OPS12IA041

NTSB incident investigation · Cessna 172S · Daytona Beach, FL · October 15, 2011

Incident · No injuriesIncident investigationFinal report
Date
October 14, 2011, 22:08 local (Oct 15, 2011, 02:08 UTC)
Place
Daytona Beach, FL
Injuries
3 uninjured
Phase of flight
Takeoff
Aircraft
N488ERCessna 172SN551ERCessna 172S
Defining events
Takeoff: Miscellaneous/otherApproach-VFR pattern final: Near midair/TCAS alert/loss of separation
Weather
Visual (VMC) · Night
Status
Completed · report January 15, 2013
Report
Approved by Office Director
NTSB office
Operational Factors Division
Parties
Embry Riddle Aeronautical University, FAA, NATCA
Case key
82109

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

On this page

Probable cause

The NTSB’s determination of the probable cause, and any contributing factors.

The departing pilot's incorrect runway selection and non-compliance with an air traffic control clearance. Contributing to the incident was the air traffic controller's inadequate monitoring of the departing aircraft to ensure that the pilot complied with the clearance issued and his failure to issue conflict resolution advisories.

Findings · 4

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings.

Analysis

A local controller cleared the Cessna 172 for takeoff on runway 7L; however, the pilot instead departed from runway 25R and passed within about 400 feet vertically and 500 feet laterally of another Cessna 172 that was turning on final approach to runway 7L. The air traffic controller responsible for the two aircraft did not notice that the pilot of the departing aircraft was using the wrong runway and did not intervene to resolve the conflict with the arriving aircraft. The local controller failed to maintain situational awareness of the airplanes in his Class C airspace and failed to provide timely actions, instructions, or advisories that would have assisted the pilots in identifying the conflict in order to resolve it.

Factual narrative

The factual narrative677 words

SUMMARY On October 14, 2011, at about 2208 Eastern daylight time, a pilot deviation occurred at the Daytona Beach International Airport (DAB), Daytona Beach, Florida, when Riddle 488 (R488) a Cessna 172, was cleared for takeoff on runway 7L but instead departed from runway 25R. Riddle 551 (R551), a Cessna 172, was turning base to final approach for runway 7L and was opposite direction of R488. The two airplanes passed within approximately 400 feet vertically and 500 feet laterally at about three-quarters of a mile from the threshold of runway 7L. Both airplanes were operating under 14 Code of Federal Regulations Part 91 and were conducting operations in the local area. The airplanes were piloted by Embry-Riddle Aeronautical University (ERAU) students at Daytona Beach, Florida. Both airplanes were under control of DAB airport traffic control tower (ATCT), the primary airport in the Class C airspace. A pilot deviation report was filed on R488. The incident occurred during nighttime visual meteorological conditions. There was no damage to either aircraft and no injuries to passengers. HISTORY OF FLIGHT At 2206:57, R551 contacted DAB tower to report circling to land runway 7L from the runway 16 RNAV approach. Approximately one minute later, the DAB Local Controller (LC) issued the takeoff clearance to R488: “… without delay, fly runway heading runway 7L shortened , N2 cleared for takeoff , I will transition you in the upwind.” R488 read back “runway heading cleared for takeoff.” At 2208:48, the tower radar display showed a target and unassociated data block over the approach end of runway 7L, indicating 300 feet, climbing opposite direction (departing runway 25R) toward R551, which was turning final. The data block contained altitude information only. At 2209:03, the conflict alert (CA) activated on the limited data block for R488, which indicated 400 feet, and R551’s data tag, which indicated 600 feet. Nine seconds after the CA activated, the aircraft was auto-acquired and the data block displayed R488’s call sign. Twenty-one seconds after the CA had activated, R551 reported to DAB tower “we just had traffic depart on us here…just went right over us from runway 7L.” The local controller had not provided a traffic advisory or safety alert to either airplane. At 2209:32, the LC responded “R551, 7L shortened cleared to land”, then asked R488 to say position. R488 reported she was on a 245 heading. The LC instructed the pilot to make an immediate right turn, fly heading 070, and informed her that she had departed the wrong direction. R488 apologized for the wrong runway departure and followed the LC’s instructions. R488 climbed above the pattern altitude and the LC instructed the pilot to maintain 1000 feet if she wanted to remain in the pattern. The LC directed her to make a left 180 degree turn and asked her if she had runway 7L in sight. The pilot responded that she did, and she was issued a clearance to land runway 7L shortened. Approximately twominutes later, R488 informed the LC that she had flown over the runway and requested to continue on a 060 heading. The LC issued R488 a clearance to land on runway 7R. As R488 was on the final approach to runway 7R, the pilot reported that she was going around. The LC instructed R488 to go around, sequenced her in the pattern, and gave her clearance to land on runway 7R. At about 2218, R488 landed on runway 7R without further incident. R551 had landed on runway 7L at about 2210. As R551 was taxiing to the ramp, the LC asked the pilot if he had the conflicting airplane in sight when the incident occurred. The pilot responded that he had the opposite direction traffic in sight. The two airplanes passed within approximately 400 feet vertically and 500 feet laterally at about three-quarters of a mile from the threshold of runway 7L. RADAR DATA Radar data for this report was obtained from the DAB Airport Surveillance Radar (ASR-9). For further information, see the Air Traffic Control Group Chairman's Report in the docket for this case.

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident.

Aircraft · 2

Registration
N488ER
Reported as
Cessna 172S
Category
Airplane
Serial number
172S10555
Engine
Lycoming IO-360-L2A, 180 horsepower, reciprocating
Damage
No damage
Flight
Instructional · Part 91
Operator
Embry Riddle Aeronautical University, doing business as Embry Riddle Aeronautical University
Registered owner
Avn Air LLC
Departed
DAB · Daytona Beach, FL
Destination
DAB · Daytona Beach, FL
Flight plan
Unknown
Airport
DAB · Daytona Beach International

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
N551ER
Reported as
Cessna 172S
Category
Airplane
Serial number
172S10548
Engine
Lycoming IO-360-L2A, 180 horsepower, reciprocating
Damage
No damage
Flight
Instructional · Part 91
Departed
DAB · Daytona Beach, FL
Destination
DAB · Daytona Beach, FL
Flight plan
Unknown
Airport
DAB · Daytona Beach International

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.

Weather

Conditions
Visual (VMC) · Night
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
None
Temperature
66 °F, dew point 63 °F
Altimeter
29.92 inHg
Observed at
KDAB

Docket · 7

The files NTSB released with the investigation on November 5, 2012, on NTSB’s docket system: statements, records, photos and specialists’ reports. 2.0 MB in all.