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Last updated on May 20, 2013 at 19:57 EDT

TSB Update on Midair Collision between Beechcraft V35B Bonanza and Piper PA-28-140 Cherokee near Warrenton, Virginia (A12H0001)

August 22, 2012

GATINEAU, QC, Aug. 22, 2012 /PRNewswire/ -

The Accident

On 28 May 2012, at 1605 Eastern Daylight Time, near Warrenton, Virginia,
a Beechcraft V35B Bonanza was in a shallow climb headed southbound when
it collided with a Piper PA-28-140 Cherokee, which was in level flight
headed in a southeasterly direction. As a result of the collision, the
Bonanza broke up in flight and the pilot and flight instructor were
fatally injured in the crash. The pilot, who was the sole occupant of
the Cherokee, was able to conduct a forced landing in a pasture
approximately 6 nautical miles south of the Warrenton-Fauquier Airport
(KHWY). The pilot was taken to hospital and later released.

The Investigation Team

The Transportation Safety Board of Canada (TSB) was delegated the
authority to investigate this accident by the National Transportation
Safety Board (NTSB) under Annex 13 of the Convention on International
Civil Aviation, Section 5.1. The investigation is being conducted under
the laws and policies applicable to the TSB.

The investigation team is led by TSB Investigator-in-Charge, Jon Lee.
Mr. Lee has 25 years aviation experience: 12 years as a commercial
pilot in the aviation industry, and 13 years as an aircraft accident
investigator. He is assisted in this investigation by experts in flight
operations, aircraft performance, aircraft systems, aircraft engines,
human performance and air traffic control. While most of these experts
come from the TSB, assistance has also been provided by the NTSB, the
Federal Aviation Administration (FAA), Hawker Beechcraft and Piper
Aircraft Inc.

Investigation Process

Each investigation consists of three phases. The first phase is the
field phase, when information is gathered from a number of sources; it
includes examination of the wreckage and accident site. The second
phase is the post-field phase where information continues to be
gathered and the analysis begins. The final phase is the report
production phase. This phase includes writing the report, consulting
designated reviewers and, once the Board approves the final report,
preparing the report for release to the public.

This investigation has now entered phase 2. While continuing to
accumulate the information it needs, the team has now begun the work of
analyzing the considerable amount of data in order to determine what
happened, why it happened and, what needs to be done to ensure this
does not happen again.

Work Completed to Date

Progress has been made in a number of areas. The accident site was
extensively photographed and documented, and all major aircraft
components were located. The team reviewed eye-witness statements taken
by local law enforcement officials, and had several conversations with
the surviving pilot. Air traffic controllers were also interviewed.

Relevant records were examined. FAA air traffic radar data along with
flight path information recorded on a GPS in the Cherokee were
retrieved. This information provides valuable data that will assist
investigators in understanding what happened during the moments leading
up to the collision.

What We Know

Both aircraft were certified, equipped and maintained in accordance with
existing regulations and approved procedures. Nothing was found to
indicate that there were any airframe failures or system malfunctions
before or during the flight. All control surfaces were accounted for,
and all damage to both aircraft was attributable to the collision and
impact forces.

Records indicate that the Bonanza pilot and instructor and the Cherokee
pilot were certified and qualified for the flight in accordance with
existing regulations.

Both aircraft were flying under visual flight rules (VFR). VFR flight
requires a pilot to be able to see outside the cockpit, to control the
aircraft’s attitude, navigate, and avoid obstacles and other aircraft.
Governing agencies establish specific requirements for VFR flight,
including minimum visibility and distance from clouds, to ensure that
aircraft operating under VFR are visible from enough distance to ensure
safety.

The weather for the Warrenton area was consistent with good visual
meteorological conditions with visibilities well in excess of the
minimums required for VFR.

After departing the Culpeper Airport and levelling at 2000 feet above
sea level, the pilot of the Cherokee contacted Potomac terminal radar
approach control (TRACON) and requested air traffic control services to
conduct a practice instrument approach into the Warrenton Airport. The
Potomac TRACON controller was in the process of radar identifying the
Cherokee when the collision occurred. The collision alert alarm had
sounded on the controller’s console before the collision.

Investigation Activities in Progress

The TSB is proceeding along several avenues of investigation
concurrently in order to understand why the aircraft collided. To that
end, investigators, assisted by specialists in aircraft performance and
human performance, are reviewing factors that may have contributed to
this tragic accident. A field-of-view analysis is being performed for
each aircraft to determine whether either aircraft would have been
visible to either pilot as they approached.

The TSB has classified this occurrence as a midair collision. The issues
being actively investigated are:

        --  the effectiveness of "see and be seen" as a defense for
            aircraft flying under  VFR; and
        --  FAA policies and procedures regarding controller responses to
            collision alerts between VFR aircraft.

Communication of Safety Deficiencies

Should the investigation team uncover a safety deficiency that
represents an immediate risk to aviation, the Board will communicate
without delay in an effort to make the aviation system safer.

The Families

The TSB investigation team knows that the survivor and the families who
lost loved ones want answers. As we continue our work, our hope is that
we will be able to answer: What happened? Why did it happen? What can
we learn so that it does not happen again? We look for these answers in
order to make a safer transportation system.

     ____________________________________________________________________
    |The information posted is factual in nature and does not contain any|
    |analysis. Analysis of the accident, along with the findings of the  |
    |Board will come when the final report is released. The investigation|
    |is ongoing.                                                         |
    |____________________________________________________________________|

The TSB is an independent agency that investigates marine, pipeline,
railway and aviation transportation occurrences. Its sole aim is the
advancement of transportation safety. It is not the function of the
Board to assign fault or determine civil or criminal liability.

This news release, photos and other related material can be found on the
TSB website at www.bst-tsb.gc.ca.

SOURCE TRANSPORTATION SAFETY BOARD OF CANADA


Source: PR Newswire