N6027KBeech F33A · 1978

On September 7, 2016, at 1048 eastern daylight time, a Beech F33A, N6027K, and a Diamond Aircraft Industries DA20-C1, N85WP, collided in midair on the final approach leg of the traffic pattern to runway 35 at West Georgia Regional Airport (CTJ), Carrollton, Georgia. The Beech was substantially damaged, and the private pilot was fatally injured. The Diamond was destroyed, and the flight instructor and the student pilot were fatally injured. The Beech was registered to and operated by the private pilot. The Diamond was registered to and operated by Falcon Aviation Academy LLC. Both flights were conducted under the provisions of 14 Code of Federal Regulations (CFR) Part 91; the Beech pilot was conducting a personal flight, and the Diamond pilots were conducting an instructional flight. Visual meteorological conditions prevailed, and no flight plans were filed for either flight. The Beech departed from Fulton County Airport (FTY), Atlanta, Georgia, about 0915, and the Diamond departed from Newnan Coweta County Airport (CCO), Newnan, Georgia, about 1000.

According to personnel from Falcon Aviation Academy, the pilots of the Diamond were practicing traffic pattern operations and landings at CTJ. The Diamond entered the traffic pattern, followed a few minutes later by N263CF and then by N169PS, both Falcon Aviation Academy DA20s. The flight instructor and student pilot on board N263CF saw the Beech on the downwind leg of the traffic pattern. Moments later, the flight instructor and student pilot on board N169PS entered the traffic pattern from the east. They looked down and to the left, in the direction of the final approach path for runway 35, and saw two airplanes collide. The instructors and the students on board both trailing DA20s reported that they did not hear the Beech pilot broadcasting his intentions on the CTJ common traffic advisory frequency (CTAF) but they heard the accident Diamond making position calls in the traffic pattern before the collision, with the last call being made on the final approach.

Another flight instructor employed by Falcon Aviation Academy reported that he was familiar with the Beech pilot and his airplane. He had just completed a flight at CCO and heard the Beech pilot broadcasting traffic pattern calls for CTJ about the time of the accident; however, the Beech pilot was broadcasting over the CCO CTAF of 122.7 MHz. The flight instructor reported that the Beech pilot was not in the traffic pattern at CCO at the time of the transmissions.

Radar data provided by Federal Aviation Administration (FAA) air traffic control personnel indicated that the Beech pilot entered an extended left downwind for CTJ from the north, above and behind the accident Diamond, which was on the downwind leg of the traffic pattern. The ground speed of the Beech was about 50 knots greater than the ground speed of the Diamond. The last radar returns were on the downwind leg, about 2,000 ft above mean sea level, or about 850 ft above the ground. The locations of the last radar returns showed the airplanes approaching the base leg for runway 35.

The Diamond was not equipped with GPS data recording capability. A portable GPS receiver recovered from the Beech recorded the accident flight. The recording indicated that the Beech was established on the downwind leg for runway 35, about 2,500 ft GPS altitude and 150 knots groundspeed. The CTJ airport elevation was 1,164 ft. The Beech descended toward the base leg, turning base about 2,200 ft and 122 knots. The Beech turned onto final about 1,450 ft and 79 knots. The last recorded data point was at 1048:00, with the Beech at 1,201 ft and 76 knots, about 607 ft south of the runway 35 threshold.

The Beech Pilot

The pilot of the Beech, age 79, held an FAA private pilot certificate with airplane single-engine land and instrument airplane ratings. He held an FAA third-class medical certificate with a restriction to have glasses available for near vision. He reported 2,500 total hours of flying experience on his FAA third-class medical certificate application that was dated October 5, 2015. His personal pilot logbook was not located.

According to the owner's representative (insurance adjuster), the Beech pilot reported that he completed a Beechcraft Pilot Proficiency Program on October 30, 2015, at Blairsville, Georgia. This was confirmed verbally and accepted as a current flight review by the insurance company.

The Diamond Flight Instructor

The flight instructor in the Diamond, age 24, held an FAA commercial pilot certificate with ratings for airplane multi-engine land, airplane single-engine land, and instrument airplane. She held an FAA flight instructor certificate with a rating for airplane single-engine, and she held an FAA first-class medical certificate with a restriction to wear glasses. She was seated in the right cockpit seat. She reported 600 total hours of flying experience on her FAA first-class medical certificate application that was dated March 16, 2016. A review of her pilot logbook revealed about 850 hours total time, including 721 hours in single-engine airplanes and 366 hours as a flight instructor.

The Diamond Student Pilot

The student pilot in the Diamond, age 20, held an FAA student pilot certificate. He held an FAA second-class medical certificate with no restrictions. He was seated in the left cockpit seat. He enrolled in the ab initio training program at Falcon Aviation Academy on August 4, 2016, and had logged about 22 hours of flight time.

Beech

The off-white- and blue/gold-colored Beech F33A was a single-engine, low-wing airplane with a conventional tail. A review of the airplane's maintenance and airworthiness records revealed that an enhanced Whelen light-emitting diode (LED) wingtip position and anti-collision light system, model OR6502GE/OR6502RE, and a Whelen LED tail position and anti-collision light system, model OR5002V, were installed on the airplane per FAA Supplemental Type Certificate, dated November 10, 2014. The airplane was equipped with landing and taxi lights. The airplane was not equipped with a traffic advisory system (TAS), traffic alert and collision avoidance system (TCAS), or automatic dependent surveillance-broadcast (ADS-B) equipment or displays. The Beech's avionics suite included a King KX 155 VHF communication/navigation transceiver and a Garmin GNS 530 GPS/communication/navigation all-in-one unit.

According to information provided by the owner's representative, the Beech's most recent annual inspection was completed on or about July 13, 2016. At the time of the inspection, the airframe had accumulated about 4,549 total hours of operation.

Diamond

The white- and blue-colored Diamond DA20 was a single-engine, low-wing airplane with a T-tail configuration. It was equipped with wingtip-mounted anti-collision strobe lights and navigation position lights, and a landing and taxi light. The airplane was not equipped with a TAS, TCAS, ADS-B equipment or displays. The Diamond's avionics suite included an iCOM AC-A200 VHF air band transceiver and a Garmin GNS 430 GPS/communication/navigation all-in-one unit.

The Diamond's most recent annual inspection was completed on August 9, 2016. At the time of the inspection, the airframe had accumulated about 1,990 total hours of operation.

The CTJ 1055 weather observation included wind calm, visibility 10 statute miles, scattered clouds at 8,500 ft, temperature 30°C, dew point 19°C, and an altimeter setting 30.30 inches of mercury.

Beech

The off-white- and blue/gold-colored Beech F33A was a single-engine, low-wing airplane with a conventional tail. A review of the airplane's maintenance and airworthiness records revealed that an enhanced Whelen light-emitting diode (LED) wingtip position and anti-collision light system, model OR6502GE/OR6502RE, and a Whelen LED tail position and anti-collision light system, model OR5002V, were installed on the airplane per FAA Supplemental Type Certificate, dated November 10, 2014. The airplane was equipped with landing and taxi lights. The airplane was not equipped with a traffic advisory system (TAS), traffic alert and collision avoidance system (TCAS), or automatic dependent surveillance-broadcast (ADS-B) equipment or displays. The Beech's avionics suite included a King KX 155 VHF communication/navigation transceiver and a Garmin GNS 530 GPS/communication/navigation all-in-one unit.

According to information provided by the owner's representative, the Beech's most recent annual inspection was completed on or about July 13, 2016. At the time of the inspection, the airframe had accumulated about 4,549 total hours of operation.

Diamond

The white- and blue-colored Diamond DA20 was a single-engine, low-wing airplane with a T-tail configuration. It was equipped with wingtip-mounted anti-collision strobe lights and navigation position lights, and a landing and taxi light. The airplane was not equipped with a TAS, TCAS, ADS-B equipment or displays. The Diamond's avionics suite included an iCOM AC-A200 VHF air band transceiver and a Garmin GNS 430 GPS/communication/navigation all-in-one unit.

The Diamond's most recent annual inspection was completed on August 9, 2016. At the time of the inspection, the airframe had accumulated about 1,990 total hours of operation.

General

The main wreckage of both airplanes came to rest in a grass field, about 408 ft south of the approach end of runway 35, on the extended centerline of the runway. The Diamond came to rest in an upright position. The Beech came to rest inverted and on top of the Diamond wreckage. The wreckage debris field was about 350 ft long and about 80 ft wide, oriented on a heading of 350º. All major structural components of both airplanes were accounted for within the wreckage debris field.

Beech

The wreckage of the Beech was generally intact; the wings and empennage remained attached to the fuselage. Flight control cable continuity was established from the cockpit controls to the flight control surfaces. The ailerons, elevator, and rudder remained attached in their respective positions on the wings, horizontal stabilizer, and rudder. Blue-colored paint transfer marks were found on the lower surface of the right wing, near wing station 108. Impact damage with paint transfer was found on the top of the fuselage around station 131.

The nose gear separated from the airplane during the impact sequence. White paint transfer markings were observed on the nose gear tire. The left and right main landing gear were found in the extended positions. White paint transfer markings were observed on the left, main gear tire. The wing flaps were extended 20º.

The master and avionics switches were found in the "on" positions. The strobe light switch was found in the "on" position. The taxi light switch was found in the "on" position, and the landing light was found in the "off" position; however, both switches had impact damage. The position of the navigation light switch could not be determined because of impact damage.

The engine remained attached to the firewall. External examination of the engine did not reveal physical evidence of a mechanical malfunction or anomaly. The propeller assembly separated from the engine at the crankshaft/propeller flange junction. The fracture surfaces exhibited features consistent with overload. The propeller blades remained attached to the hub and displayed chordwise scratches, blade twisting, leading edge gouging, and surface polishing.

A laminated card titled "LOCAL AREA FREQ" and dated April 27, 2009, was found in the Beech's cockpit. The card, which listed the frequencies for multiple airports in the area, listed the frequency for the CTAF at CTJ as 122.7 MHz.

Diamond

The Diamond came to rest upright, under the wreckage of the Beech. Flight control continuity was confirmed from the elevator and rudder to the cockpit controls. Aileron control continuity was confirmed from the right aileron to the cockpit controls. The left wing separated from the fuselage during the impact sequence. The left aileron control tubes had multiple fractures that exhibited overload signatures. The empennage separated from the fuselage about 14 inches forward of the vertical stabilizer root leading edge.

Blue paint transfer marks were observed on the leading edge of the Diamond's right wing. The marks were about 8 inches long and 12 inches from the wing root. The Diamond's landing, taxi, strobe, and position light switches were impact-damaged, and their preimpact positions could not be determined.

Lightweight pieces of the Diamond were found on a northerly path, beginning 340 ft south of the main wreckage. One of the most southerly pieces of wreckage debris was the right half of the Diamond's elevator. Closer examination revealed black transfer markings on the upper surface of the elevator that were consistent in color and tread pattern with the right main landing gear tire of the Beech. Examination of the Diamond's horizontal stabilizer revealed similar transfer markings on its upper surface. The other small pieces of debris located south of the main wreckage were identified as sections of the Diamond's canopy and wing root/fuselage skin.

FAA Rules, Regulations, and Guidance to Pilots

Title 14 CFR 91.113 addresses aircraft right-of-way rules and states, in part, the following:

(b) 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. When a rule of this section gives another aircraft the right-of-way, the pilot shall give way to that aircraft and may not pass over, under, or ahead of it unless well clear.

(f) Overtaking. Each aircraft that is being overtaken has the right-of-way and each pilot of an overtaking aircraft shall alter course to the right to pass well clear.

(g) Landing. Aircraft, while on final approach to land or while landing, have the right-of-way over other aircraft in flight or operating on the surface, except that they shall not take advantage of this rule to force an aircraft off the runway surface which has already landed and is attempting to make way for an aircraft on final approach. When two or more aircraft are approaching an airport to 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 which is on final approach to land or to overtake that aircraft.

The FAA's Aeronautical Information Manual (AIM), dated December 10, 2015, paragraph 5-5-8, includes pilot procedures for see-and-avoid while in flight and states, "When meteorological conditions permit, regardless of type of flight plan or whether or not under control of a radar facility, the pilot is responsible to see and avoid other traffic, terrain, or obstacles."

The AIM, paragraph 4-1-9, also describes operations to/from airports without an operating control tower and the use of a CTAF and states, in part, the following:

a. Airport Operations Without Operating Control Tower

1. There is no substitute for alertness while in the vicinity of an airport. It is essential that pilots be alert and look for other traffic and exchange traffic information when approaching or departing an airport without an operating control tower…To achieve the greatest degree of safety, it is essential that all radio-equipped aircraft transmit/receive on a common frequency identified for the purpose of airport advisories.

b. Communicating on a Common Frequency

The key to communicating at an airport without an operating control tower is selection of the correct common frequency…A CTAF is a frequency designated for the purpose of carrying out airport advisory practices while operating to or from an airport without an operating control tower.

The AIM describes the recommended communication procedures regarding departure aircraft on the CTAF and states, "Pilots of inbound traffic should monitor and communicate as appropriate on the designated CTAF from 10 miles to landing. Pilots of departing aircraft should monitor/communicate on the appropriate frequency from start-up, during taxi, and until 10 miles from the airport unless the CFRs or local procedures require otherwise."

The Pilot's Handbook of Aeronautical Knowledge (FAA-H-8083-24A), section 13, addresses scanning procedures for visually acquiring traffic:

The pilot can contribute to collision avoidance by being alert and scanning for other aircraft. This is particularly important in the vicinity of an airport.

The See-and-Avoid Concept

The FAA issued AC 90-48D, "Pilots' Role in Collision Avoidance," in April, 2016 to alert all pilots "…to the potential hazards of midair collisions and near midair collisions (NMAC), and to emphasize those basic problem areas related to the human causal factors where improvements in pilot education, operating practices, procedures, and improved scanning techniques are needed to reduce midair conflicts."

AC 90-48D stated that each person operating an aircraft, regardless of whether the operation was conducted under IFR or VFR, shall maintain a vigilant lookout for other aircraft at all times. Regarding visual scanning, the AC specifically stated that "Pilots should remain constantly alert to all traffic movement within their field of vision, as well as periodically scanning the entire visual field outside of their aircraft to ensure detection of conflicting traffic.". AC 90-48D also described several specific methods that pilots could use to visually acquire other traffic.

The Beech Pilot

The Georgia Bureau of Investigation Division of Forensic Sciences performed an autopsy of the Beech pilot and the cause of death was blunt trauma of the head and chest, and the manner of death was accident.

The FAA's Bioaeronautical Research Sciences Laboratory, Oklahoma City, Oklahoma, performed toxicology testing and identified doxazosin and losartan in the pilot's blood, and doxazosin, dextromethorphan, and its metabolite dextrorphan in urine. Doxazosin and losartan are blood pressure medications also named Cardura and Cozaar, respectively. The pilot reported the use of doxazosin and losartan to the FAA during his most recent FAA third-class physical. Dextromethorphan is an over-the-counter cough suppressant available in a number of products.

The Diamond Flight Instructor

The Georgia Bureau of Investigation Division of Forensic Sciences performed an autopsy of the Diamond flight instructor and the cause of death was blunt head trauma, and the manner of death was accident.

The FAA's Bioaeronautical Research Sciences Laboratory, Oklahoma City, Oklahoma, performed toxicology testing of the flight instructor. The specimens tested negative for carbon monoxide, ethanol, and a wide range of drugs, including major drugs of abuse.

The Diamond Student Pilot

The Georgia Bureau of Investigation Division of Forensic Sciences performed an autopsy of the Diamond student pilot and the cause of death was blunt trauma of the head and torso, and the manner of death was accident.

The FAA's Bioaeronautical Research Sciences Laboratory, Oklahoma City, Oklahoma, performed toxicology testing of the student pilot. The specimens tested negative for carbon monoxide, ethanol, and a wide range of drugs, including major drugs of abuse.

The King KX 155 VHF transceiver and the Garmin GNS 530 all-in-one unit from the Beech were sent to the NTSB Vehicle Recorders Laboratory to determine the frequencies in use at the time of the accident. The examination revealed that the KX 155 communication frequencies were set to 118.17 MHz (active) and 126.22 MHz (standby). The GNS 530 communication frequencies were set to 122.7 MHz (active) and 124.050 MHz (standby). The waypoint communications information page for CTJ was accessed during the examination even though the installed GNS 530 aviation database expired as of November 12, 2015. The CTAF/UNICOM on the displayed page showed the correct frequency of 122.975 MHz.