LaGrange Airport NMAC and fatal crash

Started by Live2Learn, August 12, 2015, 03:43:37 AM

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Live2Learn

A year ago February a tragic accident occurred at LaGrange Airport, GA.  Three persons (civilians) in a BE 95-B55 were killed while doing a practice ILS approach.  The relatively low time (in the accident aircraft) was unable to execute a successful go around when he saw a glider and tow plane  approaching from an intersecting runway.  The accident report can be found at www.ntsb.gov.  It's NTSB accident number ERA14FA128.  It is a good read, as are the dozen or so documents in the NTSB accident docket.  Several lessons can be drawn from the NTSB Factual report, the Probable Cause statement, and the background information in the Docket.  Several factors related to communications, and some conflicting statements about the location of the tow plane at the time of the attempted go around are mentioned in the NTSB Factual Report or the Docket, but not brought forward to the summary presented in the Probable Cause statement.

The NTSB Probable Cause (PC) statement is below.  Not stated in the PC, but mentioned in the NTSB Factual report as well as the Docket is that the tow plane and glider were CAP. 


The accident airplane was inbound to the airport, conducting an instrument approach in visual meteorological conditions, when the pilot announced its position over the airport's common traffic advisory frequency (CTAF). Witnesses described the accident airplane's approach as fast and stated that the airplane never touched down. The accident airplane's engines then rapidly accelerated to full power before the airplane pitched up into a steep climb, banked left, rolled inverted, and struck the ground in a nearly vertical nose-down attitude, about 3,600 feet down the 5,599-foot-long runway. Throughout the morning of the accident, glider operations were being conducted on an intersecting runway. As the accident airplane floated down the runway, witnesses observed a tow plane accelerating down the intersecting runway with a glider in tow; The tow plane pilot then announced over the CTAF, "abort abort abort." The glider was then released from the tow plane and landed undamaged on the runway prior to the intersection of the two runways, while the tow plane crossed over the intersecting runway before taxiing back to the ramp.  Examination of the wreckage revealed no preimpact mechanical anomalies. According to witnesses on the airport, neither the glider nor tow plane appeared to be in immediate conflict with the accident airplane just before the accident; they stated that the accident pilot could have safely continued the landing. Additionally, the three pilots onboard the accident airplane had flown into the airport earlier in the day and were aware of the glider operations being conducted on the other runway.  However, the accident pilot's observed reaction, as evidenced by the sudden application of full engine power followed by the airplane's abrupt increase in both pitch attitude and bank angle, suggest that he may have been surprised by the appearance of the glider and tow plane in his field of vision and perceived an imminent collision.  The FAA airport manual contained advisories for glider operations at the accident airport. Examination of the airport rules and regulations, published on the airport website, revealed that a local notice to airmen (NOTAM) was required to be filed prior to the conduct of glider operations. Additionally, a "spotter" was prescribed to be used during glider operations, positioned in a location from which the entire length of the intersecting runway could be viewed, in order to avoid conflicts with other aircraft. According to the airport rules and regulations, the tow plane and glider were prohibited from taking off without approval from the spotter. On the day of the accident, no NOTAM had been filed regarding the day's glider operations, nor was a spotter being used. Interviews with the glider operator revealed a widespread lack of knowledge regarding these published rules. Furthermore, while airport management was aware of the rules with regard to glider operations, there was no method in place to ensure compliance with the published risk management practices.

OCCURRENCES
Approach-VFR go-around - Abrupt maneuver
Approach-VFR go-around - Aerodynamic stall/spin
Approach-VFR go-around - Loss of control in flight
Uncontrolled descent - Collision with terr/obj (non-CFIT)

FINDINGS
Personnel issues-Psychological-Perception/orientation/illusion-Perception-Pilot - C
Personnel issues-Action/decision-Action-Unneccessary action-Pilot - C
Personnel issues-Task performance-Use of equip/info-Aircraft control-Pilot - C
Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Angle of attack-Capability exceeded - C
Personnel issues-Task performance-Communication (personnel)-Following instructions-Pilot of other aircraft - F
Organizational issues-Support/oversight/monitoring-Oversight-Oversight of operation-Airport - F

Findings Legend: (C) = Cause, (F) = Factor
Accident (Continued)
__________________________________________________________________________________________________________________________________________
The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The pilot's overreaction to a perceived conflict with a tow plane and glider on an intersecting runway, which resulted in a loss of control during an attempted aborted landing. Contributing to the accident was the failure of the glider tow operator to follow and the airport operator to ensure compliance with published airport rules and regulations for glider tow operations.