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ASN Wikibase Occurrence # 45427
Last updated: 27 January 2021
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Type:Silhouette image of generic BE76 model; specific model in this crash may look slightly different
Beechcraft 76 Duchess
Owner/operator:Pinnacle Aviation Services, Inc.
Registration: N1828A
C/n / msn: ME422
Fatalities:Fatalities: 1 / Occupants: 1
Other fatalities:0
Aircraft damage: Written off (damaged beyond repair)
Location:Carlsbad, CA -   United States of America
Phase: Take off
Departure airport:Carlsbad, CA (KCRQ)
Destination airport:
Investigating agency: NTSB
A Mooney and a Beech collided in midair on the downwind for right traffic to runway 24. A pilot in the Beech contacted Palomar ground control (GC) at 1247, requesting taxi from its fixed base operator (FBO) to runway 24. The pilot of the Mooney called Palomar tower at 1255:37, reporting 10 miles north of the airport for landing. The local controller (LC) instructed the Mooney pilot to enter right traffic for runway 24 and report downwind. The air traffic control tower had a digital bright radar indicator tower equipment (DBRITE) radar. The LC stated that the DBRITE location in the cab put it out of the line of sight of the majority of the LC's traffic scan, so using the DBRITE for reference required the LC to divert her attention from the traffic in the pattern and on the runway. She observed the Mooney's identity next to its target on the DBRITE. She put the Mooney on the arrival list, and continued working other traffic. Radar data indicated that the Mooney's target followed the coastline from Oceanside to a point about 3 miles northwest of Palomar. The airplane then turned eastbound and tracked toward the right downwind leg for runway 24. At 1258:08, the LC cleared the Beech for takeoff, and the pilot acknowledged. The Beech's first radar target appeared at 1258:39, and the airplane passed the departure end of the runway at 1259:02. The Beech immediately turned right crosswind. At 1259:27, the LC transmitted a traffic advisory to the Mooney, advising of the Beech on right crosswind turning to downwind. In the same transmission, the LC also advised the Beech pilot of the Mooney traffic inbound on the 45-degree entry to downwind. There was no response from either airplane. According to the LC, the airplanes collided immediately after this transmission. At 1259:36, the Mooney radar target crossed the path of the Beech target, at a mode C reported altitude of 1,300 feet mean sea level (msl), and the two targets merged. Measurement on the plot of the radar targets determined that the convergence angle was 124 degrees. One witness observed the Mooney, which was light brown with dark brown accents, bank to the right immediately prior to impact. Another witness reported that both airplanes appeared to turn at the last second, but both turned the same way into each other. Witnesses reported that the two airplanes merged, and then they saw a puff of white smoke. A piece of wing fell from the Mooney, and the airplane immediately went into a nosedive. The Mooney entered a rapid descent, striking the ground at 1259:43, approximately 300 yards from the estimated collision point. The Beech, which was white with blue accents, banked left and maintained that attitude for a few seconds. To some witnesses, the bank angle approached 90 degrees, while to others it appeared to go to an inverted position. Then the airplane's nose down attitude became steeper until it nosed vertically into the ground. The airplane landed about 100 yards from one witness, who did not observe any attempts at recovery. The last radar target, received at 1259:48, showed the airplane descending through a mode C reported altitude of 500 feet. During the period that the airplane was taxiing, the ground controller characterized the LC's workload as light to moderate, with no unusual circumstances in the traffic pattern. There were "a few" clouds west of the airport that were close enough to be a factor for departures. They could cause pilots to turn somewhat earlier than normal if necessary to maintain adequate clearance. Evaluation of all evidence determined that the conflict was detectable both visually and on the tower radar display. When the LC realized that they were in conflict, her actions were too late to provide the pilots with adequate time to maneuver to avoid a collision. The local controller's loss of situational awareness contributed to the accident. FAA order 7110.65 "Air Traffic Control" prescribed ATC procedures and phraseology for use by persons providing air traffic control services. Paragraph 3-1-1 instructed
Probable Cause: failure of the pilots of both airplanes to maintain an adequate visual lookout and to see and avoid each other. A contributing factor was the failure of the controller to detect and resolve the conflict between the airplanes.



Revision history:

28-Oct-2008 00:45 ASN archive Added
21-Dec-2016 19:24 ASN Update Bot Updated [Time, Damage, Category, Investigating agency]
09-Dec-2017 17:49 ASN Update Bot Updated [Operator, Total fatalities, Total occupants, Source, Narrative]

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