What You Don\'t Know Can Hurt you
Statistics are like a bikini......what they reveal is interesting, but what they cover is vital.
9 January 1983
Atlantic Ocean, 30 miles south of Cherry Point, North Carolina
Midair Collision:
Beechcraft D-55 Baron, N7142N/F-4C Phantom II, 63-7536
7 Fatal
International flying to and from the US is just like flying anywhere within the US, insofar as the actual piloting goes. You takeoff from one field, climb to an altitude, follow a planned routing, and descend and land at another field. The main flying differences only being further overwater legs and/or the reduction of available navaids, depending on where it is you're flying to and from. The biggest difference between international and intranational flying is the increased regulatory compliance required for flights outside of US borders. Everything from differing insurance requirements, to ICAO regulations, to radio station/radio operator certificate requirements, etc are all items that need to be planned for and executed. Flight planning-wise, one of the most important considerations for the pilot is how he's going to exit and, more importantly, re-enter US airspace; especially in todays times. Again, ATC and US Customs procedures aren't rocket science, but knowing what regulations you have to comply with is imperative, and they must be followed by the numbers. For ADIZ penetrations, that means being on an IFR or DVFR flight plan; and if on the DVFR flight plan, further notifying ATC of estimated time/position/altitude of ADIZ penetration no later than 15 minutes prior to doing it. For Customs requirements, that means one hour prior notification of arrival at one of 30+ international "airports of entry", whichever is closest to your point of entry into the US; fines for no or inadequate notice can be steep. In short, to fly internationally, you must be cognizant of and adhere to the additional regulations involved in undertaking this endeavor.
On 9 January 1983, a Beech D-55 Baron, N7142N, departed Nassau, Bahamas on a flight to Norfolk, Virginia. During his pre-flight planning at the Nassau FSS, the pilot had originally planned his flight to follow Atlantic Route 3 at 8,500' to Wilmington, North Carolina thence direct Norfolk, but was advised that he would need to re-route, since all arrivals from the caribbean required entry through Florida in order to clear US Customs. The pilot amended his routing to land at Fort Pierce, Florida in order to clear Customs, then depart for Norfolk. Following takeoff from Nassau at 1340 EST, the pilot was advised to contact Bahamian en-route VFR advisory service for activation of his DVFR flight plan. Bahamian FSS personnel never heard from N7142N, and hence, his flightplan was never formally opened. For the next 3 hours, N7142N and it's 7 onboard crossed the Atlantic Ocean and approached US airspace. At around 1630 EST, the pilot of 7142N contacted Washington ARTCC and advised that he was 50 miles south of New Bern, North Carolina at 9,500' proceeding direct Norfolk, Virginia, and requested deviation around some weather he was encountering. Center issued a squawk code of 0524, and advised the pilot of 7124N that they didn't see any weather in the area of his reported position. Additionally, ATC advised that he didn't see a secondary radar return from the same position either. The pilot acknowleged, informing that he was on the Wilmington (NC) VORTAC 133 for 56 miles that he would recycle his transponder, and further requested ATC to notify Customs of his pending arrival at Norfolk, Virginia.
About 20 minutes prior to N7142Ns first contact with Washington ARTCC, the US Air Force Semi-Automatic Ground Equipment (SAGE) radar facility at Fort Lee, Virginia detected an airborne radar target penetrating the Atlantic Coastal ADIZ inside Warning Area 122 (W-122). SAGE is a long-range Ground Control Intercept (GCI) radar system that is used to monitor the ADIZ areas, in support of the North American Aerospace Defense Command (NORAD). The contact picked up by the GCI controllers couldn't be matched to any known or pending flight information of flightplans on file. As per standard procedure, the radar contact was classified as "Unknown", and a "Scramble" order was issued to the 191st Fighter Interceptor Group Alert Facility at Seymour-Johnson AFB, North Carolina. 7 minutes later, two McDonnell-Douglas F-4C Phantom II fighters from the 171st Fighter Interceptor Squadron of the Michigan Air National Guard, callsign Juliet-Lima 25 and 26, got airborne from Seymour-Johnson, and were given an initial heading and altitude of 130 and FL 230 prior to handoff from Washington Center to their GCI control. A few minutes prior to the departure of the F-4s, the SAGE GCI controllers queried both Washington and Jacksonville ARTCCs concerning a 1200 squawk radar contact within W-122 and whether either Center was talking to or working with that contact. Both Centers advised GCI that they weren't (this is 15 minutes prior to the Baron's first contact with Washington ARTCC). Handed-off from Center to GCI, JL 25 and 26 were cleared to FL 250, and told to take up a 160 heading to intercept the single contact that was at their 170 degrees for 110 miles. GCI further advised that the unknown was heading 010, speed 200 kts at 6,500', and briefed the fighters to expect vectors for a stern intercept/visual identification on the target, and to approach no closer than 500' from the target. Still 3 minutes before the time the Beech Baron first contacted Washington ARTCC, the F-4s were being vectored to, and were within, 10 miles of the Baron. They had been cleared down to 10,000' block 13,000' for the intercept, and the lead F-4 pilot advised GCI that IMC existed below 13,000'. 3 minutes after 7142N's initial contact with Washington Center (and while Center is still trying to get a radar contact and sort out 7142s information) GCI vectored the F-4s into a trail position on the Baron at 8 miles, and advised the fighters to slow below .78M in order to manage their overtake. At this time, GCIs responsibility is to vector the fighters into a position to where they can begin searching with their own onboard radars, acquire the target, and move-in to complete the intercept. Until the fighters can take over the intercept on their own, GCI must manage the F-4s heading, airspeed, and altitude, in order to effect placing them in the optimum position to allow them to target-acquire themselves. JL 25 remained in VMC just above the solid undercast at 13,000' and continued driving up the target's 7 o'clock, deliberately keeping the target about 15 degrees right-offset in order to enhance radar acquisition by the fighter's onboard systems and additionally, provide for a horizontal separation factor in concert with the vertical-separation factor already in-effect due to the altitude differences of the target aircraft and the fighters. Additionally, approaching with this offset allowed the F-4 to "slide in" to a loose formation on the target as he came alongside. JL 25 was unable to acquire the target with it's onboard radar on this pass, and GCI turned the F-4s away from the target, giving them a left 360-degree turn in order to reposition them for the intercept. During this turn, JL 25 and 26 swapped lead position, with JL 26 assuming the lead. JL 26s Weapon System Officer (WSO) acquired the target with his onboard radar and JL 26 descended, entering IMC and leveling-off at 1000' below the target's altitude (based on the onboard radar readout), while maintaining the right offset from the target by coming up the target's 7 o'clock like JL 25 did, as opposed to closing from direct 6 o'clock.
During this time, Washington Center called GCI via landline, and advised them that they had just begun talking to a Baron 7142N that they believed was lost. Center explained that they were attempting to radar-identify the target, and that it could be the target that the F-4s were coming up in trail on. GCI acknowleged Washington Center's information, but continued the intercept due to the inconclusive nature of the information. During this time, the weather in the area had gotten worse, with the undercast rising to 14,000'. JL 26 and 25 were now both solidly "popeye", or in IMC. GCI updated the target info as "360/7" and shortly thereafter, JL 26 advised that they had a contact at 020 for 6. GCI acknowleged that that was their target, and JL 26 called "Judy", indicating that they had positive radar contact, and would complete the intercept with their onboard radar. JL 26 was cleared for this and reminded to approach no closer than 500' to the target. At this same time, 11 minutes after 7142Ns initial contact with Washington ARTCC, the Center controller had given a "squawk-ident" instruction to the flight. Center advised GCI that he'd identified the target as "the one that's at Juliet Lima's 12 o'clock for 6 or 7 miles." Since there was no flight plan or other information on 7142N in regards to what or who he really was, the GCI senior-director elected to have the F-4s complete the intercept in order to acquire a positive ID, a standard procedure. JL 26 revised his closure minimum to no closer than 1,500' for IMC (500' VMC), and continued inbound at 230 KIAS (50 kts closure) while maintaining the target in a right-offset. Approaching the target's 7 o'clock and coming to 1,500' of the target, the pilot of JL 26 still couldn't see the Baron, and the WSO received a "break X" indication on his radar scope; indicating that they were at the minimum closure range. The pilot of JL 26 initiated a 30 degree left turn and began a climb in order to terminate the intercept and separate from the target. Meanwhile, Washington Center has radar identified 7142N, and the controller advised the pilot that he was inside a Warning Area, and fighters had been sent up to intercept him. The Washington Controller issued 7142N a left turn in order to get him out of the W-122, and headed towards New Bern. As 7142N rolled into his left turn, JL 26 had just terminated his radar contact, and was in his own climbing left turn in order to separate from the target. Due to JL 26s much wider turn radius with it's increasing speed, and the left turn 7142N had now initiated; it was inevitable that the turn circles of JL 26 and 7142N would intersect. Unluckily, the intersection point was at the same point in space that both aircraft were at. The pilot and WSO of JL 26 felt a bump and received warning lights in their cockpits. At that time, it was realized that they'd collided with the Baron. In fact, JL 26 and 7142N had collided at nearly the same bank angle, at the same altitude, and only slightly offset in heading. Consequently, JL 26s left wing sliced 7142N in half longitudinally from tail to nose, destroying 7142N and tearing the left drop tank from JL 26. JL 26 subsequently declared an emergency and returned uneventfully to Seymour-Johnson AFB. US Marine Corps and US Coast Guard helicopters were dispatched to the location of the midair in order to search for wreckage and survivors. Only some small debris and some life vests were ever found from 7142N, but the ocean wasn't the only place wreckage of 7142N was found. Upon returning to Seymour-Johnson AFB, JL 26 was found to have numerous scratches and gashes on it's lower fuselage. Propeller slash marks were found all along the left wing, and large pieces of human hair, bone, skin, and heavy amounts of smeared blood were found embedded in the left wing leading edge. Also embedded in the left wing leading edge of the F-4 was the Baron's rudder tab hinge wire, a section of the Baron's front plexiglass windscreen, and the Baron's manifold pressure gauge.
Probable Cause
The NTSB did not issue a formal Probable Cause for this accident. Three different "Statements of Cause" were issued by 4 different members of the Board. Statements of Cause simply highlight various causal and/or contributing factors, while not pinpointing a primary causal factor. They each centered on varying factors; everything from the F-4 crew not maintaining safe separation, to the Baron pilot not following proper flight planning procedures for international operations.
Personally, as far as the accident itself goes....that is, the actual collision.....in MikeDs professional opinion, it was bad timing with the simultaneous ATC-directed turn of the Baron coinciding with the breakaway turn of the F-4 as it terminated it's intercept.
Secondary Factors
Again, while no formal secondary factors were formally listed as-such by the NTSB, I'll compile a number of the causal factors here to highlight this.
*Weather- Instrument Meterologial Conditions
*Regulations Not Followed (flight)- Pilot In Command-IMC penetration
*Aircraft Speed- Dissimiliar
Tertiary Factors
Again, none formally named as-such. MikeDs selections:
*Regulations Not Followed (ATC)- Pilot In Command (ADIZ/Flight Plan)
*Communications- Incompatible- military/civilian UHF/VHF
MikeD says:
This accident highlights the importance of complying with rules and regulations, especially in this day and age. Had the pilot of 7142N:
1. Activated his flight plan; and failing that,
2. Complied with his flight-planned routing
none of the events following would've happened. The pilot of 7142Ns unfamiliarity or indifference to the regulations didn't cause the accident; but they set the stage to keep the various safety factors constantly trying to get through the holes of the Swiss Cheese Model, and hence, little chance for the multiple chain's to be broken. As this situation was set in motion by these initial events, all the following pieces fell into place, which when taken individually, were no problem; but they put all the players in the proper position to where bad timing would seal the fate of the two flight crews. Lets look at them individually:
N7142N pilot: As I stated before, the pilot's actions and inactions just after takeoff set the stage for this accident. While not directly responsible for the midair himself, the pilot of 7142N made some grave errors in judgement that, again, all "helped out" in keeping the chain of events going with no chance for a break. Everything from not activating his flightplan so ATC would know who he was, to not flying his flightplanned (and required) route to Florida, to entering and maintaining IMC while on a VFR flightplan, all were outside factors that helped enable this accident to build-up. In fact, at the time of the intercept over the Atlantic, the pilot of 7142N, had he been following his flightplan, would've then been taking off from Fort Pierce, Florida. Whether the pilot of 7142N simply didn't know the regulations, or chose not to follow them, or maybe forgot what he'd filed and was still thinking the first flightplan (assumed by his request for Customs to await his arrival at Norfolk) will never be known.
Juliet-Lima 25/26 crew: The crews of JL 25 & 26 executed their mission in compliance with the appropriate regulations and directives in-place at the time. Through their debrief and onboard recording device transcripts, I determine that they were aware of, and complying with, the regulations necessary for the mission; and were executing the same in an efficient and safe manner, given the weather conditions they were facing, as well as the dissimiliar performance levels of the Baron and the F-4. The actual collision itself was the timing of the Baron's ATC-directed turn, and their breakaway turn when they reached minimum radar range and lost radar contact.
Washington ARTCC controller: The Washington Controller did his best to deal with a "pop up" traffic that he had absolutely no previous information on. He appeared to quickly and efficiently attempt to identify who 7142N was, and kept the USAF GCI site informed via landline of all of his findings. According to testimony, he gave the Baron the final left turn in order to expedite it's exit from the Warning Area it was in, and to get it on course. The Washington Center controller couldn't see exactly what the F-4s were doing, since with Center radar, the planes that close were just one big merged-target blip anyway; and in any event, he wasn't working the F-4s, GCI was. In this author's opinion, Center's actions were reasonable.
SAGE GCI controller/staff: The GCI radar controllers, when they receive a radar target nearing or inside the ADIZ, have 2 minutes to correlate it with an active or pending flightplan. At the end of 2 minutes, the target is classified as "Unknown" and a scramble launch of fighter jets is ordered; anything done in order to reclassify the target as "Friendly" or "Hostile." These regulations are in-place and set in stone. On average, and during this time of the early 1980s when the Cold War was still very much going on, about 200 targets per year would be classified as "Unknown." Fighters would get scrambled for about 80% of these, with the remainder being IDd through the help of the FAA. In 1982 alone, 10 Soviet-Block aircraft were intercepted operating off the east coast of the US.
Final Thoughts: As we all know, accidents start with a baseline event or events, and are allowed to continue on their "path-to-destruction" by the actions or inactions of various factors, all of which attempt to get through multiple layers of Cheese in Reason's Swiss Cheese model of system failure. Each layer of cheese has some influence to break the event-continuity cycle of differing chains of events. In this accident, it can be seen how important it is to follow established rules and regulations, and how the failure to do so can set events in motion that might or might not get broken at sometime between the first action, and the accident itself. The type of situation in this accident is even more pronounced post 9/11 with the heightened awareness of security and the concern of aviation being used as a weapon against the US again.
This accident is yet one more in the long list of accidents that cause regulations to become "written in blood." 7 people contributed their blood in this case, as the ink that re-emphasizes the importance of following established rules and regulations. They became the latest statistics for failure to follow rules; and like the quote in at the top of this article says, "........what they reveal is interesting, but what they cover is vital."
And you can take that to the bank.
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.
Statistics are like a bikini......what they reveal is interesting, but what they cover is vital.
9 January 1983
Atlantic Ocean, 30 miles south of Cherry Point, North Carolina
Midair Collision:
Beechcraft D-55 Baron, N7142N/F-4C Phantom II, 63-7536
7 Fatal
International flying to and from the US is just like flying anywhere within the US, insofar as the actual piloting goes. You takeoff from one field, climb to an altitude, follow a planned routing, and descend and land at another field. The main flying differences only being further overwater legs and/or the reduction of available navaids, depending on where it is you're flying to and from. The biggest difference between international and intranational flying is the increased regulatory compliance required for flights outside of US borders. Everything from differing insurance requirements, to ICAO regulations, to radio station/radio operator certificate requirements, etc are all items that need to be planned for and executed. Flight planning-wise, one of the most important considerations for the pilot is how he's going to exit and, more importantly, re-enter US airspace; especially in todays times. Again, ATC and US Customs procedures aren't rocket science, but knowing what regulations you have to comply with is imperative, and they must be followed by the numbers. For ADIZ penetrations, that means being on an IFR or DVFR flight plan; and if on the DVFR flight plan, further notifying ATC of estimated time/position/altitude of ADIZ penetration no later than 15 minutes prior to doing it. For Customs requirements, that means one hour prior notification of arrival at one of 30+ international "airports of entry", whichever is closest to your point of entry into the US; fines for no or inadequate notice can be steep. In short, to fly internationally, you must be cognizant of and adhere to the additional regulations involved in undertaking this endeavor.
On 9 January 1983, a Beech D-55 Baron, N7142N, departed Nassau, Bahamas on a flight to Norfolk, Virginia. During his pre-flight planning at the Nassau FSS, the pilot had originally planned his flight to follow Atlantic Route 3 at 8,500' to Wilmington, North Carolina thence direct Norfolk, but was advised that he would need to re-route, since all arrivals from the caribbean required entry through Florida in order to clear US Customs. The pilot amended his routing to land at Fort Pierce, Florida in order to clear Customs, then depart for Norfolk. Following takeoff from Nassau at 1340 EST, the pilot was advised to contact Bahamian en-route VFR advisory service for activation of his DVFR flight plan. Bahamian FSS personnel never heard from N7142N, and hence, his flightplan was never formally opened. For the next 3 hours, N7142N and it's 7 onboard crossed the Atlantic Ocean and approached US airspace. At around 1630 EST, the pilot of 7142N contacted Washington ARTCC and advised that he was 50 miles south of New Bern, North Carolina at 9,500' proceeding direct Norfolk, Virginia, and requested deviation around some weather he was encountering. Center issued a squawk code of 0524, and advised the pilot of 7124N that they didn't see any weather in the area of his reported position. Additionally, ATC advised that he didn't see a secondary radar return from the same position either. The pilot acknowleged, informing that he was on the Wilmington (NC) VORTAC 133 for 56 miles that he would recycle his transponder, and further requested ATC to notify Customs of his pending arrival at Norfolk, Virginia.
About 20 minutes prior to N7142Ns first contact with Washington ARTCC, the US Air Force Semi-Automatic Ground Equipment (SAGE) radar facility at Fort Lee, Virginia detected an airborne radar target penetrating the Atlantic Coastal ADIZ inside Warning Area 122 (W-122). SAGE is a long-range Ground Control Intercept (GCI) radar system that is used to monitor the ADIZ areas, in support of the North American Aerospace Defense Command (NORAD). The contact picked up by the GCI controllers couldn't be matched to any known or pending flight information of flightplans on file. As per standard procedure, the radar contact was classified as "Unknown", and a "Scramble" order was issued to the 191st Fighter Interceptor Group Alert Facility at Seymour-Johnson AFB, North Carolina. 7 minutes later, two McDonnell-Douglas F-4C Phantom II fighters from the 171st Fighter Interceptor Squadron of the Michigan Air National Guard, callsign Juliet-Lima 25 and 26, got airborne from Seymour-Johnson, and were given an initial heading and altitude of 130 and FL 230 prior to handoff from Washington Center to their GCI control. A few minutes prior to the departure of the F-4s, the SAGE GCI controllers queried both Washington and Jacksonville ARTCCs concerning a 1200 squawk radar contact within W-122 and whether either Center was talking to or working with that contact. Both Centers advised GCI that they weren't (this is 15 minutes prior to the Baron's first contact with Washington ARTCC). Handed-off from Center to GCI, JL 25 and 26 were cleared to FL 250, and told to take up a 160 heading to intercept the single contact that was at their 170 degrees for 110 miles. GCI further advised that the unknown was heading 010, speed 200 kts at 6,500', and briefed the fighters to expect vectors for a stern intercept/visual identification on the target, and to approach no closer than 500' from the target. Still 3 minutes before the time the Beech Baron first contacted Washington ARTCC, the F-4s were being vectored to, and were within, 10 miles of the Baron. They had been cleared down to 10,000' block 13,000' for the intercept, and the lead F-4 pilot advised GCI that IMC existed below 13,000'. 3 minutes after 7142N's initial contact with Washington Center (and while Center is still trying to get a radar contact and sort out 7142s information) GCI vectored the F-4s into a trail position on the Baron at 8 miles, and advised the fighters to slow below .78M in order to manage their overtake. At this time, GCIs responsibility is to vector the fighters into a position to where they can begin searching with their own onboard radars, acquire the target, and move-in to complete the intercept. Until the fighters can take over the intercept on their own, GCI must manage the F-4s heading, airspeed, and altitude, in order to effect placing them in the optimum position to allow them to target-acquire themselves. JL 25 remained in VMC just above the solid undercast at 13,000' and continued driving up the target's 7 o'clock, deliberately keeping the target about 15 degrees right-offset in order to enhance radar acquisition by the fighter's onboard systems and additionally, provide for a horizontal separation factor in concert with the vertical-separation factor already in-effect due to the altitude differences of the target aircraft and the fighters. Additionally, approaching with this offset allowed the F-4 to "slide in" to a loose formation on the target as he came alongside. JL 25 was unable to acquire the target with it's onboard radar on this pass, and GCI turned the F-4s away from the target, giving them a left 360-degree turn in order to reposition them for the intercept. During this turn, JL 25 and 26 swapped lead position, with JL 26 assuming the lead. JL 26s Weapon System Officer (WSO) acquired the target with his onboard radar and JL 26 descended, entering IMC and leveling-off at 1000' below the target's altitude (based on the onboard radar readout), while maintaining the right offset from the target by coming up the target's 7 o'clock like JL 25 did, as opposed to closing from direct 6 o'clock.
During this time, Washington Center called GCI via landline, and advised them that they had just begun talking to a Baron 7142N that they believed was lost. Center explained that they were attempting to radar-identify the target, and that it could be the target that the F-4s were coming up in trail on. GCI acknowleged Washington Center's information, but continued the intercept due to the inconclusive nature of the information. During this time, the weather in the area had gotten worse, with the undercast rising to 14,000'. JL 26 and 25 were now both solidly "popeye", or in IMC. GCI updated the target info as "360/7" and shortly thereafter, JL 26 advised that they had a contact at 020 for 6. GCI acknowleged that that was their target, and JL 26 called "Judy", indicating that they had positive radar contact, and would complete the intercept with their onboard radar. JL 26 was cleared for this and reminded to approach no closer than 500' to the target. At this same time, 11 minutes after 7142Ns initial contact with Washington ARTCC, the Center controller had given a "squawk-ident" instruction to the flight. Center advised GCI that he'd identified the target as "the one that's at Juliet Lima's 12 o'clock for 6 or 7 miles." Since there was no flight plan or other information on 7142N in regards to what or who he really was, the GCI senior-director elected to have the F-4s complete the intercept in order to acquire a positive ID, a standard procedure. JL 26 revised his closure minimum to no closer than 1,500' for IMC (500' VMC), and continued inbound at 230 KIAS (50 kts closure) while maintaining the target in a right-offset. Approaching the target's 7 o'clock and coming to 1,500' of the target, the pilot of JL 26 still couldn't see the Baron, and the WSO received a "break X" indication on his radar scope; indicating that they were at the minimum closure range. The pilot of JL 26 initiated a 30 degree left turn and began a climb in order to terminate the intercept and separate from the target. Meanwhile, Washington Center has radar identified 7142N, and the controller advised the pilot that he was inside a Warning Area, and fighters had been sent up to intercept him. The Washington Controller issued 7142N a left turn in order to get him out of the W-122, and headed towards New Bern. As 7142N rolled into his left turn, JL 26 had just terminated his radar contact, and was in his own climbing left turn in order to separate from the target. Due to JL 26s much wider turn radius with it's increasing speed, and the left turn 7142N had now initiated; it was inevitable that the turn circles of JL 26 and 7142N would intersect. Unluckily, the intersection point was at the same point in space that both aircraft were at. The pilot and WSO of JL 26 felt a bump and received warning lights in their cockpits. At that time, it was realized that they'd collided with the Baron. In fact, JL 26 and 7142N had collided at nearly the same bank angle, at the same altitude, and only slightly offset in heading. Consequently, JL 26s left wing sliced 7142N in half longitudinally from tail to nose, destroying 7142N and tearing the left drop tank from JL 26. JL 26 subsequently declared an emergency and returned uneventfully to Seymour-Johnson AFB. US Marine Corps and US Coast Guard helicopters were dispatched to the location of the midair in order to search for wreckage and survivors. Only some small debris and some life vests were ever found from 7142N, but the ocean wasn't the only place wreckage of 7142N was found. Upon returning to Seymour-Johnson AFB, JL 26 was found to have numerous scratches and gashes on it's lower fuselage. Propeller slash marks were found all along the left wing, and large pieces of human hair, bone, skin, and heavy amounts of smeared blood were found embedded in the left wing leading edge. Also embedded in the left wing leading edge of the F-4 was the Baron's rudder tab hinge wire, a section of the Baron's front plexiglass windscreen, and the Baron's manifold pressure gauge.
Probable Cause
The NTSB did not issue a formal Probable Cause for this accident. Three different "Statements of Cause" were issued by 4 different members of the Board. Statements of Cause simply highlight various causal and/or contributing factors, while not pinpointing a primary causal factor. They each centered on varying factors; everything from the F-4 crew not maintaining safe separation, to the Baron pilot not following proper flight planning procedures for international operations.
Personally, as far as the accident itself goes....that is, the actual collision.....in MikeDs professional opinion, it was bad timing with the simultaneous ATC-directed turn of the Baron coinciding with the breakaway turn of the F-4 as it terminated it's intercept.
Secondary Factors
Again, while no formal secondary factors were formally listed as-such by the NTSB, I'll compile a number of the causal factors here to highlight this.
*Weather- Instrument Meterologial Conditions
*Regulations Not Followed (flight)- Pilot In Command-IMC penetration
*Aircraft Speed- Dissimiliar
Tertiary Factors
Again, none formally named as-such. MikeDs selections:
*Regulations Not Followed (ATC)- Pilot In Command (ADIZ/Flight Plan)
*Communications- Incompatible- military/civilian UHF/VHF
MikeD says:
This accident highlights the importance of complying with rules and regulations, especially in this day and age. Had the pilot of 7142N:
1. Activated his flight plan; and failing that,
2. Complied with his flight-planned routing
none of the events following would've happened. The pilot of 7142Ns unfamiliarity or indifference to the regulations didn't cause the accident; but they set the stage to keep the various safety factors constantly trying to get through the holes of the Swiss Cheese Model, and hence, little chance for the multiple chain's to be broken. As this situation was set in motion by these initial events, all the following pieces fell into place, which when taken individually, were no problem; but they put all the players in the proper position to where bad timing would seal the fate of the two flight crews. Lets look at them individually:
N7142N pilot: As I stated before, the pilot's actions and inactions just after takeoff set the stage for this accident. While not directly responsible for the midair himself, the pilot of 7142N made some grave errors in judgement that, again, all "helped out" in keeping the chain of events going with no chance for a break. Everything from not activating his flightplan so ATC would know who he was, to not flying his flightplanned (and required) route to Florida, to entering and maintaining IMC while on a VFR flightplan, all were outside factors that helped enable this accident to build-up. In fact, at the time of the intercept over the Atlantic, the pilot of 7142N, had he been following his flightplan, would've then been taking off from Fort Pierce, Florida. Whether the pilot of 7142N simply didn't know the regulations, or chose not to follow them, or maybe forgot what he'd filed and was still thinking the first flightplan (assumed by his request for Customs to await his arrival at Norfolk) will never be known.
Juliet-Lima 25/26 crew: The crews of JL 25 & 26 executed their mission in compliance with the appropriate regulations and directives in-place at the time. Through their debrief and onboard recording device transcripts, I determine that they were aware of, and complying with, the regulations necessary for the mission; and were executing the same in an efficient and safe manner, given the weather conditions they were facing, as well as the dissimiliar performance levels of the Baron and the F-4. The actual collision itself was the timing of the Baron's ATC-directed turn, and their breakaway turn when they reached minimum radar range and lost radar contact.
Washington ARTCC controller: The Washington Controller did his best to deal with a "pop up" traffic that he had absolutely no previous information on. He appeared to quickly and efficiently attempt to identify who 7142N was, and kept the USAF GCI site informed via landline of all of his findings. According to testimony, he gave the Baron the final left turn in order to expedite it's exit from the Warning Area it was in, and to get it on course. The Washington Center controller couldn't see exactly what the F-4s were doing, since with Center radar, the planes that close were just one big merged-target blip anyway; and in any event, he wasn't working the F-4s, GCI was. In this author's opinion, Center's actions were reasonable.
SAGE GCI controller/staff: The GCI radar controllers, when they receive a radar target nearing or inside the ADIZ, have 2 minutes to correlate it with an active or pending flightplan. At the end of 2 minutes, the target is classified as "Unknown" and a scramble launch of fighter jets is ordered; anything done in order to reclassify the target as "Friendly" or "Hostile." These regulations are in-place and set in stone. On average, and during this time of the early 1980s when the Cold War was still very much going on, about 200 targets per year would be classified as "Unknown." Fighters would get scrambled for about 80% of these, with the remainder being IDd through the help of the FAA. In 1982 alone, 10 Soviet-Block aircraft were intercepted operating off the east coast of the US.
Final Thoughts: As we all know, accidents start with a baseline event or events, and are allowed to continue on their "path-to-destruction" by the actions or inactions of various factors, all of which attempt to get through multiple layers of Cheese in Reason's Swiss Cheese model of system failure. Each layer of cheese has some influence to break the event-continuity cycle of differing chains of events. In this accident, it can be seen how important it is to follow established rules and regulations, and how the failure to do so can set events in motion that might or might not get broken at sometime between the first action, and the accident itself. The type of situation in this accident is even more pronounced post 9/11 with the heightened awareness of security and the concern of aviation being used as a weapon against the US again.
This accident is yet one more in the long list of accidents that cause regulations to become "written in blood." 7 people contributed their blood in this case, as the ink that re-emphasizes the importance of following established rules and regulations. They became the latest statistics for failure to follow rules; and like the quote in at the top of this article says, "........what they reveal is interesting, but what they cover is vital."
And you can take that to the bank.
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.
