In flying.......carelessness and overconfidence are usually far more dangerous than deliberately accepted risks.
25 May 1988
2 Miles East of Raleigh-Durham International Airport, North Carolina (KRDU)
Midair Collision:
Cessna 172N, N737GU/ Piper PA-28R-200, N44018
2 Fatal
This is the third installment of a series of midair collisions I'm profiling in my resumption of MikeDs Aircraft Accident Analyses. Midair collisions are interesting, just as all aviation accidents are, due to the many situational dynamics that can be present, yet produce the same result: two aircraft coming together. Each midair I've profiled so far has a very unique sequence of events, proving that there are many ways and means of bringing two aircraft together in the vast sky that exists within the earth's atmosphere. As per usual, we don't find new ways to bring aircraft together in the sky, we just remake and/or repeat the same time-proven and blood-written situations that have been occurring since nearly the birth of flight. While the usually common denominator of failure to see and avoid seems to rear it's ugly head a majority of the time, it shares it's space with many different factors that can be as primary-causal as failure to see and avoid, secondarily related that help the failure to thrive, or stand alone. In today's accident, many judgemental, operational, and common sense errors were made; both by omission as well as by commission. Since Mr Murphy is all about equal-opportunity, the end result of this accident was hardly to be unexpected.
On the night of 25 May 1988, 3 pilots from a Petersburg, Virginia FBO had flown in a C-172, 737GU, to Raleigh-Durham International Airport, North Carolina (KRDU), from Petersburg. The purpose of the flight on that night was to pick up N44018, a Piper PA-28R-200 Arrow. N44018 had been left at KRDU in order to have one of it's two VHF comm radios fixed, however when the 3 pilots arrived at KRDU, they found out that the repairs had not occurred due to a parts problem. The three conferred, and decided to take N44018 back to Petersburg. Two of the pilots would fly in N44018, and the original pilot of N737GU would remain with that aircraft and return to Petersburg also. For the return flight, the 3 pilots planned to fly in night visual formation with the Piper in the lead, followed by the Cessna. The 3 pilots formulated a crude communications plan whereby the Cessna would monitor both ATC as well as a selected air-air frequency, while the Piper would use it's one comm radio to monitor ATC until clear of the RDU ARSA (Airport Radar Service Area), to where it would then switch to the preplanned air-air frequency for the remainder of the VFR flight. There is no evidence of any other formation briefing items discussed between the two crews beyond air-air communications. The first hiccup for the flight began on the clearance delivery frequency. Both N44018 and N737GU obtained separate ATC clearances (non-standard for a formation flight, this will be covered more in the discussion section). N44018 was given a departure heading of 090, and altitude of 1500' MSL, and a departure frequency of 125.3. N737GU was given a departure heading of 350, an altitude of 1500' MSL, and a departure frequency of 132.35. N737GUs pilot queried clearance delivery as to why he had different departure instructions, since he was flying with N44018. Clearance delivery was understandably confused by this query, since both aircraft had requested separate clearances, with neither informing ATC of any formation intentions. After several explanations to clearance delivery, the situation was finally resolved when ATC agreed to drop 737GUs clearance from the system, and show it as part of N44018s ATC clearance, with a 090 departure heading for both. That problem finally getting resolved, both aircraft called for and received taxi instructions to the active runway. Both aircraft called for and received takeoff clearace with N44018 taking off first, followed a short delay later by N737GU. The pilot of N737GU stated that shortly after takeoff, he flew to a position on the left side of N44018, and noticed that the Piper was in a slight right turn to the 090 departure heading, leveling at 1500' MSL. The Cessna pilot further stated that as he was trimming his aircraft, he noticed the Piper accelerating and beginning to outrun him. At about this same time, the local controller handed off the flight to the RDU TRACON controller. The Cessna pilot changed to frequency 132.35 (his previously assigned departure freq), and unsuccessfully attempted to contact departure. By this time, the Piper had disappeared from his view. The Cessna pilot felt it necessary to find the correct frequency and inform both ATC as well as the Piper's crew that he'd lost sight of the Piper, and began to reference a frequency card in the seat next to him in order to find the correct departure frequency. All this time, the Cessna's pilot still had not regained visual with the Piper, however he attempted to crosscheck the frequency card as well as look out for the Piper by holding the card out in front of him as he flew. The Cessna pilot had found a frequency he was going to attempt communication on, when the collision with the Piper occurred. The Cessna, in full power, had overrun the Piper and collided with it in near level flight, with an approximate 10 degree heading crossing angle. The Cessna's propeller and nose landing gear impacted the left side of the Piper Arrow's vertical stabilizer and fuselage. Following the collision, the Piper began an immediate left descending spiral and impacted the ground, fatally injuring the two pilots onboard. The Cessna suffered engine failure and a severed nose landing gear, however the pilot was able to successfully turn back towards KRDU and land on Runway 32, minus the nose gear and most of the propeller. The collision occurred about 1 minute after the frequency change had been given from tower to TRACON.
Probable Cause
*Visual Lookout- Not Maintained- Pilot In Command N737GU
*Inflight Planning/Decision- Improper- Pilot In Command N737GU
Secondary Factors
*Preflight Preparation- Inadequate- Pilot In Command N737GU
*Preflight Preparation- Inadequate- Pilot In Command N44018
*Diverted Attention- Pilot In command N737GU
*Formation Flying/Procedures- Improper- Pilot In Command N737GU
*Overconfidence in Personal Ability- Pilot In Command N737GU
Tertiary Factors
*Light Condition- Dark Night
MikeD Says:
If there really is a definition of "an accident that should never happen," or "an accident that should be completely avoidable," this one certainly ranks at or very near the top. There are so many questions that can be asked of this accident regards what the crews were thinking, why they were doing what they were doing, what was the benefit of taking the risk they were, etc, etc. The pilot of N737GU was a 30 year old Commercial ASMEL/ASES rated pilot, with an additional rotorcraft category rating on his Commercial certificate. He had 3660 Total Time at the time of the accident. However, neither member of the flight had any experience with formation flying. I've said time and again, that regardless of how many hours someone may have, formation flying is a flying all to it's own. If you're not trained in formation methods, responsibilities, and procedures, then you have absolutely no business engaging in any sort of formation flying. Period. Period again. The margin for error is so low, and the required knowlege so high, that there is absolutely no operationally pressing need for pilots not trained in formation flying, to engage in such. The mistakes both crews made, demonstrated with painful certainty that neither crew had even the most rudimentary training on formation procedures, much less any training on formation flying. And with this lack of training and experience, they still decided to embark on a night formation rejoin and flight......a fairly difficult and SA-taxing endeavor even for someone with a good amount of experience in formation flying. The mistakes these guys made could fill a proverbial laundry list:
Inadequate Preflight Planning: The only planning done by both crews was coordinating a frequency to talk on, and which aircraft would be on what frequency. There was no discussion on lost communication procedures, lead and wingman formation responsibilities, formation communication rules (ROE), basic discussion on formation references on the Piper and which types of formations would be flown or could be expected (which neither crew knew anyway). The pilot of 737GU explained that, while the two crews had discussed a contingency plan for if they got separated outside the RDU ARSA on their way to their destination, there was no discussion on any plans for what would be done in the event of "lost wingman" when still within the ARSA. What was the rationale for this? According to the pilot of 737GU, it was "that was too close in, for any formation separation to be anticipated." That's a very surprising statement. One of the biggest parts of formation flight planning is the concept of contingencies....what to do if? These must be covered from takeoff roll all the way to landing, since differing phases of flight will normally require different contingency planning, often for the same problem(s). The fact that nothing of anything I wrote above, was covered in any way, shape, or form in a pre-mission brief, is further evidence that both crews were suffering from a good degree of both overconfidence as well as nonchalance, regarding mission preparation.
Inadequate Formation Procedures: This was painfully demonstrated in the initial check-in to clearance delivery. One of the hallmarks of an experienced formation flyer, is radio discipline. In formation flying, the designated flight leader does all communications to ATC. As the lead of the flight, that's one of his responsibilities. On that note, only one clearance is given to a formation flight.....that of the flight leader. Number 2's response is only to say "2", when a clearance or other instructions are given. He can ask for clarification on an interflight frequency, but the primary ATC frequency isn't for interflight comm. If any questions are required, and there is only one radio available, then a query to go "off freq" momentarily is appropriate, to the pre-selected interflight freq. The fact that both aircraft checked in with clearance delivery separately, was the primary reason ATC didn't think they were a formation. The Piper, as the lead aircraft, should've been the only one requesting anything. Comm is SO important in formation flying, because how comm starts out on initial check-in's, is what sets the tone for the flight to follow. Generally, you have lousy comm on check-in, the flight will reflect that in how it goes. This was painstakingly proven to a fatal degree in this accident. Additionally, there was no discussion on of basic formation references for the Piper....what the Cessna pilot should be looking at, what formation is what. If you don't know these during the day, you sure as hell aren't going to know a darn thing for night. Pre-briefing as much of the flight's procedures is extremely important in order that both crews can be on the same page and can anticipate what will be happening at any given stage of the flight. It also serves to keep radio comm on administrative stuff to an absolute minimum; another mark of a professional formation-trained crew. With none of this training in your back pocket, you're an accident just waiting to happen, as both these crews were.
Misplaced Priorities: Both crews had hugely misplaced priorities. In addition to all of the above, the Piper crew failed to lead, and the Cessna pilot failed to be a wingman. Of course, there is no way they could have been, since none of the crews knew the procedures anyway to begin with. As stated above, the Cessna pilot should never have been on the wrong departure frequency, since his clearance (all inclusive.....the heading/altitude/and departure frequency) was cancelled when he was put on the Piper's clearance as per normal formation ROE. Following takeoff, he couldn't fly proper formation references due to the fact that he hadn't been trained in any, in day much less night. Following the frequency change, he shouldn't have worried if he couldn't get a hold of TRACON. The Piper should be the only one checking-in anyway as the formation leader. The Cessna should never talk, except to acknowlege the check-in. Even if the Cessna didn't acknowlege the check-in, it's certainly not the end of the world. HAD the Piper crew knew what they were doing as a formation leader, they would've kept track of their wingman. Failing that, then they would've cranked their neck around and checked that the Cessna was with them when it didn't respond to the check-in to TRACON. So long as they can see that, they can "rock" the Cessna in and work the frequency muck-up via hand signals (day), or flashlight signals (night). The Cessna pilot's PRIMARY responsibility was what the responsibility for every formation wingman is: deconfliction. The Cessna's pilot dropped his deconfliction responsibilities over simple and relatively unimportant (in the bigger scheme of things) items as a wrong comm frequency. Once he lost visual on his leader, he should've spent his PRIMARY time regaining a visual from the last known position of the Piper, NOT referencing a comm card. He knew what their clearance was, and knew that the Piper isn't going to make some crazy maneuvering to some off-the-wall heading or altitude, so he should've had a good reference for where to begin looking to reacquire the Piper. Additionally, and I alluded to this earlier as a wingman responsibility that was never briefed or understood in the inadequate preflight brief. If the Cessna pilot couldn't regain visual, there should've been a pre-briefed plan for deconfliction. Examples of this would be to take 100' vertical separation. For example, the Cessna could've immediately climbed to 1700' MSL to look for the Piper. Or, if the city lights were causing the Piper's lights to "blend-in", he could've legally descended 100' and given himself a "look up" angle to work with. Either way, he'd still be in some form of standard formation, which is defined as within 100' and 1 mile of the lead aircraft. Heck, even taking 200' of separation one way or the other would still be legal, if not at least to avoid colliding with an airplane you know is still somewhere close to you. The fact that the pilot spent any time looking at a frequency card, instead of 100% attention regaining visual, tells me that at that time, the hair on the back of his neck never stood up......never had that impending feeling of doom that someone with formation experience would definitely feel at that particular moment in the same circumstances. Additionally, the Cessna pilot stated that it had been agreed that the Piper would operate at a reduced throttle setting, while the Cessna would operate at full throttle. Again, another example of lack of training in formation procedures and further evidence of no formation training. The wing aircraft should never operate at full throttle. Lead's power management should always allow the wingman excess power to "push it up" as necessary, to maintain formation positioning in whatever formation may be being flown at the time.
The Rest of the Story
There was an interesting amount of follow-on events regarding this accident, and certificate action taken by the Federal Aviation Administration (FAA) against the pilot of N737GU, the sole survivor. These events revolved around FAA action against the pilot, an appeal to the NTSB by the pilot against the action taken by the FAA resulting in a rare NTSB overruling of an FAA action; and an FAA appeal that was upheld on the even more rare overturn of an NTSB Administrative Law Judge ruling.
In 1989, following the accident, the FAA suspended the pilot's airman's certificate for a period of 180 days under two FAR's:
1. 14 CFR 91.9; Careless or Reckless Operation (now 14 CFR 91.13a...MikeD)
Aircraft operations for the purpose of air navigation. No person
may operate an aircraft in a careless or reckless manner so as to
endanger the life or property of another.
2. 14 CFR 91.65; Operating Near Other Aircraft (now 14 CFR 91.111a....MikeD)
No person may operate an aircraft so close to another aircraft
as to create a collision hazard.
In the order of suspension, the FAA alleged that:
"1. At all times material herein, you were and are the holder of Commerical pilot certificate XXXXXXXXX.
2. On or about 25 May 1988, you operated civil aircraft N737GU, a Cessna 172N, the property of another, on a flight departing in formation with aircraft N44018, a Piper PA-28, from the Raleigh-Durham Airport, Raleigh, NC.
3. During the course of the above described flight, during the departure, N737GU collided with aircraft N44018.
4. As a result of the collision described in paragraph 3 above, N737GU and N44018 sustained major damage. The two occupants of N44018 received fatal injuries as a result of the accident."
In January of 1990, the pilot appealed the FAA action against his airman's certificate to the National Transportation Safety Board (a fully legal action). Amazingly, in the 1990 ruling, the NTSB Administrative Law Judge hearing the case reversed the FAA's legal action against the pilot, finding "no evidence of a lack of carelessness or unreasonableness," on the part of the pilot of N737GU, and ordering the FAA to restore the airman's certificate privileges immediately. The FAA appealed the ALJ's ruling, re-asserting that the pilot "did not act prudently in his preparation for, and conduct of, the flight in question.....and should have taken additional steps which would've diminished the likelihood of a midair collision with the flight lead's aircraft." In 1992, the NTSB sided with the FAA on it's appeal, reinstating the certificate action on the grounds of "....safety in air commerce or air transportation and the public interest require affirmation of the Administrator's order in it's entirety."
Therefore, the NTSB ordered that:
"1. The Administrator's appeal is granted.
2. The law judge's initial decision is reversed and the Administrator's order is affirmed, and
3. The 180 day suspension of the respondant's airman certificate shall begin 30 days from the date of service of this order."
MikeDs Final Thoughts
As I stated in the beginning of this profile, we don't find new ways to create midair collisions. We simply mildly modify, or refine, existing methods......season them to taste, if you will. There are midairs that occur from certainly understandable conditions.....conditions that could be mitigated, or the lessons relearned, or occurred in a situation outside the reasonable control of the parties involved (rare), or due to a previously unknown set of factors (even more rare). Then there are midairs, like any other accident of similiar causal factors, where you look at it and think "this really need not have happened." If only the proper training were there. If only the participants would've analyzed why it was so important to partake in a certain activity. In this case, why was formation flight deemed necessary, especially with all the limitations and risk clearly presenting itself? This mission, to retrieve an airplane from an outbase, is one of the more benign missions out there; yet the people involved deliberately, and for still unclear reasons, turned what should've been a very vanilla mission, into a real challenge that was full of unnecessary risk......challenge that would've tasked even the most trained formation flyers among us. It was certainly no walk in the park, and certainly not a mission (the mission it became) to be taken lightly, as the players this night in May did so. The tragedy of carelessness and overconfidence, as so eloquently stated in the opening quote of this report, showed itself to be alive and well, and truer than ever. And the results were deadly. If there's anything to take out of this accident, it's that planning, knowing your training limits, keeping within your experience level, using common sense, never being careless, managing risk versus reward for what you're planning to do, and being thorough when you do it; are traits that should never be taken for granted......
.....if you want to avoid Things That Go Bump In The Night.
MikeD
The above is not intended to be an undue criticism of the person or persons involved in the incident described. Instead, the analysis presented is intended to further the cause of flight safety and help to reduce accidents and incidents by educating pilots through the sacrifices of others in our profession.
25 May 1988
2 Miles East of Raleigh-Durham International Airport, North Carolina (KRDU)
Midair Collision:
Cessna 172N, N737GU/ Piper PA-28R-200, N44018
2 Fatal
This is the third installment of a series of midair collisions I'm profiling in my resumption of MikeDs Aircraft Accident Analyses. Midair collisions are interesting, just as all aviation accidents are, due to the many situational dynamics that can be present, yet produce the same result: two aircraft coming together. Each midair I've profiled so far has a very unique sequence of events, proving that there are many ways and means of bringing two aircraft together in the vast sky that exists within the earth's atmosphere. As per usual, we don't find new ways to bring aircraft together in the sky, we just remake and/or repeat the same time-proven and blood-written situations that have been occurring since nearly the birth of flight. While the usually common denominator of failure to see and avoid seems to rear it's ugly head a majority of the time, it shares it's space with many different factors that can be as primary-causal as failure to see and avoid, secondarily related that help the failure to thrive, or stand alone. In today's accident, many judgemental, operational, and common sense errors were made; both by omission as well as by commission. Since Mr Murphy is all about equal-opportunity, the end result of this accident was hardly to be unexpected.
On the night of 25 May 1988, 3 pilots from a Petersburg, Virginia FBO had flown in a C-172, 737GU, to Raleigh-Durham International Airport, North Carolina (KRDU), from Petersburg. The purpose of the flight on that night was to pick up N44018, a Piper PA-28R-200 Arrow. N44018 had been left at KRDU in order to have one of it's two VHF comm radios fixed, however when the 3 pilots arrived at KRDU, they found out that the repairs had not occurred due to a parts problem. The three conferred, and decided to take N44018 back to Petersburg. Two of the pilots would fly in N44018, and the original pilot of N737GU would remain with that aircraft and return to Petersburg also. For the return flight, the 3 pilots planned to fly in night visual formation with the Piper in the lead, followed by the Cessna. The 3 pilots formulated a crude communications plan whereby the Cessna would monitor both ATC as well as a selected air-air frequency, while the Piper would use it's one comm radio to monitor ATC until clear of the RDU ARSA (Airport Radar Service Area), to where it would then switch to the preplanned air-air frequency for the remainder of the VFR flight. There is no evidence of any other formation briefing items discussed between the two crews beyond air-air communications. The first hiccup for the flight began on the clearance delivery frequency. Both N44018 and N737GU obtained separate ATC clearances (non-standard for a formation flight, this will be covered more in the discussion section). N44018 was given a departure heading of 090, and altitude of 1500' MSL, and a departure frequency of 125.3. N737GU was given a departure heading of 350, an altitude of 1500' MSL, and a departure frequency of 132.35. N737GUs pilot queried clearance delivery as to why he had different departure instructions, since he was flying with N44018. Clearance delivery was understandably confused by this query, since both aircraft had requested separate clearances, with neither informing ATC of any formation intentions. After several explanations to clearance delivery, the situation was finally resolved when ATC agreed to drop 737GUs clearance from the system, and show it as part of N44018s ATC clearance, with a 090 departure heading for both. That problem finally getting resolved, both aircraft called for and received taxi instructions to the active runway. Both aircraft called for and received takeoff clearace with N44018 taking off first, followed a short delay later by N737GU. The pilot of N737GU stated that shortly after takeoff, he flew to a position on the left side of N44018, and noticed that the Piper was in a slight right turn to the 090 departure heading, leveling at 1500' MSL. The Cessna pilot further stated that as he was trimming his aircraft, he noticed the Piper accelerating and beginning to outrun him. At about this same time, the local controller handed off the flight to the RDU TRACON controller. The Cessna pilot changed to frequency 132.35 (his previously assigned departure freq), and unsuccessfully attempted to contact departure. By this time, the Piper had disappeared from his view. The Cessna pilot felt it necessary to find the correct frequency and inform both ATC as well as the Piper's crew that he'd lost sight of the Piper, and began to reference a frequency card in the seat next to him in order to find the correct departure frequency. All this time, the Cessna's pilot still had not regained visual with the Piper, however he attempted to crosscheck the frequency card as well as look out for the Piper by holding the card out in front of him as he flew. The Cessna pilot had found a frequency he was going to attempt communication on, when the collision with the Piper occurred. The Cessna, in full power, had overrun the Piper and collided with it in near level flight, with an approximate 10 degree heading crossing angle. The Cessna's propeller and nose landing gear impacted the left side of the Piper Arrow's vertical stabilizer and fuselage. Following the collision, the Piper began an immediate left descending spiral and impacted the ground, fatally injuring the two pilots onboard. The Cessna suffered engine failure and a severed nose landing gear, however the pilot was able to successfully turn back towards KRDU and land on Runway 32, minus the nose gear and most of the propeller. The collision occurred about 1 minute after the frequency change had been given from tower to TRACON.
Probable Cause
*Visual Lookout- Not Maintained- Pilot In Command N737GU
*Inflight Planning/Decision- Improper- Pilot In Command N737GU
Secondary Factors
*Preflight Preparation- Inadequate- Pilot In Command N737GU
*Preflight Preparation- Inadequate- Pilot In Command N44018
*Diverted Attention- Pilot In command N737GU
*Formation Flying/Procedures- Improper- Pilot In Command N737GU
*Overconfidence in Personal Ability- Pilot In Command N737GU
Tertiary Factors
*Light Condition- Dark Night
MikeD Says:
If there really is a definition of "an accident that should never happen," or "an accident that should be completely avoidable," this one certainly ranks at or very near the top. There are so many questions that can be asked of this accident regards what the crews were thinking, why they were doing what they were doing, what was the benefit of taking the risk they were, etc, etc. The pilot of N737GU was a 30 year old Commercial ASMEL/ASES rated pilot, with an additional rotorcraft category rating on his Commercial certificate. He had 3660 Total Time at the time of the accident. However, neither member of the flight had any experience with formation flying. I've said time and again, that regardless of how many hours someone may have, formation flying is a flying all to it's own. If you're not trained in formation methods, responsibilities, and procedures, then you have absolutely no business engaging in any sort of formation flying. Period. Period again. The margin for error is so low, and the required knowlege so high, that there is absolutely no operationally pressing need for pilots not trained in formation flying, to engage in such. The mistakes both crews made, demonstrated with painful certainty that neither crew had even the most rudimentary training on formation procedures, much less any training on formation flying. And with this lack of training and experience, they still decided to embark on a night formation rejoin and flight......a fairly difficult and SA-taxing endeavor even for someone with a good amount of experience in formation flying. The mistakes these guys made could fill a proverbial laundry list:
Inadequate Preflight Planning: The only planning done by both crews was coordinating a frequency to talk on, and which aircraft would be on what frequency. There was no discussion on lost communication procedures, lead and wingman formation responsibilities, formation communication rules (ROE), basic discussion on formation references on the Piper and which types of formations would be flown or could be expected (which neither crew knew anyway). The pilot of 737GU explained that, while the two crews had discussed a contingency plan for if they got separated outside the RDU ARSA on their way to their destination, there was no discussion on any plans for what would be done in the event of "lost wingman" when still within the ARSA. What was the rationale for this? According to the pilot of 737GU, it was "that was too close in, for any formation separation to be anticipated." That's a very surprising statement. One of the biggest parts of formation flight planning is the concept of contingencies....what to do if? These must be covered from takeoff roll all the way to landing, since differing phases of flight will normally require different contingency planning, often for the same problem(s). The fact that nothing of anything I wrote above, was covered in any way, shape, or form in a pre-mission brief, is further evidence that both crews were suffering from a good degree of both overconfidence as well as nonchalance, regarding mission preparation.
Inadequate Formation Procedures: This was painfully demonstrated in the initial check-in to clearance delivery. One of the hallmarks of an experienced formation flyer, is radio discipline. In formation flying, the designated flight leader does all communications to ATC. As the lead of the flight, that's one of his responsibilities. On that note, only one clearance is given to a formation flight.....that of the flight leader. Number 2's response is only to say "2", when a clearance or other instructions are given. He can ask for clarification on an interflight frequency, but the primary ATC frequency isn't for interflight comm. If any questions are required, and there is only one radio available, then a query to go "off freq" momentarily is appropriate, to the pre-selected interflight freq. The fact that both aircraft checked in with clearance delivery separately, was the primary reason ATC didn't think they were a formation. The Piper, as the lead aircraft, should've been the only one requesting anything. Comm is SO important in formation flying, because how comm starts out on initial check-in's, is what sets the tone for the flight to follow. Generally, you have lousy comm on check-in, the flight will reflect that in how it goes. This was painstakingly proven to a fatal degree in this accident. Additionally, there was no discussion on of basic formation references for the Piper....what the Cessna pilot should be looking at, what formation is what. If you don't know these during the day, you sure as hell aren't going to know a darn thing for night. Pre-briefing as much of the flight's procedures is extremely important in order that both crews can be on the same page and can anticipate what will be happening at any given stage of the flight. It also serves to keep radio comm on administrative stuff to an absolute minimum; another mark of a professional formation-trained crew. With none of this training in your back pocket, you're an accident just waiting to happen, as both these crews were.
Misplaced Priorities: Both crews had hugely misplaced priorities. In addition to all of the above, the Piper crew failed to lead, and the Cessna pilot failed to be a wingman. Of course, there is no way they could have been, since none of the crews knew the procedures anyway to begin with. As stated above, the Cessna pilot should never have been on the wrong departure frequency, since his clearance (all inclusive.....the heading/altitude/and departure frequency) was cancelled when he was put on the Piper's clearance as per normal formation ROE. Following takeoff, he couldn't fly proper formation references due to the fact that he hadn't been trained in any, in day much less night. Following the frequency change, he shouldn't have worried if he couldn't get a hold of TRACON. The Piper should be the only one checking-in anyway as the formation leader. The Cessna should never talk, except to acknowlege the check-in. Even if the Cessna didn't acknowlege the check-in, it's certainly not the end of the world. HAD the Piper crew knew what they were doing as a formation leader, they would've kept track of their wingman. Failing that, then they would've cranked their neck around and checked that the Cessna was with them when it didn't respond to the check-in to TRACON. So long as they can see that, they can "rock" the Cessna in and work the frequency muck-up via hand signals (day), or flashlight signals (night). The Cessna pilot's PRIMARY responsibility was what the responsibility for every formation wingman is: deconfliction. The Cessna's pilot dropped his deconfliction responsibilities over simple and relatively unimportant (in the bigger scheme of things) items as a wrong comm frequency. Once he lost visual on his leader, he should've spent his PRIMARY time regaining a visual from the last known position of the Piper, NOT referencing a comm card. He knew what their clearance was, and knew that the Piper isn't going to make some crazy maneuvering to some off-the-wall heading or altitude, so he should've had a good reference for where to begin looking to reacquire the Piper. Additionally, and I alluded to this earlier as a wingman responsibility that was never briefed or understood in the inadequate preflight brief. If the Cessna pilot couldn't regain visual, there should've been a pre-briefed plan for deconfliction. Examples of this would be to take 100' vertical separation. For example, the Cessna could've immediately climbed to 1700' MSL to look for the Piper. Or, if the city lights were causing the Piper's lights to "blend-in", he could've legally descended 100' and given himself a "look up" angle to work with. Either way, he'd still be in some form of standard formation, which is defined as within 100' and 1 mile of the lead aircraft. Heck, even taking 200' of separation one way or the other would still be legal, if not at least to avoid colliding with an airplane you know is still somewhere close to you. The fact that the pilot spent any time looking at a frequency card, instead of 100% attention regaining visual, tells me that at that time, the hair on the back of his neck never stood up......never had that impending feeling of doom that someone with formation experience would definitely feel at that particular moment in the same circumstances. Additionally, the Cessna pilot stated that it had been agreed that the Piper would operate at a reduced throttle setting, while the Cessna would operate at full throttle. Again, another example of lack of training in formation procedures and further evidence of no formation training. The wing aircraft should never operate at full throttle. Lead's power management should always allow the wingman excess power to "push it up" as necessary, to maintain formation positioning in whatever formation may be being flown at the time.
The Rest of the Story
There was an interesting amount of follow-on events regarding this accident, and certificate action taken by the Federal Aviation Administration (FAA) against the pilot of N737GU, the sole survivor. These events revolved around FAA action against the pilot, an appeal to the NTSB by the pilot against the action taken by the FAA resulting in a rare NTSB overruling of an FAA action; and an FAA appeal that was upheld on the even more rare overturn of an NTSB Administrative Law Judge ruling.
In 1989, following the accident, the FAA suspended the pilot's airman's certificate for a period of 180 days under two FAR's:
1. 14 CFR 91.9; Careless or Reckless Operation (now 14 CFR 91.13a...MikeD)
Aircraft operations for the purpose of air navigation. No person
may operate an aircraft in a careless or reckless manner so as to
endanger the life or property of another.
2. 14 CFR 91.65; Operating Near Other Aircraft (now 14 CFR 91.111a....MikeD)
No person may operate an aircraft so close to another aircraft
as to create a collision hazard.
In the order of suspension, the FAA alleged that:
"1. At all times material herein, you were and are the holder of Commerical pilot certificate XXXXXXXXX.
2. On or about 25 May 1988, you operated civil aircraft N737GU, a Cessna 172N, the property of another, on a flight departing in formation with aircraft N44018, a Piper PA-28, from the Raleigh-Durham Airport, Raleigh, NC.
3. During the course of the above described flight, during the departure, N737GU collided with aircraft N44018.
4. As a result of the collision described in paragraph 3 above, N737GU and N44018 sustained major damage. The two occupants of N44018 received fatal injuries as a result of the accident."
In January of 1990, the pilot appealed the FAA action against his airman's certificate to the National Transportation Safety Board (a fully legal action). Amazingly, in the 1990 ruling, the NTSB Administrative Law Judge hearing the case reversed the FAA's legal action against the pilot, finding "no evidence of a lack of carelessness or unreasonableness," on the part of the pilot of N737GU, and ordering the FAA to restore the airman's certificate privileges immediately. The FAA appealed the ALJ's ruling, re-asserting that the pilot "did not act prudently in his preparation for, and conduct of, the flight in question.....and should have taken additional steps which would've diminished the likelihood of a midair collision with the flight lead's aircraft." In 1992, the NTSB sided with the FAA on it's appeal, reinstating the certificate action on the grounds of "....safety in air commerce or air transportation and the public interest require affirmation of the Administrator's order in it's entirety."
Therefore, the NTSB ordered that:
"1. The Administrator's appeal is granted.
2. The law judge's initial decision is reversed and the Administrator's order is affirmed, and
3. The 180 day suspension of the respondant's airman certificate shall begin 30 days from the date of service of this order."
MikeDs Final Thoughts
As I stated in the beginning of this profile, we don't find new ways to create midair collisions. We simply mildly modify, or refine, existing methods......season them to taste, if you will. There are midairs that occur from certainly understandable conditions.....conditions that could be mitigated, or the lessons relearned, or occurred in a situation outside the reasonable control of the parties involved (rare), or due to a previously unknown set of factors (even more rare). Then there are midairs, like any other accident of similiar causal factors, where you look at it and think "this really need not have happened." If only the proper training were there. If only the participants would've analyzed why it was so important to partake in a certain activity. In this case, why was formation flight deemed necessary, especially with all the limitations and risk clearly presenting itself? This mission, to retrieve an airplane from an outbase, is one of the more benign missions out there; yet the people involved deliberately, and for still unclear reasons, turned what should've been a very vanilla mission, into a real challenge that was full of unnecessary risk......challenge that would've tasked even the most trained formation flyers among us. It was certainly no walk in the park, and certainly not a mission (the mission it became) to be taken lightly, as the players this night in May did so. The tragedy of carelessness and overconfidence, as so eloquently stated in the opening quote of this report, showed itself to be alive and well, and truer than ever. And the results were deadly. If there's anything to take out of this accident, it's that planning, knowing your training limits, keeping within your experience level, using common sense, never being careless, managing risk versus reward for what you're planning to do, and being thorough when you do it; are traits that should never be taken for granted......
.....if you want to avoid Things That Go Bump In The Night.
MikeD
The above is not intended to be an undue criticism of the person or persons involved in the incident described. Instead, the analysis presented is intended to further the cause of flight safety and help to reduce accidents and incidents by educating pilots through the sacrifices of others in our profession.
