Pilot Debrief

BEECH A36 near Pawtucket, RI — 2008-06-06

Final reportNYC08LA207
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Date
2008-06-06
Location
Pawtucket, RI, USA
Airport
SFZ
Aircraft
BEECH A36
Registration
N27199
Category
Airplane
Highest injury
Minor
Fatalities
0

Probable cause

Both pilots' failure to see and avoid the other airplane. Contributing to the accident was the air traffic controllers failure to notify either pilot of the potential conflict.

NTSB narrative

A Piper PA-30 was on an instrument flight rules (IFR) flight plan in instrument meteorological conditions and was cleared for an instrument approach. As the Piper approached the missed approach point, the pilot visually acquired the airport, and notified the air traffic controller to cancel his IFR flight plan. According to the Piper pilot, after the controller acknowledged the cancellation request, the pilot retuned his radio to the Common Traffic Advisory Frequency (CTAF) and announced his intention for landing. Due to the wind direction, the Piper pilot elected to circle and land on Runway 15, which was in the opposite direction of his approach. The pilot of a Beech A36, who was ready to depart from Runway 5 of the same airport, and who was also on an IFR flight plan, requested permission to take off but was told to "hold for release" by the controller. However, the controller did not explicitly inform the Beech pilot of the reason for the delay. Less than a minute later, the controller released the Beech. The two airplanes collided near the intersection of the two runways. Both pilots reported that they were not aware of the other airplane until immediately prior to the collision. Several witnesses heard the Beech pilot announce his intentions multiple times, but did not hear the Piper pilot's transmissions. The investigation also revealed that the two controllers were both aware of the proximity of the two airplanes, but neither one communicated that information to either of the pilots. A review of the recorded communications also revealed that the approach controller had a brief personal conversation with another controller just prior to the accident. The lack of received position or intent transmissions from the Piper, and the controllers' failure to inform the pilots of the proximity of the two airplanes, deprived the pilots of information that was critical to the pilots' situational awareness, and which could have enabled one or both pilots to prevent this accident.

NTSB coding

View NTSB final report

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