MIA00FA041

NTSB accident investigation · Piper PA-44-180 · Deland, FL · December 3, 1999

Accident · FatalField investigationFinal report
Date
December 3, 1999, 10:23 local (15:23 UTC)
Place
Deland, FL
Injuries
4 fatal
Phase of flight
Approach
Aircraft
N3038NPiper PA-44-180N153ERPiper PA-28-161
Weather
Visual (VMC) · Day
Status
Completed · report May 16, 2001
Report
Approved by Office Director
Case key
47870

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 inadequate visual lookout by the pilot-in-command (PIC)/certified flight instructor (CFI) of both aircraft. Contributing factors in the accident were: 1) the frequency congestion of the CTAF 2) the poor in-flight planning decision by the PIC/CFI of the Seminole for his continuing a practice instrument approach to within approximately .6 nautical mile from the approach end of the runway with opposing airplanes departing on the upwind leg, and 3) the absence of guidance in the Aeronautical Information Manual and Advisory Circulars as to how or when to terminate a practice instrument approach to an airport that does not have an operating control tower.

The inadequate visual lookout by the pilot-in-command (PIC)/certified flight instructor (CFI) of both aircraft. Contributing factors in the accident were: 1) the frequency congestion of the CTAF 2) the poor in-flight planning decision by the PIC/CFI of the Seminole for his continuing a practice instrument approach to within approximately .6 nautical mile from the approach end of the runway with opposing airplanes departing on the upwind leg, and 3) the absence of guidance in the Aeronautical Information Manual and Advisory Circulars as to how or when to terminate a practice instrument approach to an airport that does not have an operating control tower.

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 collisionApproach - faf/outer marker to threshold (ifr)
Airport facilities,unicom - congestedFactor
In-flight planning/decision - poorPilot in command(cfi)Factor
Information unavailableFaa(other/organization)Factor
Visual lookout - inadequatePilot in command(cfi)Cause
Visual lookout - inadequatePilot of other aircraftCause
Midair collisionTakeoff - initial climb
Airport facilities,unicom - congestedFactor
Visual lookout - inadequatePilot in command(cfi)Cause
Visual lookout - inadequatePilot of other aircraftCause
In-flight planning/decision - poorPilot of other aircraftFactor
Information unavailableFaa(other/organization)Factor

Analysis

After the Cadet airplane departed, the flight proceeded to the DeLand airport and remained in the traffic pattern for runway 05; individuals heard announcements while in the pattern. After the Seminole airplane departed, requests to perform instrument approaches to the DeLand airport were denied; the controller responded to the request, '...delands saturated right now unable any approaches at deland....' The flight was vectored then cleared for a VOR approach to a runway 16 at Daytona Beach then vectored and cleared for a VOR approach to runway 23 at the DeLand airport. While inside the final approach fix inbound, radar service of the Seminole flight was terminated. Two individuals heard a voice announce on the DeLand CTAF, 'VOR 23.' The witnesses did not hear the distance, intentions, airport ID, or aircraft ID. The Seminole flight continued on the VOR approach; the last radar target of the Seminole was approximately .6 nautical mile from the approach end of runway 23. Several individuals heard the Cadet flight announce on the DeLand CTAF that the flight was departing runway 05. One witness reported that the Cadet used almost the full length of the runway, became airborne, then banked to the left and disappeared behind trees. The airplanes collided in-flight near the departure end of runway 05; the wreckage of both airplanes came to rest within approximately 1/2 nautical mile from the departure end of runway 05. An impact signature from one of the propeller blades from the left engine of the Seminole was noted on top of the engine of the Cadet; the impact signature was within approximately 25 degrees from being perpendicular. Several individuals reported frequency congestion of the DeLand CTAF from other airports that utilize the same frequency. Prior to the accident, ERAU personnel had informally inquired about having the frequency changed due to that very reason; the frequency was not changed before the accident. Advisory circulars and the AIM does not address when to terminate a practice instrument approach to an uncontrolled airport.

After the Seminole airplane departed, requests to perform instrument approaches to the DeLand airport were denied; the controller responded to the request, '...delands saturated right now unable any approaches at deland....' The flight was vectored then cleared for a VOR approach to a runway 16 at Daytona Beach then vectored and cleared for a VOR approach to runway 23 at the DeLand airport. After the Cadet airplane departed, the flight proceeded to the DeLand airport and remained in the traffic pattern for runway 05; individuals heard the flight announce while in the traffic pattern. While inside the final approach fix inbound, radar service of the Seminole flight was terminated. Two individuals heard a voice announce on the DeLand CTAF, 'VOR 23.' The witnesses did not hear the distance, intentions, airport ID, or aircraft ID. The Seminole flight continued on the VOR approach; the last radar target of the Seminole was approximately .6 nautical mile from the approach end of runway 23. Several individuals heard the Cadet flight announce on the DeLand CTAF that the flight was departing runway 05. One witness reported that the Cadet used almost the full length of the runway, became airborne, then banked to the left and disappeared behind trees. The airplanes collided in-flight near the departure end of runway 05; the wreckage of both airplanes came to rest within approximately 1/2 nautical mile from the departure end of runway 05. An impact signature from one of the propeller blades from the left engine of the Seminole was noted on top of the engine of the Cadet; the impact signature was within approximately 25 degrees from being perpendicular. Several individuals reported frequency congestion of the DeLand CTAF from other airports that utilize the same frequency. Prior to the accident, ERAU personnel had informally inquired about having the frequency changed due to that very reason; the frequency was not changed before the accident. Advisory circulars and the AIM does not address when to terminate a practice instrument approach to an uncontrolled airport.

Factual narrative

Same as narrative MIA00FA041A.

History of flight

On December 3, 1999, about 1023 eastern standard time, a Piper PA-44-180 (Seminole) airplane, N3038N, registered to and operated by Phoenix East Aviation, Inc., and a Piper PA-28-161 (Cadet) airplane, N153ER, registered to and operated by Embry-Riddle Aeronautical University, collided in-flight near the departure end of runway 5 at the DeLand Municipal-Sidney H Taylor Field Airport, DeLand, Florida. Visual meteorological conditions prevailed at the time and a local instrument flight rules (IFR) flight plan was filed for the 14 CFR Part 91 instructional flight of the Seminole airplane. No flight plan was filed for the 14 CFR Part 91 instructional flight of the Cadet airplane; none was required. Both airplanes were destroyed and the certified flight instructor (CFI) and commercial pilot-rated student of the Seminole airplane were fatally injured. The CFI and private pilot-rated student of the Cadet airplane also were fatally injured. The Seminole flight originated about 0939 from the Daytona Beach International Airport, Daytona Beach, Florida. The Cadet flight originated about 0921, also from the Daytona Beach International Airport, Daytona Beach, Florida.

According to a transcription of communications from Daytona Beach Air Traffic Control Tower (DAB ATCT), a flightcrew member in the Cadet contacted clearance delivery and requested a visual flight rules (VFR) clearance to Leesburg. The flight was cleared to taxi to runway 7R at 0911:48, and was cleared for takeoff at 0920:52. After takeoff, air traffic control (ATC) communications were transferred to Daytona Beach departure control then to the Daytona Beach South-Arrival Radar position. The flight remained in contact with that facility from 0924:45, to 0934:11, when the controller advised the flight to proceed on course, squawk the VFR transponder code, and provided the frequency of the next ATC facility. That transmission was acknowledged; there were no further recorded transmissions from the flightcrew with the DAB ATCT.

The transcription of communications from DAB ATCT indicates that a flightcrew member in the Seminole airplane contacted clearance delivery and requested, "a local IFR clearance ah we would like to shoot ah VOR 23 approach deland to be followed by ndb approach runway thirty deland and uh then we'll break off and come back for an ILS later." The controller cleared the flight to the DeLand airport via radar vectors; the clearance was read back by a flightcrew member. The flight was cleared to taxi to runway 7L at 0918:50, and was cleared for takeoff at 0938:48. After takeoff, ATC communications were transferred to the Daytona Beach North-Arrival Radar position. While in contact with that facility, at 0942:10, a flightcrew member asked the controller, "ah three zero three eight november is it possible we can have the full approach sir uh to fly over the vor", to which the controller responded, "...unable vor uh vor deland approach." A flightcrew member advised the controller "three eight November a mile north of Ormond is fine sir." The controller responded, "...not for you sir unable vor two three approaches fly tower assigned heading now." The controller advised the flight the heading to fly, and "...unable vor two three at deland." A flightcrew member responded that they would like to perform if possible a non directional beacon (NDB) instrument approach to runway 30 at DeLand. The controller advised, "okay three eight november delands saturated right now unable any approaches at deland let me rephrase that unable any approaches at deland." A flightcrew member responded that they would like to execute a very high frequency omni-directional range station (VOR) approach to runway 16, and a NDB approach to a runway at the New Smyrna Beach Municipal Airport. A flightcrew member questioned whether they could execute the full VOR approach. The flight was vectored then cleared for the VOR approach to runway 16 at the Daytona Beach International Airport, and told to expect to break off the approach four miles north of Daytona. At 0959:28, the controller questioned the flight if they wanted to execute an instrument landing system (ILS) approach after the VOR approach, and also if they had another request. A flightcrew member responded with the registration number of the airplane and the controller stated, "...after this I ah vor 16 would you like an approach at deland now" to which a flightcrew member responded, "ah yes we'll take the deland after this one sir." The controller questioned what kind of approach they would like to execute at DeLand and a flightcrew member responded, "we'd like ah the vor two three if possible." The controller advised the flight to expect that and a flightcrew member questioned if they would be able to execute the full approach to which controller advised the flight to stand by. The controller advised the flight to expect the full approach and the VOR approach would be broken off in about another 1 1/2 miles. At 1001:23, the controller canceled the approach clearance and gave heading and altitude to fly, which was acknowledged. At 1003:53, the controller who was handling the Seminole flight briefed the relieving controller. The handling controller advised the relieving controller in part that the flightcrew was expecting the full VOR approach to runway 23.

At 1006:07, the relieving controller advised the Seminole flight to proceed direct to the Ormond Beach VORTAC and to join the 212-degree radial. A flightcrew member advised the controller that the flight was "proceeding for establishment..." and descending to 1,600 feet. The controller cleared the flight to descend to 1,600 feet and advised the flight to change to another frequency. At 1012:06, a flightcrew member advised the controller on the new frequency that the flight was descending to 1,600 feet. At 1012:30, the controller cleared the flight for the VOR approach to runway 23 at the DeLand Municipal Airport. At 1015:11, the controller advised the flight to use caution due to constant parachute jumping in progress. A flightcrew member responded "...roger", and at 1017:32, the controller questioned if the flight was going to perform a full stop landing to which a flightcrew member responded, "negative sir we uh we gonna breakoff and do some airwork and then come back with an ils full stop we'll advise you." The controller advised the flight to report canceling on the frequency, which was acknowledged. At 1018:02, a flightcrew member advised the controller that the flight was canceling at this time and the controller responded, "november three zero eight november radar service terminated squawk one two zero zero frequency change is approved." This transmission was acknowledged; there were no further recorded transmissions from the flightcrew with DAB ATCT.

Witnesses reported seeing the Cadet airplane in the traffic pattern to runway 5 at DeLand Municipal-Sidney H Taylor Field Airport (KDED) for two patterns; they also reported hearing radio calls from a flightcrew member of the airplane while in the traffic pattern on the KDED common traffic advisory frequency/UNICOM (CTAF). Two individuals who were flying reported hearing a radio call from a flightcrew member of an unidentified airplane report, "VOR 23" on the KDED CTAF frequency; one individual reported he did not recall hearing the identification of the airplane, or hear the person announce the distance or intentions. Several individuals reported hearing a flightcrew member of the Cadet airplane report on the KDED CTAF frequency that the flight was departing runway 5. One witness reported that the Cadet airplane used almost the full length of the runway, became airborne, then banked to the left and disappeared behind trees. A witness who was located near the accident site, reported seeing an airplane flying north and another airplane flying west. She reported seeing the col

Aircraft · 2

Registration
N3038N
Reported as
Piper PA-44-180
Category
Airplane
Serial number
44-7995229
Airframe hours
13,979
Engine
Lycoming O-360-E1A6D, 180 horsepower, reciprocating
Damage
Destroyed
Flight
Instructional · Part 91
Registered owner
Phoenix East Aviation
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · November 23, 1999 · 44 hours before
Departed
DAB · Daytona Beach, FL
Flight plan
IFR
Airport
DED · Deland Municipal-Sidney H

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
N153ER
Reported as
Piper PA-28-161
Category
Airplane
Serial number
2841178
Airframe hours
10,411
Engine
Lycoming O-320-D3G, 160 horsepower, reciprocating
Damage
Destroyed
Flight
Instructional · Part 91
Registered owner
Embry-Riddle Aeronautical Univ
Airworthiness certificate
Standard, Normal
Last inspection
Continuous airworthiness · September 17, 1999 · 61 hours before
Departed
DAB · Daytona Beach, FL
Airport
DED · Deland Municipal-Sidney H, runway 5, 4,379 × 75 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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot, aircraft N3038N
Age
51
Certificates
Flight instructor, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Seat
Right
Toxicology
Performed
Flight hours
7,357 total · 6,399 as pilot in command
Role
Pilot, aircraft N153ER
Age
22
Certificates
Flight instructor, Commercial
Airplane ratings
Single-engine sea, Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Right
Toxicology
Performed
Flight hours
827 total · 781 as pilot in command

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
4,800 ft broken
Temperature
64 °F, dew point 52 °F
Altimeter
30.00 inHg
Observed at
DAB, 14 nm away

Docket · 67

The files NTSB released with the investigation on April 27, 2001, on NTSB’s docket system: statements, records, photos and specialists’ reports. 22.0 MB in all.

Supplement A-N3038NItem 1 · .PDF · 268 KBSupplement B-N3038NItem 2 · .PDF · 466 KBSupplement E-N3038NItem 3 · .PDF · 123 KBWitness StatementsItem 4 · .PDF · 1.3 MBTranscript of Radio CommunicationsItem 5 · .PDF · 849 KBReports from Federal AgenciesItem 6 · .PDF · 173 KBReports from Local AgenciesItem 7 · .PDF · 600 KBReports from Parties to the Investigation-Lycoming (N3038N)Item 8 · .PDF · 240 KBOther Pertinent Forms and Reports-Personnel StatementsItem 9 · .PDF · 1.1 MBStatement of Party Representatives to NTSB InvestigationItem 10 · .PDF · 230 KBRelease of Aircraft Wreckage, NTSB Form 6120.15 - N3038NItem 11 · .PDF · 98 KBToxicological Report - N3038NItem 12 · .PDF · 116 KBRecorded Radar StudyItem 13 · .PDF · 3.2 MBPhoto 1: View of the accident site of N153ERItem 14 · .PDF · 181 KBPhoto 2: View of the accident site of N3038N. No negativeItem 15 · .PDF · 98 KBPhoto 3: View of the separated left engine with attached propeller hub and 1 propeller blade from N3038NItem 16 · .PDF · 202 KBPhoto 4: Aerial photograph. Arrow labeled "1" points to the location of the wreckage of N3038N. Note the approach end of runway 23. No negativeItem 17 · .PDF · 101 KBPhoto 5: View of the Cadet with a section of the left wing and left engine from the Seminole visible.Item 18 · .PDF · 172 KBPhoto 6: View of the Cadet with a section of the left wing and engine of the Seminole visible.Item 19 · .PDF · 128 KBPhoto 7: View of the Cadet with a section of the Seminole in the backgroundItem 20 · .PDF · 157 KBPhoto 8: View of the SeminoleItem 21 · .PDF · 151 KBPhoto 9: View of the SeminoleItem 22 · .PDF · 121 KBPhoto 10: View of the fractured propeller blade from the left propeller of the SeminoleItem 23 · .PDF · 211 KBPhoto 11: View of the left engine and fractured propeller blade of the Seminole matching impact signatures on the top of the engine of the CadetItem 24 · .PDF · 185 KBPhoto 12: Closer view matching the impact signatures of the leading edge of the fractured propeller blade from the left propeller of the Seminole to the top of the engine from the CadetItem 25 · .PDF · 124 KBPhoto 13: Closer view matching the impact signatures of the leading edge of the propeller blade from the left propeller of the Seminole to the top of the engine from the CadetItem 26 · .PDF · 118 KBSupplement A-N153ERItem 27 · .PDF · 239 KBSupplement B-N153ERItem 28 · .PDF · 402 KBSupplement E-N153ERItem 29 · .PDF · 122 KBPilot/Operator Aircraft Accident Report, NTSB Form 6120.1 - N3038NItem 30 · .PDF · 457 KBPilot/Operator Aircraft Accident Report, NTSB Form 6120.1 - N153ERItem 31 · .PDF · 442 KBReports from Parties to the Investigation-Lycoming (N153ER)Item 32 · .PDF · 177 KBReports from Parties to the Investigation-Embry-Riddle Aeronautical UniversityItem 33 · .PDF · 60 KBReports from Parties to the Investigation-Meggit/S-TecItem 34 · .PDF · 68 KBReports from Parties to the Investigation-Piper (Wreckage Distribution List).Item 35 · .PDF · 158 KBOther Pertinent Forms and Reports-Flight Progress Strip (N153ER)Item 36 · .PDF · 15 KBOther Pertinent Forms and Reports-Flight Progress Strip (N3038N).Item 37 · .PDF · 22 KBOther Pertinent Forms and Reports-Dispatch Flight Plan (N3038N)Item 38 · .PDF · 39 KBOther Pertinent Forms and Reports-Memo from Grant Brophy, Embry-Riddle Aeronautical UniversityItem 39 · .PDF · 150 KBOther Pertinent Forms and Reports-Excerpts from the maintenance log and VOR accuracy sheet (N3038N)Item 40 · .PDF · 237 KBOther Pertinent Forms and Reports-Excerpt from the Aeronautical Information ManualItem 41 · .PDF · 437 KBOther Pertinent Forms and Reports-Advisory Circular 90-42FItem 42 · .PDF · 750 KBOther Pertinent Forms and Reports-Advisory Circular 90-48CItem 43 · .PDF · 793 KBOther Pertinent Forms and Reports-Advisory Circular 90-66AItem 44 · .PDF · 933 KBOther Pertinent Forms and Reports-Information to student (N153ER)Item 45 · .PDF · 202 KBOther Pertinent Forms and Reports-Application for renewal of private radio station licenseItem 46 · .PDF · 96 KBOther Pertinent Forms and Reports-Statement from Floyd W. HouserItem 47 · .PDF · 46 KBOther Pertinent Forms and Reports-Statement from Ghassan M. ReslanItem 48 · .PDF · 38 KBOther Pertinent Forms and Reports-Aircraft Flight Record (N153ER)Item 49 · .PDF · 144 KBOther Pertinent Forms and Reports-Instrument Approach ChartItem 50 · .PDF · 190 KBRelease of Aircraft Wreckage, NTSB Form 6120.15-N153ERItem 51 · .PDF · 102 KBToxicological Report-N153ERItem 52 · .PDF · 129 KBRecorded Radar Study (Revision #1)Item 53 · .PDF · 359 KBRecorded Radar Study (Revision #1) Table 1 - Converted Data (BCN 0112, N153ER)Item 54 · .PDF · 1.3 MBRecorded Radar Study (Revision #1) Table 2 - Converted Data (BCN 0257, N3038N)Item 55 · .PDF · 1.2 MBRecorded Radar Study (Revision #1) Table 3 - Range and Azimuth Data (BCN 0112, N153ER)Item 56 · .PDF · 543 KBRecorded Radar Study (Revision #1) Table 4 - Range and Azimuth Data (BCN 0257, N3038N)Item 57 · .PDF · 528 KBRecorded Radar Study (Revision #1) Table 5 - Last three radar returnsItem 58 · .PDF · 29 KBRecorded Radar Study (Revision #1) Figure 1 (A-D) - Ground Track Plot of N3038NItem 59 · .PDF · 284 KBRecorded Radar Study (Revision #1) Figure 2 - Ground Track Plot of N153ERItem 60 · .PDF · 75 KB
All 67 files on NTSB’s docket

FAA reports on this event · 2

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