NTSB Factual Report

On December 8, 2007, at 1454 eastern standard time, a Piper PA-30, N766CC, operated by an private owner, and a Cessna 152, N24478, operated by Rohan Aviation, Incorporated, doing business as Kemper Aviation, were destroyed in a mid-air collision over The Everglades, near Parkland, Florida. The certificated private pilot in the Piper and the certificated student pilot in the Cessna were fatally injured. Visual meteorological conditions prevailed. The Piper was operating on an instrument flight rules (IFR) flight plan from Ocala International Airport-Jim Taylor Field (OCF), Ocala, Florida, to Pompano Beach Airpark (PMP), Pompano Beach, Florida. The personal flight was conducted under 14 Code of Federal Regulations (CFR) Part 91. The Cessna, which was not operating on a flight plan, departed Palm Beach County Airport (LNA), Lantana, Florida, for Fort Lauderdale Executive Airport (FXE), Fort Lauderdale, Florida. The solo instructional flight was also conducted under 14 CFR Part 91.

According to a representative of the flight school, the student pilot had intended to fly from Lantana, over Willis Gliderport (FA44), Boynton Beach, Florida, then southward over a practice area, before turning southeastward and landing in Fort Lauderdale.

A review of Federal Aviation Administration (FAA) air traffic control data and voice transmissions revealed no voice communications with the Cessna, and none would have been required. Both airplanes had operating transponders and altitude encoders, with the Piper operating on a discreet transponder code, and the Cessna operating on a standard 1200 code for visual flight rules (VFR) traffic. Prior to the collision, the Piper was headed eastbound and the Cessna was headed southbound.

At 1440, the Piper pilot contacted Miami Approach Control, reporting he was at 4,000 feet, for the "localizer one five at Pompano."

At 1441, the controller cleared the Piper pilot to descend to 3,000 feet, which the pilot acknowledged, and at 1946, the controller instructed the pilot to fly heading 090, which the pilot also acknowledged.

At 1448, the controller told the Piper pilot to descend to 2,000 feet, which the pilot acknowledged.

At 1451:49, with the Piper indicating an altitude of 2,000 feet, the controller advised the pilot of VFR traffic, "two o'clock," northbound at 1,700 feet. The pilot did not initially see the other airplane, but after another advisory by the controller, the pilot acknowledged the traffic in sight at 1452:12.

The controller then provided services to pilots of five other airplanes, including an advisory about the Piper to one of them, and responded to another controller's inquiry.

At 1453:35, the controller advised the Piper pilot, "traffic eleven o'clock, two miles, southbound, altitude indicates two thousand two hundred," and the pilot responded, "six charlie charlie searchin' for traffic."

The controller then communicated with two other airplanes, until 1454:30, when he advised, "six charlie charlie, that traffic's passing left to right two thousand two hundred." Immediately thereafter, there was an unintelligible transmission on the frequency that was cut off.

There were no further transmissions from the Piper. Radar data indicated that, at the time of the last transmission, the Piper was heading 091 degrees at 2,000 feet, and the Cessna was heading 177 degrees at 2,200 feet.

AIRCRAFT INFORMATION

The Piper was a twin engine, low wing airplane, and the Cessna was a single engine, high wing airplane. There were no voice or data recording devices on either airplane.

The Piper's maintenance logbooks were not recovered. The Cessna's latest 100-hour inspection was completed on November 30, 2007.

PERSONNEL INFORMATION

The Piper pilot, age 56, held a private pilot certificate with airplane single engine land, airplane single engine sea, airplane multi-engine land, and instrument airplane ratings. The pilot's logbook was not recovered.

The Piper pilot's latest FAA third class medical certificate was issued on August 14, 2006, and on that date, he indicated 2,000 hours of flight time. Noted on the pilot's medical certificate, under limitations, was, "Must wear corrective lenses."

The Cessna pilot, age 25, held a student pilot certificate. His latest FAA first class medical certificate was dated June 22, 2007, with no restrictions noted. The student pilot's logbook was not recovered; however, flight school records indicated that he had 100 hours of flight time.

The air traffic controller entered the FAA in 1988, transferred to Miami ATCT/TRACON (Air Traffic Control Tower/Terminal Radar Approach Control) in December 1996 and became fully qualified in February 1998. The controller also held a commercial certificate with multi-engine and instrument instructor ratings, and was an active flight instructor, mostly in the Opa Locka, Florida, area.

Interviews with the controller revealed no personal or physical issues, and that the air traffic control equipment and working conditions were "normal."

METEROLOGICAL INFORMATION

Weather, reported at Pompano Beach Airpark, about 12 nautical miles to the southeast, at 1453, included scattered clouds at 2,300 feet, and visibility 10 miles.

A U.S. Naval Observatory sun position calculation for Palm Beach, at 1450, indicated that the sun was 27.6 degrees above the horizon, 221.4 degrees from true north. Magnetic variation was about 5.5 degrees west, indicating a relative sun position of about 227 degrees magnetic.

WRECKAGE INFORMATION

A debris field was located in the Everglades, about 1 mile west of the eastern shore, in the vicinity of 26 degrees, 20.83 minutes north latitude, 80 degrees, 18.92 minutes west longitude. Debris was scattered over several acres, in an area of 6- to 8-foot sawgrass overlying water that varied in depth from 6 inches to an estimated 8 feet.

The most prominent wreckage from the Cessna consisted of the wings, and part of the cabin overhead section. The engine, landing gear, and sections of the flooring and tail were found elsewhere in the debris field. The propeller was not located.

All flight control surfaces from the Cessna were accounted for at the scene.

There was a concave indentation along the leading edge of the right wing, about 9 feet long and 2 feet deep. The right wing strut was cleanly cut through, perpendicular to the plane of the strut, about 3 feet from the upper attach point.

The underside of the left wing exhibited cut marks, and scarring consistent with an impact of the left strut. The inboard 1 foot of the left aileron was displaced upwards about 6 inches.

The empennage was separated from the main cabin area, and the cabin roof, sides, and floor were all separated from each other. The landing gear and floor of the cabin remained attached. The vertical stabilizer was separated from the horizontal stabilizer, which was separated from the empennage.

The instrument panel was missing, including the altitude encoder; however, the engine mixture control was found in the rich position, and the throttle was bent at a mid-travel position.

The orange-colored propeller spinner was crumpled inward, and exhibited some rotational deformation and loss of paint.

The main wreckage of the Piper consisted of both wings, with the right engine attached to the wing and the right propeller attached to the engine. The left engine, and sections of the cabin and tail were found elsewhere in the debris field.

All flight control surfaces from the Piper were accounted for at the scene. The outboard 6-foot section of the left wing was separated from the rest of the wing. Within that section, there was an indentation, about 3 feet from the outboard edge and18 inches in depth, with orange paint transfers. Placement of the Cessna propeller spinner in the indentation revealed matched deformations. Angular measurements between folds in the indentation and the Piper's main wing spar correlated to an impact approximately nose level, and from about 50 degrees to the left of the Piper's centerline.

The cockpit area was destroyed, and the fuselage area aft of the cabin, which had fore and aft scratches on the upper left side, was displaced from left to right and split at the top. The instrument panel was destroyed. The tail section was separated from the aft fuselage. The stabilator remained attached, and the leading edge of the inboard 18 inches, forward of the spar, were displaced downward about 90 degrees. The left side of the vertical stabilator exhibited scratches on the left side, and was bent over to the right at mid-height, about 90 degrees.

The right engine propeller blades exhibited some "S" bending, and were bent aft. The left engine propeller was missing, and not recovered

Except for the cut left strut on the Cessna, there were no definitive propeller slash marks on either airplane.

AIR TRAFFIC CONTROL INFORMATION

An Air Traffic Control Group was formed to review air traffic control data, air traffic procedures, and air traffic controller actions leading up to the accident. Findings from the Group Chairman's Factual Report included:

A review of recorded conflict alert information revealed that there was a continuous conflict alert between the Piper and an aircraft on transponder code 1200 from 1953:40 until the collision occurred. Aural conflict alert alarm tones were audible in the background of recorded radio transmissions.

According to FAA Order 7110.65, Air Traffic Control,

Paragraph 2-1-2, Duty Priority:

"Give first priority to separating aircraft and issuing safety alerts as required in this order. Good judgment shall be used in prioritizing all other provisions of this order based on the requirements of the situation at hand.

Because there are many variables involved, it is virtually impossible to develop a standard list of duty priorities that would apply uniformly to every conceivable situation. Each set of circumstances must be evaluated on its own merit, and when more than one action is required, controllers shall exercise their best judgment based on the facts and circumstances known to them. That action which is most critical from a safety standpoint is performed first..

Provide additional services to the extent possible, contingent only upon higher priority duties and other factors including limitations of radar, volume of traffic, frequency congestion, and workload."

Paragraph 2-1-6, Safety Alert:

"Issue a safety alert to an aircraft if you are aware the aircraft is in a position/altitude which, in your judgment, places it in unsafe proximity to terrain, obstructions, or other aircraft. Once the pilot informs you action is being taken to resolve the situation, you may discontinue the issuance of further alerts. Do not assume that because someone else has responsibility for the aircraft that the unsafe situation has been observed and the safety alert issued; inform the appropriate controller.

NOTE:

1. The issuance of a safety alert is a first priority once the controller observes and recognizes a situation of unsafe aircraft proximity to terrain, obstacles, or other aircraft. Conditions, such as workload, traffic volume, the quality/limitations of the radar system, and the available lead time to react are factors in determining whether it is reasonable for the controller to observe and recognize such situations. While a controller cannot see immediately the development of every situation where a safety alert must be issued, the controller must remain vigilant for such situations and issue a safety alert when the situation is recognized.

2. Recognition of situations of unsafe proximity may result from MSAW/E-MSAW/LAAS, automatic altitude readouts, Conflict/Mode C Intruder Alert, observations on a PAR scope, or pilot reports.

3. Once the alert is issued, it is solely the pilot's prerogative to determine what course of action, if any, will be taken.

Aircraft Conflict/Mode C Intruder Alert. Immediately issue/initiate an alert to an aircraft if you are aware of another aircraft at an altitude which you believe places them in unsafe proximity."

The controller involved in the accident was providing services to a mix of VFR and IFR aircraft.

During an interview, the air traffic controller was asked if he considered issuing a safety alert after seeing the conflict between the Piper and the other aircraft. He stated that he did not believe it was necessary because the aircraft were showing 200 feet of vertical separation. He also did not notice any heading changes by either aircraft after issuing the first traffic advisory.

The controller also stated that conflict alerts were fairly common in the facility's airspace as it was "a very busy area with lots of training and VFR flights."

14 CFR Part 91.113, right-of-way rules, includes:

"General. When weather conditions permit, regardless of whether an operation is conducted under instrument flight rules or visual flight rules, vigilance shall be maintained by each person operating an aircraft so as to see and avoid other aircraft. When a rule of this section gives another aircraft the right-of-way, the pilot shall give way to that aircraft and may not pass over, under, or ahead of it unless well clear.

Converging. When aircraft of the same category are converging at approximately the same altitude (except head-on, or nearly so), the aircraft to the other's right has the right-of-way..."

RADAR INFORMATION

The altimeter setting at Fort Lauderdale International Airport about the time of the accident was 30.22 inches Hg, requiring a positive 300-foot adjustment to convert mode C values to true altitude. The application of the correction confirmed that the Piper was level at an indicated 2,000 feet and the Cessna was level at an indicated 2,200 feet. Neither airplane appeared to change altitude just prior to the collision.

Palm Beach TRACON radar data from 1420 to 1500 revealed that the radar system could "see" aircraft close to, and/or on the surface at Lantana. During that period, 32 aircraft with operating mode C altitude readouts either arrived or departed.

Uncorrected first altitudes reported for the departure flights, and the last altitudes for the arrival flights indicated that 7 aircraft reported an altitude of -100 feet, 20 reported -200 feet, 3 reported -300 feet, and 1 reported -400 feet. The remaining flight, the Cessna, reported a mode C altitude of 0 feet.

Radar data also revealed that when the controller first advised the Piper pilot of the presence of the contact, the Cessna was generally heading about 224 degrees. During the time the controller was advising other airplanes, the Cessna was turning left, to where it was heading 177 degrees when the collision occurred.

MEDICAL AND TOXICOLOGICAL INFORMATION

The body of the Piper pilot was recovered on December 10, 2007, and had been submerged in water and mud. An autopsy was subsequently performed by the Palm Beach County Office of the District Medical Examiner, and the cause of death was determined to be "multiple blunt trauma injuries." Toxicological testing was performed in conjunction with the autopsy. Ethanol was detected in the liver at 0.033 g/dL. Urine drug testing was negative, including for cannabinoids at a cutoff concentration of 0.05 mg/mL.

The autopsy report for the Piper pilot noted extensive head and facial trauma and did not note either the presence or the absence of corrective lenses.

Additional toxicological testing was performed by the FAA Forensic Toxicology Research Team, Oklahoma City, Oklahoma. No blood was available for testing. Results included:

0.0297 (ug/ml, ug/g) TETRAHYDROCANNABINOL CARBOXYLIC ACID (MARIHUANA) detected in Urine

0.0521 (ug/ml, ug/g) TETRAHYDROCANNABINOL CARBOXYLIC ACID (MARIHUANA) detected in Liver

0.0887 (ug/ml, ug/g) TETRAHYDROCANNABINOL CARBOXYLIC ACID (MARIHUANA) detected in Kidney

FAA testing for volatiles noted, in part:

17 (mg/dL, mg/hg) ETHANOL detected in Urine

166 (mg/dL, mg/hg) ETHANOL detected in Muscle

78 (mg/dL, mg/hg) ETHANOL detected in Heart

FAA testing also included the indication of "3.15 (pmol/nmol) SEROTONIN METABOLITE RATIO detected in Urine" and noted, "Concentrations of s

NTSB Probable Cause

Both pilots' failure to see and avoid the other airplane. Contributing to the accident were the erroneous readouts from the Cessna's altitude encoder.