Missed Communication: Cessnas Collide, Part 2

Credit: National Transportation Safety Board

Editor's Note: This is the second of two parts analyzing the accident involving a Cessna 150 that collided with a Citation CJ4 on landing. The investigation and conclusions continue below. 

The pilot of the Citation had flown for the airplane’s owner, Avis Industrial Corp., for 37 years. He was 70 years old and reported having 35,437 total flight hrs, of which 2,537 were in the Citation.

He held an Airline Transport Pilot certificate and a flight instructor’s certificate, and he had a second class medical certificate that required him to use corrective lenses. In an interview, he said he heard no one make any radio calls on UNICOM and he could not recall doing so either. He said his landing lights were on, but not his pulse lights.

The eight-year-old Citation was equipped with an autopilot, an angle of attack indicator, a stall warning system, a data recorder, electronic displays, flight bag and ADS-B. The ADS-B provided onboard weather and satellite tracking.

The pilot said he selected terrain and traffic information at a 10-mile scale on the copilot’s display but left his primary display on a 50-mile scale. During the accident approach, he did not remember seeing any traffic on the copilot’s display but he was mostly looking outside. 

Interestingly, the pilot of the jet had flown with the other accident pilot about six weeks before the accident in that pilot’s Cessna 150. The 31-year-old private pilot had recently purchased the airplane and wanted to get some dual instruction in it. He had logged most of his 71.9 flight hrs. in a Cessna 172.

The Citation pilot reported that the private pilot flew very well and that his airplane was equipped with a transponder. He could not say for sure if the transponder worked.

None of the four passengers on board the jet saw the other plane. Three people in the airport lobby witnessed the collision.

The UNICOM radio was turned on and working, and the airport manager said he saw the Cessna 150 taxiing out and heard him call for back taxi on 122.7.

“The next thing I saw was the Citation landing. I got up and remembered the 150 back taxiing, saw the 150 rolling on takeoff. I couldn’t believe what I was seeing. I started heading toward the radio to warn somebody...but it felt like slow motion, it happened too quickly,” he said.

He went on: “I saw the Citation after touch down, saw the 150 take off, pull up, and for a split second thought it was going to miss, but saw it clip the tail and hit.” Regarding safety concerns, he said “I don’t feel like it was anything other than the worst possible timing. We have planes in and out of here without radios. I don’t know what could have been done differently.”

One person said he heard the Citation pilot make an announcement on short final. However, no transmission was recorded on the cockpit voice recorder (CVR). The last transmission from the jet was at 1707 when the pilot canceled his IFR clearance.

Both airplanes were painted white. In daytime hazy conditions, the white paint may have reduced the pilots’ ability to see each other because of a lack of visual contrast against the background.

Conclusions

Based on the length of time it would have taken the 150 pilot to back taxi, turn around, and commence takeoff, I think he made his UNICOM announcement before the pilot of the Citation had switched to that frequency.

There was a two-minute interval before the collision, which was at 1709, when both pilots were tuned to the UNICOM frequency. If either pilot had announced his intentions on the advisory frequency during that time, they would have been able to avoid the collision.

The NTSB’s probable cause was “the failure of both pilots to see and avoid the other airplane as they converged on intersecting runways. Contributing to the accident was the jet pilot’s not monitoring the airport’s traffic advisory frequency, known reduced visibility of the intersecting runways, and hazy weather condition.”

Although the NTSB issued no recommendations in this case, the staff apparently made some safety enhancement suggestions to Marion airport officials.

In response, Marion airport reworded and enlarged the runway end warning signs, purchased a UNICOM recorder, installed video surveillance cameras, and changed ground training for local pilots to emphasize the limited visibility at the runway ends.

The jet operator on the field, presumably Avis Industrial Corp., painted the tail of their new jet red to improve its visibility. 

It’s my surmise that the jet pilot did monitor the UNICOM frequency, but something broke his concentration on radio communication, and he forgot to self announce his presence on final approach.

He was also lulled by the Grissom controller’s remark that there was no traffic between the jet and the field. I suspect the 150 pilot did not turn on his transponder until just before he commenced takeoff, making him invisible to the air traffic controller.

The FAA provides plenty of useful guidance that pertains to this accident. Advisory Circular (AC) 90-66B, “Non-Towered Airport Flight Operations” and AC 80-48D, “Pilots’ Role in Collision Avoidance” address ways to manage the hazards the pilots faced in the Marion accident. 

The Airman Information Manual (AIM) Table 4-1-1 “Summary of Recommended Communication Procedures” is also good information.

Line one of the table for UNICOM airports says outbound aircraft should self-announce “before taxiing and before taxiing on the runway for departure.”

Pilots should understand that means just before takeoff. Line one also says for inbound aircraft to announce “10 miles out, entering downwind, base and final, and leaving the runway.”

If a straight-in pilot were to make a second announcement at an altitude just above regular traffic pattern altitude, it could be life-saving for a pilot about to make his base to final turn. It could also alert a pilot about to take off or land on a different runway.

If pilots at uncontrolled airports would turn on their transponders when taxiing for takeoff, that would improve the ability of air traffic controllers to advise inbound aircraft.

The Citation pilot alluded to training he received at Flight Safety, but investigators did not pursue the subject of his training. If they are not already doing so, I think Part 142 schools that train business and corporate pilots would be wise to include operations at uncontrolled airports in their curricula.

One of their subjects should be communications during those last two minutes before takeoff and landing.

Roger Cox

A former military, corporate and airline pilot, Roger Cox was also a senior investigator at the NTSB. He writes about aviation safety issues.