFAA Aircraft Accident PackageItem 17 · .PDF · 1.0 MBToxicological ReportsItem 18 · .PDF · 180 KBStatement of Party Representatives to NTSB InvestigationItem 19 · .PDF · 312 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 20 · .PDF · 177 KBAerial PhotoItem 21 · .PDF · 1.4 MBPhoto 1. 172RG Main WreckageItem 22 · .PDF · 1.3 MBPhoto 2. 172RG Left WingItem 23 · .PDF · 813 KBPhoto 3. 172RG PropellerItem 24 · .PDF · 1.5 MBPhoto 4. 172RG Right WingItem 25 · .PDF · 1.1 MBPhoto 5. 182 Main WreckageItem 26 · .PDF · 1.4 MBPhoto 6. 182 Main Wreckage Tree RemovedItem 27 · .PDF · 1.3 MBPhoto 7. 182 EmpennageItem 28 · .PDF · 1.1 MBPhoto 8. 182 Right WingItem 29 · .PDF · 894 KBPhoto 9. 182 Left WingItem 30 · .PDF · 1.3 MBPhoto 10. 182 Propeller BladeItem 31 · .PDF · 1.3 MBPhoto 11. 182 Blue Paint MarkItem 32 · .PDF · 2.1 MB

FAA reports on this event · 2

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