NTSB Factual Report

HISTORY OF FLIGHT

On November 15, 2002, at 1908 eastern standard time, a Mooney M10 (Cadet), N9502V, and a Piper PA-32R-300 (Lance), N216CL, were substantially damaged when they collided while maneuvering for an approach to Essex County Airport (CDW), Caldwell, New Jersey. The certificated private pilot in the Mooney, and the certificated private pilot in the Piper were fatally injured. Night visual meteorological conditions prevailed, and no flight plan was filed for either flight. The personal flights were conducted under 14 CFR Part 91.

According to radar data and communication tapes from the Federal Aviation Administration (FAA), the Mooney had been conducting touch-and-go landings on runway 22 at CDW. The pilot of the Piper departed Alexandria Airport (N85), Pittstown, New Jersey, about 1830. At 1905, he established communication with the air traffic control tower (ATCT), and reported that he was about 7.5 miles west northwest of the airport, at 2,500 feet msl. The tower controller acknowledged the transmission, and instructed the pilot of the Piper to report a right downwind for runway 22. There were no further communications between the controller and the pilot of the Piper.

Review of the radar data revealed that both accident airplane targets were depicted on the CDW tower non-standard D-Brite radar display. Prior to the collision, the Mooney had completed a go-around. The Mooney target displayed a transponder code of 1200, and flew an upwind leg for runway 22. Several seconds before the collision, the Mooney target was turning right toward a northeasterly direction, consistent with a crosswind to downwind leg for runway 22. The Mooney target displayed an altitude of 1200 feet, which was the published traffic pattern altitude. The Piper target displayed only a primary radar return, but the pilot had reported an altitude of 2,500 feet during his initial transmission to the CDW tower. The Piper target was west of the Mooney target, and appeared to converge in an easterly direction, consistent with a 45-degree entry into the right traffic pattern for runway 22.

At the time of the collision, the tower controller was in communication with 9 airplanes, including the two accident airplanes six were operating in the traffic pattern.

Three people witnessed the mid-air collision. The first witness was a student pilot, at a restaurant near the airport. The witness observed that one airplane was slow, and he assumed it was in the traffic pattern for CDW. It passed over the witness heading east, with both nav lights and the rotating beacon illuminated. The witness then saw a second set of nav lights converge from the right of the first airplane. He estimated that the airplanes converged on a 45-degree angle. The second witness, who was a helicopter pilot, was walking through his office parking lot. He observed the Piper, "...in the traffic pattern, heading east, straight and level..." The Mooney then suddenly "popped" into vision in what appeared to be a climbing right turn. Both airplanes had position lights illuminated, and converged at an approximate 45-degree angle. The third witness, who was a flight instructor, was flying an upwind leg for runway 22. He saw one airplane on a downwind leg, and was struck by the other aircraft while turning crosswind to downwind. The airplanes appeared to converge on an approximate 90-degree angle. The flight instructor added that it was possible:

"...the aircraft on downwind was not established in the traffic pattern prior to the accident and was in fact entering the traffic pattern incorrectly: instead of entering on a 45' angle to the midfield downwind, it is possible that he entered the pattern already on his downwind leg."

The flight instructor further stated that both airplanes were well lit at the time, and both pilots should have been able to see each other.

The accident occurred during the hours of darkness; located approximately 40 degrees, 52.35 minutes north longitude, 74 degrees, 18.15 minutes west latitude.

PILOT INFORMATION

The pilot of the Mooney held a private pilot certificate, with a rating for airplane single engine land. His most recent FAA third class medical certificate was issued on March 12, 2002. According the pilot's logbook, he had accumulated a total flight experience of approximately 108 hours; of which, about 7 hours were at night.

The pilot of the Piper held a private pilot certificate, with ratings for airplane single engine land, multi-engine land, and instrument airplane. His most recent FAA third class medical certificate was issued on August 25, 2001. According to the pilot's logbook, he had accumulated a total flight experience of approximately 653 hours; of which, about 112 hours were at night.

AIRCRAFT INFORMATION

The Mooney's most recent annual inspection was performed on March 20, 2002. At that time, the airplane had approximately 1,738 hours of total flight time. It had accumulated about 44 hours of flight time since the annual inspection.

The Piper's most recent annual inspection was performed on February 1, 2002. At that time, the airplane had approximately 3,572 hours of total flight time. It had accumulated about 80 hours of flight time since the annual inspection.

METEOROLOGICAL INFORMATION

The reported weather at CDW, at 1853, was: wind calm; visibility 10 miles; sky clear; temperature 50 degrees F, dew point 37 degrees F; altimeter 30.04 inches Hg.

WRECKAGE INFORMATION

Both wreckage sites were located in a residential neighborhood, about 1 mile northwest of the airport. Both sites were documented on November 15 and 16, 2002, and the wreckage was subsequently moved to a secure hangar for further examination during November 16 to 18, 2002. A strong smell of fuel was present at both wreckage sites.

The main wreckage of the Mooney was located approximately 40 degrees, 52.346 minutes north latitude, and 74 degrees, 18.153 minutes west longitude, on Fairfield Road, Fairfield, New Jersey. It was oriented about a 260-degree heading, and consisted of both wings, the engine, and the cockpit area. The rear fuselage, empennage, and horizontal stabilizer had separated from the main wreckage and were located about 500 feet south of the main wreckage. The vertical stabilizer was located on a rooftop about 400 feet south of the main wreckage.

Examination of the Mooney wreckage revealed tire-tread markings on the left side of the empennage. Additionally, propeller strikes were observed along both wings. Four strikes were found on the trailing edge of the left wing, originating about 15 inches inboard of the wing tip, and progressing toward the wing root. There was approximately 14-16 inches of spacing between each propeller strike. Seven strikes were observed on the trailing edge of the right wing, originating about 11 inches from the wing root, and extending toward the wing tip. There was approximately 17-20 inches of spacing between each propeller strike. All prop strikes were cut into the wing surface about a 45-degree angle to the chordline. Flight control continuity was established from the right aileron to the base of the cockpit control column. The left aileron had separated from the control rod due to impact forces, and continuity could not be verified. Control continuity was established from the elevator, rudder, and elevator trim to the aft bulkhead area.

The main wreckage of the Piper was located approximately 40 degrees, 52.348 minutes north latitude, and 74 degrees, 18.025 minutes west longitude, in the front yard of a residence along Plog Road, Fairfield, New Jersey. It was oriented about a 080-degree heading, and consisted of all major components of the airplane except the left wingtip. The left wingtip was located about 750 feet west of the main wreckage, in the vicinity of the empennage from the Mooney. Flight control continuity was established from the horizontal stabilator and base of the rudder, to the aft baggage area. Continuity was also established from the left aileron to the cockpit, and the right wing bell crank to the cockpit. Due to impact damage, continuity could not be established for the flaps.

MEDICAL AND PATHOLOGICAL INFORMATION

Autopsies were performed on both pilots by the Regional Medical Examiner Office, Newark, New Jersey.

Toxicological testing was conducted on the pilots at the FAA Toxicology Accident Research Laboratory, Oklahoma City, Oklahoma. The toxicological report for the pilot of the Mooney was negative for drugs and alcohol. Review of the toxicology report for the pilot of the Piper revealed:

"0.477 (ug/ml, ug/g) BUTALBITAL detected in Urine

0.609 (ug/ml, ug/g) BUTALBITAL detected in Blood

CHLORPHENIRAMINE detected in Urine

DIPHENYHYDRAMINE present in Urine

DIPHENYHYDRAMINE detected in Liver

METOPROLOL detected in Urine

METOPROLOL detected in Liver"

The Safety Board's Medical Officer reviewed information from the pilot's FAA medical records, medical records from his personal physician, correspondence from his personal physician, and pharmacy records.

According to the manager of the FAA Civil Aeromedical Institute, there was insufficient blood to test the levels of over-the-counter antihistamines, Chlorpheniramine and Diphenyhydramine.

Review of the pilot's medical records and a letter from his personal physician revealed that the pilot started antibiotic treatment for Lyme disease during 1999. In a letter dated November 3, 1999, the manager of the FAA Aeromedical Certification Division stated:

"Our review of your medical records has established that you are eligible for a third-class medical certificate...Because of your Lyme disease, operation of aircraft is prohibited at any time new symptoms or adverse changes occur or if you experience side effects from, or require a change in medication.

The pilot's last prescription for antibiotics was filled on May 12, 2001.

On May 26, 1999, during a telephone conversation with his personal physician, the pilot complained of headaches. The physician issued a prescription for 10 Fiorinal (Butalbital) capsules, which was filled on the same day.

His personal physician further stated that on two occasions the pilot was advised by Aviation Medical Examiners that his blood pressure was "high-normal," and was advised that he could try a beta-blocker drug. His physician's notes dated April 20, 2000 stated, "blood pressure: 140/88 right arm sitting. On Toprol (metoprolol) XL 50 mg ½ daily." His physician's notes dated August 8, 2001 stated, "blood pressure 130/84 left arm sitting. Continue Toprol XL 25 mg once daily.

On the pilot's most recent application for a medical certificate, dated August 25, 2001, he answered "no" for item 17.a. "Do you currently use any medication," and item 18.a. "Frequent or severe headaches."

TESTS AND RESEARCH

On December 12, 2002, the transponder unit from the Piper was inspected and tested at the manufacturer's facility, under the supervision of an FAA inspector. Due to impact damage, the position of the on-off switch could not be determined. A test display head, test antenna, and test wiring connector was attached to the unit. When power was applied, the unit powered up and tested satisfactorily.

On March 17, 2003, the strobe light from the Mooney was tested under the supervision of a Safety Board investigator. The light was connected to a 14-volt power supply. After approximately 4 seconds, the light illuminated, and then flashed about every 3 seconds afterward. Additionally, several witnesses reported seeing lights on both airplanes.

AIR TRAFFIC CONTROL

An Air Traffic Control (ATC) group was formed, and consisted of a Safety Board group chairman, an FAA accident investigator, and a representative from the National Air Traffic Controller's Association. The group convened at the CDW tower on November 18, 2002. The group reviewed voice recordings, radar data, tower procedures, and interviewed controllers.

According to the group report, three controllers were on duty at the time of the accident. At 1849, two controllers were in the cab, and one controller was in the break room. The accident controller had been working ground control, and said he was not busy. He then combined positions to let the second controller in the cab go out of the tower for a meal break, which left only one controller in the cab. At that time, there were four aircraft in the traffic pattern, and the pilot of a fifth aircraft was requesting entry into the pattern.

About 1852, the accident controller recorded a new ATIS broadcast, but started to "get busy," and forgot to activate the transmitter. At 1902, there were six airplanes in the traffic pattern. At 1904, a pilot performed a go-around due to insufficient spacing behind another aircraft, and a flight instructor reported that he was cut-off on base leg. The Mooney was identified as the other airplane that cut-off the flight instructor. The controller then instructed the pilot of the Mooney to go-around. The Mooney continued the approach, and then performed a go-around. The flight instructor later reported that, "the tower was having trouble identifying who was who in the traffic pattern." At 1905, the controller acknowledged the initial transmission of the Piper, but did not provide a sequence or traffic advisory. Seconds later, another pilot reported being cut-off in the traffic pattern.

Additionally, at 1907, the controller spent approximately 1 minute conversing with the pilot of a helicopter who used a non-standard position report. When the collision occurred at 1908, the controller did not see it, nor did he provide traffic advisories to either pilot. The controller later said that he thought the Mooney would be ahead of the Piper in the traffic pattern.

During the interviews, the third controller stated that he left the tower at 1615 for a meal break. He subsequently returned to the tower, but remained in the break room until the accident occurred. As a result, the third controller was out of the cab for a period of approximately 3 hours.

The accident controller stated that he entered on duty with the FAA on September 1, 1998. He was initially assigned to New York Center, then transferred to CDW on May 9, 1999. He became fully rated at CDW about one year later, and transferred to New York TRACON (terminal radar approach control). He withdrew himself from training and returned to CDW about 8 months later.

All three controllers stated that they used a "scratch pad" to keep track of aircraft in the traffic pattern. After the accident, the controller's "scratch pad" was not retained. The accident controller also stated that facility technique was generally not to initiate traffic calls, just to resolve conflicts.

ADDITIONAL INFORMATION

Review of Federal Aviation Regulation (FAR) 91.113(b) revealed:

"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..."

Review of FAR 91.113(d) revealed:

"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..."

Review of FAR 91.113(g) revealed:

"Landing...When two or more aircraft are approaching an airport for the purpose of landing, the aircraft at the lower altitude has the right-of way, but it shall not take advantage of this rule to cut in front of another with is on final approach to land or to overtake that aircraft."

Review of the FARs did not reveal any right-of-way information regarding an aircraft established in a traffic pattern, while another aircraft is entering the traffic pattern.

Both wreckages were released to representatives of the respective insurance companies on November 18, 2002.

SAFETY RESULTS

After the accident, the management within the CDW tower reminded employees of the current policies:

If three controllers are on duty, two must be in the tower.

A controller is not

NTSB Probable Cause

The inadequate visual lookout of both pilots. Factors in the accident were the FAA controller's failure to provide a traffic advisory, the improper decision among the three controllers to leave only one controller in the cab, and night conditions.