NTSB Factual Report

HISTORY OF FLIGHT

On December 3, 1999, about 1023 eastern standard time, a Piper PA-44-180 (Seminole) airplane, N3038N, registered to and operated by Phoenix East Aviation, Inc., and a Piper PA-28-161 (Cadet) airplane, N153ER, registered to and operated by Embry-Riddle Aeronautical University, collided in-flight near the departure end of runway 5 at the DeLand Municipal-Sidney H Taylor Field Airport, DeLand, Florida. Visual meteorological conditions prevailed at the time and a local instrument flight rules (IFR) flight plan was filed for the 14 CFR Part 91 instructional flight of the Seminole airplane. No flight plan was filed for the 14 CFR Part 91 instructional flight of the Cadet airplane; none was required. Both airplanes were destroyed and the certified flight instructor (CFI) and commercial pilot-rated student of the Seminole airplane were fatally injured. The CFI and private pilot-rated student of the Cadet airplane also were fatally injured. The Seminole flight originated about 0939 from the Daytona Beach International Airport, Daytona Beach, Florida. The Cadet flight originated about 0921, also from the Daytona Beach International Airport, Daytona Beach, Florida.

According to a transcription of communications from Daytona Beach Air Traffic Control Tower (DAB ATCT), a flightcrew member in the Cadet contacted clearance delivery and requested a visual flight rules (VFR) clearance to Leesburg. The flight was cleared to taxi to runway 7R at 0911:48, and was cleared for takeoff at 0920:52. After takeoff, air traffic control (ATC) communications were transferred to Daytona Beach departure control then to the Daytona Beach South-Arrival Radar position. The flight remained in contact with that facility from 0924:45, to 0934:11, when the controller advised the flight to proceed on course, squawk the VFR transponder code, and provided the frequency of the next ATC facility. That transmission was acknowledged; there were no further recorded transmissions from the flightcrew with the DAB ATCT.

The transcription of communications from DAB ATCT indicates that a flightcrew member in the Seminole airplane contacted clearance delivery and requested, "a local IFR clearance ah we would like to shoot ah VOR 23 approach deland to be followed by ndb approach runway thirty deland and uh then we'll break off and come back for an ILS later." The controller cleared the flight to the DeLand airport via radar vectors; the clearance was read back by a flightcrew member. The flight was cleared to taxi to runway 7L at 0918:50, and was cleared for takeoff at 0938:48. After takeoff, ATC communications were transferred to the Daytona Beach North-Arrival Radar position. While in contact with that facility, at 0942:10, a flightcrew member asked the controller, "ah three zero three eight november is it possible we can have the full approach sir uh to fly over the vor", to which the controller responded, "...unable vor uh vor deland approach." A flightcrew member advised the controller "three eight November a mile north of Ormond is fine sir." The controller responded, "...not for you sir unable vor two three approaches fly tower assigned heading now." The controller advised the flight the heading to fly, and "...unable vor two three at deland." A flightcrew member responded that they would like to perform if possible a non directional beacon (NDB) instrument approach to runway 30 at DeLand. The controller advised, "okay three eight november delands saturated right now unable any approaches at deland let me rephrase that unable any approaches at deland." A flightcrew member responded that they would like to execute a very high frequency omni-directional range station (VOR) approach to runway 16, and a NDB approach to a runway at the New Smyrna Beach Municipal Airport. A flightcrew member questioned whether they could execute the full VOR approach. The flight was vectored then cleared for the VOR approach to runway 16 at the Daytona Beach International Airport, and told to expect to break off the approach four miles north of Daytona. At 0959:28, the controller questioned the flight if they wanted to execute an instrument landing system (ILS) approach after the VOR approach, and also if they had another request. A flightcrew member responded with the registration number of the airplane and the controller stated, "...after this I ah vor 16 would you like an approach at deland now" to which a flightcrew member responded, "ah yes we'll take the deland after this one sir." The controller questioned what kind of approach they would like to execute at DeLand and a flightcrew member responded, "we'd like ah the vor two three if possible." The controller advised the flight to expect that and a flightcrew member questioned if they would be able to execute the full approach to which controller advised the flight to stand by. The controller advised the flight to expect the full approach and the VOR approach would be broken off in about another 1 1/2 miles. At 1001:23, the controller canceled the approach clearance and gave heading and altitude to fly, which was acknowledged. At 1003:53, the controller who was handling the Seminole flight briefed the relieving controller. The handling controller advised the relieving controller in part that the flightcrew was expecting the full VOR approach to runway 23.

At 1006:07, the relieving controller advised the Seminole flight to proceed direct to the Ormond Beach VORTAC and to join the 212-degree radial. A flightcrew member advised the controller that the flight was "proceeding for establishment..." and descending to 1,600 feet. The controller cleared the flight to descend to 1,600 feet and advised the flight to change to another frequency. At 1012:06, a flightcrew member advised the controller on the new frequency that the flight was descending to 1,600 feet. At 1012:30, the controller cleared the flight for the VOR approach to runway 23 at the DeLand Municipal Airport. At 1015:11, the controller advised the flight to use caution due to constant parachute jumping in progress. A flightcrew member responded "...roger", and at 1017:32, the controller questioned if the flight was going to perform a full stop landing to which a flightcrew member responded, "negative sir we uh we gonna breakoff and do some airwork and then come back with an ils full stop we'll advise you." The controller advised the flight to report canceling on the frequency, which was acknowledged. At 1018:02, a flightcrew member advised the controller that the flight was canceling at this time and the controller responded, "november three zero eight november radar service terminated squawk one two zero zero frequency change is approved." This transmission was acknowledged; there were no further recorded transmissions from the flightcrew with DAB ATCT.

Witnesses reported seeing the Cadet airplane in the traffic pattern to runway 5 at DeLand Municipal-Sidney H Taylor Field Airport (KDED) for two patterns; they also reported hearing radio calls from a flightcrew member of the airplane while in the traffic pattern on the KDED common traffic advisory frequency/UNICOM (CTAF). Two individuals who were flying reported hearing a radio call from a flightcrew member of an unidentified airplane report, "VOR 23" on the KDED CTAF frequency; one individual reported he did not recall hearing the identification of the airplane, or hear the person announce the distance or intentions. Several individuals reported hearing a flightcrew member of the Cadet airplane report on the KDED CTAF frequency that the flight was departing runway 5. One witness reported that the Cadet airplane used almost the full length of the runway, became airborne, then banked to the left and disappeared behind trees. A witness who was located near the accident site, reported seeing an airplane flying north and another airplane flying west. She reported seeing the collision and observed that one of the airplanes descended straight down and the other airplane turned to the northwest. Copies of the witness statements are an attachment to this report.

PERSONNEL INFORMATION

The CFI of the Seminole airplane was employed as a flight instructor by Phoenix East Aviation, Inc., from June through August 1999, and from September 1, 1999, through the date of the accident with the title, Director of Corporate Flight Training. He was the holder of an airline transport pilot certificate with ratings airplane single and multiengine land. He was also the holder of a flight instructor certificate with ratings airplane single and multiengine, and instrument airplane; it was scheduled to expire December 31, 2000. He was issued a first class medical certificate on June 21, 1999, with the limitation that he posses lenses to correct for near and intermediate vision. A review of his located pilot logbooks revealed he had logged a total time of approximately 7,357 hours, of which 6,399 hours were as pilot-in-command and 4,897 hours were as a flight instructor; the last logged flight was November 3, 1997, which consisted of an instrument competency check. The student of the Seminole airplane was the holder of a commercial pilot certificate with ratings airplane single and multi-engine land, instrument airplane. He was issued a first class medical certificate on October 21, 1999, with no limitations. He had logged a total time of 5,513 hours, of which 2,996 hours were logged as second-in-command. He did not log any flight time as pilot-in-command between December 6, 1996, and the last entry in his logbook dated October 21, 1999. The student was receiving instruction towards the issuance of an airline transport pilot certificate.

The CFI of the Cadet airplane was employed as a flight instructor by Embry-Riddle Aeronautical University from September 8, 1998, through the date of the accident as a full-time flight instructor. He was the holder of a commercial pilot certificate with ratings airplane single engine land and sea, multiengine land, and instrument airplane. He was also the holder of a flight instructor certificate with ratings airplane single and multiengine land, instrument airplane; it was scheduled to expire March 31, 2001. He had logged a total of about 827 hours total time, of which about 397 hours were as a CFI, and 781 hours were as pilot-in-command. The student of the Cadet airplane was the holder of a private pilot certificate with ratings airplane single engine land, instrument airplane. She was issued a first class medical certificate on October 6, 1998, with no limitations. She logged a total time of approximately 168 hours, of which 102 hours were as pilot-in-command. The student was receiving instruction to accomplish procedures that were not performed on a previous "stage check" and also to perform maneuvers that were listed as unsatisfactory or marginal on three previous flights near the middle on November.

AIRCRAFT INFORMATION

The Seminole airplane was inspected last in accordance with a 100-hour inspection on November 23, 1999; the airplane had accumulated approximately 44 hours since the inspection at the time of the accident. The airplane was equipped in part with a DME transceiver and two navigation and communication transceivers. The VOR check was accomplished last on November 26, 1999; (required every 30 days to operate civil aircraft under IFR conditions). The pitot static system was inspected last on July 22, 1999. Copies of the VOR receiver check sheet, and pitot static system test maintenance entry are an attachment to this report.

The Cadet airplane was inspected last in accordance with a phase 2 progressive inspection on September 17, 1999; the airplane had accumulated approximately 60 hours since the inspection. The airplane was equipped in part with one communication transceiver.

METEOROLOGICAL INFORMATION

A METAR weather observation taken at the Daytona Beach Municipal Airport at 0953, indicates that the wind was calm, and the visibility was 10 miles. A broken ceiling existed at 4,800 feet, the temperature and dew point were approximately 63 degrees and 52 degrees Fahrenheit, respectively. The altimeter setting was 30.08 inHg. The Daytona Beach Municipal Airport is located approximately 056 degrees and 14 nautical miles from the accident site.

COMMUNICATIONS

Transcriptions of communications from Daytona Beach Air Traffic Control Tower containing contacts with the flightcrew members of the Seminole and Cadet airplanes are an attachment to this report. There were no reported communication difficulties with either airplane during the communications with the Daytona Beach ATCT.

AIRPORT INFORMATION

The Common Traffic Advisory Frequency (CTAF) at the DeLand Municipal-Sidney H Taylor Field Airport is 122.8. The CTAF is not recorded at the DeLand Municipal Airport, or at nearby airports that utilize the same CTAF. There is no air traffic control tower at the airport. The private radio station license issued to the City of DeLand for UNICOM frequency 122.8 was renewed in February 1996, by the Federal Communications Commission (FCC) after submission of the renewal application by the city.

The initial approach fix (IAF) for the VOR or GPS approach to runway 23 at DeLand is the Ormond Beach VORTAC (OMN), frequency 112.6. The final approach fix (FAF) for the approach is the DONGS intersection which is located in part 11 nautical miles distance measuring equipment (DME) from the OMN VORTAC on the 212-degree radial. The minimum descent altitude (MDA) for the accident airplane category for a straight in approach is 640 feet mean sea level (561 feet above ground level), and the published missed approach point (MAP) is depicted as being 5.6 nautical miles from the FAF. The frequency for Daytona Beach Approach Control is 125.35.

According to a written statement by a pilot and airplane owner who is also an air traffic controller, he was flying his airplane on the day of the accident and stated that, "As a Tower controller, I am experienced in determining aircraft positions through radio communication. After 17 years in the business, I have never witnessed frequency congestion as bad as it was on December 3. Both 122.7 and 122.8 [frequencies] were so unmanageable and absolutely chaotic that it is very understandable how no one on either frequency could understand what was going on." He also stated that he heard radio calls from pilots at 7 different airports on the DeLand CTAF. A copy of his statement is an attachment to this report. Another witness located on the DeLand Municipal Airport associated with a skydive operation reported that on the day and time of the accident, she was not listening to the portable VHF radio that they have tuned to the DeLand CTAF. She further reported that in the past, she has heard radio calls from pilots on the DeLand CTAF from five different airports. A copy of the NTSB Record of Conversation is an attachment to this report.

According to the Embry-Riddle Aeronautical University (ERAU) Aviation Safety Program Manager (ASPM), on October 5, 1999, ERAU began operating 10 airplanes at the DeLand airport under a program titled Center for Aviation Training at Embry-Riddle (CATER). After beginning operations at DeLand and before the accident, personnel from the CATER program began "a dialog" with the city engineer of the DeLand City Council regarding existing frequency congestion and bleed over of the DeLand "UNICOM" frequency from other airports that utilize the same frequency. The CATER personnel and the ERAU ASPM individual also discussed the issue of existing frequency congestion and bleed over. It was decided to approach personnel from the city of DeLand who is the license holder of the UNICOM frequency and to request a frequency change. A copy of the ERAU memorandum related to this subject is an attachment to this report.

According to personnel from the City of DeLand, "a very casual comment was made at the end of October 1999, asking if sometime in the future, DeLand might consider a frequency change. Being of a very informal nature, an application was not filed." A copy of the letter is an attachment to this report.

WRECKAGE AND IMPACT INFORMATION

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NTSB Probable Cause

The inadequate visual lookout by the pilot-in-command (PIC)/certified flight instructor (CFI) of both aircraft. Contributing factors in the accident were: 1) the frequency congestion of the CTAF 2) the poor in-flight planning decision by the PIC/CFI of the Seminole for his continuing a practice instrument approach to within approximately .6 nautical mile from the approach end of the runway with opposing airplanes departing on the upwind leg, and 3) the absence of guidance in the Aeronautical Information Manual and Advisory Circulars as to how or when to terminate a practice instrument approach to an airport that does not have an operating control tower.