NTSB Factual Report

HISTORY OF FLIGHT

On September 17, 2002, about 1300 Pacific daylight time, a Mooney M-20E, N7199U, collided in midair with a Beech 76 (Duchess), N1828A, about 1 mile northwest of McClellan-Palomar Field, Carlsbad, California. The private/pilot owner was operating the Mooney under the provisions of 14 CFR Part 91. The pilot, the sole occupant, sustained fatal injuries; the airplane was destroyed. The personal cross-country flight departed Modesto, California, at 1004, en route to Visalia, California, and departed Visalia at an undetermined time en route to Palomar. Pinnacle Aviation Services, Inc., was operating the Beech under the provisions of 14 CFR Part 91. The certified flight instructor (CFI) pilot and commercial pilot undergoing multiengine instruction (PUI) sustained fatal injuries; the airplane was destroyed. The local training flight departed Palomar at 1258. Visual meteorological conditions prevailed, and no flight plan had been filed for either airplane. The primary wreckage of the Mooney was at 33 degrees 08.223 minutes north latitude and 117 degrees 17.926 minutes west longitude. The primary wreckage of the Beech was at 33 degrees 08.608 minutes north latitude and 117 degrees 18.335 minutes west longitude.

The National Transportation Safety Board investigator-in-charge (IIC) reviewed recorded radio transmissions between air traffic control tower (ATCT) personnel at Palomar and the airplanes. The IIC converted all times to PDT.

A pilot in the Beech contacted Palomar ground control (GC) at 1247, requesting taxi from its fixed base operator (FBO) to runway 24. The ground controller instructed the pilot to taxi to runway 24 via taxiway A.

The pilot of the Mooney called the local controller (LC) at Palomar tower at 1255:37, reporting 10 miles north of the airport, over Oceanside harbor, for landing. There were no other transmissions from the Mooney pilot. The LC instructed the pilot to enter right traffic for runway 24 and report downwind. The pilot of the Beech reported ready for takeoff on runway 24 at 1256:02. The LC instructed the pilot to hold short of the runway. At 1257:32, the LC cleared the Beech to taxi into position and hold. At 1258:08, the LC cleared the Beech for takeoff, and the pilot acknowledged.

At 1259:27, the LC transmitted a traffic advisory to the Mooney, advising of the Duchess on right crosswind turning to downwind. In the same transmission the LC also advised the Duchess pilot of the Mooney traffic inbound on the 45-degree entry to downwind. There was no response from either airplane. According to the LC, the airplanes collided immediately after this transmission. There was no further ATC contact.

One witness observed the Mooney, which was light brown with dark brown accents, bank to the right immediately prior to impact. Another witness reported that both airplanes appeared to turn at the last second, but both turned the same way into each other. Witnesses reported that the two airplanes merged and then they saw a puff of white smoke. A piece of wing fell from the Mooney, which immediately went into a nosedive.

The Beech, which was white with blue accents, banked left and maintained that attitude for a few seconds. To some witnesses the bank angle approached 90 degrees, while to others it appeared to go to an inverted position. Then the airplane's nose down attitude became steeper until it nosed vertically into the ground. The airplane landed about 100 yards from one witness, who did not observe any attempts at recovery.

A Safety Board ATC specialist reviewed recorded radar data and submitted a factual report, which is attached. The following paragraphs summarize his findings.

The Beech's first radar target appeared at 1258:39, and the airplane passed the departure end of the runway at 1259:02. The Beech immediately turned right crosswind and crossed the arrival track of the Mooney at 1259:36, at a mode C reported altitude of 1,400 feet. The Beech continued roughly northbound, then entered a rapid descent and struck the ground east of Cannon Road. The last radar target, received at 1259:48, showed the airplane descending through a mode C reported altitude of 500 feet.

The Mooney followed the coastline from Oceanside to a point about 3 miles northwest of Palomar. The airplane then turned eastbound and tracked toward the right downwind leg for runway 24. At 1259:36, the Mooney crossed the path of the Beech, at a mode C reported altitude of 1,300 feet, and the two targets merged. The Mooney entered a rapid descent, striking the ground approximately 300 yards from the estimated collision point at 1259:43.

PERSONNEL INFORMATION

Mooney Pilot

A review of Federal Aviation Administration (FAA) airman records revealed that the pilot held a private pilot certificate with an airplane single engine land rating. The pilot held a third-class medical certificate issued on September 15, 2000. It had the limitation that the pilot must wear corrective lenses. The IIC located no personal flight records for the pilot. The aeronautical experience listed in this report came from a review of the airman FAA records on file in the Airman and Medical Records Center located in Oklahoma City, Oklahoma. These records indicated that as of the medical examination, the pilot had a total time of 1,300 hours with 60 hours logged in the previous 6 months.

Beech Duchess Pilots

Certified Flight Instructor (CFI)

A review of FAA airman records revealed that the CFI held a commercial pilot certificate with ratings for airplane single engine and multiengine land, as well as instrument airplane. He held a certified flight instructor certificate with ratings for airplane single engine and multiengine land, as well as instrument airplane. He held a first-class medical certificate issued on March 11, 2002. It had the limitation that the pilot must wear corrective lenses.

The operator submitted a written report. This report indicated that the CFI had a total flight time of 1,700 hours. He accumulated 184 hours in the last 90 days, and 58 in the last 30 days. He had 100 hours in this make and model.

Pilot Undergoing Instruction (PUI)

A review of FAA airman records revealed that the PUI held a commercial pilot certificate with airplane single engine land and instrument airplane ratings. The PUI held a first-class medical certificate issued on December 18, 2000. It had no limitations or waivers.

An examination of the pilot's logbook indicated an estimated total flight time of 325 hours. She logged about 30 hours in the last 90 days, and 15 in the last 30 days. She had an estimated 20 hours in this make and model.

AIRCRAFT INFORMATION

Mooney

The airplane was a Mooney M20-E, serial number 417. The engine was a Lycoming IO-360-A1A, serial number L-869-51A. The insurance company reported an approximate total airframe time of 4,600 hours, and it had an annual inspection on February 8, 2002.

Beech 76 Duchess

The airplane was a Beech 76 Duchess, serial number ME-422. The operator reported that it had an annual inspection dated April 11, 2002, at a total time of 3,000 hours.

The left engine was a Textron Lycoming O-360-A-1G6D engine, serial number L-2320-36A.

The right engine was a Textron Lycoming LO-360-A-1G6D engine, serial number L-555-71A.

METEOROLOGICAL CONDITIONS

A routine aviation weather report (METAR) for Palomar (CRQ) was issued at 1253. It stated: skies clear; visibility 10 miles; winds from 220 degrees at 7 knots; temperature 66 degrees Fahrenheit; dew point 59 degrees Fahrenheit; altimeter 29.81 inches of mercury (inHg).

A special observation taken by tower personnel at 1313 reported: skies clear; visibility 8 miles; winds from 230 degrees at 8 knots; temperature 66 degrees Fahrenheit; dew point 59 degrees Fahrenheit; altimeter 29.84 inHg.

COMMUNICATIONS

Both airplanes were in contact with the Palomar ATCT on frequency 118.6.

WRECKAGE AND IMPACT INFORMATION

Investigators from the Safety Board, the FAA, and Textron Lycoming inspected the wreckage at the accident scene.

Mooney

The Mooney came to rest in brushy trees on the side of a ravine. The empennage was vertical to the horizon. The propeller blades had leading edge gouges as well as blue and white paint transfer marks. The outboard left leading edge of the horizontal stabilizer was crushed up and aft. The paint on the top surface of the horizontal stabilizer was chipped, scratched, and gouged. The bare metal skin in the chipped paint areas contained blue paint marks.

A 4-foot section of the Mooney's left wing tip came to rest in a field at 33 degrees 08.27 minutes north latitude and 117 degrees 18.096 minutes west longitude. This was about 365 yards from the main wreckage.

Beech

The Beech came to rest in a drainage area adjacent to a new home development construction site. The empennage was bent and twisted to the left. The left wing was more damaged than the right. A piece of the left wing located with the main wreckage had light brown paint transfer marks. The outboard flap hinge bent inboard; it fractured and separated. The flap hinge and the lower wing skin adjacent to it had light brown paint transfer marks. The inboard flap hinge bent inboard, and had light brown paint transfer marks. All of the paint transfer marks were similar in color to the Mooney.

A 3-foot piece of the Beech's left wing tip came to rest at 33 degrees 08.32 minutes north latitude and 117 degrees 18.08 minutes west longitude. This was about 465 yards from the main wreckage.

The outboard left wing had slashes in two areas that were 19 inches apart. The outboard slash went through the bottom skin of the wing beginning at the landing light and angled inboard 10 degrees as it continued aft to the rear spar. The inboard slash went through the bottom wing skin near the leading edge and angled inboard 10 degrees as it continued aft through both the upper and lower surfaces of the left aileron. The metal on the edges of the slash marks was bent in an up direction.

The outboard section of the left elevator had two slash marks, which were about 19 inches apart. These slash marks angled inboard 10 degrees from front to rear. The metal on the edges of the slash marks was bent in an up direction.

MEDICAL AND PATHOLOGICAL INFORMATION

The San Diego County Coroner completed autopsies on all of the pilots. The FAA Toxicology and Accident Research Laboratory performed toxicological testing of specimens of the pilots.

The results of analysis of the specimens for the Mooney pilot contained no findings for tested drugs. The FAA laboratory did not test for carbon monoxide or cyanide. The report contained the following results: 20 (mg/dL, mg/hg) ehtanol detected in muscle; 1 (mg/dL, mg/hg) acetone detected in kidney. A note indicated that the ethanol found in this case was from postmortem ethanol formation and not from the ingestion of ethanol.

The results of analysis of the specimens for the Duchess CFI contained no findings for volatiles and tested drugs. The FAA laboratory did not test for carbon monoxide or cyanide.

The results of analysis of the specimens for the Duchess PUI contained no findings for carbon monoxide, cyanide, volatiles, and tested drugs.

TESTS AND RESEARCH

Aeronautical Information Manual (AIM)

Palomar ATCT was a nonapproach control tower. The Airport/Facility Directory Southwest U.S. indicated that Palomar was Class D airspace.

The AIM noted that the FAA was responsible for insuring the safe and efficient use of the National Airspace System (NAS) of the United States for both military and civil aviation. They designed the AIM to provide the aviation community with basic flight information and air traffic control procedures for use in the NAS.

Section 3 of the AIM described Class D airspace. It was generally that airspace from the surface to 2,500 feet above the airport elevation (charted in msl) surrounding those airports that had an operational control tower. It said that the configuration of each Class D airspace area was individually tailored. The airspace would normally be designed to contain instrument approach procedures. Paragraph 3.2.5(e) stated that no separation services were provided to VFR [visual flight rules] aircraft in flight.

Paragraph 4-1-15 in the AIM describes Safety Alerts. "A safety alert will be issued to pilots of aircraft being controlled by ATC if the controller is aware the aircraft is at an altitude which, in the controller's judgment, places the aircraft in unsafe proximity to terrain, obstructions, or other aircraft. The provision of this service is contingent upon the capability of the controller to have an awareness of a situation involving unsafe proximity to terrain, obstructions, and uncontrolled aircraft. The issuance of a safety alert cannot be mandated, but it can be expected on a reasonable, though intermittent basis. Once the alert is issued, it is solely the pilot's prerogative to determine what course of action, if any, to take. This procedure is intended for use in time critical situations where aircraft safety is in question. Noncritical situations should be handled via the normal traffic alert procedures."

AIM paragraph 4-3-1 provided general information. It pointed out that increased traffic congestion, aircraft in climb and descent attitudes, and pilot preoccupation with cockpit duties were some factors that increased the hazardous accident potential near the airport. It emphasized that pilots must be particularly alert when operating in the vicinity of an airport. It defined some rules, practices, and procedures that pilots should be familiar with and adhere to for safe airport operations. Paragraph 4-3-1-(e) reminded pilots in communication with a tower controller, who may have radar available, that they should not assume that constant radar monitoring and complete ATC radar services were being provided.

FAA order 7110.65 "Air Traffic Control"

FAA order 7110.65 "Air Traffic Control" prescribed ATC procedures and phraseology for use by persons providing air traffic control services.

Paragraph 2-1-1 outlined ATC service. It stated that, "the primary purpose of the ATC system is to prevent a collision between aircraft operating in the system and to organize and expedite the flow of traffic. In addition to its primary function, the ATC system has the capability to provide (with certain limitations) additional services. The ability to provide additional services is limited by many factors, such as the volume of traffic, frequency congestion, quality of radar, controller workload, higher priority duties, and the pure physical inability to scan and detect those situations that fall in this category. It is recognized that these services cannot be provided in cases in which the provision of services is precluded by the above factors. Consistent with the aforementioned conditions, controllers shall provide additional service procedures to the extent permitted by higher priority duties and other circumstances. The provision of additional services is not optional on the part of the controller, but rather is required when the work situation permits."

Paragraph 2-1-2 indicated duty priorities. Paragraph 2-1-2 (a) instructed controllers to give first priority to separating aircraft and issuing safety alerts as required in the order. It stated that good judgment shall be used in prioritizing all other provisions of the order based on the requirements of the situation at hand. It specified that controllers should first perform the action that was most critical from a safety standpoint.

Paragraph 2-1-2 (b) instructed controllers to provide additional services to the extent possible, contingent only upon higher priority duties. Other contingency factors include limitations of radar, volume of traffic, frequency congestion, and workload.

Order 7110.65, paragraph 2-1-6 discussed safety alerts. It directed controllers to issue a safety alert to an aircraft if they were aware that the aircraft was in a position or attitude, which in their judgment placed it in unsafe proximity to terrain, obstructions, or other aircraft. Once the pilot informed t

NTSB Probable Cause

failure of the pilots of both airplanes to maintain an adequate visual lookout and to see and avoid each other. A contributing factor was the failure of the controller to detect and resolve the conflict between the airplanes.