NTSB Factual Report

HISTORY OF FLIGHT

On June 17, 2003, about 1951 eastern daylight time, a Cessna 172N, N4903F, registered to and operated by Gulfstream Academy of Aeronautics, as a Title 14 CFR Part 91 personal flight, and a Cessna 182Q, N759XA, registered to and operated by Flying Double Eagle Inc., as a Title 14 CFR Part 91 personal flight, collided while in cruise flight, over the Atlantic ocean, about 300 yards east of the Deerfield Beach pier, Deerfield Beach, Florida. Visual meteorological conditions prevailed, and no flight plans were filed for either flight. Both airplanes were destroyed, and the private-rated pilot and two passengers on N4903F, as well as the commercial-rated pilot and one passenger on N759XA received fatal injuries. The Cessna 172's flight originated at Fort Lauderdale Executive Airport (FXE), Fort Lauderdale, Florida, the same day, about 1835, and the Cessna 182's flight originated at the Fort lauderdale international Airport, (FLL), about 1940.

During the minutes preceding, and up to the time of the accident, N4903F, the Cessna 172, had been following the shoreline southbound. N759XA, the Cessna 182, was proceeding northbound. The Cessna 172 had departed Fort Lauderdale Executive Airport about 1835, and it had proceeded toward Stuart Airport, north of Palm Beach International Airport (PBI). The pilot had contacted PBI Terminal Radar Approach Control (TRACON) for authorization and for radar advisory service, and was assigned a transponder code of 0205. At 1919:51, the pilot of the Cessna 172 advised PBI TRACON that he was going to proceed over the coast and return to Fort Lauderdale Executive Airport. The PBI TRACON controller acknowledged and said, "I will need you around a thousand feet east of the shoreline." The pilot acknowledged. Radar indicated that the Cessna 172 was about 10 miles north of PBI, and the airplane proceeded east to the shoreline, then southbound along the shore at an indicated altitude of 1,000 to 1,100 feet. At 1942:07, the PBI controller instructed the pilot of the Cessna 172 to "remain on the same transponder code, radar service terminated, contact Boca tower, one one eight point four two for transition." The pilot read back the frequency and acknowledged. At this time radar indicated the airplane was approximately 10 miles south of PBI, and about 8 miles north-northeast of BCT. At 1943:30, radar indicated that the transponder code being transmitted by the Cessna 172 changed from 0205 to 1200. At 1944:25, the pilot of the Cessna 172 contacted Boca Raton tower (BCT) and said, "Skyhawk four niner zero three foxtrot, about seven miles north over the shoreline, would like to, to Lauderdale Executive, would like to transition your airspace please." The controller said, "zero three fox I believe that is, transition southbound approved, the altimeter two nine nine six, report east." The pilot read back the altimeter setting.

The pilot of the Cessna 182 had departed the Bahamas, landed and cleared customs at the Fort Lauderdale International Airport, and was continuing on to his final destination, Boca Raton, Florida. At 1946:25, the pilot of the Cessna 182 contacted Pompano Beach tower (PMP) and advised that he was "northbound, VFR along the beach landing Boca Raton." The PMP controller acknowledged and advised the pilot to "report passing east of the field."

At 1948:46, the pilot of N47DM, an uninvolved airplane, called BCT tower, and requested to taxi to the active runway. The controller acknowledged and the pilot said he would like to pick up his IFR clearance. During this radio communications exchange, radar indicated the Cessna 172 passed east of BCT, and there was no record of the pilot of the Cessna 172 having reported his position east.

At 1949:05, the pilot of the Cessna 182 transmitted to the PMP tower controller, "reporting east of the field." Radar indicted the Cessna 182 was about 2 miles east of PMP about that time. The PMP tower controller responded, and instructed the pilot to contact BCT tower, and the pilot acknowledged. At 1949:11, the BCT controller read the IFR clearance to the pilot of N47DM, the pilot read back the clearance. At the same time that the pilot of N47DM was reading back the IFR clearance on the ground control frequency, the pilot of Cessna 182 was transmitting on the local control frequency, "seven five niner x-ray alpha good evening." At 1949:34, on the ground control frequency, the BCT controller said, "that is correct", then less than three seconds later on the local control frequency said, "roger, no reported traffic south, frequency change approved, good night." At this time, radar indicated the Cessna 172 was 3 miles south southeast of BCT at 1,000 feet, and the Cessna 182 was 2 miles northeast of PMP at 1,000 feet. The airplanes were about 5 miles apart, and on opposite courses.

At 1949:44, the pilot of Cessna 182 repeated, "seven five niner x-ray alpha good evening." The BCT controller responded, "Cessna calling say again", to which the pilot repeated the information, and the the controller confirmed the call sign. The pilot acknowledged and said, "one thousand feet, VFR northbound along the beach, six and a half miles to the south, landing Boca." The controller acknowledged and instructed the pilot to enter and report a two mile right base for runway 5, and the pilot of the Cessna 182 acknowledged.

At 1950:37, radar indicated the Cessna 172 exited the BCT Class D airspace at 1,000 feet, and about the same time the Cessna 182 exited the PMP Class D airspace at 900 feet, with both airplanes being less than one mile apart, and still on opposite courses. Radar data indicated that the airplanes collided between 1950:52 and 1950:57.

At 1953:19, the pilot of N47DM transmitted that he was ready for departure from runway five. The BCT controller called PBI TRACON for release, and cleared N47DM for takeoff. At 1956:15, N9BC called PMP Tower and said, "have you been informed of an aircraft crash around Deerfield Pier, may have been two aircraft, a midair." The PMP controller said that he had not heard, and would be closing soon, but would call Boca tower. At 1957:21, the PMP controller called BCT and advised that the sheriff's department helicopter pilot reported that there was a midair collision near Deerfield Pier.

See the NTSB Air Traffic Control Group Chairman's Facual Report.

Several witnesses along the shoreline stated that they observed the accident, and they saw and heard both accident airplanes approach each other in normal level cruise flight. They said the airplanes flew directly toward each other, head on, at close to the same altitude. Some witnesses said that it appeared as if they were practicing for an airshow performing aerial demonstrations, and remarked that they were surprised when the collision occurred. As the airplanes drew close to each other, the witnesses said that the left wings collided as the airplanes maneuvered, and there was a loud noise associated with the impact. According to the witnesses, both airplanes along with associated debris, descended, and impacted the water.

PERSONNEL INFORMATION

According to information obtained from the president of Gulfstream Academy of Aeronautics, Inc., the pilot of the Cessna 172 had been conducting flight training with the academy since March of that year and was aspiring to become an airline pilot. Records obtained from the operator, as well as the FAA showed that the pilot of the Cessna 172 held a private pilot certificate with a single-engine land rating, issued less than a week before the accident, on June 12, 2003. He also held a first class medical certificate issued on March 3, 2003 with no stated limitations or restrictions. At the time of the accident, he had accumulated about 75 total hours of flight experience, all of which were within the last 90 days.

FAA records showed that the pilot of the Cessna 182 held a commercial pilot certificate with airplane single engine land, sea, and instrument ratings. The pilot also held an FAA airframe and powerplant mechanic's license, and a second-class medical certificate, issued on April 3, 2002. According to the pilot's flight logbook, he had accumulated about 890 hours of total flight experience at the time of the accident.

AIRCRAFT INFORMATION

N4903F was a 1979 Cessna 172N, serial number 17273100. Records obtained from the operator showed that the Cessna 172 had received a 100-hour inspection on June 7, 2003, and at that time it had accumulated a total flight time of about 8,833 hours. The airplane was equipped with a 160 horsepower Lycoming O-320-H2AD engine, serial number L-3004-76T. At the time of the accident, the engine had logged approximately 8,193 hours. It was also equipped with a McCauley fixed pitch propeller, model number 1C160/DTM 7557.

N759XA was a 1978 Cessna 182Q, serial number 18266330, and records obtained from the operator showed that the airplane had received an annual inspection on September 3, 2002, at which time it had accumulated about 2,208 flight hours. The airplane was equipped with a 230 horsepower Teledyne Continental O-470-U engine, serial number 467134. The engine was last overhauled at 2,208 flight hours, at the time of the annual inspection. It was also equipped with a McCauley constant speed hydraulically actuated propeller; model number C2A34C204, serial number 771363.

METEOROLOGICAL INFORMATION

Daylight visual meteorological conditions prevailed at the time of the accident. The Boca Raton Airport, Boca Raton, Florida, 1945, surface weather observation was, 4,500 feet scattered, visibility 10 statute miles, wind from 160 degrees at 5 knots, temperature 29 degrees C, dew point temperature 24 degrees C, altimeter setting 29.96 inHg. Boca Raton, Florida, is located about 4 miles to the northwest of the accident site.

WRECKAGE AND IMPACT INFORMATION

After recovery from the ocean both wreckages were examined. The entire forward and top portion of the cabin and cockpit of the Cessna 172 had separated at about the windshield level. There was damage from the firewall and all the way aft, with the cockpit gages having incurred damage. The cabin interior had incurred extensive damage, and the seats, along with their restraints, had separated from their anchor points and seat rails, respectively.

The right wing of the Cessna 172 had separated into two large sections and there was leading edge and forward spar damage. Both the flap and aileron had remained attached, and there were two smaller pieces of leading edge skin, but the outer wing tip portion was missing. Sections of the right wing, had been located, and were found entangled with pieces of the right wing of the Cessna 182, at the location where the main wreckage of the Cessna 182 had come to rest.

The left wing of the Cessna 172 had fragmented into nine pieces and the entire span of the wing exhibited compression damage. The tail section had remained attached to the fuselage and the vertical stabilizer exhibited signatures consistant with the impact with the Cessna 182. The right horizontal stabilizer had separated from the tail section. When examined control continuity was confirmed to the separation points, and all separations were consistent with tension overload. The Cessna 172's right wing tank was intact, but the fuel lines have been breached. Seawater, along with a faint smell of fuel was noted. The fuel tank had been breached and was crushed in the aft direction.

The propeller had remained attached to the crankshaft, and one blade was bent slightly aft and exhibited "s-type" bending at the tip, as well as chordwise scoring to the blade's face. The other blade had curled aft against the engine, and it exhibited tip damage and chordwise scoring. The Cessna 172's engine had remained partially attached to the airframe by cables as well as engine mounts, and several accessories had detached. Cursory examination of the engine revealed continuity to the drive train to areas where the missing accessories would have been attached. When the crankshaft was rotated, the engine expelled air and water through the exhaust ports of each cylinder. The spark plugs exhibited normal wear to their electrodes, and corrosion was present throughout the engine, consistent with saltwater immersion.

The Cessna 182's top portion of the cockpit and cabin had also separated at about the windshield level. There was damage from the firewall aft, and the gauges and internal portions of the cabin had also incurred damage. The cabin interior had incurred extensive damage, and the seats, along with their restraints, had separated from their anchor points and seat rails, respectively.

The Cessna 182's right wing had separated into several sections, and the outboard section was missing, as well as the aileron, and there was leading edge and spar damage to the wing as well. The right wing of the Cessna 172 had been found entangled with this wing. The left wing of the Cessna 182 had separated from the fuselage, and there was structural damage to the wing root and leading edge. The tail section had remained attached the cabin of the airplane. The vertical stabilizer exhibited signatures consistent with wing impact from the Cessna 172, the horizontal stabilizers and elevators had incurred impact damage as well. Flight control continuity was established to all separation points, and all separation points have signatures consistent with tension overload.

The Cessna 182's propeller had separated from the crankshaft, and the hub assembly was not found. Both propeller blades exhibited s-type bending at the tips, with gouging on the leading edges, and scoring in a chordwise direction. The Cessna 182's right fuel bladder had been breached, and had separated into several sections. The left fuel bladder was intact and it contained fuel and seawater. The fuel lines had been breached at the wing root area. The Cessna 182's engine has separated from the engine mount, and no accessories were attached. Cursory examination of the engine revealed continuity to the drive train to areas where the missing accessories would have been attached. When the crankshaft was rotated, the engine expelled air and water through the exhaust ports of each cylinder. The spark plugs exhibited normal wear to their electrodes, and corrosion was present throughout the engine, consistent with saltwater immersion.

MEDICAL AND PATHOLOGICAL INFORMATION

Postmortem examination of the pilot of the Cessna 172 was performed by a pathologist with the District 17 Medical Examiner's Office, Fort Lauderdale, Florida, on June 18, 2003. The cause of death was attributed to multiple blunt traumatic injuries. No findings which could be considered causal to the accident were reported.

The FAA Toxicology Laboratory, Oklahoma City, Oklahoma, conducted toxicology studies on specimens from the pilot of the Cessna 172. Specimens were tested for the presence of carbon monoxide, cyanide, volatiles, and drugs. Diphenhydramine was found to be present in blood and in the liver.

Postmortem examination of the pilot of the Cessna 182 was performed by a pathologist with the District 15 Medical Examiner's Office, Fort Lauderdale, Florida, on June 19, 2003. The cause of death was attributed to multiple blunt traumatic injuries. No findings which could be considered causal to the accident were reported.

The FAA Toxicology Laboratory, Oklahoma City, Oklahoma, conducted toxicology studies on specimens from the pilot of the Cessna 182. The specimens were tested for the presence of carbon monoxide, cyanide, volatiles, and drugs. Ethanol was found to be present in blood, the liver, the heart, and the muscles, with the levels ranging from 23 (mg/dl, mg/hg) to 53 (mg/dl, mg/hg).

ADDITIONAL INFORMATION

On June 21, 2003, the NTSB released both the Cessna 172 and the Cessna 182 wreckages to Mr. Steve Smalley, President, Air and Sea Crash Recovery. Fort lauderdale, Florida. The NTSB retained the Cessna 172's communications radios for fur

NTSB Probable Cause

**This case was revised 6/10/2005 and 2/24/2016. Refer to the public docket for this accident for details.**

The failure of the pilot of N4903F, the Cessna 172, and the pilot of N759XA, the Cessna 182, to see and avoid each other while operating in Class E airspace, resulting in a midair collision. Contributing to the accident was the lack of traffic information being provided to the pilot of the Cessna 182 about known traffic in the vicinity, because the controller forgot about the Cessna 172' s reported path and altitude, and the Cessna 172 pilot's change of his transponder code, which precluded the possibility of an ATC collision alert before the accident.