Aviation Accident Summaries

Aviation Accident Summary WPR15FA010

Yerington, NV, USA

Aircraft #1

N3558C

CESSNA 170B

Aircraft #2

N991TP

PETTIT SAVANNAH

Analysis

A Cessna 170B and a Pettit Savannah collided in midair shortly after both took off from the same airstrip. The airplanes were the second and third airplanes in a group of three airplanes whose pilots planned to depart from a fly-in at the airstrip, form up together in the traffic pattern, and then depart the area. The first airplane took off and turned left 180 degrees onto the downwind leg of the traffic pattern, and it was followed by the Cessna. Subsequently, the Savannah took off on a heading about 45 degrees to the left of the airstrip's heading and entered a climbing left turn. Witnesses reported that when the airplanes collided, the Cessna was flying level on a westerly heading on the downwind leg, and the Savannah was on about a north heading in a climbing left turn. The witnesses observed the airplanes collide at nearly a perpendicular angle. Postaccident examination of the airplanes' wreckage revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation of either airplane. A collision angle calculated from paint transfer and scratches on the Savannah's right wing indicated that the airplanes collided at an angle of about 90 degrees, consistent with the witness reports. The evidence indicated that the Savannah pilot attempted a join-up maneuver without maintaining adequate awareness of the Cessna's position. Before the collision occurred, the Savannah was in a climbing left turn and likely could not see the Cessna. The Savannah's pilot should have executed a clearing procedure during climb out to verify the position of the Cessna before attempting the join up. Also, had the Cessna's pilot executed a clearing procedure while on downwind, he might have been able to observe the Savannah as it was departing. The Savannah pilot's toxicology testing identified diphenhydramine, tramadol, mefloquine, and trazodone in the muscle and liver. Additionally, tetrahydrocannabinol (THC) and its inactive metabolite tetrahydrocannabinol carboxylic acid were detected in the lung, liver, and brain. The investigation was unable to determine why the pilot was using mefloquine or if he had any adverse effects from the medication. The combined effects of diphenhydramine, tramadol, trazodone, and THC, all of which cause sedation, likely impaired the Savannah pilot's decision-making.

Factual Information

HISTORY OF FLIGHTOn October 12, 2014 about 0812 Pacific daylight time, a Cessna 170B, N3558C, and an experimental amateur built Pettit Savannah, N991TP, collided in midair about 12 miles north of Yerington, Nevada. The commercial pilot, sole occupant of the Cessna, and the private pilot, sole occupant of the Savannah, were fatally injured. Both the Cessna and Savannah impacted terrain and were destroyed. Both airplanes were registered to and operated by the pilot as a Title 14 CFR Part 91 personal flight. Visual meteorological conditions prevailed, and no flight plan was filed for either flight. The Cessna departed from a nearby dry lake bed about 0809 and the Savannah about 0811. Both airplanes had a planned destination of Carson City, Nevada. Witnesses, who were participating in a fly in, located at the dry lake bed, reported that they observed the experimental Savannah take off about 45 degrees to the left of the outlined airstrip runway heading and then turn immediately left towards the Cessna and another airplane on the downwind leg. The Cessna was heading west while flying on downwind and the Savannah was climbing out to the north and turning left while attempting to join up with the Cessna. The witnesses observed the airplanes impact at nearly a perpendicular angle to each other. According to the pilot in the first airplane that just departed the airstrip, the Cessna and Savannah airplane were to join up with his airplane and then depart the local area, flying as three airplanes together in a loose formation. His airplane was the lead airplane on downwind and the Cessna was the second airplane established on downwind. The Savannah was the third and last airplane in the group, and planned to join with the other two airplanes on the traffic pattern downwind. PERSONNEL INFORMATIONThe pilot, age 48, held a commercial pilot certificate with an airplane multi engine land, single-engine land, single engine sea, and instrument ratings. He was also a Certified Flight Instructor in airplane single engine and a ground instructor. The most recent medical was a third-class airman medical certificate on June 06, 2014, with no limitations stated. The pilot reported on his most recent medical certificate application; that he had accumulated 2,500 total flight hours and 300 hours in the last six months. AIRCRAFT INFORMATIONThe four-seat, high-wing, fixed-gear airplane, serial number 26602, was manufactured in 1954. It was powered by a Lycoming O-360A1A, 180-hp engine. Review of the maintenance logbook records showed that the most recent inspection was an annual inspection completed on November 29, 2013, at a total airframe time of 12,022.9 hours. The most recent engine inspection was an annual inspection on November 29, 2013, at a total operating time of 2,754.8 hours. METEOROLOGICAL INFORMATIONThe 0755 Carson Airport (CXP), Carson City, Nevada, recorded data from the automated weather observation station, located about 27 miles east of the accident site, revealed conditions were wind calm, visibility 10 statute miles, clear sky, temperature 7 degrees Celsius, dew point 2 degrees Celsius, and an altimeter setting of 29.97 inches of mercury. AIRPORT INFORMATIONThe four-seat, high-wing, fixed-gear airplane, serial number 26602, was manufactured in 1954. It was powered by a Lycoming O-360A1A, 180-hp engine. Review of the maintenance logbook records showed that the most recent inspection was an annual inspection completed on November 29, 2013, at a total airframe time of 12,022.9 hours. The most recent engine inspection was an annual inspection on November 29, 2013, at a total operating time of 2,754.8 hours. ADDITIONAL INFORMATIONSeveral personal electronic devices were sent to the NTSB Vehicle Recorders Division for potential data download. Some of devices had recoverable data. However, of the devices that had data, no information pertinent to the investigation was present. Federal Aviation Administration (FAA) regulations [14 CFR 91.113(b)] required that each person operating an aircraft maintain vigilance so as to "see and avoid other aircraft." When aircraft of the same certification category are converging, "the aircraft to the other's right has the right-of-way." However, the FAA Pilot's Handbook of Aeronautical Knowledge (FAA-H-8083-25B) noted that even if entitled to the right-of-way, a pilot should yield if another aircraft seemed too close. The handbook also stated that high-wing and low-wing aircraft have their respective blind spots. The pilot of a high-wing aircraft should momentarily raise the wing in the direction of the intended turn and look for traffic prior to commencing the turn. The handbook further states that in order to assist with collision avoidance, pilots should execute clearing procedures periodically during sustained periods of straight-and-level flight. During climbs and descents, pilots should execute gentle banks left and right to permit visual scanning of the airspace. Vigilance should also be maintained during training operations and clearing turns should be made prior to a practice maneuver being performed. The manufacturer provided information related to the field of view from the high-wing, Cessna airplane. An individual seated in the left pilot's seat, has a view from approximately 51 degrees up and 10 degrees down out the front windshield. When looking out the left side window, the view is approximately from level to 66 degrees down. When looking out the cabin on the opposite side window, the field of view is restricted to 0 degrees up and about 26 degrees down. Additionally, the aft view is about 28 degrees to the right and 63 degrees to the right. A rejoin is used to expedite forming up together with another airplane and is frequently used in military formation flying. The maneuver is complex, since closure rate, airspeed, altitude, and alignment with the airplane that one is forming up to must be continuously monitored. According to Air Force's Primary Flying Manual for their T-6 primary trainer airplane, the following factors contribute significantly to the potential for a midair collision: Failure of the lead airplane to properly clear or visually monitor the number 2 airplane during a critical phase of flight, such as a rejoin. Failure of the number 2 airplane to recognize excessive overtake and the failure of the number 2 airplane to maintain lateral or vertical separation during rejoins. Further examination of the airframe and engine was accomplished by the NTSB investigator-in charge (IIC), an additional NTSB investigator, and an investigator from Textron Aviation. The flattened portion of the Cessna's wing leading edge corresponded to the width and shape of the damaged portion of the Savannah's vertical stabilizer and rudder. A collision angle was calculated utilizing the paint transfer and scratches on the Savannah's right wing. The two airplanes collided about on a 90 degrees converging angle. The examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. COMMUNICATIONSThe accident airplanes were not in contact with Air Traffic Control and the remote, mountainous area where the dry lake bed was located provided no radar coverage.

Probable Cause and Findings

The failure of the Savannah pilot to maintain awareness of the position of the Cessna while attempting a join up maneuver. Contributing to the accident was the impaired decision-making of the Savannah's pilot due to the combined effects of licit and illicit medications. Also contributing to the accident was the failure of the Cessna pilot to maintain awareness of the position of the Savannah as it was departing.

 

Source: NTSB Aviation Accident Database

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