Aircrash Investigation: Midair Collision | $5.4Million Lawsuit

Now when we think of aircraft accidents, we typically don't think of highly experienced pilots with thousands of flight hours. Ee usually think of inexperienced pilots, or pilots who haven't flown in a long time who lack proficiency in their aircraft. Yet time and time again we do see experienced pilots showing up in the accident reports making mistakes. Although what we certainly do not expect to see is an accident where two pilots involved, one is an accident investigator himself for the FAA, and the other the chief medical officer, a very experienced doctor for the NTSB. However on May 28, 2012 Mike Duncan, the chief medical officer for the NTSB and his flight instructor Paul Gardella, took off on a flight to complete Mike's flight review in his bonanza and around 4:00 p.m. on that nice calm and clear day that Bonanza collided with Thomas Proven's Cherokee 140, who happens to be an accident investigator for the FAA himself. Tom departed from Culpepper Airport in his cherokee 1:40 and proceeding over towards Warrenton requested an RNAV approach to runway 33. Just for practice on this nice calm clear day. The controller initially told to standby as he was pretty busy working other eye for aircraft in his airspace. Mike's bonanza and Tom's cherokee did come a little close together here at point A, but they were actually 600 feet vertically apart in about point nine miles apart as well. So suddenly knowing at that point if either pilot saw the other aircraft about a minute after that initial call from Tom the controller did get back to him and had him and her into his Cherokees transponder a discreet squawk code so he would appear on his radar screen and then over the course the next minute began briefing a relief controller who's going to go ahead and take over that station. Well the first controller went on break so a new controller came in and sat down at the station and then started getting acquainted with all the aircraft in the area. Both ifr aircraft and as well as Tom and Mike's VFR aircraft despite Tom doing that r nabbed a three-three approach he was still a VFR aircraft. The new controller went ahead and asked Tom to press ident. He did. The controller missed it at first, asked him to press it a second time and then went ahead and confirmed the airport and type of approach that he was requesting. That happened at about 1603 and 33 seconds at 1604 and eight seconds. About 30 seconds later, an audio conflict alert they sounded in the visual alert appeared on the controllers position screen so the controller was alerted by the software on radar saying hey two airplanes are getting close to each other the controller went ahead and looked at the screen saw that the alert was for the bonanza and for the Cherokee and decided since there was still 500 feet vertically between them that a conflict didn't really exist. The controller instead this point went ahead and diverted his attention to ensuring there would be separation between two converging IFR aircraft that he was responsible for In the 44 seconds after that conflict alerts first sounded at the controllers position he was very busy with other aircraft issuing frequency changes telling other AI fighter craft to level off to turn ensuring separation between other aircraft he was responsible for because he wasn't primarily responsible for VFR aircraft. After about 44 seconds passed and he finally caught a break he went ahead advised Tom flying the piper that he had been radar identified and also to please climb to 3,000 feet and indicated to him that there was traffic in the area to keep an eye out. Unfortunately there was no response from Tom because the collision had already occurred. The two aircraft met on about a 45 degree convergent path from the Piper's left side. The TSB up in Canada did a lot of analysis here and they determined that the field of view analysis figuring out where everyone was sitting and where heads were in the cockpit, where the flight instructors had was that the view should not have been obscured in that either aircraft should have been able to see the other aircraft approaching each other. As the two aircraft collided the propeller on the Cherokee severed the bonanzas fuselage just after the pilot seats. Without the empennage and the rudder vader's attached the bonanzas cockpit and wings entered into a dive and unfortunately resulted an impact that was not survivable to either pilot. The right rudder Bader in the aft portion of empennage and tail cone of the bonanza remain embedded in the Piper's fuselage.The cherokees engine subsequently failed and there was also a loss of airspeed education to the airspeed indicator in Tom's aircraft. Tom then glided his aircraft down into a pasture and during that landing the aircraft skidded through a narrow path and a line of trees in the right wing detached there was no post-impact fire luckily however Tom did get pretty banged up in that forced landing. It's important to know here that Tom did hit his head pretty hard and suffered some head injuries during that touchdown enjoying the impact of the trees however his Piper was not equipped with shoulder harnesses. Had that cherokee had shoulder harnesses installed the injuries may not have been so severe. Overall here the weather was great there's barely any clouds in the sky. It was light winds and one of the aircraft was talking to approach control. It's an important reminder to all of us that despite talking to approach control as a VFR aircraft you're not guaranteed any sort of separation between you and other aircraft and that guarantee of separation is really predicated on another human on the other end of the scope. Controllers do make mistakes just as we as pilots do. Both aircraft were equipped with transponders and they were both on at the time of impact however neither aircraft was equipped with any sort of T cast or any sort of conflict alert system or collision alert system on board the airplane. Well the ultimate safeguard to this is seen avoid that was what it was in place at the time of this incident and unfortunately it was not enough to keep all three of our pilots safe that day. Well the requirement for a DSB out is just around the corner here in 2024 flying in this type of airspace it certainly is not required throughout all the air space in the United States and ADSB out does not provide any information in to the cockpit unless you have ADSB in as well to receive some sort of traffic and weather information. While no T Cass or TIF system can never prevent all mid-air collisions it certainly may have played an important role in this particular scenario to keep these two aircraft separated and let at least one of the aircraft know that there is another airplane very near to it. Going forward what we can take away from this accident is this: talking to ATC is a great idea but it doesn't guarantee you anything you're the pilot command enjoy the ultimate and final authority to the safety that flight. You are the very last safeguard to ensuring the safety of that flight. You yourself nothing else and no one else. Keep your head on a swivel especially on those calm clear VFR days where everyone's out flying. Don't get too distracted with the avionics and the fancy buttons inside your own airplane and especially iPads and things like that. I know myself as a flight instructor I've fallen into the trap many times of focusing on something like a garment 430 and trying to teach a student that well we're both looking inside the aircraft at that GPS unit and not looking outside the airplane for other aircraft. It may be best to teach things like iPads and GPS units on the ground and then simply focus on flying the airplane when you're in the air. As a side note to this accident installing shoulder harnesses into your airplane can be a great investment especially if you ever have to use them. You'll be very very glad that you do have them. They are in cars for a reason and they should be in all airplanes. It definitely makes a huge impact in your safety in the event of a forced landing whether or not it's due to some sort of an accident or made air collision. Anytime you're going to have a hard landing a shoulder harness is going to reduce the injury felt by the occupants. And lastly here this accident really underscores one key point: absolutely no one is immune from crashing an airplane. Despite how many hours you might have. Despite your experience or your level of proficiency. Despite flying with an instructor on board or even being an accident investigator yourself. Someone who you would never think would ever have an aircraft accident. It's up to us to be alert on our a-game and be ready to be that last final stopgap to ensure the safety of your flight.

Channel: FLY8MA.com Flight Training

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Rating: 4.803236 out of 5

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Id: iM3oNcQx_uU

Length: 7min 34sec (454 seconds)

Published: Wed Mar 07 2018