NTSB Factual Report

HISTORY OF FLIGHT

On February 19, 1993, at about 1057 eastern standard time, a Robinson R22B, N621SG, and a Cessna 152, N5532Q, were destroyed following a midair collision over the Fulton County Airport in Atlanta,Georgia. Both aircraft were destroyed in the collision, and the four crew members on board the two aircraft were fatally injured. The Robinson R22B was being operated under 14 CFR Part 91 by Prestige Helicopters, Incorporated of Lawrenceville, Georgia, and the Cessna 152 was being operated under 14 CFR Part 91 by Peachtree Dekalb Flight Academy, Incorporated of Chamblee, Georgia. Visual meteorological conditions existed at the time, and no flight plan had been filed by either aircraft for the local training flights. Both aircraft departed Peachtree Dekalb Airport at about 1000.

The Robinson R22B helicopter departed Peachtree DeKalb Airport at about 1000 for the purpose of conducting a helicopter instrument rating practical examination. At 1032:30 the pilot of the helicopter, N621SG, contacted the Atlanta Approach Control and advised the controller that the aircraft was being used for the purpose of conducting an instrument check ride, and requested a Very High Frequency Omnirange (VOR) approach to Runway 26 at the Fulton County Airport. The pilot requested that this approach be followed by a missed approach, and then proceed to the Initial Approach Fix (IAF) for a holding turn and an Instrument Landing System (ILS) approach to Runway 8 at the Fulton County Airport, and then to be followed by an Automatic Direction Finder (ADF) approach to Runway 8.

At 1033:41 Atlanta Approach Control contacted the Fulton County Airport Control Tower and advised the tower personnel that the helicopter intended to execute a VOR approach to Runway 26. The Approach Control Personnel did not advise the Tower that the Helicopter was conducting an instrument check ride. The Fulton County Tower approved the request and Approach Control Cleared the helicopter for the approach. At 1036:10 the pilot of the helicopter contacted the Fulton County Tower and the tower advised the helicopter that it appeared to be about one half mile north of course. At 1038:23 the control tower cleared the helicopter for the low approach, and again advised that the helicopter was north of course. The pilot advised that they were following the instrument indications in the cockpit and requested a missed approach to the IAF for the ILS. The tower cleared the helicopter for a missed approach direct to the IAF. At 1042:37 the pilot of the helicopter contacted Atlanta Approach, advised that he was executing the missed approach, and was cleared to execute one turn in the holding pattern and then to execute the ILS approach to Runway 8. At 1054:51 the helicopter was advised to again contact the Tower.

At 1055:03 the pilot of the helicopter contacted the Fulton County Airport Air Traffic Control Tower, and was cleared as number two for the approach following a Piper Seminole, which was pointed out to the helicopter. At 1055:20 the pilot of the helicopter stated "Okay we got the Seminole in sight six two one sierra golf we'll be low approach back around for the NDB." The tower personnel responded "Helicopter one sierra golf roger number two runway eight cleared low approach." At 1056:51 Fulton County Tower advised the helicopter "Helicopter one sierra golf Cessna ahead and to your left touch and go runway niner." The pilot of the helicopter responded "Sierra Golf". At 1057:40 the pilot of a twin Cessna N3417G asked the tower what the explosion over the field was, and the tower responded "a helicopter and a cessna".

The Cessna 152, N5532Q departed Peachtree Dekalb Airport at about 1000 for the purpose of flight instruction. At 1046:46 the pilot of N5532Q contacted the Fulton County Air Traffic Control Tower and requested landing instructions for Runway 9 at the Fulton County Airport. The Tower instructed N5532Q to report left downwind for landing Runway 9.

At 1051:52 N5532Q reported left downwind for landing Runway 9. The tower cleared N5532Q for touch and go landing on Runway 9 and advised the pilot of King Air traffic three and one half miles west of the field landing on Runway 8. At 1055:47 the Tower again cleared N5532Q for touch and go landing on Runway 9. No further conversations were made with N5532Q. During the approach to the airport and landing approach of N5532Q, the Tower pointed out numerous traffic to the pilot of N5532Q, however, the Tower did not point out the helicopter, N621SG, to the pilot of N5532Q.

Witnesses stated that at the time of the mid air collision, the Cessna N5532Q was apparently descending on final approach for Runway 9, and it appeared that the helicopter, N621SG, was executing a climbing left turn just past the approach end of Runway 8. The witnesses stated that the helicopter appeared to overtake the Cessna.

PERSONNEL INFORMATION

Mr. Ronald M. Lorber, the pilot in command of the Robinson R22B, N621SG, was a commercial pilot with airplane single engine land, helicopter, and instrument airplane ratings. Mr. Lorber was taking the practical examination for a helicopter instrument rating at the time of the accident. Normal procedure during this examination would have been for Mr. Lorber to have been wearing a vision restricting device for this flight, which would limit his ability to see outside the aircraft cockpit. During the ILS approach, Mr. Lorber's attention would be entirely focussed on the aircraft instrument panel.

Mr. Richard Hull, the examiner/observer of the Robinson R22B, N621SG, was an airline transport pilot with airplane single engine, airplane multiengine, helicopter, and airplane and helicopter instrument ratings. Mr. Hull also held a flight instructor's certificate with airplane single engine, airplane multiengine, helicopter, and airplane and helicopter instrument ratings. Mr. Hull's duties during the helicopter instrument practical examination would be to evaluate Mr. Lorber in accordance with the Federal Aviation Administration Practical Test Standards, and to act as an observer during the flight. During an ILS approach, the examiner's attention would be divided between the instrument panel, and outside of the aircraft to observe other traffic in the area. During an ILS approach, as the flight approaches the decision height (DH), the movement of the localizer and glideslope needles becomes more rapid. The examiner must devote more and more of his attention to the instrument readings in the cockpit in order to insure that the applicant is using proper control inputs to maintain course and altitude. During an examination, the examiner must allow the applicant to initiate an improper procedure in order to properly evaluate the applicant, unless a hazardous situation intervenes.

Mr. William Meagher III, the flight instructor/pilot in command of the Cessna 152, N5532Q was a commercial pilot with airplane single engine land, airplane multiengine land, and instrument airplane ratings. He also held a flight instructor certificate with airplane single engine, airplane multiengine, and instrument airplane ratings. As a flight instructor of a student pilot, Mr. Meagher's responsibilities would include teaching his student techniques and procedures used in order to obtain a private pilot's certificate. This would include the practice of insuring clearance from other aircraft during flight. A normal practice during traffic pattern operations would be for the pilot to check the final approach path, prior to turning from base to final, and insure that no other aircraft were on final for the same runway.

Mr. Dan Dunn, the student pilot of the Cessna 152, N5532Q held a student pilot certificate with no ratings.

Additional pilot information may be obtained in this report under the sections titled First Pilot Information, and in Supplement E.

AIRCRAFT INFORMATION

The Robinson R22B, N621SG, while not certified for flight under instrument conditions, was equipped with the necessary equipment for instrument flight training. The pilot in command/applicant position in the Robinson R22B is the right pilot seat. The observer/examiner position is the left pilot seat.

Visibility from the left pilot seat looking directly ahead of the aircraft, both above and below the aircraft flight path is unobstructed. Located above the door and extending toward the nose of the aircraft is a structural panel approximately 10 inches in width and 18 inches in length. This panel creates a blind spot for the pilot in the left seat, above and to the left side of the aircraft flight path.

According to personnel who have instructed in the Robinson R22B, the normal approach speed used for instrument approaches is 90 knots indicated airspeed.

The pilot/student position in the Cessna 152 would normally be the left seat, and the instructor/observer would normally utilize the right pilot seat.

According to the Cessna 152 Information Manual, the approach speed for a short field landing is 54 knots indicated airspeed.

METEOROLOGICAL INFORMATION

Meteorological information may be obtained in this report under the sections titled Weather Information.

AERODROME INFORMATION

The Fulton County Airport has three runways, Runway 14/32, Runway 8/26, and Runway 9/27. While Runways 8/26 and 9/27 are numbered as having different headings, they are actually parallel to each other. The distance between the centerline of Runways 8/26 and 9/27 is 400 feet. Runway 8/26 is 5,796 feet in length, and 100 feet in width. Runway 9/27 is 2,801 feet in length, and 60 feet in width. The landing threshold of Runway 9 is located 2,346.62 feet east of the landing threshold of Runway 8. The Air Traffic Control Tower at Fulton County Airport is located approximately 2500 feet east of the approach end of Runway 8.

WRECKAGE INFORMATION

The wreckage was distributed over an area approximately 600 feet in length. The direction of the wreckage path was approximately 090 degrees. The first pieces of the wreckage were parts of the Cessna right wing. These pieces were found in the bottom of a ravine approximately 100 yards north of the approach end of runway 8. Some of the Cessna wing parts showed white paint transfer marks, that matched the white paint on the rotor blades of the helicopter.

The main wreckage of the Cessna was located on the approach end of runway 14, and the main wreckage of the Robinson helicopter was located on the parallel taxiway to runway 14 adjacent to the approach end of the runway.

The fuselages of both aircraft had been nearly consumed by post crash fire.

See Wreckage Distribution Diagram attached to this report for further information.

MEDICAL AND PATHOLOGICAL INFORMATION

The Medical Examiner listed the cause of death of Mr. Lorber as generalized blunt force trauma. The Toxicology report for Mr. Lorber was negative for drugs and ethanol.

The Medical Examiner listed the cause of death of Mr. Hull as generalized blunt force trauma. The Toxicology report for Mr. Hull was negative for drugs and ethanol.

The Medical Examiner listed that cause of death of Mr. Meagher as generalized blunt force trauma. The Toxicology report for Mr. Meagher was negative for drugs and ethanol.

The Medical Examiner listed the cause of death of Mr.Dunn as generalized blunt force trauma. The Toxicology report of Mr. Dunn showed that his blood contained 61.300 (ug/ml, ug/g) Acetaminophen. The Toxicology report was negative for ethanol.

ADDITIONAL INFORMATION

The published missed approach procedure for the ILS Runway 8 at the Fulton County Airport is a climb straight ahead to 1700 feet followed by a climbing left turn to 3000 feet, and proceed direct to the locator outer marker.(See Attached ILS Runway 8 Approach Chart.)

The Air Traffic Control Procedures applicable to this accident are found in Federal Aviation Administration Order 7110.65H.

Paragraph 2-21 states, "Unless an aircraft is operating within the Positive Control Area or omission is requested by the pilot, issue traffic advisories to all aircraft (IFR/VFR) on your frequency when in your judgement their proximity may diminish to less than the applicable separation minima. Where no separation minima applies, such as for VFR aircraft outside an ARSA, TRSA, or TCA, issue traffic advisories to those aircraft on your frequency when in your judgement their proximity warrants it."

Paragraph 3-90 sates, "Establish the sequence of arriving and departing aircraft by requiring them to adjust flight or ground operation as necessary to establish proper spacing."

Paragraph 3-92 states, "Authorize simultaneous, same direction operations on parallel runways, on parallel landing strips, or on a runway and a parallel landing strip only when the following conditions are met:

a. Operations are conducted in VFR conditions unless visual separation is applied.

b. Two-way radio communication is maintained with the aircraft involved and pertinent traffic information is issued.

c. The distance between the runways or landing strips is in accordance with the minima in Table 3-92[1] (use the

greater minimum if two categories are involved)."

The wreckage of Cessna N5532Q was released to Mr. Kevin Twiss, the owners insurance representative, on February 25, 1993.

The wreckage of Robinson N621SG was released to Mr. Royce Bosselman, the owners insurance representative, on February 25, 1993.

NTSB Probable Cause

THE FAILURE OF THE PILOT/APPLICANT OF THE R22B, N621SG, TO FOLLOW LOW APPROACH PROCEDURES, AND THE FAILURE OF THE DESIGNATED EXAMINER/OBSERVER IN THE R22B TO MAINTAIN VISUAL SEPARATION FROM THE CESSNA 152, N5532Q. CONTRIBUTING FACTORS TO THE ACCIDENT WERE: THE INSUFFICIENT RESPONSE OF BOTH PILOTS OF THE R22B IN REPLY TO TRAFFIC INFORMATION, THE LOCAL CONTROLLER'S FAILURE TO OBTAIN POSITIVE CONFIRMATION OF VISUAL ACQUISITION OF THE CESSNA 152 FROM THE PILOTS OF THE R22B, AND THE FAILURE OF THE LOCAL CONTROLLER TO REMAIN ATTENTIVE TO THE CONVERGING TRAFFIC AND ISSUE APPROPRIATE INSTRUCTIONS TO AVOID THE COLLISION.