NTSB Factual Report

History of Flight

On June 21, 1995, at 1108 hours Pacific daylight time, a McDonnell Douglas C54G, N4989P, and a Beech B58P, N156Z, collided about 1 mile east of Ramona Airport, Ramona, California. N4989P was registered to and operated by Aero Union Corporation, Chico, California; N156Z was registered to and operated by the USDA Forest Service (herein referred to as Forest Service), Boise, Idaho. Both airplanes were engaged in aerial fire suppression activities; N4989P was operating as Tanker 19, and N156Z was operating as Lead 56. Both airplanes were destroyed by impact forces and the resulting postimpact fire. Two residences, a water tank, and two vehicles were also destroyed. The two flight crewmembers aboard Tanker 19 and the certificated airline transport pilot aboard Lead 56 sustained fatal injuries. Visual meteorological conditions prevailed. Lead 56 departed Ontario Airport, Ontario, California, at 0800 hours; Tanker 19 departed Hemet-Ryan Airport, Hemet, California, at 1022 hours.

Both airplanes were engaged in fire suppression activities over the Butterfield Ranch about 30 miles northeast of Ramona Airport. After departing Ontario Airport, Lead 56 flew over the fire area and conducted fire spotting and led several air tankers to specific drop areas. Lead 56 remained over the area until relieved by another Forest Service airplane, Lead 55, at 1100 hours.

Tanker 19 departed Hemet-Ryan Airport on its initial fire suppression activities over the Butterfield Ranch at 0845 hours. Tanker 19 made two fire retardant drops and returned to Hemet-Ryan Airport for additional fire retardant chemicals. Tanker 19 landed at Hemet-Ryan Airport at 0927 hours and then departed at 1022 hours. After arriving over the Butterfield Ranch fire, Lead 56 instructed all tankers to orbit over the desert, about 6 miles northeast of the fire area.

About 1050 hours, Lead 55 with two pilots on board relieved Lead 56. Lead 56 briefed Lead 55 on the fire suppression status and then flew to Ramona Airport. At 1058 hours, Lead 55 instructed all tankers, except Tanker 153, to return to Ramona Airport; Tanker 153 returned to Hemet-Ryan Airport.

Lead 55's pilot said that before departing the fire area he called all tankers on the tactical frequency to assure that they responded to his release instructions. All the tankers, except Tanker 19, immediately responded. Lead 55's pilot again called Tanker 19, and Tanker 19 then acknowledged the instructions.

Lead 55's pilot said he heard Lead 56 transmit that he was 9 miles out and requested fuel on the helicopter's fire operations frequency. Moments later, Lead 55's pilot switched to the air tankers' operations frequency and heard Lead 56 call for fuel. Lead 55 asked Lead 56 to order fuel for his airplane, but did not receive a response.

Lead 55's pilot then said he heard Lead 56 in the traffic pattern making some radio transmissions, and then said he thought he heard Tanker 19 reporting on initial approach about 8 miles east of the airport. After hearing Lead 56's calls, the check pilot aboard Lead 55 said "midair, midair." Lead 55's pilot said that he only saw a small flash followed by a large fire ball from the crash site. Lead 55 was between 2 - 3 miles east of the airport.

After seeing the fire ball, Lead 55's pilot said that he observed a Grumman S2 aircraft making a left crosswind turn over the airport and a small general aviation airplane departing the area toward the north. Lead 55 then instructed all tankers to climb and divert to Hemet.

The check airman aboard Lead 55 told National Transportation Safety Board investigators that he heard Lead 56 transmit over the Ramona Airport's common traffic advisory frequency (CTAF -- 122.7 MHz). The pilot reported that he was on initial approach to runway 27 for a 360-degree overhead approach. The check airman then told Safety Board investigators that Lead 56's transmission was made on the helicopter's fire operations frequency, 123.975 MHz. He said that he did not observe Lead 56 and did not hear Tanker 19 make any transmissions.

When Lead 55 was about 5 miles behind Tanker 19, the check airman said he saw a general aviation airplane on the downwind leg, and another airplane on the base leg behind Tanker 19. Moments later, he saw Tanker 19 pitch up to a near vertical nose-up attitude and then nose down and descend uncontrolled. The check airman was not aware that Lead 56 was involved in the accident.

Another pilot (Tanker 70, a Grumman S2) told Safety Board investigators that after being released from the fire area he followed Tanker 19 toward Ramona Airport. He said that he and several tankers, including Tanker 19, had been orbiting the area at 6,000 feet mean sea level (msl). When Lead 55's pilot released the tankers, he followed Tanker 19 to the airport and immediately began a shallow descent direct to Ramona Airport; he was flying at 180 knots indicated airspeed.

He said that he heard Tanker 19 make two transmissions over the CTAF. The first transmission was when the flight was 8 miles east of the airport and the second when the flight was on initial approach, about 2 miles east of the airport. He said that when Tanker 19 made the second call he (Tanker 70) was descending through 2,500 msl (about 1,200 feet above the ground). Tanker 19 was ahead of him flying at 180 knots and began to "slow down" and was slightly below the horizon.

He said he heard Lead 56 make a radio transmission over the CTAF, but could not recall what was said and until the collision, he did not see Lead 56. Shortly after Tanker 19 made the last transmission, he saw Tanker 19's tail (empennage) separate. Tanker 19 immediately pitched down and entered an uncontrolled descent until colliding with the terrain.

A California Department of Forestry air attack officer, a nonflying crewmember on a Rockwell OV-10, N401DF (Air Attack 310), told Safety Board investigators that helicopter fire operations continued over the fire area after the air tankers returned to the airport. He said that he was monitoring all frequencies; four FM tactical frequencies and two VHF frequencies, 122.925 MHz (air attack frequency) and 123.975 MHhz (helicopter's fire operations frequency), while flying over the fire area. He heard Lead 56 transmit twice on one of the VHF frequencies. The initial transmission was when Lead 56 was departing the fire area and the second transmission was when Lead 56 reported that he was 10 miles east of Ramona Airport for landing. The air attack officer was not monitoring the airport's CTAF.

Safety Board investigators interviewed several ground witnesses. The consensus of the ground witnesses was that Lead 56 was trailing Tanker 19 from above and to the left. Lead 56 appeared to then accelerate during the descent and strike Tanker 19's vertical stabilizer. Both airplanes' empennages separated and the airplanes entered an uncontrolled descent until impact. Tanker 19 descended in a nose-down attitude and Lead 56 was in a flat spin.

A general aviation pilot departing the area and a tanker pilot taxiing to the tanker base said that they heard both airplanes transmit their position over the CTAF.

Some of the witnesses said that both airplanes executed the 360-degree overhead approach before the collision, and that both airplanes' landing gears were retracted.

The approximate collision coordinates are: 33 degrees, 02.14 minutes north latitude and 116 degrees, 53.19 minutes west longitude.

Crew Information

N4989P (Tanker 19)

Pilot-in-Command (PIC)

The PIC was employed by Aero Union Corporation (herein referred to as Aero Union) since 1984. He held a commercial pilot certificate with airplane single and multiengine land, instrument airplane, and DC-4, L-P2V, and L-188 type ratings. He also held an unrestricted second-class medical certificate that was issued by a designated Federal Aviation Administration (FAA) medical examiner on April 5, 1995.

The operator provided the Safety Board with both pilots' flight records that included excerpts from their personal flight hours logbook. The flight hours reflected on page 3 of this report were derived from examination of these records, and the pilot's Forest Service Airplane Pilot Qualification and Approved Record dated April 10, 1995.

The examination revealed that the captain had accrued a total of 6,100 hours, including 5,400 hours as PIC. He had also flown 750 hours as PIC in the accident airplane make and model. During the 60 days preceding the accident, the pilot accrued more than 10 hours in the accident airplane make and model. During the preceding 24 hours of the accident, the PIC and the Second-in-Command (SIC) had flown 4 hours.

The pilot satisfactorily completed a PIC proficiency check under the provisions of 14 CFR 61.58, an instrument competency check as required by 14 CFR 61.57, and demonstrated the skill and knowledge requirements as required by 14 CFR Part 137.19 on April 13, 1995.

In addition to the certificates noted above, the PIC held an expired flight instructor certificate with airplane single engine and instrument airplane ratings. He also held an aircraft mechanic certificate with airframe and powerplant ratings.

Second-in-Command (SIC)

The SIC was employed by Aero Union on May 29, 1995. She held an airline transport pilot (ATP) certificate with an airplane multiengine land rating. She received the ATP certificate on April 9, 1995. The certificate was endorsed for commercial privileges with an airplane single engine land rating. She also held an unrestricted first-class medical certificate that was issued by a designated FAA medical examiner on December 1, 1994.

The flight hours reflected in Supplement E of this report were derived from the company's records and the Forest Service Airplane Pilot Qualification and Approved Record dated May 30, 1995. The examination revealed that the first officer accrued 2,142 hours, of which 2,064 hours were flown as PIC. During the preceding 90 days of the accident, the SIC accrued 135 hours that included 6 hours as SIC in the accident airplane make and model.

The SIC satisfactorily completed a SIC proficiency check under the provisions of 14 CFR 61.55, and demonstrated the skill and knowledge requirements as required by 14 CFR Part 137.19 on April 30, 1995.

Aero Union's Chief Pilot noted in the SIC's training records that he did not observe any problems during the training and [that she had] nice awareness at all times.

In addition to the certificates noted above, the SIC held a flight instructor certificate with airplane single engine and instrument airplane ratings. She also held a flight engineer certificate with a turbojet powered rating, and an aircraft mechanic certificate with airframe and powerplant ratings.

N156Z (Lead 56)

The pilot was employed by the Forest Service. He held an airline transport pilot certificate with an airplane multiengine land rating; the certificate was endorsed for commercial privileges with an airplane single engine land rating. He also held an unrestricted first-class medical certificate that was issued by an FAA designated airman medical examiner on January 17, 1995.

Safety Board investigators recovered the pilot's flight hours logbook. The flight hours reflected in this report (LAX-95-F-A219B) were derived from the pilot's logbook and the Pilot/Operator Aircraft Accident Report, NTSB 6120.1/2, submitted by the Forest Service and include the accident flight. The logbook and aircraft accident report disclosed that the pilot accrued 5,494 hours, of which 505 hours were in the accident airplane make and model. During the preceding 90 days of the accident, the pilot logged 97 hours in the accident airplane make and model. He also flew 13.8 hours during the preceding 24 hours of the accident.

The pilot satisfactorily completed the airline transport pilot flight test on February 2, 1995. The flight test satisfied the biennial flight review requirements of 14 CFR 61.56.

In addition to the pilot certificates noted above, the pilot held a flight instructor certificate with airplane single engine, multiengine, and instrument airplane ratings.

Aircraft Information

N4989P

The airplane was registered to and operated by Aero Union and was operating under contract to the Forest Service. The U.S. Forest Service exercised operational control of the airplane during its fire suppression operations.

The airplane was originally operated by the U.S. Air Force. The FAA issued the airplane a multiple airworthiness certificate pursuant to the provisions of 14 CFR 21.187, a standard airworthiness certificate in the transport category on April 12, 1984, and a special airworthiness certificate in the restricted category on October 17, 1984. The operating limitations specify, in part:

. . . no person may operate this aircraft for other that the purpose for which the special airworthiness certificate was issued [Forest and Wildlife Conservation] and in accordance with operating limitation contained in FAR 91.313 with special operating limitations to operate over densely populated areas, in congested airways, from busy airports where passenger transport operations are being conducted and those contained herein. . .

Aero Union maintained the airplane under 14 CFR 91.409(F)4; a continuous airworthiness program. The airplane flight hours and maintenance data reflected in this report were obtained from the operator's Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1/2. According to the report, the airplane and engines were last inspected on May 1, 1995. The airplane accrued 10 flight hours since the inspection and 23,507 total hours at the time of the accident.

N156Z

The airplane is registered to and maintained by the U.S. Department of Agriculture Forest Service. Examination of the airplane's maintenance records disclosed that the airplane is maintained according to the manufacturer's inspection program that consists of six phases.

Beechcraft West, Ontario International Airport, conducted the last inspection, a phase 4 inspection, on June 15, 1995. At the time of the accident, the airplane accrued 9.7 hours since the inspection. There were no deferred maintenance discrepancies that would have affected the airplane's performance.

Meteorological Information

Ramona Airport does not have an official weather observation facility. The weather data reflected on page 4 of this report were obtained from the pilot and ground witnesses. According to the witnesses, visual meteorological conditions existed at the time of the accident and the surface and airborne visibility exceeded 20 miles.

According to a Safety Board computer generated Sun and Moon position program, at the time and position of the collision the sun was 66.6 degrees above the horizon on a bearing of 091.8 degrees.

Airport Information

Ramona Airport is operated by the County of San Diego, San Diego, California. The airport is located 2 miles east of the city. It has one 4,000-foot-long by 150 feet wide asphalt surfaced runway. The runway is oriented in an east/west direction (9/27). The field elevation is 1,393 feet msl.

The airport manager told Safety Board investigators that she was aware that air tankers sometimes execute a 360-degree overhead approach. She said that she did not specifically approve this maneuver; nor did she disapprove it.

Forest Service personnel reported that all air tankers use a 360-degree overhead maneuver when flying inbound from the east and landing on runway 27. The airplanes are to fly parallel and to the right (north) of the runway and initiate the crosswind leg over the departure end of the runway. The airplane would then continue to make left 90-degree turns until established on final approach.

The check airman aboard Lead 55 said that at a prefire season briefing, he told all pilots that the overhead maneuver would be flown at 2,000 feet above the ground. The pilot flying Tanker 70 and a CDF OV-2 (a Cessna 337) pilot said that the pilots fly the overhead approach at the established traffic pattern altitude of an airport. Th

NTSB Probable Cause

INADEQUATE VISUAL LOOKOUT BY THE BEECH 58P PILOT, AND THE OPERATOR'S INADEQUATE PROCEDURES CONCERNING 360-DEGREE OVERHEAD APPROACHES.