NTSB Factual Report

HISTORY OF THE FLIGHT

On September 15, 1995, about 1644 eastern daylight time, an Aerospatiale TB-9, N117ER, operated by Embry-Riddle Aeronautical University (Embry-Riddle) and a Piper PA-38-112, N2351A, operated by Spruce Creek Aviation, collided while on final approach to runway 11 at New Smyrna Beach Municipal Airport, New Smyrna Beach Florida. Both flights were 14 CFR Part 91 instructional flights. Visual meteorological conditions prevailed at the time and neither flight had filed a flight plan. N117ER was destroyed and the commercial-rated flight instructor and two student pilots were fatally injured. N2351A received minor damage and the private-rated pilot was not injured. N117ER originated from Daytona Beach Regional Airport, on September 15, 1995, about 1540. N2351A originated from Spruce Creek Airport, Daytona Beach, Florida, on September 15, 1995, about 1610.

The pilot of N2351A stated he had performed four previous landings on runway 11 at New Smyrna Beach and was on his fifth approach. He reported his position by transmitting on the airport unicom frequency (unicom) while on the downwind leg. He turned base leg, reported his position on unicom, and visually checked for other aircraft on final. He did not hear transmissions from any other pilots who were on final approach or see any other aircraft on final approach. He turned to final and established his airspeed at 70 knots. While on short final he heard someone on unicom say "two planes on final, Tomahawk go around Tomahawk go around." At the same time he heard a noise and felt a bump from the bottom of his aircraft and then saw N117ER nosing down in front of him. His propeller contacted something and his engine began running rough. He proceeded to land on the runway and then turned off onto the taxiway where he stopped.

Witnesses reported that N2351A had been in the traffic pattern for runway 11 for several approaches and landings. The pilot was flying a close pattern to the runway and they heard the pilot reporting his position on unicom for each approach. No witness could remember hearing the pilots of N117ER reporting their position on unicom or seeing the aircraft before it was on short final approach. Witnesses stated there were many aircraft with the "echo romeo" call sign on unicom and they just might not have heard the pilots of N117ER reporting their position.

Witnesses saw N117ER on short final approach, and N2351A rolling wings level onto final approach about 30 feet above and just behind N117ER. The pilot in an aircraft on the ground called on unicom that there were two airplanes close together on final. There was no reaction from either aircraft. Another pilot in an aircraft on the ground then called for N2351A to go around. Shortly after this, when the aircraft were about 100 feet above the ground, N117ER was observed to pitch up 10-20 degrees and then immediately nose down to a near vertical descent from which it impacted on the displaced threshold of runway 11. N2351A continued the approach and landed on runway 11.

PERSONNEL INFORMATION

The flight instructor on N117ER had been employed by Embry-Riddle since August 18, 1995. The dual student and observer he was instructing were enrolled in the private pilot flight course and at the time of accident neither had performed solo flight.

The pilot of N2351A held a U.S. private pilot certificate issued on the basis of a Swiss private pilot certificate. He was in the U.S. to build his flight time and obtain flight training so that upon returning to Switzerland he could obtain his commercial pilot certificate.

Additional information on the pilots of N117ER and the pilot of N2351A is contained in this report under First Pilot Information and in Supplement E.

AIRCRAFT INFORMATION

Information on N117ER and N2351A is contained in this report under Aircraft Information.

METEOROLOGICAL INFORMATION

Visual meteorological conditions prevailed at the time of the accident. See Weather Information.

WRECKAGE AND IMPACT INFORMATION

N117ER and N2351A collided over the displaced threshold of runway 11 at the New Smyrna Beach Airport. Debris from the vertical stabilizer, rudder, and right stabilator of N117ER and about a 3 inch portion of propeller tip from N2351A were found in the displaced threshold area. After the collision N117ER pitched down and impacted nose first on the displaced threshold, about 300 feet past the point of collision. A post crash fire erupted. N2351A continued and landed.

Post crash examination of N117ER showed that the aircraft impacted at about a 70-80 degree nose down attitude. The post crash fire consumed the fuselage, inboard wings, and tail sections of the aircraft. The outboard portion of the right stabilator had separated from the aircraft and was found forward or southeast of the aircraft wreckage, outside of the fire area. Examination of this portion of right stabilator showed damage and transfer of black paint consistent with it having been contacted by the propeller of N2351A. The propeller of N117ER had damage consistent with it rotating at the time of impact. The engine assembly rotated after the accident. All engine accessories were consumed or damaged by the post crash fire.

Examination of N2351A showed that the 3 inch piece of propeller tip found in the area of the collision had come from its propeller. Small pieces of sheet metal debris with white and blue paint similar to the colors of N117ER were found in the propeller spinner of N2351A. Blue scrape marks similar to the color of N117ER were found on the belly of N2351A, just aft of the engine.

MEDICAL AND PATHOLOGICAL INFORMATION

Post mortem examination of the three occupants of N117ER was performed by Dr. Ronald L. Reeves, Medical Examiner, Volusia County, Florida. The cause of death for each occupant was attributed to multiple blunt force trauma.

Post mortem toxicology studies on specimens obtained from the three occupants of N117ER was performed by the Volusia County Medical Examiners Office. The specimens obtained from the pilot-in-command were negative for ethanol alcohol, basic, acidic, and neutral drugs. The tests were positive for nicotine, caffeine, and 2% carbon monoxide. The tests on specimens obtained from the dual student were negative for ethanol alcohol, basic, acidic, and neutral drugs. The tests were positive for 1% carbon monoxide. See Supplement K and toxicology reports.

Toxicology tests on specimens obtained from the pilot of N2351A were performed by the Florida Department of Law Enforcement Laboratory, Orlando, Florida. The tests were negative for ethanol alcohol, basic, acidic, and neutral drugs.

TESTS AND RESEARCH

An Embry-Riddle flight instructor stated after the accident that they were directed by their Chief Flight Instructor to teach the students to fly a long final approach with a shallow descent angle, similar to an instrument approach. The procedure requires that they extend the downwind leg of a visual approach to 1.6 nm past the end of the runway before turning base leg and final. The aircraft is then placed on the final approach 1.6 nm from the runway at 500 feet agl. This will then require about a 3 degree descent angle to the runway. In the TB-9 this would be flown at an airspeed of 67 knots. See attached diagram and information from the Chief Flight Instructor.

Flight instructors from flight schools at the New Smyrna Beach Airport and the Ormond Beach Airport, where Embry-Riddle aircraft practice takeoff and landings, stated after the accident that the long final approach with a shallow descent angle flown by the Embry-Riddle aircraft conflicts with other aircraft operating at the airports. They stated that they teach their students to fly a downwind leg 3/4 nm from the runway. When they are at a 45 degree angle to the runway approach end they turn on base leg and then final. This places them on final approach about 3/4 nm from the runway at 500 feet. They stated that the Embry-Riddle aircraft are on a much longer final approach at a lower altitude and are not in a position a pilot would expect to see conflicting traffic. There have been cases at the two airports where Embry-Riddle aircraft have been cut off by other aircraft on final approach when the other pilots did not see them on the long, low final approach.

The FAA Aeronautical Information Manual and Flight Training Handbook states that pilots should fly a basic rectangular pattern when making visual approaches to runways. The downwind leg of the pattern should be flown at the established traffic pattern altitude about 1/2 to 1 nm from the runway. The downwind leg continues past the point abeam of the approach end of the runway to where a descending medium bank 90-degree turn is made onto the base leg and then a 90-degree turn is made onto the final approach leg. The turn to final approach should be completed at least 1/4 mile from the runway. See pages from the Flight Training Handbook and Aeronautical Information Manual.

None of the pilots who were operating at the New Smyrna Beach Airport at the time of the accident, including the pilot of N2351A, recalled hearing N117ER make position reports on unicom. Several witnesses stated that there were many Embry-Riddle aircraft operating at the airport using the call sign "echo romeo." Because of this they just might not recall that specific Embry-Riddle aircraft making position reports. The Embry-Riddle Flight Operations Manual does not give instructions as to what radio calls Embry-Riddle pilots should make when performing normal landings at uncontrolled airports. The Aeronautical Information Manual states that pilots should make position reports on downwind, base, and final legs when making approaches at uncontrolled airports.

After the accident the communications radio from N117ER was inspected by FAA and King Radio engineers at the King factory. The purpose of the examination was to determine the communication frequency the radio was set to at the time of the accident. They were unable to determine the frequency do to fire damage to the radio. See FAA inspector statement and King Radio report.

Witnesses reported that several minutes before the accident an unknown aircraft had a microphone stuck in the transmit position on the New Smyrna Beach Airport unicom. This prevented other pilot's transmissions from being heard. Witnesses stated that at the time of the accident, and for a few minutes before, this condition was corrected and normal radio operations were occurring.

The operator of N2351A stated the aircraft did have a sticky microphone switch on the left control wheel several days before the accident. This condition was reported to have been corrected. The aircraft was examined by an FAA Avionics inspector after the accident. The microphone switch on the left pilots control wheel was found to stick in the transmit position on occasion or not go into the transmit position when pushed on occasion. See attached FAA Inspector statement.

ADDITIONAL INFORMATION

The wreckage of N117ER was released to Embry-Riddle Aeronautical University, Mr. Agee C. Tacker, on September 16, 1995.

The wreckage of N2351A was released to Spruce Creek Aviation, Mr. Donald E. Seawy, on September 16, 1995.

NTSB Probable Cause

the failure of the pilots of both aircraft to see and avoid each other.