NTSB Factual Report

HISTORY OF FLIGHT

On September 11, 2000, at 1246 eastern daylight time, a PA-28-161 (Cherokee), N9208N, and a PA-23-250 (Aztec), N54235, collided on final approach to land on runway 09 at the Saint Lucie International Airport in Fort Pierce, Florida. The Cherokee was operated by Flight Safety International and the Aztec was operated by the airline transport pilot under the provisions of Title 14 CFR Part 91 with no flight plans filed. Visual weather conditions prevailed at the time of the collision. The air transport pilot onboard the Aztec, and the private pilot, a Saudi Arabian citizen, onboard the Cherokee, both received fatal injuries. Both airplanes were destroyed. The Cherokee instructional flight departed Vero Beach, Florida, on a solo training flight at approximately 1220, and the Aztec departed Okeechobee, Florida, after refueling, at approximately 1230.

According to the information recovered from the Saint Lucie County Airport Air Traffic Control Tower recordings, at 1227:50, the pilot of the Cherokee radioed the tower that he was seven miles northeast of the airport inbound for touch and go landings. The pilot was instructed to report two miles northeast for a left downwind for runway 09. At 1235:29, the Cherokee was cleared for the first touch and go landing. After the landing, and as the Cherokee had reentered the traffic pattern, at 1240:16, the tower controller instructed the pilot of the Cherokee to execute a 360 degree right turn on downwind for spacing.

At 1242:06, the pilot of the Aztec, radioed the tower controller and reported 10 miles west of the airport inbound for landing. The pilot was instructed to continue straight-in and to report over the interstate. At 1245:25, the pilot of the Aztec, reported over the interstate for runway 09. The tower controller instructed the pilot of the Aztec to follow the Cherokee, who was turning base to a three mile final to runway 09. The pilot of the Aztec reported "we're looking for the Cherokee." At 1246:19, the tower controller asked the pilot of the Aztec "do you have the Cherokee off of your left wing?" The pilot of the Aztec report, "no contact." At 1646:34, the controller asked the Cherokee if he had "an Aztec alongside of ya out there?" The pilot of the Cherokee replied, "ah negative sir." The controller then told the Cherokee to "over fly runway niner, make left traffic." No response was noted from the Cherokee pilot.

At 1247, another airplane flying above the airport reported that they had just witnessed an in-flight collision three miles from the end of runway 09.

PERSONNEL INFORMATION

The pilot of the PA-28-161 (Cherokee) held a student pilot certificate. His total flight time in the Cherokee was 17.6 hours, but his total flight time in all aircraft was undetermined. The pilot also had a foreign based private pilot license from the Philippines. The pilot held a current first class medical certificate, dated May 16, 2000, with no limitations or waivers.

The pilot of the PA-23-250 (Aztec) held an airline transport pilot multi-engine land, a type rating in EMB-120, commercial pilot single-engine land, and instrument ratings. Included also were certified flight instructor single and multi-engine instrument airplane ratings. His total flight time was 7438 hours and the approximate flying time in the PA-23-250 was not determined. The pilot held a current second-class medical certificate, dated September 14, 1999, with no limitations or waivers.

AIRCRAFT INFORMATION

The PA-28-161, N9208N, was owned and operated by Flight Safety International, of Vero Beach, Florida. N9208N was a low-wing airplane powered by a Lycoming O-320-D36 engine. A review of the airplane maintenance logbooks showed that the last maintenance inspection was on September 8, 2000.

The PA-23-250, N54235, was owned by St. Lucia Petroleum, of Port St. Lucia, Florida. The airplane was operated by Roger M. Boromei of Okeechobee, Florida. N7317A was a low-wing multi-engine airplane powered by two Lycoming IO-540-C4B5 engines. A review of the airplane maintenance logbooks showed that the last maintenance inspection was September 1, 1999.

METEOROLOGICAL INFORMATION

Ft. Pierces St. Lucie County International Airport, in Florida, 1053, weather observation reported a scattered cloud layer, visibility 10 miles, wind 090 degrees at nine knots.

AIRPORT INFORMATION

Ft. Pierces St. Lucie County International Airport, in Florida, has two runways: 14/32 and 09/27. At the time of the accident, runway 09 was in use.

The Ft. Pierce air traffic control tower is operated by Federal Aviation Administration. The facility operates from 0700 to 2100 daily. There is no radar at the airport, nor does the tower have any type of radar display to augment airport operations.

WRECKAGE AND IMPACT INFORMATION

Examination of the accident site disclosed that both airplanes were 2.7 miles west of runway 09, and were within several feet of the extended centerline of the landing runway. The Cherokee was found inverted orientated on an easterly magnetic heading, and the Aztec was found in a near vertical nose down attitude orientated on a northeasterly magnetic heading. Both airplanes were located approximately 75 feet apart in a citrus fruit grove. Further examination of the damaged airplanes showed two diagonal slashes on the bottom-side of the Cherokee at a position near the right wing root, and at another position several inches inboard of the right wing tip. Chordwise damage was observed on both of the propeller blades on the Aztec.

Cherokee

The right wing remained attached to the Cherokee. The mid portion of the aileron, approximately five feet, was attached to the center hinge. Inboard ten feet of the aileron was separated, but remained attached to the inboard hinge. The flap was bent in a "V" shape, 35 inches outboard of the flap root, and the lower wing skin aft of the main spar between the wing root and the main gear was destroyed with exposed aileron cables.

The right flap had a prop strike measuring nine inches starting at the root of the flap, the second prop strike is forward of the flap and is 15 inches in length.

The right stabilator, starting at the root and trailing edge has a semi circular indention approximately 16 inches wide, and is bent downward 15 inches. There is black smearing apparent at the outboard edge of the anti servo trim tab.

The left wing remained attached to the fuselage. The fuel tank separated at the leading edge, and 27 rivets sheared. The stall strips were attached, and bent in a "V" shape. Outboard eight feet of the wings' leading edge was deformed. There were black smear marks 13 inches apart.

The vertical stabilator was flattened even with the tail cone. The rudder is separated from the vertical stabilator, but remained attached to the torque tube. The left stabilator has blue paint transfer starting at the leading edge root extending out 17 inches.

The right stabilator leading edge was deformed. A tear was noted on the stabilator skin, and the inboard trailing edge skin is crushed and wrinkled.

The right anti-servo was bent downward and had heavy black smearing. The left anti-servo tab was bent downward with black smearing. There is heavy black smearing aft of the forward tail cone rivet line which extends to the rear bulkhead.

Aztec

The left tail cone is crushed inboard approximately three inches located at the dorsal fin. The right tail cone is crushed inboard approximately 17 inches located at the dorsal fin.

The left wing is separated at the wing root, and the entire leading edge is crushed aft to the main spar outboard to the nacelle. The leading edge material nacelle to the tip is separated and destroyed. The aileron remained attached to three hinges, the outboard 12 inches of aileron is crushed up and aft a few inches. Aileron connecting rod is separated at the eyebolt. The fuel bladder is separated and destroyed. The flap is separated to the outboard hinge and the eyebolt is oblong in shape. Main gear is extended and locked with main gear doors destroyed. The engine was buried approximately four feet in the ground along with the propeller. The main spar box is broken at the wing roots.

The right wing is separated from the fuselage and the entire leading edge is separated and destroyed. All upper wing skin and 3 feet of the outboard nacelle is separated and destroyed. The aileron is separated at all hinges. The flap is separated from the inboard hinge and bent in a V shape. All fuel bladders are destroyed, and the main gear is down and locked.

MEDICAL AND PATHOLOGICAL INFORMATION

Postmortem examination of the pilot, who flew the Aztec, was performed by Dr. Hobin at the State of Florida's Office of Medical Examiners at District 19 in Ft. Pierce, Florida. The forensic toxicology was performed by the FAA Toxicology and Accident Research Laboratory, Oklahoma City, Oklahoma. The tests were negative for drugs and alcohol.

Postmortem examination of the pilot, who flew the Cherokee, was performed by Dr. Diggs at the State of Florida's Office of Medical Examiners at District 19 in Ft. Pierce, Florida. The forensic toxicology was performed by the FAA Toxicology and Accident Research Laboratory, Oklahoma City, Oklahoma. The tests were negative for drugs and alcohol.

ADDITIONAL INFORMATION

Three minutes prior to the collision, the local controller had relieved another controller at the position. Both controllers were at the local control when the accident occurred.

The controller being relieved said that he thought the Aztec was faster than the Cherokee. When asked if he had developed a sequence when he instructed the pilot of the Aztec to report over the interstate, he said no. As it pertained to the position relief briefing, he said that he initiated the recording, but an aircraft called and he unkeyed to respond to the aircraft. He then went to commence recording the briefing, but at that time, the relieving controller told him he had the traffic or indicated in some manner that he was aware of all the traffic and took over the position. There was no discussion regarding traffic.

At that time, all known traffic was displayed on the board. The controller being relieved remained plugged in because it was getting busy, and he asked the relieving controller if he should man the coordinator position. There was no response.

The controller being relieved saw the Aztec turning final over the interstate, and then he observed the Cherokee turning base leg either over or east of the interstate. It appeared to him the Aztec was passing the Cherokee on its left side. He looked away and then went looked back using binoculars. At that time, both airplanes were on final about 2-2.5 miles out. He thought the Aztec was in front and was creating distance. He told the relieving controller the airplanes very close, and he could not tell who was in front and who was behind. He continued observing, and then he witnessed the collision.

The controller being relieved heard the relieving controller give the instructions to the Cherokee to fly down the runway. When asked if the instruction would have altered the flight path of the Cherokee, he said it should not have, no. When asked why neither airplane had been told to break out, he said because it might have caused an in-flight collision rather than avoiding it.

When asked if a situation has gone too far if aircraft are so close that a resolution might cause them to hit each other, the controller being relieved said, no because of the equipment we are provided, a determination sometimes cannot be made.

The relieving controller was asked if there was any discussion about traffic, he said the controller being relieved had pointed out traffic in the pattern. He said he was standing during the relief briefing, and then he sat down at the local control position. According to the relieving controller, traffic was moderate to heavy and of routine. He believed he had the traffic picture when he took control. When asked if there had been a point at which he was concerned about the two airplanes, he said yes, when the pilot of the Aztec advised he did not have the traffic in sight.

The relieving controller was asked what he was trying to accomplish by telling the Cherokee to overfly the runway, he said that he wanted to take the airplane out of its landing configuration and it just happened to be the Cherokee. He wanted to change the landing configuration because both airplanes were pointed toward the runway at least both would not be on the runway. He noted that neither airplane had been issued a landing clearance, and he thought the clearance to fly down the runway would cause the Cherokee to keep its speed up. Since no one could tell who was on the left or right, he did not want to issue turns. He never used the binoculars to confirm the position of the two airplanes. When asked why not, he replied there was a lot going on and that a local controller does not focus on one specific situation. He noted, that he had another airplane landing and rolling out while there were others waiting to depart. When asked if he had observed the collision, he said no.

He was asked if there are times at which a controller must take other action if a pilot continues to advise he does not have his traffic in sight. He said no that traffic advisories are issued, and that you try to get them to see each other.

He was asked if spacing and sequencing are used to make sure that aircraft under his control do not collide, he said yes. He was then asked to review FAA Order 7110.65, paragraph 2-1-1, and was asked if that is the purpose of the air traffic control system.

As quoted in FAA Order 7110.65, "Air Traffic Control," "The primary purpose of the ATC system is to prevent a collision between aircraft operating in the system and to organize the flow of traffic."

He acknowledged that is pretty much what it says. He was asked why these two airplanes collided if there is a responsibility to keep them from doing so. He said, in his opinion, he is responsible for issuing traffic advisories and trying to get the pilots to see each other. He said the system failed because the pilots did not see each other and the pilot of the Aztec did not see the Cherokee. When asked if he felt satisfied with his performance he said, "yes I do."

The airplane wreckage, for the Aztec, was released on 06/12/01 to Mr. Deen, an insurance adjuster, in Atlanta, Georgia.

The airplane wreckage, for the Cherokee, was released on 06/18/01 to Mr. Don Doohen, Director of Maintenance at Flight Safety Academy, in Vero Beach, Florida.

NTSB Probable Cause

Failure of local controller to provide adequate spacing between two airplanes that resulted in a midair collision. Contributing Factors: the local controller declined receiving a formal brief before relieving the controller on duty. The controller who was relieved failed to ensure proper briefing of local traffic.