Friday, January 08, 2016

Concerns Soar Over Airport As Lebanon Facility Plans Improvements: Lebanon Municipal Airport (KLEB), Grafton County, New Hampshire

West Lebanon — While most city residents and officials described a package of proposed improvements for Lebanon Municipal Airport as better than previous plans, they also expressed concern that the facility would continue to be a drain on the municipal budget and a detriment to the surrounding neighborhood.

The mixed reviews came Tuesday night when the public was invited to comment on a proposed master plan put together by two consulting firms, Binghamton, N.Y.-based McFarland Johnson and Vanasse Hangen Brustlin of Watertown, Mass.

The consultants have recommended $34.9 million in runway improvements along with reconstruction of the airport taxiways, parking lot and Airpark Road.

Many of the favorable comments noted the plan would have less of an impact on the surrounding landscape than previous proposals.

“These guys have been listening,” said Lebanon resident Peter Brown, who used to live near the airport on Poverty Lane.

Nevertheless, Brown remains worried about the airport’s cost to city taxpayers, the impact of its noise and lights on neighbors, and the effect on the environment.

Brown said he feels it’s important to keep in mind the fact that Lebanon’s is a relatively small airport, with limited clientele and a small commercial airline. Any improvements should be appropriate to the airport’s scale, he said.

To bring in more revenue, the consultants propose allowing private developers to lease space to construct two new hangars.

“I’m concerned about the fact the airport hasn’t been self-sustaining for years,” Brown said. “There’s something wrong with the model.”

West Lebanon resident Margaret Campbell said she was somewhat skeptical of the work proposed by the consultants and wondered about the need to make changes. One of her concerns is that the airport improvements might increase noise and traffic.

After considering six possible ways to bring the airport’s runways into compliance with Federal Aviation Administration regulations, consultants settled on a proposal to add crushable concrete blocks to one end of each of the airport’s two runways, McFarland Johnson’s Chad Nixon said.

Those barriers are designed to stop a plane without injuring those on board or substantially damaging the aircraft.

Runway improvements also would include relocating one end of each runway so they begin before the pavement begins — what is known as a displaced threshold.

As with most airport projects, 90 percent of the $34.9 million project — which Nixon said he expected would be constructed in phases over 20 years to spread out the cost — would be paid for by the FAA. The New Hampshire Department of Transportation and the city would split the remaining 10 percent, with each responsible for $1.75 million.

The city’s share is drawn from passenger facility charges for passengers who get on planes in Lebanon, other airport revenue and the city’s general fund.

In the 10 years from 2003 to 2013, Lebanon taxpayers contributed $18,000 to airport capital projects — 1 percent of the projects’ total cost — according to information compiled by McFarland Johnson.

The work to reconstruct the airport’s parking lot and Airpark Road also would occur over 20 years, Nixon said.

Nixon said he expected airport noise would slightly diminish as older planes are phased out.

The consultants predict modest growth in traffic at the airport, to 31,800 in 2030 from approximately 29,800 planes taking off and landing in Lebanon in 2015. This 7 percent growth rate is consistent with previous forecasts and with national trends, they said.

Like Campbell, Hall Road resident David McLaughlin said noise is his primary concern.

McLaughlin, who lives south of the airport, said he often calls Airport Manager Rick Dyment on weekends to complain about the noise, particularly noise generated by training flights that fly in continuous low circles, he said.

While he said he would prefer to see the airport property used for a solar array or a new high school, McLaughlin said, he understood that eliminating the airport would not be feasible because the city would be required to reimburse the FAA for the millions of dollars in aid it has provided to the airport over the years.

Overall, McLaughlin said, he preferred the consultants’ proposal to previous plans that would have had a greater impact on the surrounding landscape.

The City Council rejected one such proposal — a runway expansion proposal to extend the southern end of the north-south runway by 1,000 feet and to lower the elevation of a nearby hill by 30 feet for an anticipated cost of $13.3 million to $23.2 million — in 2013 .

At the time, councilors pointed to a lack of information and the price tag as reasons for their opposition to the project.

The fact that some people regarded the currently proposed improvements as better than previous proposals didn’t impress former City Councilor Steve Wood, whose Poverty Lane Orchards abuts the airport.

That was akin to saying “a kick in the (rear) is better than a kick in the nose,” he said.

Wood described the city’s stated goal of making the airport self-sustaining as disingenuous because he believes it’s not achievable.

Others, however, expressed more enthusiasm for the proposals.

“They’ve come up with a solution that is going to be beneficial for the city, for the FAA and for the neighbors,” City Councilor Carol Dustin said. “It feels good to have it somewhat settled.”

The council is expected to take up the consultants’ proposals in February.


Incident occurred January 08, 2016 Hampstead, Pender County, North Carolina

WILMINGTON, NC (WWAY) — A Pender County Emergency Manager has confirmed it was a drone that crews were looking for Friday night.

Earlier, Scott Brown with Pender County Emergency management said crews were searching for either a downed plane or downed drone near Hampstead.

Brown said dispatch received a call around 8:30 p.m. from a witness who said they saw a lit aircraft take a nosedive and disappear.

Law enforcement and other emergency crews searched in the area of Howards Landing and Forest Sound Drive.


HAMPSTEAD, NC (WECT) - Coast Guard and Pender County emergency crews searched for a downed drone in Hampstead between the Howards Landing and Forest Sound subdivisions Friday night. 

Six or seven fire, EMS, search and rescue and emergency management crews responded.

According to Petty Officer First Class Adam SanSoucie with the Coast Guard, the Coast Guard was dispatched to the Intracoastal Waterway.

A 9-1-1 caller reported seeing red and green lights fly by and then they disappeared and looked like it may have taken a nose dive into the water.

Crews were able to locate the drone.


Federal Aviation Administration Will Roll Out New Air Traffic Control System At Charlotte Douglas International Airport (KCLT)

Air traffic controllers in the tower at Charlotte-Douglas International Airport, January 8, 2016.

New air traffic control technology at Charlotte Douglas International Airport should help reduce the time spent on planes, if all goes according to plan.

It also means the old time-consuming system of verbally transmitting flight plans and clearances will be replaced by something much quieter. A new system called DataComm will send all the information digitally, directly from air traffic control to the airplane’s computers.

FAA officials were in Charlotte Friday to show off the new technology, which is scheduled to be implemented this spring. It’s part of the agency’s Next Generation or NextGen initiative, launched seven years ago. The plan includes updates to technology and procedures on the ground and in the air, with the goal of making flying more efficient. The FAA says that Charlotte-Douglas—the country’s sixth-busiest airport—will be the first in the country to use the DataComm system.

DataComm is one of the major changes planned under NextGen. New departure and approach routes are already in place at Charlotte-Douglas. And, officials plan to implement new ground control procedures later this year. All of this, the FAA says, will reduce the amount of fuel airlines use and reduce the amount of time passengers spend waiting on the tarmac.


Brainerd Lakes Regional Airport (KBRD): Possible interim manager speaks

Bob O'Brien (head of table) talks with the Brainerd Lakes Regional Airport Commission Friday about his experience in airport management.

The Brainerd Lakes Regional Airport could have an interim airport manager step in after current manager Jeff Wig takes off for a new position on Feb. 14.

Wig is taking a position as vice president working in the area of economic and business development for the Initiative Foundation and the Airport Commission has already began the process of finding his replacement.

Friday, the commission met with Bob O'Brien, a longtime airport manager who came recommended by the airport's engineer, Paul Strege, and Kim Kenville, a University of North Dakota professor in charge of the school's aviation management program.

O'Brien, 58, has spent 34 years in the airport management industry at various airports throughout Wisconsin, Indiana, Iowa, Illinois and more. He also served in the military for 20 years, mostly in the National Guard and Army Reserves.

Throughout his career, O'Brien said he wondered if he could do the No. 1 job at a big airport.

"At a small airport, you're the marketing manager, you're the finance manager, you're the operations manager, you're the public safety manager," O'Brien said. "And that's not a bad thing."

O'Brien said he isn't a political creature and prefers to focus more on business. He retired in 2011 because he wasn't having fun anymore, he said.

"I told people, openly, that if I get to 55 and I'm not having fun anymore, I'm gone," O'Brien said.

Commission member Gary Scheeler said he was concerned about that, as not every day in a job is fun.

"I don't want to work where I'm not appreciated," O'Brien said. "So that's the heart of it and I'm serious."

O'Brien could serve as interim manager and help with the search for a permanent replacement at the same time, he said. He's done it before, he said, it just depends on if that's what the commission wants him to do. But if the commission does use a search firm, he said he'd recommend ADK Executive Search.

The airport presumably wants its search for a permanent manager done quickly, O'Brien said, but also efficiently. He briefly ran through a potential timeline, which could result in about a 10-week search period, depending on how quickly the commission wanted to move. He recommended the advertisement for the position should run for three weeks in order to maximize coverage.

"A lot depends on how you roll it out and how you play it," O'Brien said.

Wig said he spoke with three airport commissioners at the Columbus Metropolitan Airport in Columbus, Georgia, where O'Brien most recently served as an interim manager in 2012.

"I don't seek these out, they find me," O'Brien said.

Wig said all three commissioners were overwhelmingly positive about O'Brien, who came into a situation where a previous manager had been fired and steadied the situation. ADK Executive Search handled the search there, but O'Brien helped guide the commission on vetting candidates.

O'Brien said he'd be willing to come to Brainerd for three to four months in winter because he enjoys the airport industry and because Brainerd is very scenic.

"You guys live in God's country," O'Brien said. "I love God's country. I live on the Wisconsin River in southwestern Wisconsin."

The commission approved a motion for Wig, O'Brien and vice-chair Don Jacobson to meet and develop a contract which can be presented to the commission for reviewal at its Jan. 15 meeting.

Scheeler asked what the typical turnover was for airport managers, because conducting a search becomes a budgeted item for the airport. O'Brien said he'd be surprised if the airport found someone who would finish their career in Brainerd, as most tend to stay in one place for three to five years.

"If your goal as an aviation manager is to grow with the industry," O'Brien said, "then you're not camping out, you're there for the experience."

O'Brien's fee in Columbus, before expenses, was $17,000 per month. The rate he proposed to the commission is $10,000 per month. Wig said his salary including benefits was $8,625 per month.

One or two other people have inquired about the interim manager position, Wig said. He's told them the commission won't be considering the interim manager for the permanent position and the airport is looking for someone who can help with the job search as well as serve as an interim manager.

The interim manager won't be an airport employee, Wig said, but instead be a contracted consultant. Because of that difference, the airport doesn't have to follow the same process as it would if it were hiring an employee.

"I know airports, I know how to do the job," O'Brien said. "I don't know you folks, but you're human beings and reasonable people can agree. I'm certain I can meet your expectations."

Search firms discussed

Wig provided the commission with information on two firms that could be hired to conduct the search for a permanent airport manager. David Drown Associates works extensively with city and county governments in Minnesota on executive searches, Wig said. The commission could contract their services at a discount, because of an agreement the city of Brainerd has with the National Joint Powers Alliance, he said.

The fee for the commission would be $7,500 plus expenses, which would make it one of the least expensive search firms options, Wig said. However, he said he is concerned the firm doesn't mention placing someone in an airport management position, so its advertising and recruitment network might not fit for the airport.

"This firm would have a lot of work to do on one of the most critical pieces, and that is identifying candidates," Wig said. "Finding out where candidates are, working informal networks."

Wig has served on job search committees before, and he said expenses usually cover travel costs, which is standard in the search industry. The firm's proposal does not cover finding an interim manager.

The most highly recommended search firm Wig contacted was ADK Executive Search, with three different people Wig spoke to recommending the firm. The firm focuses almost exclusively on airport needs, he said, and offers two different levels of assistance.

The HR Assist product covers the entire search process up to the interviews, Wig said, and costs $16,900. They will identify, contact and vet candidates, he said, and perform all duties remotely.

"They basically develop a shortlist and then hand that shortlist over to the airport," Wig said.

The full service search covers everything including on-site interviews, Wig said, and costs $28,000 plus expenses for two site visits. Those expenses would be less than $3,000, he said.


Woman who caused American Airlines flight diversion charged with assault: Sarah Buffett allegedly attempted to smash aircraft window with remote

A woman whose unruly behavior caused an American Airlines flight from Charlotte to London to be rerouted to Philadelphia last summer was charged Thursday with assault.

Sarah Buffett, 41, of Charlotte, allegedly needed to be physically restrained by flight crew and passengers during a red-eye flight that departed Charlotte Douglas International Airport on July 22 at 11:17 p.m. Flight 732, operated by U.S. Airways, was diverted to Philadelphia International Airport, landing on July 23 at 4:36 a.m. The diversion inconvenienced 267 passengers.

Buffett, seated in first class, allegedly became physically aggressive and was damaging her seat, according to a criminal complaint filed July 22 by the U.S. Attorney's Office for the Eastern District of Pennsylvania. She allegedly attempted to smash the aircraft window with an entertainment system remote before getting out of her seat and acting in a menacing manner in front of the cockpit door.

Flight attendants needed assistance from passengers to place Buffett in plastic restraints, according to the complaint. She allegedly removed the restraints twice before being held down by a passenger and had tape wrapped around her lower legs.

Buffett told investigators that she drank at least three glasses of wine and took a Zaleplon pill prescribed for her insomnia, the complaint said. She claims not to remember anything after requesting not to be served dinner. Her next memory, she told investigators, came after being physically restrained by an unknown male and learning of the flight's diversion.

If convicted, Buffett faces a maximum prison sentence of one year, one year of supervised release and a fine.

Federal Judge in Dallas Says Delta Can Stay at Love Field (KDAL)

A federal judge ruled Friday that Southwest Airlines can't kick Delta out of Dallas Love Field while the airlines fight over space at the airport.

U.S. District Court Judge Ed Kinkeade said that Delta passengers would be inconvenienced if the carrier had to move its flights while the courts handle a lawsuit over the dispute.

Delta Air Lines Inc. has five daily flights at Love Field. Southwest Airlines Co. operates 180 and controls 18 of the airport's 20 gates.

A spokeswoman for Delta said the Atlanta-based airline was pleased with the ruling. A spokesman for Southwest said the ruling wasn't the end of the case and the company was considering its options.

Southwest, which is headquartered next to the airport, could appeal the judge's injunction. Either way, the case could wind up going to trial.

Delta had used gates leased by United Airlines, but Southwest paid United $120 million to sublease those gates, then tried to evict Delta. Airport rules allow new competitors to use gates if they are idle long enough for more flights.

The judge said that Southwest and the city of Dallas, which owns the airport, were "playing a game of musical chairs" to deny space for Delta. He said that Delta is likely to win a breach of contract claim against Southwest.

Kinkeade's ruling came three months after a hearing that provided a rare glimpse into the time and money airlines will spend to block a competitor and dominate an airport.

In an email that surfaced because of the case, Southwest's CEO told a city official the airline would invest its money elsewhere if the city let Delta keep using the gates.

During the hearing Kinkeade told a Southwest executive, "This is about as sharp-elbowed a deal as you can do."

Southwest has long dominated Love Field, which is smaller than Dallas-Fort Worth International Airport but closer to downtown and some of the wealthiest neighborhoods in Dallas.


Cirrus SR22, C-GXXJ, Decora Design & Facility Management Ltd: Accident occurred January 08, 2016 near Concord Regional Airport (KJQF), North Carolina

Decora Design & Facility Management Ltd:

NTSB Identification: ERA16LA085 
14 CFR Part 91: General Aviation
Accident occurred Friday, January 08, 2016 in CONCORD, NC
Aircraft: CIRRUS SR22, registration: C-GXXJ
Injuries: 2 Uninjured.

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.

On January 8, 2016, at 1538 eastern standard time, a Cirrus SR22, Canadian registration C-GXXJ, owned and operated by a private individual, was substantially damaged during impact with terrain, after deployment of the Cirrus Airplane Parachute System (CAPS), following a loss of control near Concord Regional Airport (JQF), Concord, North Carolina. The private pilot and passenger were not injured. Instrument meteorological conditions prevailed and an instrument flight rules flight plan was filed for the personal flight that departed Erie International Airport (ERI), Erie, Pennsylvania, about 1100. The flight was destined for Charlotte/Douglas International Airport (CLT), Charlotte, North Carolina. The airplane was operated under the provisions of Title 14 Code of Federal Regulations Part 91.

The pilot stated that while the autopilot was engaged and the airplane established on the instrument landing system approach to runway 36R at CLT, he observed a "vertical flag drop" [on the primary flight display (PFD)], which indicated to him that the airplane was below the glideslope. The autopilot did not correct for the deviation. Subsequently, as the airplane entered visual meteorological conditions below a cloud layer, the pilot observed [the PFD] was indicating that the airplane was on course; however, the runway was to his right. Air Traffic Control (ATC) instructed the pilot to go-around and later provided vectors to JQF, located about 15 miles to the northeast.

The pilot hand-flew the airplane toward JQF and was cleared for the GPS approach to runway 02. He initially believed the clearance was for runway 20, and as a result he had difficulty finding the appropriate "fix." After he realized the error, he asked for and received vectors for the GPS approach to runway 02. During that approach, after he was established on the inbound course, the pilot engaged the autopilot again. As he did so, the airplane began to climb and bank sharply to the right. The pilot reported that he then received "terrain" and "envelope protection" warnings, as well as an advisory from ATC indicating he was "too low, and needed to climb." He pushed the "Straight and Level" button on the autopilot, but the airplane did not respond. He then deployed the CAPS and secured the engine. The airplane descended into a residential area, landed in a grass yard and impacted a chain link fence.

The 1540 recorded weather observation at JQF included wind 340 at 5 knots, visibility 3 miles in moderate mist with and overcast ceiling at 500 feet, temperature 45 degrees F, dew point 43 degrees F; barometric altimeter 30.80 inches of mercury

Examination of the airplane at the scene by a Federal Aviation Administration inspector revealed substantial damage to the underside of the left wing, the left main landing gear and the nose landing gear. The flaps were in the retracted position. The parachute remained attached to the airplane through its harness.

The airplane was retained for further examination. The PFD, the autopilot computer, and the multi-function display were forwarded to the NTSB Vehicle Recorder Laboratory, Washington, DC, for data recovery.

Federal Aviation Administration Flight Standards District Office: FAA Charlotte FSDO-68

How a Controller Sounds When Trying to Save an Airplane: SR22, C-GXXJ

KANNAPOLIS, N.C. – It was a close call Friday for a pilot and his wife traveling to Charlotte Douglas International Airport.

The man’s Cirrus SR22 plane was forced to make an emergency landing in a backyard in Kannapolis after running out of fuel.

“I was sitting in the house and heard a noise, a bang,” said homeowner Bud Welch. “I looked out the backdoor and there was a plane in my backyard.”

Welch was hoping for a quiet Friday night. Instead, a small engine plane crashed 20 feet from his home.

“I had my wife call 911 and then I went out to the plane,” said Welch. “The pilot and his wife were getting out.”

The small aircraft was traveling from Erie International Airport to Charlotte Douglas. They were scheduled for a fuel stop, but the pilot told investigators he didn’t receive clearance to land in Charlotte. That’s when he diverted to Concord Regional, but ran out of fuel in Kannapolis.

“Sounded like a muscle car kind of coming down the street,” said James Putortie, a witness to the crash.

“I heard it crush on a chain-link fence,” said another neighbor.

Neighbors say it’s not unusual for helicopters and planes to fly over the area, but this encounter literally hit a little too close to home.

“I mean, it’s amazing it didn’t hit the house,” said Putortie.

As bad as it sounds, the people inside the aircraft walked away unharmed.

“It was a man and a wife in the plane and I just said, ‘are y’all okay?” Naturally, they were a little shook up, so I said come in the house and come on and get your head straight,” Welch explained.

Story and video:

KANNAPOLIS — A single-engine Cirrus aircraft with a built-in parachute for safety made an emergency landing Friday afternoon in the backyard of a Western Acres home off Westchester Drive.    

The Canadian couple flying the plane were not hurt. Western Acres is located in a corner of Rowan County close to the Cabarrus County line and not too distant from Iredell County.

The pilot successfully landed the Cirrus upright. Damage was mostly to the plane’s landing gear, left wing and prop.  As it landed, the disabled plane clipped a chain-link fence in the yard of Bud and Lynn Welch.

The orange-and-white parachute ended up draped over a row of tall holly trees nearby.

“I just heard a loud noise and a thump,” Bud Welch said. He and Lynn were inside their home. Lynn informed Bud a plane was in their backyard, and while she dialed 911 for help, Bud went to check on the plane’s occupants.

“Both of them were crawling out of the plane — and they’re fine,” Welch said.

The Welches invited the couple inside their home so they could calm their nerves a bit until emergency personnel arrived. Atwell Fire Department and the N.C. Highway Patrol were the chief responders.

Welch said the couple had flown out of Canada and stopped in Reading, Pa., where they had to go through customs. They intended to stop in Charlotte to refuel when the plane started experiencing its mechanical problems over Rowan County.

The couple’s ultimate destination was Florida, Welch said.

Neighbors said the Cirrus, which weighs just over a ton, started its downward path into the subdivision from the northern end. In making its emergency landing, the plane just missed a carport of the Welches’ neighbor.

The plane also missed a nearby wooded area behind the houses on Westchester Drive.

The airframe parachute system is standard equipment on every Cirrus aircraft. This particular model was an SR22.

“I heard a big popping sound,” said 13-year-old Madison Hill, who was next door. “It sounded like a crash. … Luckily they didn’t hit anything but a fence. … You could tell they were shook up.”

James Smith, who lives a street away, said his son heard the crash and also described a noise like a gunshot, which several people figured was the sound of the parachute firing out and deploying.

Looking around at all the people and emergency vehicles, Bud Welch said it was definitely the most excitement he had seen during his 18 years on Westchester Drive.

- See more at:


A Cirrus SR22 plane crashed in a residential area near Concord Friday at 3:38 p.m., FAA officials said.

The aircraft departed Erie International Airport, Erie, Pennsylvania and was enroute to Charlotte Douglas International Airport.

The pilot and his wife originally departed from Toronto.

They went off course because of the weather and planned to stop in Charlotte to refuel but were forced to land in the residential area.

They deployed the Cirrus Airframe Parachute System (CAPS) at the last second in the emergency landing.

No injuries were reported.

Officials said it crashed near Westchester Drive.



No injuries were reported from the site of a plane crash in Rowan County Friday afternoon. 

The plane reportedly went down in a residential neighborhood just before 3:45 p.m. on Westchester Drive near Kannapolis. Officials say a husband and wife were flying from Canada to Florida with stops in between.

They were planning to stop in Charlotte to refuel, but were thrown off course by the weather conditions, according to officials.

The couple reportedly tried to stop several airports but couldn't. They eventually deployed the Cirrus Airframe Parachute System (CAPS) and floated to the ground in the middle of a neighborhood - landing in someone's yard.

The woman in the home told WBTV that she and her husband heard a loud sound then looked outside to see the plane in their yard. They helped the couple out of the plane and took them inside.

"We heard a loud noise or a thump and my husband said 'what was that?' As I got out to look around I said there's a plane in the back yard," Lynn Welch said.  "And he said ' well I'm going to see if everybody is okay, he dialed 911 and went to see the people in the plane."

"I think I panicked afterward, but it's such a blessing that everybody is okay and no fire or anything like that," Welch added.

 No injuries were reported and no homes were damaged.

Officials with the National Transportation Safety Board and the FAA are investigating the crash.


A small plane crashed in Kannapolis, NC off of Westchester Drive Friday afternoon.

The plane landed in the backyard of Bud Welch.

"We were just in the house, my wife and I, we heard a loud noise and kind of a thunk. She looked out the back and said, 'there's a plane in our backyard,'” he said.

Welch told FOX 46 he went into the backyard to check on the married couple inside the plane.

"They left from Canada. They were going to Florida for two weeks’ vacation. They set down in Pennsylvania to go through customs. They were trying to land in Charlotte to refuel and something happened to the plane,” he explained.

The couple was not hurt.

The only thing damaged was Welch’s chain link fence.

The cause of the crash remains under investigation by the FAA.


KANNAPOLIS, N.C. -- A couple traveling from Canada crash landed their small plane in Kannapolis on Friday afternoon.

No one was seriously injured.

Emergency crews were called to Westchester Drive at about 3:30 p.m.

The plane went down behind some houses.  

A neighbor who helped the couple climb from the wreckage says they weren't hurt, but were, naturally, very shaken up.

The couple had planned to make a stop over in Charlotte.

Rescuers haven't said why they didn't make it.



Cessna 172M Skyhawk, N1285U and Rockwell Sabreliner 60SC, N442RM: Fatal accident occurred August 16, 2015 near Brown Field Municipal Airport (KSDM), San Diego, California

The National Transportation Safety Board traveled to the scene of this accident.

Aviation Accident Final Report  -   National Transportation Safety Board:

Docket And Docket Items  -   National Transportation Safety Board:

Aviation Accident Data Summary  -   National Transportation Safety Board:

Aviation Accident Final Report   -  National Transportation Safety Board:

Docket And Docket Items  -   National Transportation Safety Board:

Aviation Accident Data Summary  -   National Transportation Safety Board:

NTSB Identification: WPR15MA243A
14 CFR Part 91: General Aviation
Accident occurred Sunday, August 16, 2015 in San Diego, CA
Aircraft: CESSNA 172M, registration: N1285U
Injuries: 5 Fatal.

NTSB Identification: WPR15MA243B
14 CFR Part 91: General Aviation
Accident occurred Sunday, August 16, 2015 in San Diego, CA
Aircraft: NORTH AMERICAN ROCKWELL NA265-60SC, registration: N442RM
Injuries: 5 Fatal.

NTSB investigators traveled in support of this investigation and used data obtained from various sources to prepare this aircraft accident report.


***This report was modified on October 31, 2016. Please see the docket for this accident to view the original report.***

***Refer to docket for all figures.***

On August 16, 2015, about 1103 Pacific daylight time, a Cessna 172M, N1285U, and an experimental North American Rockwell NA265-60SC Sabreliner, N442RM (call sign Eagle1), collided in midair about 1 mile northeast of Brown Field Municipal Airport (SDM), San Diego, California. The pilot (and sole occupant) of N1285U and the two pilots and two mission specialists aboard Eagle1 died; both airplanes were destroyed. N1285U was registered to a private individual and operated by Plus One Flyers under the provisions of 14 Code of Federal Regulations (CFR) Part 91 as a personal flight. Eagle1 was registered to and operated by BAE Systems Technology Solutions & Services, Inc., for the US Department of Defense as a public aircraft in support of the US Navy. No flight plan was filed for N1285U, which originated from Montgomery-Gibbs Executive Airport, San Diego, California. A mission flight plan was filed for Eagle1, which originated from SDM about 0830 and was returning to SDM. Visual meteorological conditions prevailed at the time of the accident.

On the morning of the accident, the SDM airport traffic control tower (ATCT) had all control positions (local and ground control) in the tower combined to the local control position. The position was staffed by a qualified local controller (LC)/controller-in-charge (CIC) who was conducting on-the-job training with a developmental controller (LC trainee) on the local control position. The LC trainee was transmitting control instructions for all operations; however, the qualified LC was closely monitoring the LC trainee's actions and was responsible for all activity at that position.

According to air traffic control (ATC) radar and voice communications data, the pilot of N1285U contacted the SDM ATCT at 1049:44 and requested touch-and-go maneuvers in the visual flight rules (VFR) traffic pattern. N1285U was inbound about 6 miles to the northeast of SDM, at an indicated altitude of 2,600 ft. About that time, another Cessna 172 (N6ZP) and a helicopter (N8360R) were conducting operations in the VFR traffic pattern, and a Cessna 206 Stationair (N5058U) was inbound for landing after carrying parachutists to a local drop zone about 5 nautical miles (nm) east of the field.

Between about 1049 and 1054, N6ZP and the helicopter continued to conduct approaches, N5058U landed on runway 26L, a Skybolt (N81962) reported west of SDM for landing on runway 26L, and a Cessna Citation (XALVV) reported straight in for landing on runway 26R. At 1052:57, the LC trainee cleared the pilot of N1285U for a touch-and-go on runway 26R, which the pilot acknowledged. At 1054:46, when N1285U was on final approach of the first approach to runway 26R, the pilot advised the LC trainee that he was going to go around. The LC trainee acknowledged the transmission and instructed the pilot to follow "a Cessna" (N6ZP) on the right downwind.

At 1056:31, the LC trainee advised the pilot of N1285U to expect runway 26L on the next approach, which the pilot acknowledged. At that time, three aircraft were using runway 26R (Global Express [N18WZ] was inbound for landing, N6ZP was on a right base for a touch-and-go, and XALVV was on short final) and three aircraft were using runway 26L (N1285U was turning right downwind for the touch-and-go, N81962 was on a left downwind for landing, and N8360R was conducting a touch-and-go operation). Figure 1 shows the aircraft in the SDM traffic pattern about 8 minutes before the accident.

At 1057:22, the LC trainee cleared the pilot of N1285U for a touch-and-go on runway 26L, and at 1057:27, the pilot acknowledged the clearance. At 1058:22, the LC trainee cleared the pilot of N6ZP for a touch-and-go on runway 26L. At 1058:29, the pilot of N6ZP stated, "…ah two six right cleared touch and go." After the pilot of N1285U completed the touch-and-go on runway 26L, the pilot turned the airplane right, crossing through the departure corridor of runway 26R, and entered a right downwind for runway 26R.

At 1059:04, when Eagle1 was 9 miles west of SDM, the flight crew contacted the SDM ATCT and requested a full-stop landing. Throughout Eagle1's cockpit voice recorder (CVR) recording, the pilot, seated in the left seat, was communicating on the radio and responding to checklists, consistent with that pilot acting as the pilot monitoring and the copilot, seated in the right seat, acting as the pilot flying. The LC trainee instructed the Eagle1 flight crew to enter a right downwind for runway 26R at or above an altitude of 2,000 ft mean sea level (msl).

At 1059:18, the pilot of N5058U reported holding short of runway 26L on taxiway C. (N5058U had landed on runway 26L at 1052:30 and was returning to runway 26L for takeoff.) The LC trainee mistakenly advised the pilot of N5058U to hold short of runway 26R. The pilot of N5058U clarified that he was holding short of 26L, and, at 1059:31, the LC trainee acknowledged the transmission. That was the last transmission from the LC trainee. At 1059:33, the qualified LC terminated the LC trainee's training and took over control of communications due to increased traffic. The LC trainee signed off the position but remained in the tower to observe operations. From this time until the collision occurred (about 1103), the LC was controlling nine aircraft.

During the next 2 minutes, the LC made several errors that were either corrected by him or by the pilots under his control. At 1059:44, after the pilot of N6ZP completed a touch-and-go on runway 26R, he requested a right downwind departure from the area. The LC did not respond. At 1100:23, the LC instructed, "stationair five eight uniform two six right cleared for I'm sorry two six left cleared for takeoff." At 1100:29, the pilot of N5058U stated, "uh I'm sorry was that for five eight uniform?" The LC then cleared the pilot of N5058U for takeoff from runway 26L. At 1100:36, the LC transmitted, "helicopter six zero romeo there is a ces ah cen ah correction stationair just ahead they are going to the right runway base leg for two six left." At 1100:46, the pilot of N6ZP repeated his request for departure; the LC then approved N6ZP's departure request, and N6ZP departed the traffic pattern in a northeasterly direction. At 1100:53, the LC instructed the helicopter pilot, "helicopter six zero romeo listen up turn crosswind" before correcting the instruction 4 seconds later to "turn base." At 1101:15, the Eagle1 CVR recorded the copilot state, "got one on the runway," and at 1101:19, the Eagle1 CVR recorded the pilot comment, "wowww. he's like panicking" (with an emphasis on panicking). Figure 2 shows the aircraft in the SDM traffic pattern from about 1101 until the time of the accident.

At 1101:49, the Eagle1 CVR recorded one of the mission specialists seated outside the cockpit ask "see him right there?" At 1102:14, while on the right downwind leg (and, according to radar data, while overtaking N1285U from behind and to the left) and abeam the tower, the Eagle1 flight crew reported to the ATCT that they had traffic in sight to the left and the right of their position. Radar data indicated that N6ZP was to the left of Eagle1 and heading to the northeast, and N1285U was between Eagle1 and SDM, on a closer-in right downwind leg.

At 1102:32, the LC instructed the pilot of N6ZP, which he thought was the Cessna on right downwind, to make a right 360° turn over the airport and rejoin the downwind. Despite the fact that, at that time, N6ZP was 2.3 nm northeast of the airport and was departing the area, the pilot of N6ZP acknowledged the instruction and initiated a right turn. At the same time, Eagle1's CVR recorded the pilot asking, "you still got the guy on the right side?"

At 1102:42, the LC instructed the Eagle1 flight crew to turn base and cleared the flight to land on runway 26R. The LC stated in the postaccident interview that after he cleared the Eagle1 flight crew to land, he looked up to ensure that Eagle1 was turning base and noticed that the Cessna on downwind (which he still thought was N6ZP) was continuing on its downwind track and had not begun the turn that he had issued. At 1102:56, the LC contacted the pilot of N6ZP, and the N6ZP pilot replied by stating that he was turning. At 1102:59, Eagle1's CVR recorded the pilot comment "I see the shadow but I don't see him."

At 1103:04, the LC transmitted "November eight five uniform"; this was the first ATC transmission with N1285U in almost 6 minutes and the first communication between the LC and N1285U. At 1103:07, the pilot of N1285U acknowledged the transmission, "eight five uniform." At 1103:08, the LC asked the pilot of N1285U if he was still on the right downwind leg. The pilot of N1285U did not respond. The LC and the LC trainee then witnessed Eagle1 and N1285U collide.

Two witnesses located on the ramp at SDM saw the two airplanes flying eastbound, to the north of SDM. The witnesses turned away momentarily, and as they turned back, they saw an explosion, followed by airplane fragments falling to the ground. Another witness located about 2 miles east-northeast of SDM saw both airplanes at the same altitude, on intersecting flightpaths. That witness reported that the smaller airplane was flying away from the airport and that the larger airplane was flying toward the airport and descending. He noted that neither airplane appeared to make any corrective action before the collision and stated that after the collision, the smaller airplane broke apart, while the larger airplane lost a wing, nosed down, and impacted the ground.

The LC stated in a postaccident interview that the traffic level was "light and not complex" at the beginning of the training session. He stated that he noticed the traffic volume and complexity became "moderate" when the LC trainee was under instruction, which prompted the LC to terminate training and take over communications. He reported that, at that time, he had four issues to resolve, one of which was the potential conflict between Eagle1 and the Cessna on the right. He indicated that he saw Eagle1 on a midfield right downwind leg when the pilot of Eagle1 reported that he was "abeam and had the traffic to the left and right in sight." The LC stated that, at that time, Eagle1 was flanked by two Cessnas. Although the Cessna on the right of Eagle1 was N1285U, the LC believed that the Cessna on the close-in right downwind was N6ZP; therefore, he instructed the pilot of N6ZP to make a right 360° turn to rejoin the midfield downwind. He stated that he felt the turn would resolve the conflict with Eagle1 and that the right turn would help the Cessna avoid Eagle1's wake turbulence. When the pilot of N6ZP acknowledged the turn, the LC believed that the pilot of the Cessna to the right of Eagle1 had received the instructions and that the potential conflict with Eagle1 would be resolved. The LC then instructed Eagle1 to turn base and cleared the flight crew to land on runway 26R.

The LC stated that after he cleared the Eagle1 flight crew to land, he looked up to ensure that Eagle1 was turning as instructed. When the LC noticed that the Cessna to the right of Eagle1 had not started the right 360° turn, he began to query the pilot of N6ZP and then the pilot of N1285U. At that point, he witnessed the collision.

The LC also indicated in the postaccident interview that controllers have personal limits about how many airplanes they could handle and that he could handle four aircraft on runway 26R and three aircraft on runway 26L. When the LC was asked what caused him to realize that the Cessna was N1285U and not N6ZP, he said it dawned on him that he had a right downwind departure, and through the process of elimination, it could not have been anyone else. The LC trainee stated in a postaccident interview that when the Cessna on the right did not start the right turn, he suggested to the LC that the intended aircraft may have been N1285U. The LC indicated that, in retrospect, he should have issued a traffic alert; however, the moment he realized that Eagle1 was turning into N1285U, it was too late to help. Figure 3 shows the calculated flight tracks of Eagle1 and N1285U. Figure 4 shows the aircraft under SDM ATCT control from 1049 until the time of the collision.


N1285U Pilot

The pilot, age 60, held a private pilot certificate for airplane single-engine land issued on December 2, 1997. His most recent Federal Aviation Administration (FAA) third-class medical certificate was issued on November 20, 2014, with limitations stating that he must wear corrective lenses for near and distant vision. The pilot's logbooks revealed that he had accumulated about 277 total flight hours, including 9.7 hours in the last 6 months.

Eagle1 Pilot (Pilot Monitoring)

The pilot, age 41, held an airline transport pilot certificate issued on April 1, 2011, and a flight instructor certificate issued on November 8, 2008 (most recent renewal on November 25, 2014). He held instructor ratings for airplane multiengine, single-engine, single-engine instrument, and glider. His most recent FAA first-class medical certificate was issued on April 30, 2015, with no limitations. According to BAE, the pilot had about 4,480 total flight hours. In the 90 days before the accident, he logged 18 hours in airplanes, including 4 hours in the accident airplane make and model. His most recent flight review was completed on April 13, 2015. The pilot was seated in the left seat and was acting as the pilot monitoring.

Eagle1 Copilot (Pilot Flying)

The copilot, age 66, held an airline transport pilot certificate issued on March 8, 2005, and a flight instructor certificate issued on October 20, 2009. The copilot held ratings for airplane multiengine and single-engine land. His most recent FAA first-class medical certificate was issued on January 12, 2015, with the limitation that he must wear corrective lenses. According to BAE, the copilot had about 7,150 total flight hours, and his most recent flight review was completed on April 13, 2015. The copilot was seated in the right seat and was acting as the pilot flying.

Local Controller/Controller-in-Charge

The local controller at the time of the accident, age 59, was a certified professional controller and CIC. He had 37 years of ATC experience: 5 years in the US Air Force, 24 years with the FAA, and 8 years with his current employer. He was qualified on all positions in the SDM ATCT on September 18, 2014, and was certified as an SDM CIC on September 19, 2014. He was designated as an on-the-job training instructor on February 10, 2015. His most recent recurrent training was completed on July 31, 2015, and included, but was not limited to, the topics of runway separation, visual separation, limited aviation weather reporting station (LAWRS), and opposite direction operations. His most recent FAA second-class medical certificate was issued on September 23, 2014, with the limitation that he must wear corrective lenses. He indicated in a postaccident interview that he was in compliance with the limitation at the time of the accident.

Local Control Trainee

The LC trainee, age 27, was qualified on ground and flight data control positions on June 25, 2015. He completed local controller classroom training on June 22, 2015, and started on-the-job training on the local control position on June 27, 2015. His most recent recurrent training was completed on July 31, 2015, and included, but was not limited to, the topics of runway separation, visual separation, LAWRS, and opposite direction operations. His most recent FAA second-class medical certificate was issued on April 28, 2015, with no limitations.


N1285U Airplane

The white- and yellow-colored Cessna 172M was a high-wing, four-seat airplane manufactured in 1976 and powered by a Lycoming O-320-D2G engine rated at 160 horsepower, installed under RAM Aircraft Modifications supplemental type certificate SA2375SW. The airplane had a gross weight of 2,300 lbs. The most recent annual inspection was conducted on July 15, 2015. At the time of inspection, the airplane had a total time of 9,848.1 flight hours. It was equipped with a rotating beacon light, anticollision strobe lights, navigation position lights, a landing light, and a taxi light. The operational status of each lighting system at the time of the accident could not be determined. N1285U 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 white-colored North American Rockwell NA265-60SC Sabreliner was a low-wing, five-seat airplane manufactured in 1974 and powered by two Pratt and Whitney JT12A-8 turbojet engines, each rated at 3,000 lbs of thrust. The accident airplane was operating with an experimental airworthiness certificate because it had been modified with an external test pod attached to the lower side of the airplane aft of the nose landing gear. The airplane had a maximum gross weight of 22,900 lbs. According to the maintenance records, the most recent annual inspection was conducted on July 20, 2015. At the time of inspection, the airplane had a total time of 13,418 flight hours. The Sabreliner was equipped with a Fairchild GA-100 CVR with 30 minutes of analog audio on a continuous loop tape in a four-channel format. It was equipped with anticollision lights on the vertical tail and under the fuselage just forward of the main wheel well, wing ice inspection lights, strobe and position lights on the tail cone and each wing tip, and landing-taxi lights forward of the nose landing gear. The operational status of each lighting system at the time of the accident could not be determined. The Sabreliner was not equipped with a TAS, TCAS, or ADS-B equipment or displays.


The 1053 SDM automated weather observation included wind from 310º at 6 knots, visibility 10 statute miles, clear skies, temperature 33º C, dew point 19º C, and an altimeter setting of 29.87 inches of mercury.


SDM is located about 14 nm southeast of San Diego on the Otay Mesa at an elevation of 526 ft msl. The rising terrain associated with the Otay Mountain peaks begins about 2 miles east-northeast of SDM, and the highest terrain, at an elevation of 3,566 ft msl, is located about 8 miles east of SDM. Designated skydiving areas are located at SDM and at a second location about 3 miles east of SDM (see figure 5).

SDM has two parallel runways. Runway 8L/26R measures about 7,972 ft long and 150 ft wide, and runway 8R/26L measures about 3,180 ft long and 75 ft wide. Although the published traffic pattern for 26R is right traffic, it is common in west operations for controllers to use a right traffic pattern for both runways 26R and 26L due to the proximity of Tijuana Airport, Tijuana, Mexico, to the south of SDM. Some helicopter traffic is assigned to use a left traffic pattern for runways 26L and 26R. The published VFR pattern altitude at SDM is 1,526 ft for runway 8L/26R and 1,126 ft for runway 8R/26L. SDM operates within class D airspace, which includes the airspace extending upward from the surface to and including 3,000 ft msl within a 2.6-mile radius of SDM. (These dimensions are nonstandard; the normal radius is around 5 miles.)

The SDM ATCT is a nonapproach control federal contract tower, operated and staffed by a private company. Local controllers at nonapproach control towers must devote the majority of their time to visually scanning the runways and local area. The SDM ATCT employed five controllers; at the time of the accident, the ATCT was operating and had three controllers in the facility, which was the normal staffing schedule for that day and time. Both accident airplanes were operating under VFR in the class D airspace and were communicating with and being provided ATC services by SDM ATCT personnel. After the accident, on August 26, 2015, the SDM ATCT issued a corrective action plan regarding inconsistencies in how controllers were issuing traffic advisories and safety alerts. The plan required controllers to review FAA JO 7110.65V, Air Traffic Control, paragraphs 2-1-6 and 2-1-21, as refresher training before working an operational position.


Cockpit Voice Recorder

The CVR was recovered from the Eagle1 wreckage and forwarded to the National Transportation Safety Board (NTSB) vehicle recorders laboratory in Washington, DC, for readout. The CVR had 30 minutes of analog audio on a continuous loop tape in a four-channel format: one channel for each of the two pilot stations, one channel for the cockpit observer station, and one channel for the cockpit area microphone (CAM). The magnetic tape was retrieved from within the crash-protected case and was successfully downloaded.

The quality of the CVR audio information was degraded due to the erase mechanism not completely erasing the previous recordings, especially on the CAM channel. Timing on the transcript was established by correlating the CVR events to the common events recorded by SDM ATC. The CVR recording started at 1032:28 and ended at 1103:10. Due to the poor quality of the CVR recording, the SDM ATC transcript was used in conjunction with the CVR recording to clarify the flight crew's radio transmissions.


The wreckage was located in a large open area about 1 1/2 miles northeast of SDM and consisted of two primary debris fields, one for each airplane.

N1285U Airplane

N1285U's debris field, which was about 1,200 ft long and aligned on a magnetic heading of 055º, contained some components and fragments from Eagle1 and was located about 400 ft northeast of the Eagle1 debris field. The N1285U main wreckage contained the engine, propeller, and part of the main cabin. The main cabin wreckage consisted of parts of the floor, seats, and cabin structure. The engine remained partially attached to the firewall and exhibited impact damage to its left side, revealing cylinder components. The propeller assembly was found separated from the engine and partially buried in a small crater. The propeller was heavily gouged in multiple directions, and one blade had aft bending.

The left wing remained attached to a portion of the cabin roof and came to rest inverted. The wing and roof section had thermal damage. The flap and aileron remained attached to the wing. The inboard portion of the leading edge of the left wing displayed impact damage and red transfer marks. The fuselage and right wing were highly fragmented and spread throughout the debris field.


Most of the Eagle1 wreckage was contained within a radius of about 100 ft; no parts from N1285U were located within that radius. The Eagle1 main wreckage was on a magnetic heading of 060º and consisted of the cabin area, left wing, empennage, both engines, and the externally mounted test pod. The forward cabin area came to rest on its upper left side and was crushed. The remaining cabin area was crushed and had thermal damage. The left wing came to rest on its trailing edge, supported at an angle by the landing gear. Both engines were found near the tail section and displayed crush damage. The test pod and internal equipment had impact and thermal damage.

The Eagle1 right wing was found on a road near the N1285U debris field, about 400 ft north of the Eagle1 main wreckage. A power transmission line near the wing's location was separated during the accident. The wing displayed leading-edge damage from near the tip to the separation point from the inboard portion of the wing. About 4 ft of the inboard wing was separated and recovered with the main wreckage. A 5-ft section of leading edge, from the stall fence inboard, displayed leading-edge damage revealing the internal surfaces of the wing. The lower surface of the wing displayed metallic impact marks and paint transfer marks.

Follow-up Examination

Detailed examination of the wreckage from both airplanes was conducted at a secure facility several days after the accident. The right wing of Eagle1 was positioned with the N1285U wreckage, and investigators conducted an examination for contact evidence between the airplanes. The Eagle1 right wing had impact marks consistent with the impact of N1285U's engine. Specifically, the spacing of the impact marks on the inboard lower surface of the Eagle1 right wing were consistent with the spacing of the N1285U engine crankcase upper studs, flanges, and engine lifting eye. The angle of the marks relative to the Eagle1's longitudinal axis was about 30º and indicates that this was the convergence angle between the airplanes. The damage on the N1285U crankcase upper studs, flanges, and engine lifting eye was consistent with impact from its left side and with the computed convergence angle.

In addition, the conformity of the Cessna fuselage, wing strut, and wing spar damage to the Eagle1 wing shape indicates that the Eagle1 right wing impacted the left side of the Cessna. The evidence is consistent with the longitudinal axes of the two airplanes being approximately perpendicular to one another at the time of impact, with Eagle1 approaching the Cessna from the left, and with the Eagle1 right wing below the Cessna left wing.

The reconstruction of the airplanes' flightpaths, based on radar data, is described in the NTSB's Aircraft Performance and Cockpit Visibility Study for this accident. The collision geometry resulting from the trajectory reconstruction is consistent with the collision geometry indicated by the wreckage examination.


The FAA's Civil Aerospace Medical Institute performed toxicology testing on tissue specimens from the three pilots. The specimens tested negative for ethanol and major drugs of abuse.

The LC and LC trainee on duty at the time of the accident tested negative for drugs and alcohol.


Aircraft Performance and Cockpit Visibility Study

The NTSB's investigation examined the ability of the N1285U and Eagle1 pilots to see and avoid the other aircraft. To determine approximately how each aircraft would appear in the pilots' fields of view, the position of the "target" aircraft in a reference frame attached to the "viewing" aircraft must be calculated. This calculation depends on the positions and orientation (pitch, roll, and yaw angles) of each aircraft, as well as the location of the pilots' eyes relative to the cockpit windows. Position and orientation information for both airplanes was estimated based on an analysis of the radar data, combined with models of each airplane's aerodynamic performance. For this study, the relative positions of the two aircraft were calculated beginning at 1100:06.0 and then at 0.05-second intervals up to the collision, which occurred at 1103:10.2. The time, location, and altitude of the collision were determined based on extrapolation of the radar data, the wreckage locations of both aircraft, and the time of the end of Eagle1's CVR recording. The locations of the structures and transparencies of Eagle1 in its copilot's (right seat) field of view, and of N1285U in its pilot's (left seat) field of view, were determined from the interior and exterior dimensions of representative airplanes, as measured using a laser scanner. The structural obscurations to each pilot's view were merged with the calculated relative position data and are discussed below. The study assumed a nominal pilot seating (and eye) position in each cockpit and evaluated a matrix of eye displacements from the nominal eye position. The variations in eye position indicated that pilot head movements can move the target airplane's positon in the field of view into and out of areas that are obscured from the pilots. For Eagle1, the visibility of N1285U from the copilot's seat is sensitive to the pilot's eye position relative to the top and left edges of the Eagle1 R2 window, and for N1285U, the visibility of Eagle1 is sensitive to the pilot's eye position relative to the post between the left door window and the windshield (see figure 6 for a top-down view of the Eagle1 forward fuselage with cockpit windows labeled). The description of the visibility from each aircraft that follows is based on the pilots' eyes at "nominal" positions, determined by the eye positions of persons of similar stature to the accident pilots seated in exemplar airplanes. The Aircraft Performance and Cockpit Visibility Study for this accident describes how the visibility from each airplane changes with variation in eye position and notes that head movements in several directions while scanning for traffic can make otherwise obscured aircraft visible.

Eagle1's 10 cockpit windows (5 on each side of the airplane) are labeled L1 through L5 for the left windows and R1 through R5 for the right windows, as shown in figure 6. The Cessna windows are the windshield, left window, and right window.

At 1100:06, N1285U was climbing through 540 ft over runway 26L after completing its touch-and-go operation, and Eagle1 was 6 nm west and 1 nm north of the SDM runway 26R threshold, descending through 2,380 ft.

At 1100:29, Eagle1's CVR recorded the copilot comment "got one on short final" (likely Global Express N18WZ), and Eagle1 was descending through 2,260 ft, 1 nm north and 4.9 nm west of the runway 26R threshold. N1285U was climbing through 780 ft, along the extended centerline of runway 26L, and about 800 ft past the departure end of that runway. N1285U would have been located in Eagle1's R1 window. The other aircraft in the pattern would have been located in roughly the same area, except for the other Cessna 172, N6ZP, which was to the left in the R1 window. Eagle1 would have appeared in N1285U's windshield. The aircraft were 4.1 nm apart.

At 1100:55, N1285U was climbing through 1,150 ft about 1,200 ft west of the departure end of runway 26R and began a right turn to cross over the extended centerline of 26R to enter the right traffic pattern for that runway. Eagle1 was at 2,190 ft, about 1 nm north and 3.6 nm west of the runway 26R threshold, about 2.4 nm from N1285U, and would have been located in N1285U's windshield about in line with the top of the instrument panel. N1285U would have been located in Eagle1's R1 window.

At 1101:15.5, Eagle1's CVR recorded the copilot state "got one on the runway" (likely N18WZ). At this time, N18WZ may have been obscured behind the post separating Eagle1's R1 and R2 windows, if the copilot's eyes had been looking from the "nominal" position. Since the copilot saw and commented on N18WZ, however, he may have been leaning closer to the window to scan for traffic, bringing N18WZ more into view. N1285U would have appeared in Eagle1's R2 window and was 1.2 nm away. Eagle1 would have appeared in the N1285U pilot's field of view near the forward edge of the post separating the left window from the windshield.

At 1101:24.6, Eagle1 was level at 2,100 ft, about 1 nm north and 2.4 nm west of the runway 26R threshold, when the pilot stated "I got twelve o'clock on a climb out." At this time, the Cessna 206 (N5058U) had recently departed from runway 26L. N1285U was 0.8 nm from Eagle1, climbing through 1,600 ft and turning from crosswind to right downwind for runway 26R, 0.5 nm north and 1.7 nm west of the runway 26R threshold. N1285U would have appeared in Eagle1's R2 window; N5058U would have appeared slightly below and to the left of N1285U. Eagle1 would have been hidden from the N1285U pilot's view behind the window post between the left window and windshield.

At 1101:43.1, N1285U would have been located just to the left of the window post separating Eagle1's R2 and R3 windows, and N5058U would have been just to the right of this post (see figure 7a). Eagle1 would have appeared in the left window of N1285U, just below the wingtip (see figure 7b). Eagle1 and N1285U were both on the right downwind leg for runway 26R, with Eagle1 about 0.4 nm north of N1285U.

At 1101:49.0, Eagle1's CVR recorded one of the mission specialists seated outside of the cockpit ask "see him right there?" Eagle1 was at about 2,040 ft, 1.1 nm north and 1.4 nm west of the runway 26R threshold. N1285U was level at 1,700 ft, 0.7 nm north and 1.3 nm west of the threshold. The airplanes were about 0.5 nm apart, and N1285U would have appeared in Eagle1's R3 window near the right edge of the post separating the R2 and R3 windows. Eagle1 would have been obscured from the N1285U pilot's view by the left wing.

At 1102:14.0, when the Eagle1 flight crew reported "…right downwind abeam. traffic to the left and right in sight," Eagle1 was at about 2,110 ft, 1.3 nm north and 0.4 nm west of the runway 26R threshold. N6ZP would have appeared in Eagle1's L1 window and was the only aircraft to Eagle1's left. N1285U would have appeared in Eagle1's R3 window. N1285U was descending through 1,650 ft, about 0.7 nm north and 0.5 nm west of the runway 26R threshold. Eagle1 would have remained obscured from the N1285U pilot's view by the left wing. Other airborne traffic to the right of Eagle1 at this time included a Piper airplane (N5442P), the helicopter (N8360R), and the Cessna 206 (N5058U).

At 1102:32.0, when the LC mistakenly instructed N6ZP to make a right 360º turn, intending the instruction for N1285U, Eagle1's CVR recorded the pilot ask "you still got the guy on the right side?" N1285U was 0.8 nm away and would have appeared in Eagle1's R3 window (see figure 8a). Also to Eagle1's right were N8360R (on short final approach for runway 26L), N5442P (on a left base leg for runway 26L), and N5058U (which was climbing through 1,500 ft about 2.6 nm to the west of the runway 26R threshold). Eagle1 would have been obscured from the N1285U pilot's field of view by the left wing and strut (see figure 8b). Eagle1 started banking to the right, turning toward right base, shortly after this time.

At 1102:42.0, when the LC instructed the pilot of Eagle1 to "turn base two six right cleared to land," Eagle1 was descending through 1,960 ft in a right bank, about 1.3 nm north and 0.7 nm east of the runway 26R threshold. N1285U was descending through 1,460 ft, about 0.6 nm north and 0.3 nm east of the threshold, and would have appeared in Eagle1's R3 window (see figure 9a). Eagle1 would have appeared in the N1285U pilot's field of view near the edge or slightly behind the window post separating the left window from the windshield (see figure 9b). The airplanes were still about 0.8 nm away from each other.

At 1102:59.3, Eagle1's CVR recorded the pilot state "I see the shadow but I don't see him." The only aircraft close enough to Eagle1 to cast a shadow visible to Eagle1's pilot was N1285U, which was 0.5 nm away and would have appeared in the upper part of Eagle1's R2 window. At this time, Eagle1 may again have been obscured from the N1285U pilot's view by the post between the right window and the windshield.

At 1103:04.0, when the LC called N1285U, apparently realizing that he may have instructed the wrong airplane to make the right 360° turn, Eagle1 and N1285U were 0.3 nm apart, with Eagle1 descending through 1,490 ft and N1285U descending through 1,370 ft. N1285U would have appeared near the top left corner of Eagle1's R2 window, and Eagle1 may have remained obscured behind N1285U's left window post.

At 1103:08.0, when the controller asked the N1285U pilot if he was still on downwind, Eagle1 and N1285U were about 0.1 nm apart. N1285U may have been obscured by the post between Eagle1's R1 and R2 windows, and Eagle1 may have been obscured by N1285U's window post (see figures 10a and 10b).

In-Cockpit Traffic Display Simulation

The FAA's Aeronautical Information Manual (AIM) (dated December 10, 2015, and revised on May 26, 2016), paragraph 4-5-7, states that ADS-B is a surveillance technology deployed throughout the National Airspace System. The ADS-B system is composed of aircraft avionics and a ground infrastructure. Onboard avionics determine the position of an aircraft by using the GPS and transmit its position along with additional information about the aircraft to ground stations for use by ATC and other ADS-B services. This information is transmitted at a rate of approximately once per second. ADS B avionics can have the ability to both transmit and receive information. The transmission of ADS-B information from an aircraft is known as ADS-B Out. The receipt of ADS-B information by an aircraft is known as ADS-B In. On January 1, 2020, all aircraft operating within the airspace defined in 14 CFR 91.225 will be required to transmit the information defined in 14 CFR 91.227 using ADS-B Out avionics.

The ADS-B capabilities that enhance pilots' awareness of airborne traffic in their vicinity are described in FAA Advisory Circular (AC) 20-172B, "Airworthiness Approval for ADS-B In Systems and Applications." Per the AC, this capability allows an appropriately equipped aircraft to receive and display another aircraft's ADS-B Out information, as well as ground station broadcast information, from services like traffic information services-broadcast (TIS-B) and automatic dependent surveillance-rebroadcast (ADS-R). The received information is processed by onboard avionics and presented to the flight crew on a display. ADS-B In avionics enable a number of aircraft surveillance applications and can enhance visual acquisition by displaying nearby traffic on a plan view (bird's eye view) relative to own-ship. The traffic information assists pilots in visually acquiring traffic out the window while airborne but does not relieve them of see-and-avoid responsibilities. Additionally, the information derived through ADS-B In applications can be used to provide voice annunciations to flight crews to draw attention to alerted traffic.

For this accident, simulated in-cockpit displays of traffic information for both Eagle1 and N1285U were created based on the TIS-B information that would have been displayed to the pilots of each airplane assuming that both aircraft were equipped with ADS-B In capability and avionics capable of displaying and aurally annunciating the traffic information. In addition, the simulation assumes that at least one ADS-B-Out-equipped aircraft was operating in the vicinity of the two accident aircraft, to trigger the broadcast of TIS-B information from a ground station, as currently, aircraft equipped with only ADS-B In cannot trigger the broadcast of this information. The images from the NTSB's in-cockpit traffic display simulation presented in figures 11 through 13 are representative of the minimum operations specifications for such displays contained in RTCA document DO-317B but do not duplicate the implementation or presentation of any particular operational display exactly. The actual images presented to a pilot depend on the range scale and background graphics selected by the pilot (which could reflect various implementations and combinations of moving maps, terrain elevation data, and weather information, rather than the simple black background presented here). In addition, the aircraft N numbers shown in figures 11 through 13 are included here for clarity but would not be presented in an actual display because none of the aircraft in the SDM pattern (except for N18WZ) were ADS-B Out equipped (an actual display could include the N number for N18WZ).

The NTSB's in-cockpit traffic display simulation for Eagle1 indicates that at 1059:04, open (outlined), cyan-colored, arrowhead-shaped targets representing the local traffic at SDM would have appeared at the 1 o'clock position, 8 nm from Eagle1, and traffic inbound for the San Diego area would have appeared at Eagle1's 9 to 11 o'clock position, 8 nm from Eagle1. N1285U would have been depicted 500 ft below Eagle1 east of the airport on a final approach leg. As Eagle1 continued its east-bound track toward SDM, N1285U would have disappeared from view (loss of radar contact). At 1059:48, as Eagle1 approached 6 nm from SDM, N6ZP would have appeared over SDM as an open arrowhead and turned right to remain in the traffic pattern for runway 26R. At 1100:16, N6ZP would have changed to a filled cyan-colored arrowhead before becoming established on the downwind leg at 1100:49. (N6ZP would eventually cross over the projected flightpath of Eagle1 at 1101:49, headed northeastbound.) At 1100:57, when Eagle1 was about 3.5 nm from the runway 26R threshold, N1285U would have reappeared on Eagle1's display as a filled, cyan-colored arrowhead at Eagle1's 1 o'clock position, about 2.5 nm from and 1,100 ft below Eagle1. At 1101:38, N1285U's symbol would have changed to alert status (a filled, yellow-colored arrowhead, enclosed by a yellow circle), and Eagle1 would have received an aural alert advising, "Traffic, 2 o'clock, low, less than 1 mile, climbing" (see figure 11).

As shown in figure 12, at 1101:38, as N1285U turned onto the downwind leg and as Eagle1 was receiving its aural alert, N1285U's display would have depicted Eagle1 at N1285U's 8 o'clock position, 0.6 nm from and 400 ft above N1285U. At 1102:14, both Eagle1 and N1285U were positioned abeam the tower, and Eagle1 reported traffic to the left and right in sight. N6ZP would also have been shown on the displays departing the SDM area heading in a northeastern direction 400 ft above N1285U and at the same altitude as Eagle1.

At 1102:59.3, during Eagle1's base turn, the pilot stated, "I see the shadow but I don't see him." At this time, N1285U would have been depicted on Eagle1's display at Eagle1's 2 o'clock position, between Eagle1 and the runway 26R threshold, 1 nm from and 500 ft below Eagle1. At 1103:07, about 3 seconds before the collision, N1285U would have again changed to alert status (yellow, circled arrowhead), and Eagle1 would have received a second aural alert advising, "Traffic, 1 o'clock, same altitude, zero miles" (see figure 13). At the same time, Eagle1 would have changed to alert status on N1285U's display, and N1285U would have received an aural alert advising, "Traffic, 11 o'clock, same altitude, zero miles, descending." Additional details about the traffic information that could have been displayed during the accident scenario can be found in the Aircraft Performance and Cockpit Visibility Study.


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.

The FAA's AIM, dated April 3, 2014, 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 4-1-16, describes the manner in which pilots could expect to receive traffic safety alerts from ATC and states, in part, the following:

A safety alert will be issued to pilots of aircraft being controlled by ATC if the controller is aware the aircraft is at an altitude which, in the controller's judgment, places the aircraft in unsafe proximity to terrain, obstructions or other aircraft. The provision of this service is contingent upon the capability of the controller to have an awareness of a situation involving unsafe proximity to terrain, obstructions and uncontrolled aircraft. The issuance of a safety alert cannot be mandated, but it can be expected on a reasonable, though intermittent basis. Once the alert is issued, it is solely the pilot's prerogative to determine what course of action, if any, to take. This procedure is intended for use in time critical situations where aircraft safety is in question. Noncritical situations should be handled via the normal traffic alert procedures….

Controllers will immediately issue an alert to the pilot of an aircraft under their control if they are aware of another aircraft which is not under their control, at an altitude which, in the controller's judgment, places both aircraft in unsafe proximity to each other. With the alert, when feasible, the controller will offer the pilot the position of the traffic if time permits and an alternate course(s) of action.

Title 14 CFR 91.123, "Compliance with ATC Clearances and Instructions," states the following:

(a) When an ATC clearance has been obtained, no pilot in command may deviate from that clearance unless an amended clearance is obtained, an emergency exists, or the deviation is in response to a traffic alert and collision avoidance system resolution advisory. However, except in Class A airspace, a pilot may cancel an IFR flight plan if the operation is being conducted in VFR weather conditions. When a pilot is uncertain of an ATC clearance, that pilot shall immediately request clarification from ATC.

The See-and-Avoid Concept

The FAA issued AC 90-48C, "Pilots' Role in Collision Avoidance," in 1983 to alert all pilots "…to the potential hazards of midair collisions and near midair collision, 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." (This version of the AC was in place at the time of the accident; an updated version, AC 90-48D, was issued in April 2016 and is discussed further below.)

AC 90-48C stated that each person operating an aircraft, regardless of whether the operation was conducted under instrument flight rules 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" (emphasis in the original). AC 90-48C also described several specific methods that pilots could use to visually acquire other traffic.

Finally, the AC provided data on the time required for a pilot to recognize an approaching aircraft and execute an evasive maneuver. The total time to identify an approaching aircraft, recognize a collision course, decide on action, execute the control movement and allow the aircraft to respond was estimated to be around 12.5 seconds.

In 1991, the Australian Transport Safety Bureau (ATSB) published a research report titled "Limitations of the See-and-Avoid Principle." The report discusses the role of the see-and-avoid concept in preventing collisions and some of its inherent limitations:

Cockpit workload and other factors reduce the time that pilots spend in traffic scans. However, even when pilots are looking out, there is no guarantee that other aircraft will be sighted. Most cockpit windscreen configurations severely limit the view available to the pilot. The available view is frequently interrupted by obstructions such as window-posts which totally obscure some parts of the view and make other areas visible to only one eye....Visual scanning involves moving the eyes in order to bring successive areas of the visual field onto the small area of sharp vision in the centre of the eye. The process is frequently unsystematic and may leave large areas of the field of view unsearched….The physical limitations of the human eye are such that even the most careful search does not guarantee that traffic will be sighted….An object which is smaller than the eye's acuity threshold is unlikely to be detected and even less likely to be identified as an approaching aircraft….The human visual system is better at detecting moving targets than stationary targets, yet in most cases, an aircraft on a collision course appears as a stationary target in the pilot's visual field. The contrast between an aircraft and its background can be significantly reduced by atmospheric effects, even in conditions of good visibility. An approaching aircraft, in many cases, presents a very small visual angle until a short time before impact. In addition, complex backgrounds such as ground features or clouds hamper the identification of aircraft via a visual effect known as 'contour interaction'. This occurs when background contours interact with the form of the aircraft, producing a less distinct image. Even when an approaching aircraft has been sighted, there is no guarantee that evasive action will be successful.

The ATSB report also discusses the value of alerted versus unalerted searches for traffic:

A traffic search in the absence of traffic information is less likely to be successful than a search where traffic information has been provided because knowing where to look greatly increases the chance of sighting the traffic (Edwards and Harris 1972). Field trials conducted by John Andrews found that in the absence of a traffic alert, the probability of a pilot sighting a threat aircraft is generally low until a short time before impact. Traffic alerts were found to increase search effectiveness by a factor of eight. A traffic alert from ATS or from a radio listening watch is likely to be similarly effective (Andrews 1977, Andrews 1984, Andrews 1987).

The ATSB report concludes, in part, that "The see-and-avoid principle in the absence of traffic alerts is subject to serious limitations….Unalerted see-and-avoid has a limited place as a last resort means of traffic separation at low closing speeds but is not sufficiently reliable to warrant a greater role in the air traffic system."

Cockpit Display of Traffic Information

In April 2016, the FAA published an update to "Pilots' Role in Collision Avoidance" (AC 90-48D), which highlights aircraft systems and technologies available to improve safety and aid in collision avoidance. Among those technologies, the recommended safety equipment includes TAS, TCAS (I and II), and ADS-B with display capability. The updated AC also discusses the information provided by each of these systems and stresses that they are intended as a supplement to, and not replacement for, the visual acquisition and avoidance of other aircraft.

Regarding the use of ADS-B as a tool to aid in a pilot's situational awareness, the AC states, in part, the following:

ADS-B is a system for air traffic surveillance. The FAA has mandated ADS-B Out by 2020 on all aircraft operating in current Mode C airspace (around Class B and C airspace and above 10,000 feet). With ADS-B, each aircraft broadcasts its own Global Positioning System (GPS) position along with other information like heading, ground track, groundspeed, and altitude (ADS-B Out). To see other aircraft, you must be equipped with ADS-B In to process the data signals.

The AC describes how other systems that actively interrogate other aircraft would continue to be useful beyond the FAA-mandated ADS-B Out requirement in 2020:

Active Traffic Systems. Active traffic systems (including TAS and TCAS) use Mode A, C, or S transponder interrogations to determine aircraft bearing and distance. Altitude is determined by reported Mode C altitude. After 2020, aircraft will be required to broadcast ADS-B Out and this data can be interpreted by aircraft with ADS-B In, but aircraft will still be required to have a Mode C or S transponder in airspace where it is currently required; thus, active traffic systems will continue to function. Most TAS systems will have ADS-B In capability available as an upgrade so these systems can interpret signals from either source.

Active Traffic Systems in an ADS-B Environment. Active traffic systems are valuable for three reasons in an ADS-B environment. First, even after January 1, 2020, not all aircraft will have ADS-B Out, particularly in airspace which does not require it. Thus, without an active traffic system, those unequipped aircraft would not display on a cockpit traffic display even if you had ADS-B In. Second, an active traffic system will display all aircraft independent of the type of ADS-B Out, since all aircraft will still be required to have a Mode C or Mode S transponder. Third, ADS-B is dependent on GPS signals, so during periods of poor satellite geometry or solar storms, GPS position and thus ADS-B could be disrupted and less reliable, meaning an active traffic system can act as a backup to ADS-B in the cockpit.

In 1977, the Massachusetts Institute of Technology published a report for the FAA, titled Air-to-Air Visual Acquisition Performance with Pilot Warning Instruments (PWI), which describes how PWI could be used to aid pilots in the visual acquisition task. These instruments would generally use some electronic means to detect and then present pilots with information about particular threats, focusing their attention to where it was most needed:

The primary intent of PWI is to improve the search performance of the pilot. The PWI alarm ensures that scanning will be given high priority when it is most critical and by directing the pilot's search to a particular sector, the area to be scanned is greatly reduced. Another effect discovered in the [Intermittent Positive Control] IPC/PWI flight tests is the tendency of PWI to reduce the effect of airframe obstruction. Not only do pilots shift their positions within the cockpit in an effort to scan a threat sector, but many pilots alter the aircraft attitude in order to achieve an unobstructed view in the threat direction. Thus, PWI favorably affects the first two elements of acquisition (search and field of view). It does not alter detectability or speed of approach in any direct way.

Research into pilots' performance in the visual acquisition task conducted in support of the report found that "Unaided visual acquisition is effective as a means of separation assurance only for lower values of crossing angles (relative heading). At higher values of crossing angle the increased closure speeds and decreased visible areas reduce performance considerably."

In our report regarding a midair collision over the Hudson River (Midair Collision Over Hudson River, Piper PA-32R-300, N71MC, and Eurocopter AS350BA, N401LH, Near Hoboken, New Jersey, August 8, 2009, AAR-10/05), the NTSB stated, in part, the following;

There are inherent limitations associated with the see-and-avoid concept as the primary method for aircraft separation. These limitations include a pilot's ability to perform systematic scans, competing operational task demands, environmental factors, and blind spots associated with an aircraft's structure. Traffic advisory systems can provide pilots with additional information to facilitate pilot efforts to maintain awareness of and visual contact with nearby aircraft to reduce the likelihood of a collision.

Most traffic advisory systems, including TIS [traffic information service], have visual displays of nearby traffic that show an aircraft's position or distance, direction of travel, and relative altitude and indicate whether the aircraft is climbing or descending. The NTSB recognizes that incorporating a visual traffic display into a pilot's scan could increase workload, but any increase in workload would be offset by the safety benefits resulting from the augmented awareness of other aircraft operating in the area, as displayed by the traffic system. However, these safety benefits are not a substitute for the see-and-avoid concept. In fact, Garmin guidance stated that TIS does not relieve pilots of their responsibility to see and avoid other aircraft. Thus, pilots are responsible for paying attention to the position of other aircraft for collision avoidance and not relying solely on a traffic advisory system for aircraft position information.

FAA Guidance to Air Traffic Controllers

FAA Order 7110.65, Air Traffic Control, prescribes ATC procedures and phraseology for use by personnel providing ATC services. Paragraph 2-1-2, "Duty Priority," states, in part, that controllers should "give first priority to separating aircraft and issuing safety alerts as required in this order. Good judgment must be used in prioritizing all other provisions of this order based on the requirements of the situation at hand."

Paragraph 2-1-6, "Safety Alerts," states, in part, the following:

Issue a safety alert to an aircraft if you are aware the aircraft is in a position/altitude that, in your judgment, places it in unsafe proximity to terrain, obstructions, or other aircraft….


1. The issuance of a safety alert is a first priority…once the controller observes and recognizes a situation of unsafe aircraft proximity to terrain, obstacles, or other aircraft. Conditions, such as workload, traffic volume, the quality/limitations of the radar system, and the available lead time to react are factors in determining whether it is reasonable for the controller to observe and recognize such situations. While a controller cannot see immediately the development of every situation where a safety alert must be issued, the controller must remain vigilant for such situations and issue a safety alert when the situation is recognized….

b. Aircraft Conflict/Mode C Intruder Alert. Immediately issue/initiate an alert to an aircraft if you are aware of another aircraft at an altitude that you believe places them in unsafe proximity. If feasible, offer the pilot an alternate course of action. When an alternate course of action is given, end the transmission with the word "immediately."

Traffic Alert (call sign) (position of aircraft) Advise
You turn left/right (heading),


Climb/descend (specific altitude if appropriate)

Research on Workload

According to Mica R. Endsley and Mark D. Rodgers in a 1997 report titled Distribution of Attention, Situation Awareness, and Workload in a Passive Air Traffic Control Task: Implications for Operational Errors and Automation (FAA Report No. DOT/FAA/AM-97/13), the cognitive effects of increasing workload may include memory deficits, distraction, narrowing of attention, decreased situational awareness, and increased errors (such as readback errors or giving instruction to the wrong aircraft). Specifically, Endsley and Rodgers write the following:

This study reveals many interesting findings on the role of situation awareness and workload in operational errors. Significant deficiencies in the ongoing situation awareness of the subjects were present in this study. They had a fairly low ability to report on the existence of many aircraft, or accurately recall their location or many of their parameters. Their accuracy was significantly impacted by the number of aircraft present in the scenario and, to a lesser degree, by perceived workload.

Michael Copeland

Brown Field Municipal Airport (KSDM), San Diego, California

SAN DIEGO — The family of a pilot killed in August when two private planes collided in the air near Otay Mesa has filed a wrongful-death lawsuit against the air traffic control company and others.

Michael A. Copeland, a 55-year-old Qualcomm executive from San Diego, was the sole occupant of a single-engine Cessna 172 that collided with a twin-engine Sabreliner jet on Aug. 16 in the air above Brown Field.

All four people on the jet were also killed.

Copeland’s widow, Kathleen, filed the lawsuit this week in San Diego Superior Court along with their adult children Laura and Daniel Copeland.

The defendants named in the suit are New Jersey-based Serco Inc., which contracts with the U.S. government to provide air traffic control services at Brown Field; a manager at the airport’s control tower; and Maryland-based BAE Systems Technology Solutions and Services, which owned and operated the Saberliner.

The pilot of the jet, Jeffrey Percy, 41, was a BAE employee. His co-pilot James Hale, 66, of Adelanto was a contract employee for BAE. Both were killed in the crash.

Copeland’s family contends that the defendants were negligent — Serco in particular —because the air traffic controllers failed to maintain a safe distance between the two aircraft.

Attorney David S. Casey Jr. , who represents the family, has said the control tower communicated with the pilots of both planes before the crash.

“We tragically learned that they made miscommunications,” Casey said, explaining that both aircraft had been cleared to land at the airport, and that Copeland had been cleared to perform “touch and go” maneuvers in the Cessna.

The attorney said Copeland would not have been able to see the jet, which was flying above and behind the Cessna at a higher rate of speed.

“Michael Copeland had no idea that another plane was coming at him,” Casey said.

The plaintiffs are seeking unspecified damages.

Serco spokesman Alan Hill said in a statement Friday that Serco continues to support and cooperate fully with the Federal Aviation Administration and National Transportation and Safety Board as they work to understand the cause of the collision.

In a similar statement, BAE Systems spokesman Brian Roehrkasse said: “BAE Systems employees continue to mourn the loss of all of those killed in this tragic accident. We continue to support the investigation and because it is ongoing, we cannot comment further.”

Over the past few months, other lawsuits related to the fatal collision have been filed in Superior Court.

Hale’s family filed a lawsuit against Serco in November, while Percy’s family filed one against Serco and the airport’s control tower manager in December. The family of a passenger in the jet, John Kovach, 35, filed a lawsuit against the company in December.

The widow and teenage son of Carlos Palos, 40, the other passenger in the Saberliner, filed a lawsuit in September against Percy’s and Copeland’s estates as well as the Cessna’s owner, Plus One Flyers.

That lawsuit has been dismissed, but Copeland’s attorney said he expects it to be filed again with Serco named as the defendant.


NTSB Identification: WPR15FA243A
14 CFR Part 91: General Aviation
Accident occurred Sunday, August 16, 2015 in San Diego, CA
Aircraft: CESSNA 172M, registration: N1285U
Injuries: 5 Fatal.

NTSB Identification: WPR15FA243B 

14 CFR Part 91: General Aviation
Accident occurred Sunday, August 16, 2015 in San Diego, CA
Aircraft: NORTH AMERICAN ROCKWELL NA265-60SC, registration: N442RM
Injuries: 5 Fatal.

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

On August 16, 2015, about 1100 Pacific daylight time, two airplanes, a Cessna 172, N1285U, and an experimental Sabreliner, (Sabre 60), N442RM, collided midair approximately 1 mile northeast of Brown Field Municipal Airport (SDM), San Diego, California. The two pilots and two mission specialists aboard the Sabreliner were fatally injured. The pilot of the Cessna, the sole occupant of the airplane, was fatally injured. The Sabreliner was being operated as a public use flight by the U.S. Department of Defense in support of the U.S. Navy. The Sabreliner was registered to BAE Systems Technology Solutions & Services, Inc. The Cessna was registered to Plus One Flyers, Inc., of San Diego, California, and operated by the pilot as a personal flight under the provisions of 14 Code of Federal Regulations Part 91. Both airplanes were destroyed. Visual meteorological conditions prevailed at SDM. Both airplanes departed SDM earlier that day and a mission flight plan was on file for the Sabreliner; no flight plan was filed for the Cessna 172. A controller in the SDM air traffic control tower (ATCT) was in contact with both accident airplanes prior to the collision.

Witnesses observed the accident airplanes on the downwind leg of the traffic pattern at SDM. The witnesses turned momentarily, but then observed an explosion followed by sections of the airplanes falling to the ground. Another witness located about 2 miles east-northeast of SDM observed both airplanes at the same altitude, flying towards each other. The smaller airplane was flying from the airport, and the larger airplane was flying to the airport and descending. He stated that both airplanes did not appear to have made any avoidance actions prior to the collision. After the collision, the smaller airplane broke apart; the larger airplane banked left, impacted the ground and exploded. 

The accident site consisted of two debris fields. The Cessna's debris field was located about 400 feet northeast of the Sabreliner's debris field. The Cessna's debris field was about 1,200 feet in length on a magnetic heading of 055 degrees, and contained parts from the Sabreliner. The Cessna was highly fragmented throughout the debris field. The Sabreliner's right wing was found in the Cessna's debris field. The Sabreliner's debris field was contained within a radius of about 100 feet, and no Cessna parts were located within that radius. The Sabreliner came to rest at a magnetic heading of 060 degrees.