MIA95FA224

NTSB accident investigation · Aerospatiale TB-9 · New Smyrna Bch, FL · September 15, 1995

Accident · FatalField investigationFinal report
Date
September 15, 1995, 16:44 local (20:44 UTC)
Place
New Smyrna Bch, FL
Injuries
3 fatal, 1 uninjured
Phase of flight
Approach
Aircraft
N117ERAerospatiale TB-9N2351APiper PA-38-112
Weather
Visual (VMC) · Day
Status
Completed · report May 29, 1996
Report
Approved by Office Director
Case key
37665

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

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Probable cause

the failure of the pilots of both aircraft to see and avoid each other.

the failure of the pilots of both aircraft to see and avoid each other.

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 - vfr pattern - final approach
Visual lookout - inadequateFlight instructor(on ground)Cause
Visual lookout - inadequatePilot of other aircraftCause
In flight collision with terrain/waterDescent - uncontrolled
Midair collisionApproach - vfr pattern - final approach
Visual lookout - inadequatePilot of other aircraftCause
Visual lookout - inadequatePilot in commandCause
Miscellaneous/otherLanding - flare/touchdown

Analysis

The Aerospatiale TB-9, N117ER, was observed on short final approach, and the Piper PA-38, N2351A, had turned from base to final just above and behind the TB-9. Two pilots on the ground transmitted warnings to the aircraft but no action was taken. The aircraft collided; the TB-9 sustained stabilator damage and nosed down and crashed. The Piper landed without further incident. Pilots on the ground reported seeing the Piper performing takeoffs and landings, and heard the pilot making position reports. The pilots only observed the TB-9 while on short final approach, and did not recall hearing any position reports from the pilots. They stated there were many aircraft with similar call signs and they might have missed the calls. The operator of the TB-9 teaches their pilots to fly a 1.6 nm final approach at a 3 degree descent angle while making visual approaches. Other pilots stated that this practice conflicts with pilots who fly normal close in approaches with a 3/4 to 1 nm final approach leg. The aircraft flying the long final are at a lower altitude where a pilot making a normal visual approach would not expect to see conflicting traffic.

The Aerospatiale TB-9, N117ER, was observed on short final approach, and the Piper PA-38, N2351A, had turned from base to final just above and behind the TB-9. Two pilots on the ground transmitted warnings to the aircraft but no action was taken. The aircraft collided; the TB-9 sustained stabilator damage and nosed down and crashed. The Piper landed without further incident. Pilots on the ground reported seeing the Piper performing takeoffs and landings, and heard the pilot making position reports. The pilots only observed the TB-9 while on short final approach, and did not recall hearing any position reports from the pilots. They stated there were many aircraft with similar call signs and they might have missed the calls. The operator of the TB-9 teaches their pilots to fly a 1.6 nm final approach at a 3 degree descent angle while making visual approaches. Other pilots stated that this practice conflicts with pilots who fly normal close in approaches with a 3/4 to 1 nm final approach leg. The aircraft flying the long final are at a lower altitude where a pilot making a normal visual approach would not expect to see conflicting traffic.

Factual narrative

Same as narrative for MIA95FA224A.

History of flight

On September 15, 1995, about 1644 eastern daylight time, an Aerospatiale TB-9, N117ER, operated by Embry-Riddle Aeronautical University (Embry-Riddle) and a Piper PA-38-112, N2351A, operated by Spruce Creek Aviation, collided while on final approach to runway 11 at New Smyrna Beach Municipal Airport, New Smyrna Beach Florida. Both flights were 14 CFR Part 91 instructional flights. Visual meteorological conditions prevailed at the time and neither flight had filed a flight plan. N117ER was destroyed and the commercial-rated flight instructor and two student pilots were fatally injured. N2351A received minor damage and the private-rated pilot was not injured. N117ER originated from Daytona Beach Regional Airport, on September 15, 1995, about 1540. N2351A originated from Spruce Creek Airport, Daytona Beach, Florida, on September 15, 1995, about 1610.

The pilot of N2351A stated he had performed four previous landings on runway 11 at New Smyrna Beach and was on his fifth approach. He reported his position by transmitting on the airport unicom frequency (unicom) while on the downwind leg. He turned base leg, reported his position on unicom, and visually checked for other aircraft on final. He did not hear transmissions from any other pilots who were on final approach or see any other aircraft on final approach. He turned to final and established his airspeed at 70 knots. While on short final he heard someone on unicom say "two planes on final, Tomahawk go around Tomahawk go around." At the same time he heard a noise and felt a bump from the bottom of his aircraft and then saw N117ER nosing down in front of him. His propeller contacted something and his engine began running rough. He proceeded to land on the runway and then turned off onto the taxiway where he stopped.

Witnesses reported that N2351A had been in the traffic pattern for runway 11 for several approaches and landings. The pilot was flying a close pattern to the runway and they heard the pilot reporting his position on unicom for each approach. No witness could remember hearing the pilots of N117ER reporting their position on unicom or seeing the aircraft before it was on short final approach. Witnesses stated there were many aircraft with the "echo romeo" call sign on unicom and they just might not have heard the pilots of N117ER reporting their position.

Witnesses saw N117ER on short final approach, and N2351A rolling wings level onto final approach about 30 feet above and just behind N117ER. The pilot in an aircraft on the ground called on unicom that there were two airplanes close together on final. There was no reaction from either aircraft. Another pilot in an aircraft on the ground then called for N2351A to go around. Shortly after this, when the aircraft were about 100 feet above the ground, N117ER was observed to pitch up 10-20 degrees and then immediately nose down to a near vertical descent from which it impacted on the displaced threshold of runway 11. N2351A continued the approach and landed on runway 11.

Personnel information

The flight instructor on N117ER had been employed by Embry-Riddle since August 18, 1995. The dual student and observer he was instructing were enrolled in the private pilot flight course and at the time of accident neither had performed solo flight.

The pilot of N2351A held a U.S. private pilot certificate issued on the basis of a Swiss private pilot certificate. He was in the U.S. to build his flight time and obtain flight training so that upon returning to Switzerland he could obtain his commercial pilot certificate.

Additional information on the pilots of N117ER and the pilot of N2351A is contained in this report under First Pilot Information and in Supplement E.

Aircraft information

Information on N117ER and N2351A is contained in this report under Aircraft Information.

Meteorological information

Visual meteorological conditions prevailed at the time of the accident. See Weather Information.

Wreckage and impact information

N117ER and N2351A collided over the displaced threshold of runway 11 at the New Smyrna Beach Airport. Debris from the vertical stabilizer, rudder, and right stabilator of N117ER and about a 3 inch portion of propeller tip from N2351A were found in the displaced threshold area. After the collision N117ER pitched down and impacted nose first on the displaced threshold, about 300 feet past the point of collision. A post crash fire erupted. N2351A continued and landed.

Post crash examination of N117ER showed that the aircraft impacted at about a 70-80 degree nose down attitude. The post crash fire consumed the fuselage, inboard wings, and tail sections of the aircraft. The outboard portion of the right stabilator had separated from the aircraft and was found forward or southeast of the aircraft wreckage, outside of the fire area. Examination of this portion of right stabilator showed damage and transfer of black paint consistent with it having been contacted by the propeller of N2351A. The propeller of N117ER had damage consistent with it rotating at the time of impact. The engine assembly rotated after the accident. All engine accessories were consumed or damaged by the post crash fire.

Examination of N2351A showed that the 3 inch piece of propeller tip found in the area of the collision had come from its propeller. Small pieces of sheet metal debris with white and blue paint similar to the colors of N117ER were found in the propeller spinner of N2351A. Blue scrape marks similar to the color of N117ER were found on the belly of N2351A, just aft of the engine.

Medical and pathological information

Post mortem examination of the three occupants of N117ER was performed by Dr. Ronald L. Reeves, Medical Examiner, Volusia County, Florida. The cause of death for each occupant was attributed to multiple blunt force trauma.

Post mortem toxicology studies on specimens obtained from the three occupants of N117ER was performed by the Volusia County Medical Examiners Office. The specimens obtained from the pilot-in-command were negative for ethanol alcohol, basic, acidic, and neutral drugs. The tests were positive for nicotine, caffeine, and 2% carbon monoxide. The tests on specimens obtained from the dual student were negative for ethanol alcohol, basic, acidic, and neutral drugs. The tests were positive for 1% carbon monoxide. See Supplement K and toxicology reports.

Toxicology tests on specimens obtained from the pilot of N2351A were performed by the Florida Department of Law Enforcement Laboratory, Orlando, Florida. The tests were negative for ethanol alcohol, basic, acidic, and neutral drugs.

Tests and research

An Embry-Riddle flight instructor stated after the accident that they were directed by their Chief Flight Instructor to teach the students to fly a long final approach with a shallow descent angle, similar to an instrument approach. The procedure requires that they extend the downwind leg of a visual approach to 1.6 nm past the end of the runway before turning base leg and final. The aircraft is then placed on the final approach 1.6 nm from the runway at 500 feet agl. This will then require about a 3 degree descent angle to the runway. In the TB-9 this would be flown at an airspeed of 67 knots. See attached diagram and information from the Chief Flight Instructor.

Flight instructors from flight schools at the New Smyrna Beach Airport and the Ormond Beach Airport, where Embry-Riddle aircraft practice takeoff and landings, stated after the accident that the long final approach with a shallow descent angle flown by the Embry-Riddle aircraft conflicts with other aircraft operating at the airports. They stated that they teach their students to fly a downwind leg 3/4 nm from the runway. When they are at a 45 degree angle to the runway approach end they turn on base leg and then

Aircraft · 2

Registration
N117ER
Reported as
Aerospatiale TB-9
Category
Airplane
Serial number
1509
Airframe hours
2,429
Engine
Lycoming O-320-D2A, 160 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Instructional · Part 91
Registered owner
Embry-Riddle Aeronautical Unv.
Airworthiness certificate
Standard, Utility; Standard, Normal
Last inspection
Annual · August 8, 1995 · 79 hours before
Departed
DAB · Daytona Beach, FL
Airport
34J · New Smyrna Beach Muni, runway 11, 4,300 × 100 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.

Registration
N2351A
Reported as
Piper PA-38-112
Category
Airplane
Serial number
38-78A0649
Airframe hours
2,575
Engine
Lycoming O-235-L2C, 112 horsepower, reciprocating
Damage
Minor damage
Flight
Instructional · Part 91
Registered owner
Spruce Creek Aviation, Inc.
Airworthiness certificate
Standard, Normal; Standard, Utility
Last inspection
Annual · September 11, 1995 · 14 hours before
Departed
34J
Airport
34J · New Smyrna Beach Muni, runway 11, 4,300 × 100 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 N117ER
Age
26
Certificates
Flight instructor, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Right
Toxicology
Performed
Flight hours
668 total · 566 as pilot in command · 59 in the last 30 days
Role
Pilot, aircraft N2351A
Age
22
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
79 total · 13 in this make and model · 20 as pilot in command · 20 in the last 90 days · 19 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
100° at 9 knots
Visibility
10 statute miles
Lowest ceiling
10,000 ft broken
Temperature
84 °F, dew point 73 °F
Altimeter
30.00 inHg
Observed at
DAB, 10 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.