# NTSB NYC08LA207: Beech A36, N27199, Pawtucket, RI, June 6, 2008

- Type: NTSB accident investigation
- Classification: Accident · Minor injuries · Limited investigation · Final report
- Date: June 6, 2008, 17:45 local (21:45 UTC)
- Place: Pawtucket, RI
- Coordinates: 41.92139, -71.495834
- Nearby events: https://openairdocs.org/map.md?lat=41.9214&lon=-71.4958&mi=10
- Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping)
- Defining events: [Takeoff: Ground collision](https://openairdocs.org/ntsb-events/200); [Landing-landing roll: Ground collision](https://openairdocs.org/ntsb-events/200)
- Highest injury: Minor injuries
- Injuries: 1 minor, 2 uninjured
- Status: Completed, report March 3, 2010
- Report: Approved by Office Director
- Parties: FAA/FSDO
- NTSB case key (mKey): 68183
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC08LA207
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/68183/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=68183
- Page: https://openairdocs.org/ntsb/NYC08LA207

## Probable cause (aircraft 2)

Both pilots' failure to see and avoid the other airplane. Contributing to the accident was the air traffic controllers failure to notify either pilot of the potential conflict.

## Findings

NTSB's coded findings; those marked are part of the probable cause.

- [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · ATC personnel (probable cause), aircraft 1; cases with it: [Beech A36, 8 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md?model=1151604), [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md)
- [Attention/monitoring: monitoring other aircraft](https://openairdocs.org/ntsb-findings/02021540): Personnel issues › Psychological · Pilot (probable cause), aircraft 1; cases with it: [Beech A36, 4 cases](https://openairdocs.org/ntsb-findings/02021540/cases.md?model=1151604), [All aircraft, 231 cases](https://openairdocs.org/ntsb-findings/02021540/cases.md)
- [Attention/monitoring: monitoring other aircraft](https://openairdocs.org/ntsb-findings/02021540): Personnel issues › Psychological · Pilot of other aircraft (probable cause), aircraft 1; cases with it: [Beech A36, 4 cases](https://openairdocs.org/ntsb-findings/02021540/cases.md?model=1151604), [All aircraft, 231 cases](https://openairdocs.org/ntsb-findings/02021540/cases.md)
- [Communication (personnel): lack of communication](https://openairdocs.org/ntsb-findings/02063510): Personnel issues › Task performance · ATC personnel (probable cause), aircraft 1; cases with it: [Beech A36, 3 cases](https://openairdocs.org/ntsb-findings/02063510/cases.md?model=1151604), [All aircraft, 84 cases](https://openairdocs.org/ntsb-findings/02063510/cases.md)
- [Ceiling/visibility/precip](https://openairdocs.org/ntsb-findings/03035000): Environmental issues › Conditions/weather/phenomena · Effect on operation, aircraft 1; cases with it: [Beech A36, 2 cases](https://openairdocs.org/ntsb-findings/03035000/cases.md?model=1151604), [All aircraft, 65 cases](https://openairdocs.org/ntsb-findings/03035000/cases.md)
- [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · ATC personnel (probable cause), aircraft 2; cases with it: [Piper PA-30, 4 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md?model=7103002), [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md)
- [Ceiling/visibility/precip](https://openairdocs.org/ntsb-findings/03035000): Environmental issues › Conditions/weather/phenomena · Effect on operation, aircraft 2; cases with it: [Piper PA-30, 2 cases](https://openairdocs.org/ntsb-findings/03035000/cases.md?model=7103002), [All aircraft, 65 cases](https://openairdocs.org/ntsb-findings/03035000/cases.md)
- [Attention/monitoring: monitoring other aircraft](https://openairdocs.org/ntsb-findings/02021540): Personnel issues › Psychological · Pilot (probable cause), aircraft 2; cases with it: [Piper PA-30, 1 case](https://openairdocs.org/ntsb-findings/02021540/cases.md?model=7103002), [All aircraft, 231 cases](https://openairdocs.org/ntsb-findings/02021540/cases.md)
- [Attention/monitoring: monitoring other aircraft](https://openairdocs.org/ntsb-findings/02021540): Personnel issues › Psychological · Pilot of other aircraft (probable cause), aircraft 2; cases with it: [Piper PA-30, 1 case](https://openairdocs.org/ntsb-findings/02021540/cases.md?model=7103002), [All aircraft, 231 cases](https://openairdocs.org/ntsb-findings/02021540/cases.md)
- [Communication (personnel): lack of communication](https://openairdocs.org/ntsb-findings/02063510): Personnel issues › Task performance · ATC personnel (probable cause), aircraft 2; cases with it: [Piper PA-30, 1 case](https://openairdocs.org/ntsb-findings/02063510/cases.md?model=7103002), [All aircraft, 84 cases](https://openairdocs.org/ntsb-findings/02063510/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Takeoff: Ground collision](https://openairdocs.org/ntsb-events/200) (defining event), aircraft 1; cases with it: [Beech A36, 3 cases](https://openairdocs.org/ntsb-events/200/sequence.md?model=1151604), [All aircraft, 618 cases](https://openairdocs.org/ntsb-events/200/sequence.md)
- [Takeoff: Runway excursion](https://openairdocs.org/ntsb-events/300), aircraft 1; cases with it: [Beech A36, 20 cases](https://openairdocs.org/ntsb-events/300/sequence.md?model=1151604), [All aircraft, 3,643 cases](https://openairdocs.org/ntsb-events/300/sequence.md)
- [Landing-landing roll: Ground collision](https://openairdocs.org/ntsb-events/200) (defining event), aircraft 2; cases with it: [Piper PA-30, 2 cases](https://openairdocs.org/ntsb-events/200/sequence.md?model=7103002), [All aircraft, 618 cases](https://openairdocs.org/ntsb-events/200/sequence.md)

## Analysis (aircraft 2)

A Piper PA-30 was on an instrument flight rules (IFR) flight plan in instrument meteorological conditions and was cleared for an instrument approach. As the Piper approached the missed approach point, the pilot visually acquired the airport, and notified the air traffic controller to cancel his IFR flight plan. According to the Piper pilot, after the controller acknowledged the cancellation request, the pilot retuned his radio to the Common Traffic Advisory Frequency (CTAF) and announced his intention for landing. Due to the wind direction, the Piper pilot elected to circle and land on Runway 15, which was in the opposite direction of his approach. The pilot of a Beech A36, who was ready to depart from Runway 5 of the same airport, and who was also on an IFR flight plan, requested permission to take off but was told to "hold for release" by the controller. However, the controller did not explicitly inform the Beech pilot of the reason for the delay. Less than a minute later, the controller released the Beech. The two airplanes collided near the intersection of the two runways. Both pilots reported that they were not aware of the other airplane until immediately prior to the collision. Several witnesses heard the Beech pilot announce his intentions multiple times, but did not hear the Piper pilot's transmissions. The investigation also revealed that the two controllers were both aware of the proximity of the two airplanes, but neither one communicated that information to either of the pilots. A review of the recorded communications also revealed that the approach controller had a brief personal conversation with another controller just prior to the accident. The lack of received position or intent transmissions from the Piper, and the controllers' failure to inform the pilots of the proximity of the two airplanes, deprived the pilots of information that was critical to the pilots' situational awareness, and which could have enabled one or both pilots to prevent this accident.

## Factual narrative (aircraft 2)

HISTORY OF FLIGHT

On June 6, 2008, about 1745 eastern daylight time, a Beech A36, N27199, and a Piper PA-30, N7660Y, were substantially damaged during a runway collision at North Central State Airport (SFZ), Pawtucket, Rhode Island. The certificated private pilot and passenger of the Beech were not injured, and the certificated commercial pilot of the Piper sustained minor injuries. Instrument meteorological conditions (IMC) prevailed at the time of the accident. The Beech was operating on an instrument flight rules (IFR) flight plan, and was departing SFZ for Morristown Municipal Airport (MMU), Morristown, New Jersey. The Piper was operating on an IFR flight plan from Nantucket Memorial Airport (ACK), Nantucket, Massachusetts, to SFZ.  Both personal flights were conducted under the provisions of 14 Code of Federal Regulations (CFR) Part 91.

According to Federal Aviation Administration (FAA) air traffic control (ATC) transcripts, at 1718:56 the Piper pilot initially checked in on the radio frequency for Providence (PVD) Approach, reported that he was at four thousand feet, and requested the global positioning system (GPS) "Alpha" approach to SFZ. About 11 minutes later, the Beech pilot initially contacted PVD clearance delivery, and PVD clearance delivery responded. The Beech pilot then requested and was given his clearance, and at 1732:59, PVD clearance delivery responded with "november one nine nine and uh acknowledge holding for release please." At 1733:03 the Beech pilot acknowledged "yes holding for release ma'am."

At 1735:44, PVD approach transmitted the Piper's approach clearance, which was acknowledged by the pilot. One minute later, PVD approach issued the following instruction "twin comanche six zero yankee report cancellation of ifr in the air on this frequency or on the ground on one two four point three five change to advisory frequency approved," and at 1736:55 the Piper pilot responded with "sixty yank thank you sir." At 1737:43 the Beech pilot transmitted the following to PVD clearance delivery: "providence uh bonanza two seven one nine nine now we're holding next runway five uh ready to go [just need a release]." At 1737:57, PVD clearance responded "calling clearance was that november two seven one nine nine," and the Beech pilot responded "uh yes ma'am we're holding at runway five for departure uh one nine nine." A few seconds later, clearance delivery told the Beech pilot "november one nine nine hold for release i'll get back to you in approximately five minutes," and the Beech pilot responded with "one nine nine." Clearance delivery at 1738:11 "november one nine nine verify holding for release please," And 3 seconds later the Beech pilot responded "we're holding for release ma'am on nine nine."

At 1741:49, the Piper pilot cancelled his IFR flight plan, and then followed with another transmission that he had the airport in sight. Nine seconds later, PVD approach responded with "understand uh cancelling ifr november six zero yankee roger and uh squawk vfr frequency change approved good night." Four seconds after that, the Piper pilot acknowledged the instruction, and that was the last recorded transmission from the Piper.

Approximately one minute after the Piper pilot cancelled his IFR flight plan radar clearance delivery released the Beech for departure, with a clearance void time of five minutes. After his departure clearance was received, the Beech pilot switched his radio to the common traffic advisory frequency (CTAF), and broadcast his position and intentions twice. These broadcasts were confirmed by several witnesses located near a communication radio in a building on the airport. The Beech pilot then began his takeoff roll. About the same time, but unbeknownst to the Beech pilot, the Piper landed on runway 15.

According to the Piper pilot, as he approached the intersection of runway 5/23, at a speed of approximately 40 knots, he heard a noise outside the airplane, and saw the Beech on its takeoff roll on runway 5. According to the Beech pilot, as the airplane approached its rotation speed of 75 knots, the pilot and passenger saw the Piper approaching them from their left. The Beech pilot pulled back on the yoke in an attempt to fly over the Piper, but the airplanes collided with one another.

After the collision, which occurred when the Beech was airborne about 6 feet above the ground, the airplane descended back to the ground, veered off the runway, and came to a stop in the grass off the side of the runway. The Piper came to rest facing the opposite direction of travel, approximately 200 feet south of the runway 5 centerline, and approximately 20 feet off the pavement of runway 15.

Both pilots reported that neither one of them was aware that another airplane was operating at the airport until seconds prior to the collision.

PERSONNEL INFORMATION

Beech Pilot

The pilot, age 54, held a private pilot certificate, with ratings for airplane single-engine land and instrument airplane. His most recent FAA third-class medical certificate was issued on December 13, 2007. At the time of the accident, the pilot reported a total flight experience of 1,640 hours, including 1,000 hours as pilot in command in the accident airplane make and model, and 450 hours in instrument meteorological conditions. In the 90 days preceding the accident, the pilot logged 11 total hours of flight experience, and 3 hours of flight experience in IMC.

Piper Pilot

The pilot, age 45, held a commercial pilot certificate, with ratings for airplane single-engine land and instrument airplane, and private pilot privileges for airplane multi-engine land. At the time of the accident, the pilot reported a total flight experience of 3,215 hours, including 2,000 hours as pilot in command in the accident airplane make and model, and 418 hours of flight time in instrument meteorological conditions. In the 90 days preceding the accident, the pilot logged 62 total hours of flight experience and 7 hours of flight experience in IMC.

AIRCRAFT INFORMATION

Beech N27199

The Beech was a six seat, low wing, retractable-gear airplane, and was manufactured in 1986. It was powered by a Teledyne Continental Motors IO-550-B, 310-horsepower engine, and equipped with a McCauley controllable-pitch propeller. The airplane's most recent annual inspection was completed on October 2, 2007, and at the time of the accident the airplane had accumulated 2,662 total hours. The airplane was not equipped with a traffic alerting system.

Piper N7660Y

The Piper Comanche was a four seat, low wing, retractable-gear airplane, and was manufactured in 1965. It was powered by two Lycoming IO-320-B1A, 160-horsepower engines, equipped with Hartzell controllable pitch propellers. The most recent annual inspection was completed on April 1, 2008 and the airplane had accumulated 5,278.4 hours of total flight time at the time of inspection. The airplane was equipped with a Garmin GPS430W system which was installed in the airplane May 18, 2007. The airplane was not equipped with a traffic alerting system.

METEROLOGICAL INFORMATION

The 1735 recorded weather at SFZ reported calm winds, visibility 10 miles, an overcast cloud layer 600 feet above ground level (agl), temperature 14 degrees C, dew point 11 degrees C, and an altimeter setting of 30.13 inches of mercury.

A review of recorded weather observation at airports within a 30 mile radius of SFZ around the time of the accident showed the winds were out of the south and southwest and varied between 6 and 10 knots, and an overcast ceiling of between 500 and 900 feet agl.

AIDS TO NAVIAGATION

The published instrument approach procedure (IAP) for the very high omni-direction range (VOR)/GPS A approach to SFZ indicated that the minimum altitude at the final approach fix (FAF) was 1,900 feet mean sea level (msl), and the minimum descent altitude (MDA) for the approach was 980 feet msl, or 539 feet

## Aircraft 1

- Registration: [N27199](https://openairdocs.org/deregistered/N27199-2013-04-01), registration cancelled 2013-04-01, S/N E-2321, built 1986 (OpenAirDocs)
- Reported make and model: BEECH A36
- Registry model: [Beech A36](https://openairdocs.org/model/beech-a36) (registry code 1151604) (OpenAirDocs)
- Registry engine: [Amateur-built UNKNOWN ENG](https://openairdocs.org/engine/amateur-built-unknown-eng) (registry code 99999) (OpenAirDocs)
- Category: Airplane
- Serial number: E-2321
- Airframe hours: 2662
- Engines: Teledyne Continental IO-550-8 310 horsepower reciprocating
- Damage: Substantial damage
- Flight: Personal, Part 91
- Airworthiness certificate: Standard, Normal
- Last inspection: Annual, October 1, 2007
- Departed: SFZ, Pawtucket, NJ
- Destination: MMU, Morristown, NJ
- Flight plan: IFR
- Airport: SFZ, North Central Airport, runway 05, 5,000 × 100 ft, asphalt

## Aircraft 2

- Registration: [N7660Y](https://openairdocs.org/deregistered/N7660Y-2010-08-06), registration cancelled 2010-08-06, S/N 30-738, built 1965 (OpenAirDocs)
- Reported make and model: PIPER PA-30
- Registry model: [Piper PA-30](https://openairdocs.org/model/piper-pa-30) (registry code 7103002) (OpenAirDocs)
- Registry engine: [Lycoming IO-320 series](https://openairdocs.org/engine/lycoming-io-320-series) (registry code 41509, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: 30-738
- Airframe hours: 5278
- Engines: Lycoming IO320B1A 160 horsepower reciprocating; Lycoming IO320B1A 160 horsepower reciprocating
- Damage: Substantial damage
- Fire: On-Ground
- Flight: Personal, Part 91
- Airworthiness certificate: Standard, Normal
- Last inspection: Annual, April 1, 2008, 50 hours before
- Departed: ACK, Nantucket, MA
- Destination: SFZ, Pawtucket, NJ
- Flight plan: IFR
- Airport: SFZ, North Central Airport, runway 15, 3,210 × 75 ft, asphalt

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot, aircraft N27199; age 54; injuries: none; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review January 4, 2008; seat: left; flight hours: 1,640 total, 1,100 in this make and model, 1,492 as pilot in command, 11 in the last 90 days, 8 in the last 30 days
- Pilot, aircraft N7660Y; age 45; injuries: minor; commercial, private; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review June 1, 2007; seat: left; flight hours: 3,215 total, 2,965 in this make and model, 2,250 as pilot in command, 62 in the last 90 days, 34 in the last 30 days, 1 in the last 24 hours

## Weather

- Conditions: Instrument (IMC), Day
- Wind: calm
- Visibility: 10 statute miles
- Lowest ceiling: 600 ft overcast
- Temperature: 57 °F, dew point 52 °F
- Altimeter: 30.12 inHg
- Observed at: SFZ

## FAA reports on this event (1)

The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs).

- [Accident 20080606834709A](https://openairdocs.org/incident/20080606834709A), Jun 6, 2008: Beech A36, Pawtucket, RI, Destroyed. (-23) On June 6, 2008 at approximately 17:45 EDT a runway collision occurred at the North Central State Airport/Pawtucket, RI, N27199 was departing runway 5 on…

## Docket (15 files)

The files NTSB released with the investigation on November 13, 2009, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=68183.

- Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (N27199) (item 1, .PDF, 701 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40320565&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1%20(N27199)-Redacted.PDF
- Pilot and Passenger (N27199) written statement (item 2, .PDF, 222 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40320567&FileExtension=.PDF&FileName=Pilot%20and%20Passenger%20(N27199)%20written%20statement-Redacted.PDF
- Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (N7660Y) (item 3, .PDF, 996 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40320825&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1%20(N7660Y)-Redacted.PDF
- Pilot (N7660Y) written statement (item 4, .PDF, 102 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40320568&FileExtension=.PDF&FileName=Pilot%20(N7660Y)%20written%20statement-Redacted.PDF
- ATC Personnel Written Statement (item 5, .PDF, 194 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40320563&FileExtension=.PDF&FileName=ATC%20Personnel%20Written%20Statement-Redacted.PDF
- ATC transcript (partial) (item 6, .PDF, 233 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40320564&FileExtension=.PDF&FileName=ATC%20transcript%20(partial)-Redacted.PDF
- ATC Flight Progress Strips (item 7, .PDF): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40320823&FileExtension=.PDF&FileName=ATC%20Flight%20Progress%20Strips-Master.PDF
- Witness Statement (item 8, .PDF, 174 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40320821&FileExtension=.PDF&FileName=Witness%20Statement-Redacted.PDF
- Weather (item 9, .PDF, 98 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40320746&FileExtension=.PDF&FileName=Weather-Master.PDF
- Reports from State Agencies (item 10, .PDF, 193 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40320709&FileExtension=.PDF&FileName=Reports%20from%20State%20Agencies-Redacted.PDF
- PVD ATC Tracon Layout (item 11, .PDF, 35 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40320748&FileExtension=.PDF&FileName=PVD%20ATC%20Tracon%20Layout-Master.PDF
- Voice and Radar Files (item 12, .PDF, 10 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40320754&FileExtension=.PDF&FileName=Voice%20and%20Radar%20Files-Master.PDF
- Photo 1: Piper Airplane Front View photo courtsey of Rhode Island Airport Corporation (item 13, .PDF, 2.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40320764&FileExtension=.PDF&FileName=Photo%201%3A%20Piper%20Airplane%20Front%20View%20photo%20courtsey%20of%20Rhode%20Island%20Airport%20Corporation-Master.PDF
- Photo 2: Piper Airlpane Left Side View Photo Courtsey of Rhode Island Airport Corporation (item 14, .PDF, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40320765&FileExtension=.PDF&FileName=Photo%202%3A%20Piper%20Airlpane%20Left%20Side%20View%20Photo%20Courtsey%20of%20Rhode%20Island%20Airport%20Corporation-Master.PDF
- Photo 3: Beechcraft Airplane Left Side View Photo Courtsey of Rhode Island Airport Corporation (item 15, .PDF, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40320766&FileExtension=.PDF&FileName=Photo%203%3A%20Beechcraft%20Airplane%20Left%20Side%20View%20Photo%20Courtsey%20of%20Rhode%20Island%20Airport%20Corporation-Master.PDF

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.

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