Coolidge, AZ, USA
N94741
CESSNA 152
N994T
PIPER PA-28-161
Both airplanes involved in the mid-air collision were on simulated instrument meteorological conditions training flights in visual flight rules conditions. Both lesson profiles called for the pilot in the left-seat to wear a vision-restricting instrument training hood, while the pilot in the right seat acted as a safety/lookout pilot. The airplanes were being operated in an area of high density student training. The left seat pilot of the Piper had just rolled out of a right turn associated with the entry to a practice holding pattern to a non-controlled airport. The left-seat pilot of the Cessna had departed a non-controlled airport and was in an en route climb to the cruise altitude, at which he would return to his home airport. Neither airplane was receiving radar traffic advisories, nor was either in contact with a controlling Federal Aviation Administration (FAA) facility. The pilots in the Piper said that they were monitoring the designated practice area frequency, and had heard no other airplanes in the immediate area. The survivor in the Cessna could not clearly remember if he had been making position calls on the practice area frequency, but his radio was found set to that frequency and he said that he had been trained to make such calls. The Cessna was on a magnetic ground track of about 265 degrees, and the Piper had rolled out on a course intercept heading of 288 degrees about 10 to 15 seconds prior to the collision. The collision took place at 4,500 feet. During the collision sequence, the Cessna's right wing penetrated the lower left engine cowl of the Piper, and the Piper's left main landing gear wheel and tire impacted the right side of the Cessna's aft fuselage. After the impact, during which a portion of the Cessna's right wing and tail section separated, the Cessna entered an uncontrolled descent into the terrain and the pilots in the Piper executed a power-off forced landing. The weather at the time was reported as clear skies with 10 miles visibility. Neither safety/lookout pilot saw the other airplane prior to the collision.
HISTORY OF FLIGHT On September 9, 2009, about 0945 mountain standard time, a Cessna 152, N94741, and a Piper PA-18-161, N994T, collided about 4,500 feet mean sea level (MSL) while located about one-half mile east of Coolidge, Arizona. Neither the flight instructor nor his dual student in the PA-28-161 were injured, but one of the private pilots in the Cessna 152 received serious injuries, and the second private pilot in the Cessna 152 was killed during the accident sequence. The Cessna 152, which was operated by Air Safety Flight Academy (ASFA), was substantially damaged by the mid-air collision and the subsequent ground impact. The Piper PA-28-161, which was operated by Oxford Airline Training Center, sustained substantial damage as a result of the mid-air collision and an off-airport power-out forced landing. At the time of the accident, the Piper PA-28 was in the process of entering the holding pattern associated with the GPS approach to runway 23 at Casa Grande Airport, Casa Grande, Arizona, and the Cessna 152 was in an en route climb after departing Coolidge Municipal Airport, Coolidge, Arizona. The Cessna 152 flight originated at Glendale Municipal airport, Glendale, Arizona, about 0700. The PA-28 flight originated at Goodyear Airport, Goodyear, Arizona, at 0830. Both airplanes were operating under the provisions of 14 Code of Federal Regulations, Part 91, and both airplanes were in visual meteorological conditions. Neither flight crew had filed a Federal Aviation Administration (FAA) flight plan. According to the pilots in the PA-28, after departing Goodyear Airport, they proceeded to the Stanfield VOR (VHF Omni-directional Radio Range), where the dual student practiced holding before shooting two ILS (Instrument Landing System) approaches to Runway 05 at Casa Grande, Arizona (KCGZ). After the second ILS approach, the student executed a touch and go landing on Runway 05, and then after entering the Runway 05 upwind, announced on the KCGZ Common Traffic Advisory Frequency (CTAF) that they were on the upwind and would be tracking outbound to AYZUT (the initial approach fix (IAF) for the Global Positioning System (GPS) approach to runway 23 at Casa Grande). While passing through about 500 feet above ground level (agl), the crew of the PA-28 made another call on the KCGZ CTAF frequency, stating that they would be climbing to 4,500 feet to enter the hold at AYZUT. About that time, they also entered the frequency for the Arizona Fight Training Workgroup's (AFTW's) southeast practice area (122.85) in their number 2 communications radio. [Note: Both airplanes were operated by flight schools that are voluntary participants in AFTW. Among other things, AFTW provides an on-line Phoenix Area Terminal Area Chart that depicts AFTW-defined practice areas, within which the airplanes of participants transmit, receive, and monitor activity on specific AFTW designated frequencies (see aftw.org).] As they passed through 3,500 feet, the dual student made a call on the KCGZ CTAF, stating that they would be entering the hold at AYZUT in about one minute and thirty seconds. He then repeated that same call on the southwest practice area frequency. Upon reaching 4,500 feet, the dual student again transmitted on the KCGZ CTAF that he would be entering the hold at AYZUT. When the airplane was about 30 seconds from the IAF, the dual student made another call on the KCGZ CTAF, stating that he would be entering the hold in 30 seconds. Reportedly, up to that point in time, the crew of the PA-28 had heard a few other airplanes make calls on the KCGZ CTAF, but the advisory calls from these other airplanes indicated that their activities did not involve the area near the holding pattern at AYZUT or the inbound GPS approach course to Runway 23 at Casa Grande. The two crew members also heard a few calls from airplanes on the southeast practice area frequency, but all of those airplanes were near Phoenix-Mesa Gateway Airport (KIWA), which is located about 25 statute miles north-northwest of AYZUT. After reaching AYZUT at 4,500 feet, the dual student turned to a heading of 078 degrees to execute a parallel entry into the holding pattern, which had an inbound course of 258 degrees, and then made a call on the KCGZ CTAF to announce that he was entering the hold. The dual student then flew on the heading of 078 degrees for one minute, during which time neither he nor the CFI heard any calls on the southeast practice area frequency. He then turned right to a heading of about 288 degrees to intercept the inbound course. The dual student then transmitted on the KCGZ CTAF that he was "procedure turn inbound," for the GPS Runway 23 approach. Within what the occupants thought was about 10 to 15 seconds after rolling out on the intercept heading of 288 degrees; they both felt a sudden impact, followed immediately by the cessation of the rotation of the airplane's propeller. Immediately after the impact, the airplane lost approximately 1,000 feet, in what was estimated by the occupants to be about three to four seconds. At that point in time, the CFI took control of the airplane and looked for a field in which to perform a power-off forced landing. The CFI selected a field, and as he maneuvered toward it, the dual student made emergency radio calls; first on KCGZ CTAF, then on the VHF emergency frequency of 121.5, then on 120.1 ( the tower frequency at Phoenix-Goodyear Airport; their home base), and then on the Phoenix Approach Control frequency for the area they were in (123.7). As the CFI approached the field, he slipped the airplane in order to lose more altitude without increasing his airspeed. Almost immediately after the airplane touched down, its left main gear separated from the airframe, and the airplane slid/rolled to a stop. According to both occupants, from the time they departed Casa Grande heading to AYZUT, until the moment of impact, neither of them heard any pilots announce that they were departing Coolidge Airport, or climbing to the north after having departed Coolidge Airport. Both occupants stated that neither one of them saw the Cessna 152 prior to the collision, nor at the time of the impact did they realize that there had been a collision between themselves and another airplane. It was only after the CFI took control of the airplane that the dual student, who had been wearing a vision restricting instrument training hood prior to the impact, saw what appeared to be part of another airplane sticking out of the left side of the cowling area of the PA-28. According to a representative of Air Safety Flight Academy (ASFA), the two private pilots in the Cessna 152 were performing a dual-crew cross county flight in accordance with the ASFA FAR Part 61 Instrument Flight Training Syllabus. The lesson requirements called for the flight to depart Glendale Municipal Airport (KGEU), Glendale, Arizona, and to proceed to Marana Regional Airport KAVQ), Marana, Arizona, with the flying pilot sitting in the left seat. During the en route portion of the flight, the flying pilot was to operate the airplane in a simulated Instrument Flight Rules (IFR) mode, while wearing an instrument training vision restricting device (instrument hood). Upon arriving in Marana, the flying pilot was to park the airplane, shut the engine down, and then after making an external inspection, the pilots were to switch seats, and the other pilot would fly a simulated IFR leg back to Glendale Municipal Airport. During both legs of the flight, the non-flying pilot was to, "…look out for traffic and act as a safety pilot." The lesson did not authorize any touch-and-go or full-stop landings at any airports except the initial point of departure (Glendale Municipal) and the planned turnaround point (Marana Regional). According to the surviving pilot, he flew the first leg of the flight, which terminated at Marana Regional Airport, from the left seat. After landing at Marana, he switched seats with the other pilot, who was to fly the return leg to Glendale Municipal Airport. For reasons that were unable to be determined during the post-accident interview process, while en route back to Glendale, the occupants of the Cessna 152 decided to proceed to Coolidge Municipal Airport, Coolidge, Arizona, in order to, "…do some touch-and-go's." After performing an undetermined number of touch-and-go landings to Runway 05 at Coolidge, about 0937 the left seat (flying) pilot began a climb-out that started to the northeast, and according to recorded radar data, then began a turn to the left while passing through about 2,000 feet. The pilot continued the turn to the left, and initially rolled out on a ground track of about 245 magnetic degrees. Then about one minute later, when the airplane was due north of Coolidge Municipal Airport, the pilot turned slightly back to the right to a ground track of about 265 magnetic degrees. The radar data showed that the pilot maintained the track of about 265 magnetic degrees, and continued to climb, until the two airplanes collided. The radar data indicated that during the climb, the pilot was maintaining a climb rate that averaged between 700 and 750 feet per minute. During the collision sequence, the right wing of the 152 separated about two feet outboard of the lift strut attach fitting, and the aft portion of its fuselage separated at the second bulkhead forward of the leading edge of the horizontal stabilizer. The Cessna 152 then entered an uncontrolled descent, during which the pilot in the left seat was ejected from the airplane. The airplane eventually impacted a flat open dirt field in the inverted position. When the Cessna 152 came to rest, the non-flying pilot, who ultimately recovered from the injuries he sustained during the accident sequence, was still strapped in the right seat. In a couple of post-accident interviews with the surviving pilot in the Cessna 152, he stated that the event had been a big shock, and that he could not clearly and accurately remember most of what went on. Because of his emotional condition, and because Chinese was his primary language, he asked for the interviews to be performed through an interpreter. Although the surviving pilot later wrote a brief statement, he was unable to answer many of the interview questions, and most of the ones that he could answer were responded to in a one word response. He said that he could not remember what radio calls he had made, nor at what location or point in time might those calls have been made. He believed that he had been monitoring and transmitting on the southeast practice area frequency, but he was not sure that was the case. He could not remember exactly what airspace he had been in, or what they were doing just prior to the accident; except that they were heading back to Glendale. He believed that he had been into Coolidge Municipal Airport before, but he could not remember if that was with an instructor or not. He could not remember exactly what altitude they were at when the collision took place, but believes it might have been around 4,000 feet. He said that he did remember the "strong hit" when the two airplanes collided, and he stated that he did not remember seeing the other airplane prior to the collision. The next thing he remembered after the impact of the collision was someone on the ground telling him he was going to be alright, as they cut his seatbelt in order to facilitate his extrication. PERSONNEL INFORMATION The occupants of the Piper PA-28 were a flight instructor and a student who held a private pilot rating. The 47 year old flight instructor held a commercial pilot certificate, with airplane single-engine land and airplane multiengine land ratings, and an instrument rating. He held an instructor rating for airplane single-engine, airplane multiengine, and instrument airplane. His last FAA airman's medical, as class 3 with limitations/waivers, was on December 1, 2008. Of his 2,081 hours of total flying time, 1,250 were in a Piper PA-28. The 20 year old student, a British national, held a private pilot certificate, with airplane single-engine land, and airplane multiengine land ratings, as well as an instrument rating in airplanes. His last FAA airman's medical, a Class 1 with limitations/waivers, was on April 23, 2009. Of his 278 hours of total flying time, 228 were in a Piper PA-28. The occupants of the Cessna 152, both of whom were Chinese nationals, were both private pilots. The 23 year old pilot in the right seat (the survivor) held an airplane single-engine land rating, and his last FAA airman's medical, a class 1 without limitations or waivers, was on October 6, 2008. Of his 156 hours of total flying time, 127 were in a Cessna 152. The 27 year old pilot in the left seat (the fatality) held an airplane single-engine land rating, and his last FAA airman's medical, a class 1 without waivers or limitations, was on October 6, 2008. Of his 160 hours of total flying time, 100 were in the Cessna 152. AIRCRAFT INFORMATION The 1988 Piper PA-28-161, N994T, serial number 2816037, was registered to, and operated by, Oxford Airline Training Center Incorporated. Its last inspection (AAIP) was completed on September 4, 2009. The 1983 Cessna 152, N94741, serial number 15285778, was registered to Christiansen Aviation Incorporated, and operated by Air Safety Flight Academy. Its last inspection (100 hour) was completed on June 26, 2009. Neither airplane had a Traffic Alert and Collision Avoidance System (TCAS) installed, and neither airplane was required to have such a system. METEOROLOGICAL INFORMATION The 0930 aviation surface weather observation (METAR) recorded at Coolidge Municipal Airport, which is located about seven statute miles southeast of the collision site, indicated clear skies, calm winds, and a visibility of 10 miles. The skies had been clear, with 10 miles visibility, in the area around Coolidge since sunrise. The 0953 METAR recorded at Casa Grande Airport, which is located about 16 miles west of the collision site, indicated clear skies, winds from 080 degrees, and a visibility of 10 miles. COMMUNICATIONS Neither airplane was in contact with Phoenix Approach Control (TRACON), and according to the FAA, Phoenix Approach does not normally provide radar traffic advisories for training flights in the Casa Grande/Coolidge area. The reason that this coverage is not normally provided is due to both the very high volume of student activity, and the fact that members of AFTW have their own clearly defined and published system of making radio calls in the blind to report their position and their intentions. The occupants of the PA-28 reported that they had been making radio calls on the Casa Grande CTAF in order to report both their position and their intentions. They also reported that after reaching 3,500 feet, they monitored the AFTW southeast practice area frequency, and made one call on that frequency to announce their intention to hold at AYZUT. This call was made about one minute and thirty seconds prior to entering holding. They also reported that they did not hear any transmissions from airplanes announcing their position as being in the area of north of Coolidge or near AYZUT. According to the surviving pilot in the Cessna 152, due to the traumatic nature of the events that followed the collision between the two airplanes, including the impact with the ground after the uncontrolled descent, he did not have an exact recollection of the moments leading up to the event. He believes that they were monitoring and transmitting on the AFTW southeast practice area frequency, but he was not absolutely sure. He further stated that he always makes the calls on the radio that his instructor taught him to make, but he did not specifically remember what calls were made prior to the collision. During the post accident inspection, the Garmin GNS 430 in the PA-28 indicated that the primary frequency was set on 120.1 (Phoenix -Goodyear Tower), and the back-up frequency was 121.5 (VHF emergency). The airplane's number 2 radio, a Bendix /King KX 155, was found in the off position at the accident site, and did not illuminate or function when power was applied during the initial post-accident inspection. It was later removed from the airplane
The failure of both safety/spotter pilots to see and avoid the other airplane.
Source: NTSB Aviation Accident Database
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