NTSB Factual Report

HISTORY OF FLIGHT

On May 22, 2012, about 2200 eastern daylight time, a Piper PA-28-161, N602FT, was substantially damaged when it was struck from behind by a Piper PA-28-161, N47749, while holding short on taxiway Alpha behind another airplane, at Melbourne International Airport (MLB), Melbourne, Florida. Both airplanes were operated by FIT Aviation LLC. The certificated flight instructor and certificated private pilot in N602FT, and the certificated private pilot in N47749 were not injured. Night visual meteorological conditions prevailed, and no flight plans were filed for the instructional flights operated under Title 14 Code of Federal Regulations (CFR) Part 91.

According to the flight instructor in N602FT, he and his student were stopped behind a Cessna who was holding short of runway 9R on taxiway Alpha. The flight instructor noticed another airplane stop behind them while they were waiting for departure. A few seconds later they were struck from behind. Their position lights, landing light, and strobe lights were illuminated when the accident occurred.

According to the private pilot in N47749, he was "dispatched" about 2120 eastern daylight time. He had completed his takeoff and landing data card and then did a preflight inspection of N47749. After entering the airplane and starting the engine, he then taxied to the designated run-up area where he performed the "Ground Check" checklist. Upon contacting ground control he received instructions to taxi to runway 9R via taxiway Charlie and Alpha. He then began to taxi N47749 to the assigned runway. He was number three for departure behind N602FT, which was stopped behind a Cessna which was also operated by the flight school and was first for departure. He stopped behind N602FT and set the parking brake and then looked at the tachometer to set 1,000 revolutions per minute (rpm). The airplane then slowly moved forward and struck N602FT.

PERSONNEL INFORMATION

According to Federal Aviation Administration (FAA) and FIT Aviation records, the private pilots in both airplanes were enrolled in FIT Aviation's commercial pilot certification course. The flight instructor in N602FT was employed by FIT Aviation.

The private pilot in N47749, held a private pilot certificate with a ratings for airplane single-engine land, and instrument airplane. His most recent FAA second-class medical certificate was issued on June 30, 2011. He reported 137 total hours of flight experience, 46 of which were in the accident airplane make and model.

The private pilot in N602FT, held a private pilot certificate with a ratings for airplane single-engine land, and instrument airplane. His most recent FAA second-class medical certificate was issued on July 6, 2011. He reported 155 total hours of flight experience, 76 of which were in the accident airplane make and model.

The flight instructor in N602FT held a commercial pilot certificate with ratings for airplane single-engine land, multi-engine land, and instrument airplane. He also held a flight instructor certificate with ratings for airplane single-engine and instrument airplane. His most recent FAA first-class medical certificate was issued on June 1, 2011. He reported 782 total hours of flight experience, 738 of which were in single engine airplanes.

AIRCRAFT INFORMATION

Both airplanes involved in the accident were single-engine, four seat, low-wing monoplanes, of conventional metal construction. They were powered by carbureted, 160 horsepower, four cylinder, air cooled, direct drive, engines.

Their wings were of an all-metal, stressed-skin, fully cantilevered design, consisting of two wing panels bolted to a spar box assembly in the fuselage. The ailerons were controlled through cables and pushrods, and were dynamically balanced. The trailing edge wing flaps were manually operated.

Their empennages consisted of a vertical stabilizer; rudder, dynamically balanced stabilator, and stabilator trim tabs.

Their tricycle type landing gear was of a fixed type and consisted of shock absorbing air-oil type oleo struts.

Their two main landing gear wheels were equipped with a single disc hydraulic brake assembly which was actuated by individual cylinders attached to each rudder pedal, or by a hand lever. The hand lever also doubled as a parking brake.

According to FAA and maintenance records, N47749 was manufactured in 1977. The airplane's most recent 100 hour inspection was completed on April 30, 2012. At the time of the inspection, the airplane had accrued 7,174 total hours of operation.

According to FAA and maintenance records, N602FT was manufactured in 1989. The airplane's most recent 100 hour inspection was completed on April 30, 2012. At the time of the inspection, the airplane had accrued 17,077 total hours of operation.

METEOROLOGICAL INFORMATION

The reported weather at MLB, at 2127, included: winds 190 degrees at 9 knots, 10 miles visibility, sky clear, temperature 26 degrees C, dew point 21 degrees C, and an altimeter setting of 29.93 inches of mercury.

According to the United States Naval Observatory on the day of the accident, sunset occurred at 2010, and the end of civil twilight occurred at 2036. The phase of the Moon was a waxing crescent with 3 percent of the Moon's visible disk illuminated. Moonset was at 2145.

AIRPORT INFORMATION

Melbourne International Airport, was a towered public use airport, located 2 miles northwest from the city of Melbourne, Florida.

Aircraft operations averaged 366 per day of which, 54 percent were transient general aviation, 40 percent were local general aviation, 3 percent were commercial, 1 percent were air taxi, and 1 percent were military.

There were 248 aircraft based at the field of which, 190 were single-engine airplanes, 40 were multi-engine airplanes, 6 were helicopters, and 1 was military.

The airport had three runways:

- 9R/27L

- 9L/27R

- 05/23

At the time of the accident, runway 9R was in use. Review of published information and images of taxiway "A" which was the parallel taxiway for runway 9R, and the runup area at the approach end of runway 9R, revealed that there were no taxiway edge markings. The taxiway centerline markings were in good condition, the enhanced taxiway centerline markings prior to the runway holding position markings were in good condition, and the holding position markings were in good condition. The taxiway edge lighting was functional, the taxiway location signs were functional, the runway location signs were functional, and the runway safety area (hold short) signs were functional.

WRECKAGE AND IMPACT INFORMATION

Postaccident examination of N47749 revealed that it had sustained minor damage. The propeller exhibited chordwise scratching and leading edge gouging on its blades where they had come into contact with the left side of N602FT's stabilator. Minor scratching was also present on the right wing where it had come in to contact with the right side of N602FT's stabilator.

Postaccident examination of N602FT revealed that it had sustained substantial damage where the propeller from N47749 had come into contact with the left side of the stabilator. Multiple prop strike marks were present, and approximately 2 feet of the left outboard section had been severed from the stabilator.

TESTS AND RESEARCH

Application of Parking Brake in N47749

According to the private pilot in N47749, when he stopped at the runup area at the end of taxiway "A" there was approximately one aircraft length between his airplane and the airplane in front of him (N602FT). He thought he had set the parking brake because "immediately" after he stopped he "grabbed" the parking brake handle and pulled it back. He advised however that it was not set. He realized this after he struck N602FT. At the time he had been trying to set 1,000 rpm on the tachometer. At the time he thought that his feet were on the brake pedals. He "figured out" that "I did not put so much pressure on the brake pedals" before the "crash." When he heard the "crash" he thought that the airplane in front of him had "moved back" and he "immediately grabbed" the parking brake and set it.

N47749 Brake System Examination

Postaccident examination of N47749's brake system did not reveal evidence of any preimpact failure or malfunction that would have precluded normal operation of the brake system. When actuated, both the toe brakes, and the parking brake were functional.

Brake Servicing and Maintenance Records

The brake system was filled with MIL-H-5606, hydraulic brake fluid. The fluid level would be checked periodically and replenished when necessary. If the entire system had to be refilled, it would be filled with fluid under pressure from the brake end of the system.

No adjustment of the brake clearances was necessary. If after extended service the brake blocks became excessively worn, they were replaced with new segments.

Review of maintenance records indicated that the brake pads had been replaced on July 1, 2011, and the left brake disc had been replaced on August 9, 2011. Further review also did not reveal any recent failures or malfunctions that would have precluded normal operation of the brake system

Brake Operation

The brakes were actuated by toe brake pedals which were attached to the rudder pedals or by a hand lever and master cylinder located below and behind the center of the instrument sub panel. Hydraulic cylinders were located above each rudder pedal and adjacent to the hand brake lever. A brake fluid reservoir was installed on the top left front face of the fire wall.

The parking brake was incorporated in the master cylinder and was actuated by pulling back on the hand lever and depressing the knob attached to the left side of the handle.

The parking brake was released by pulling back on the hand lever to disengage the catch mechanism and allow the handle to swing forward.

Review of the toe brake installation indicated that that if a pilot did not place his feet in the proper position, and his toes were allowed to protrude over the toe stops on the rudder pedals, that full braking may not be available, as they would come into contact with the torque tube that the rudder pedal assembly was attached to.

Review of the parking brake installation also indicated that once the parking brake was applied that in order to obtain additional braking effort, the hand lever had to be released before once again operating the toe brakes or hand lever.

ORGANIZATIONAL AND MANAGEMENT INFORMATION

Florida Institute of Technology (FIT) was founded in 1958 to provide advanced education for professionals working in the space program at what is now the Kennedy Space Center. They offered educational programs in numerous disciplines including aeronautics.

The college of aeronautics offered both undergraduate, and master's degree programs. As part of these programs, FIT Aviation, LLC which was a wholly owned subsidiary of FIT, provided both ground and flight training for FIT students, and the general public under 14 CFR Part 141.

ADDITIONAL INFORMATION

Approximate Hours of Operation

In 2012 the FIT aviation fleet of 45 airplanes accrued approximately 38,000 total hours of operation.

Including the PA-28-161s, 42 of those airplanes incorporated a braking system similar to the accident airplane's braking system. Each flew approximately 5 to 7 flights per day. Review of the accident airplane's checklists revealed, that the parking brake was being operated at least 6 times per flight, which indicated that the parking brake was being operated on each airplane approximately 30 to 42 times per day.

Safety Actions

In order to increase safety FIT Aviation took the following actions:

1. FIT Aviation revised their Flight Operations Manual (FOM) to include a section on use of the parking brake, and including expanded guidance on the use of the parking brake in the sections of the FOM concerning aircraft startup, aircraft runup, and aircraft parking. FIT Aviation also added precautions in the FOM to not rely solely on the parking brake to keep the aircraft stationary with the engine running.

2. FIT Aviation revised their lesson plans to include emphasis on not relying solely on the parking brake to keep the aircraft stationary with the engine running.

NTSB Probable Cause

The pilot’s failure to set the parking brake and to maintain a proper visual lookout, which resulted in an on-ground collision with another airplane.