N79960 – Cessna (Textron Aviation) 172K – 2000-03-09 NTSB Accident Report

HISTORY OF FLIGHT

On March 9, 2000, about 1035 eastern standard time, [NOTE 1] a Cessna 172K, N79960, registered to Sarasota Flying Club, Inc., and operating as a 14 Code of Federal Regulations (CFR) Part 91 personal flight, and a Cessna 152, N89827, registered to Cirrus Aviation, Inc., and operating as a 14 CFR Part 91 instructional flight, collided during takeoff on runway 14 at the Sarasota Bradenton International Airport (SRQ), Sarasota, Florida. Visual meteorological conditions prevailed at the time. No flight plans were filed, nor were they required to be. The airline transport-rated pilot and pilot-rated passenger on board N79960 were killed, and the commercial-rated flight instructor and student pilot on board N89827 were killed. Both airplanes were destroyed.

At 1024:46, the pilot of N89827, which was at the Dolphin Aviation ramp, [NOTE 2] called the SRQ ground control/clearance delivery controller (GC) requesting a visual flight rules (VFR) departure. At 1025:24, the GC instructed N89827 to taxi to runway 14. N89827 proceeded to runway 14 via taxiway A. As the GC issued the taxi instructions to N89827, he was relieved by the supervisor/ground controller (SGC), who prepared a flight progress strip for N89827 indicating that the airplane was instructed to taxi to the end of runway 14 and passed it to the local controller (LC). The GC then provided a relief briefing to the SGC and left the tower cab.

At 1025:46, the pilot of N52553, a Cessna 172, called for an instrument flight rules (IFR) clearance. At 1025:56, the pilot of N5287V, a Cessna Cutlass, transmitted the following message: "Sarasota clearance seneca [er] cutlass five two eight seven victor at Jones aero [NOTE 3] with mike...negative radar to Clearwater air park." At 1026:11, the SGC issued a Class C clearance and transponder code to N5287V. The pilot of N5287V indicated that he was ready to taxi and that he was at "Jones aero." At 1026:34, the SGC instructed N5287V to "taxi westbound from Jones runway [14] foxtrot intersection." The SGC prepared a flight progress strip on N5287V indicating "14/F" and "PASE" (indicating that the airplane was a Piper Seneca). The pilot of N5287V stated that he "missed the last part," and the SGC stated, "expect the runway [14] foxtrot intersection." At 1026:46, the pilot of N5287V acknowledged the instruction, but the last part of his transmission was covered by the initial call of N79960. At 1026:55, the SGC advised N79960 to stand by and issued the IFR clearance to N52533. The pilot of N52533 stated that he was not yet ready to taxi.

At 1028:03, the pilot of N79960 [NOTE 4] stated, "at Jones and ready to taxi." The SGC issued a Class C clearance and transponder code to N79960, which the pilot acknowledged. At 1028:45, the SGC instructed N79960 to "taxi to runway[14]," which the pilot acknowledged. The SGC prepared a flight strip on N79960 indicating "14." N79960 proceeded via taxiway F and held short of runway 14 at the intersection. [NOTE 5] At 1028:52, the pilot of N52553 stated that he was "ready to taxi." The SGC confirmed N52553's location at the Dolphin Aviation ramp and issued taxi instructions "to runway [14]," which the pilot acknowledged. At 1029:41, N9801Y, a Mooney that had just landed, requested a taxi back to runway 14. At 1030:05, the SGC stated, "calling for taxiback, say again." The pilot of N9801Y responded that he would "like to taxi back and takeoff again"; the SGC advised N9801Y to stand by. At 1030:33, the pilot of N215JA, a Cessna 152 that was at Jones Aviation, stated, "we are ready to taxi." At 1030:37, the SGC instructed N9801Y to "taxi to runway [14]." At 1030:58, the pilot of N215JA stated, "at Jones...would like negative radar class C service toward Venice please." The SGC issued a Class C clearance and transponder code and directed N215JA to "taxi westbound to runway [14] foxtrot intersection." At taxiway A, N89827, N52553, and N9801Y were waiting in sequence; at taxiway F, N5287V, N79960, and N215JA were waiting in sequence.

At 1030:42, the pilot of N89827 made his first contact with the LC and stated, "ready for takeoff"; the LC instructed N89827 to "hold short." At 1031:08, the LC asked, "who's at the approach end of runway [14] ready to depart?" The pilot of N89827 stated, "eight two seven," and the LC stated, "I show you at foxtrot." At 1031:15, the pilot of N5287V transmitted, "no sir, that's eight seven victor at foxtrot"; the LC acknowledged the transmission. At 1031:29, the LC asked the pilot of N5287V if he was ready to depart; the pilot responded "affirmative." The LC stated, "I show you as a seneca...you're not a seneca are you?" The pilot stated, "no...I'm used to flying a seneca." The LC instructed N5287V to hold short.

At 1032:46, the pilot of N79960 made his first contact with the LC and stated, "this is...nine six zero we're number two ready for takeoff." The LC advised N79960 that it was "number three for departure, hold short." At 1033:57, the LC stated to N89827, "runway [14], taxi into position and hold, traffic will depart down field also." At 1034:06, the LC instructed N5287V, "runway [14] at fox[trot], taxi into position and hold." The pilot of N5287V acknowledged the instruction. At 1034:22, the LC cleared N5287V for takeoff from the taxiway F intersection.

The LC waited until N5287V became airborne, and at 1034:43, he cleared N89827 for takeoff from the approach end of runway 14, which the pilot acknowledged. Witnesses stated that they observed N89827 begin a takeoff roll from the end of runway 14. At 1034:51, the LC instructed N79960 to "taxi into position and hold," which the pilot acknowledged. Witnesses stated that when N89827 reached takeoff speed (near the 6,000-foot remaining marker), N79960 entered the runway from a taxiway on the left side of the runway. Witnesses further indicated that after N89827 lifted off and was a few feet in the air, it turned right in what appeared to be an attempt to avoid a collision with N79960. Witnesses stated that N89827 then appeared to stall and crash into N79960. Both airplanes immediately burst into flames, nosed over, and came to rest on runway 14. A loud burst of static and an emergency locator transmitter signal was heard on the air traffic control (ATC) voice tape. At 1035:21, an unidentified pilot stated, "tower you have a fire on runway [14]." The LC initiated crash, fire, and rescue response. The tower manager called the Tampa ATC tower and advised them to hold all traffic, and the LC instructed aircraft in the area to depart the pattern. Recorded radar data obtained from the FAA Tampa Approach Control, Sarasota antenna, plotted the positions of the airplanes on the airport; the radar time was 20 seconds ahead of the time on the recorded communications transcript.

In a postaccident interview with a National Transportation Safety Board investigator, the LC stated that he had been on duty in the LC position for about 20 minutes before the accident. He stated that he had "two or three Cessnas at (taxiway) F, two Cessnas and a Mooney at (taxiway) A." In addition, he stated that there were two airplanes airborne, one operating in the traffic pattern and another executing a practice approach. He stated that all airplanes except one were VFR. He further stated that he instructed the airplane that was executing the practice approach to break off the procedure early to allow the departures to leave.

In addition, the LC stated to a Safety Board investigator that initially some confusion existed about the locations of N89827 and N5287V. He stated that he cleared N5287V for takeoff and that when he observed N5287V become airborne, he cleared N89827 for takeoff. He further stated that he then instructed N79960 to taxi into position and hold. The LC stated that he issued this instruction because he recalled the pilot transmitting "number two," and the flight progress strip indicated "14." He stated that he saw two Cessnas on taxiway F "facing into the wind, in (the) runup position." He indicated that this reinforced his belief that N79960 was behind N89827 at taxiway A. The LC stated that, after issuing the instruction to N79960, he scanned the final approach area and "may have looked at the BRITE display." The LC also stated that he noticed that the Cessna holding short at taxiway A was not moving; however, he indicated that he did not attach any significance to that "because sometimes they're slow to go into position, they take a while." He stated that he then looked up at the runway and saw an explosion. He indicated that he immediately picked up the crash phone to notify airport emergency personnel.

The LC stated that he "always [states] the intersection" when clearing an aircraft for an intersection takeoff. He also indicated that there is no written standard strip marking procedure for intersection departures at the SRQ ATC tower. [NOTE 6] He stated that he marked strips "how I had been trained." He further stated that he had seen symbols such as "F/14," "14/F," or "14xF" to indicate an intersection departure from runway 14 at taxiway F. He indicated that "14" would indicate a full-length departure. He also stated that he used no particular method for sequencing strips and that GCs at SRQ typically do not place them in a sequence position before giving them to the LC.

In a postaccident interview with a Safety Board investigator, the SGC stated that he received a thorough relief briefing from the GC. The SGC also stated that the traffic at the time of the accident was moderately busy and that he did not observe any adverse weather or equipment problems. He stated that he normally states the intersection identifier when positioning aircraft for an intersection departure. He further stated that he typically marks strips using the runway number and a slant, followed by the intersection identifier, for intersection departures. The SGC indicated that he did not recall N79960 originating at Jones Aviation and that he thought that N79960 was at Dolphin Aviation "because I taxied him to [runway] 14 instead of foxtrot."

PERSONNEL INFORMATION

N79960 Pilot The pilot on board N79960, who was in the right front seat, held a U.S. airline transport pilot certificate (issued on October 3, 1975) with airplane single-engine land and rotorcraft-helicopter ratings and a commercial pilot certificate with airplane single-engine sea, airplane multiengine land, and instrument ratings. The pilot also held a flight instructor certificate (issued on April 2, 1998) with airplane single-engine, airplane multiengine, instrument airplane, and rotorcraft-helicopter ratings. His most recent FAA third-class medical examination was on February 1, 1999. In a May 19, 1999, letter, the FAA informed the pilot that he was eligible for a third-class medical certificate with the limitation that he must possess correcting glasses for near vision. The letter also stated that "because of your history of diet controlled diabetes, operation of aircraft is prohibited at any time new symptoms or adverse changes occur or any time medication and/or treatment is required." According to information supplied by the airplane operator, the pilot had accumulated over 13,000 total flight hours and had flown about 142 flight hours in the 90 days before the accident.

N79960 Pilot-Rated Passenger The pilot-rated passenger on board N79960, who was in the left front seat, held a Canadian private pilot certificate, which was restricted to flight in daylight operations and with two-way radio contact, with an airplane single-engine land rating. FAA records did not indicate that he held U.S. pilot certificates or medical certification. He held a Canadian category 3 medical certificate that was applied for and issued on May 26, 1999, with the limitation that he must wear correcting lenses. At the time of his medical application, the pilot reported that he had accumulated 1,916 total flight hours, with 45 flight hours in the last 12 months and 16 flight hours in the last 90 days.

N89827 Flight Instructor The flight instructor on board N89827, who was in the right front seat, held a U.S. commercial pilot certificate (issued on November 16, 1998) with airplane single-engine land and instrument airplane ratings and a flight instructor certificate (issued on January 13, 2000) with an airplane single-engine rating. Her most recent FAA second-class medical certificate was issued on January 3, 2000, with the limitation that she must wear correcting lenses. Pilot logbook records indicate that she had accumulated about 340 total flight hours, with 15 flight hours in the last 90 days. Her total flight instructor time was 15 flight hours.

N89827 Student Pilot The student pilot on board N89827, who was in the left front seat, held a U.S. student pilot certificate and class 3 medical certificate issued on October 28, 1998, with the limitation that he must wear correcting lenses. Pilot logbook records indicate that the student pilot had accumulated 156 total flight hours, with 25 flight hours in the last 90 days.

Supervisor/Ground Controller Before his employment with the FAA, the SRQ SGC was an air traffic controller in the U.S. Air Force, stationed at Moody Air Force Base (AFB), Georgia, and Kadena AFB, Okinawa, Japan. He holds Control Tower Operator (CTO) certificate, dated September 23, 1976. The SRQ SGC's employment with the FAA began on June 14, 1982, at SRQ. He was fully certified at SRQ on May 20, 1983, was certified as an On-the-Job Training Instructor on December 19, 1983, and was certified as a Controller-in-Charge on August 10, 1992. He held temporary details as Supervisor and Staff Specialist at SRQ and was promoted to permanent Supervisor on April 12, 1998. His operational time on position and medical certification were current at the time of the accident.

Local Controller Before his employment with the FAA, the SRQ LC was an air traffic controller in the U.S. Air Force, stationed at Travis AFB, California, from 1984 through 1988. He holds CTO certificate, dated May 23, 1988. The SRQ LC's employment with the FAA began on May 22, 1988, when he was assigned to the Nashville, Tennessee ATC tower; he became fully rated on March 5, 1990. He transferred to the Chicago O'Hare ATC tower on November 3, 1991, and became fully rated on March 17, 1993. He transferred to the Charlotte, North Carolina, ATC tower on December 11, 1995. He stated to a Safety Board investigator that he transferred to Charlotte "to get into the Southern Region" and that he intended to move to the Tampa area. He did not complete certification at Charlotte because of a transfer to the Tampa, Florida, ATC tower, where he became certified on July 7, 1996. He transferred to the SRQ ATC tower on April 25, 1999, and became fully certified on July 16, 1999. His operational time on position and medical certification were current at the time of the accident.

AIRCRAFT INFORMATION

N79960, a Cessna 172K, serial number (S/N) 17258287, was manufactured in 1969 and registered to Sarasota Flying Club, Inc. At the time of the accident, the recording tachometer read 3,891.9 hours, which was also the airplane's (and the engine's) total flight time. The airplane received an annual inspection on March 3, 2000 (2 flight hours before the accident).

N89827, a Cessna 152, S/N 15282885, was manufactured in 1978 and registered to Cirrus Aviation, Inc. At the time of the accident, the recording tachometer read 8,382.5 hours, and the airplane (and the engine) had 12,805.2 total flight hours. The airplane received an annual inspection on February 23, 2000 (42.3 flight hours before the accident).

METEOROLOGICAL INFORMATION

About 0953, the SRQ surface weather observation was sky clear, visibility 10 statute miles, wind from 200 degrees at 6 knots, temperature 75 degrees Fahrenheit (F), dew point temperature 63 degrees F, altimeter setting 30.14 inches of Mercury.

COMMUNICATIONS

There were no reported problems with communications. A person familiar with the pilot of N79960 identified him as the person who made the radio transmissions from N79960. The student pilot made the radio transmissions from N89827.

AIRPORT INFORMATION

SRQ, which is certificated under 14 CFR Part 139, is located 3 miles north of Sarasota, Florida, and has an airport elevation of 28 feet. The airport has two runways: 14-32 and 4-22. Runway 14-32 is 7,003 feet long and 150 feet wide and has a grooved asphalt surface. The distance from the beginning of runway 14 to the collision point at taxiway F was 1,292 feet, as measured by the Manatee County Sheriff's Office with a measuring wheel. The distance from the hold-short line on taxiway F to the center of runway 14 was 255 feet as measured by airport personnel.

WRECKAGE AND IMPACT INFORMATION

When N89827 impacted the top of N79960 on runway 14 at the taxiway F intersection, N89827's propeller contacted N79960's aft cabin roof, inboard wing flaps, and fuel tanks. Upon impact, a fire immediately erupted in N79960's fuel tanks. N79960 flipped inverted over the left wing and nose of N89827, and N89827's propeller separated from the engine. The two airplanes came to rest about 75 feet down the runway from the initial impact point on about a 300-degree heading. N89827 was found inverted on the runway, and N79960 was found inverted on top of N89827.

N79960 Examination of N79960 indicated that the wing flaps were in the retracted position. The elevator trim was neutral. The right wing flap had a portion cut out from the outboard trailing edge. [NOTE 7] The left and right fuel tanks exhibited fire damage. The pilot seats were extensively damaged by the postcrash fire, and the seat positions could not be determined. Continuity of the flight control system was confirmed.

N89827 The wing flap actuator was found separated from the wing, and examination of N89827 indicated that the actuator was extended to the 5-degree extended position. The flap handle was found in the retracted position. The elevator trim was neutral. The left and right fuel tanks had fire damage. Continuity of the flight control system was confirmed.

MEDICAL AND PATHOLOGICAL INFORMATION

Postmortem examinations of the pilot and pilot-rated passenger on board N79960 and the flight instructor and student pilot on board N89827 were performed by the Associate Medical Examiner in Sarasota, Florida. Toxicology studies on specimens obtained from the occupants of N79960 and N89827 were performed by employees at the Sarasota Memorial Hospital, the University of Florida Toxicology Laboratory, and the FAA Toxicology Laboratory, Oklahoma City, Oklahoma.

N79960 Pilot The cause of death was extensive thermal injury and probable carbon monoxide poisoning. All tests were negative for ethanol, cyanide, and drugs. The test results indicated 15 percent carbon monoxide in blood and 1,438 mg/dL glucose in urine. (According to the FAA Toxicology Laboratory, postmortem glucose urine levels above 100 mg/dL are considered abnormal, and elevated glucose levels can be caused by shock and burns.) FAA medical records indicate that the pilot had a history of noninsulin-dependent diabetes that was reported by his physician to be under excellent control with diet and exercise.

N79960 Pilot-Rated Passenger The cause of death was extensive thermal injury and probable carbon monoxide poisoning. All tests were negative for ethanol and cyanide. The test results indicated 14 to 16 percent carbon monoxide in blood, .019 ug/mL diphenhydramine in blood, .117 ug/mL diphenhydramine in urine, and 6.483 ug/mL acetaminophen in urine.

N89827 Flight Instructor The cause of death was a combination of extensive thermal injury and blunt force trauma to the chest. All tests were negative for ethanol and cyanide. The test results showed 7 percent carbon monoxide in blood and indicated the presence of caffeine.

N89827 Student Pilot The cause of death was extensive thermal injury and carbon monoxide poisoning. All tests were negative for ethanol and cyanide. The test results indicated 23 to 30 percent carbon monoxide in blood and the presence of quinine in urine, atenolol in blood and urine, and triamterene in blood and urine.

Controllers The FAA reported to Safety Board investigators that the SGC and the LC received postaccident alcohol and drug testing; an FAA representative reported that results for both controllers were negative.

ADDITIONAL INFORMATION

The Aeronautical Information Manual (AIM), paragraph 4-3-10, "Intersection Takeoffs," states that "[a]n aircraft is expected to taxi to (but not onto) the end of the assigned runway unless prior approval for an intersection departure is received from ground control" and advises pilots to "state their position on the airport when calling the tower for takeoff from a runway intersection." The AIM, paragraph 4-3-18, "Taxiing," also advises pilots to "[a]lways state your position on the airport when calling the tower for taxi instructions." Further, the AIM, paragraph 5-5-8a, "See and Avoid," states that "[w]hen 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."

In addition, FAA Order 7110.65, "Air Traffic Control," paragraph 3-9-6, "Same Runway Separation," states that the controller must "separate a departing aircraft from a preceding departing or arriving aircraft using the same runway by ensuring that it does not begin takeoff roll until the other aircraft has departed and crossed the runway end or turned to avert any conflict."

Further, FAA Order 7110.65, paragraph 3-1-4, "Coordination Between Local and Ground Controllers," states that "[l]ocal and ground controllers shall exchange information as necessary for the safe and efficient use of airport runways and movement areas. This may be accomplished via verbal means, flight progress strips, other written information, or automation displays." FAA Order 7110.65, paragraph 3-1-7, "Position Determination," directs controllers to "[d]etermine the position of an aircraft before issuing taxi instructions or takeoff clearance." In addition, paragraph 3-7-1, "Ground Traffic Movement," instructs controllers to "[s]tate the runway intersection when authorizing an aircraft to taxi into position to hold or when clearing an aircraft for takeoff from an intersection."

On March 10, 2000, the N79960 wreckage was released to Universal Loss Management, Inc., Orlando, Florida, and the N89827 wreckage was released to Carson-Brooks, Atlanta, Georgia. No components of either airplane were retained by the Safety Board for testing.

NOTES:

1. All times in this report are eastern standard time, based on a 24-hour clock. 2. The Dolphin Aviation ramp is on the south side of SRQ. 3. "Jones aero" is the Jones Aviation ramp, which is on the north side of SRQ. 4. The investigation could not determine which pilot in N79960 was operating the controls. 5. Title 14 CFR 91.129(i), "Takeoff, Landing, Taxi Clearance," states that "[a] clearance to 'taxi to' the takeoff runway assigned to the aircraft is not a clearance to cross that assigned takeoff runway, or to taxi on that runway at any point." 6. After the accident, SRQ amended its Standard Operating Procedures manual to incorporate guidance on standard strip marking for intersection departures. 7. The angle of the cut was 40 degrees counter clockwise from the trailing edge.