I SA47 FILE NO. 1-0016 / 1 ALLEGHEHI' AIRLINES, INC., DC-9, N988VJ AN0 A FORTH CORLPORATiON, PIPER PA-28, N7374J / NEAR FAIRLAND, INDIANA S€PTEMBER 9, 1969 ADOPTED: JULY 15, 1970 // RATION ,' , ' TABLE OF' CONT27 ?!%E synopsis . , . 1 Probable Cause . 2 1. Investisation . 3 1.1 History of the Flight ' . 3 1.2 Injuries to Persons . 4 1.3 mgrto Aircraft . 5 1.4 Other-ge . 5 1.5 Crew Information . , . 5 1.6 Aircraft Information . 5 1.7 Meteorological Infomation . , . 5 1.8 Aids to Navigation . 6 1.9 Communications , . 6 1.10 Aerodrome and Ground Fncilities . 6 1.11 Flight Recorders . .. 6 1.12 Wreckage . 7 1.13 Fire . a 1.14 Survival Aspects . , . 8 1.15 Tests and Research . 8 1.16 Other .................. 9 2. Analysis and Conclusions . 9 2.1 Analysis . 9 . 2.2 Conclusions . 15 (a) Findings . , . , . 15 (b) Probable Cause . 16 3. Recommendations . 17 Appendicss Attachments SA-417 File NO. 1-0016 NATIONAL TRAISPORTATION SAFFPY BOARD DEPAW."EI?TOF TRAIiSFCITATION AIECCRAET ACCIDENT REPORT Adopted: July 15, 1970 ALtM;mY AIRLINES, IIE., E-9, li988VJ AND A FOHPII CORPORATION, PIPE3 PA-28, 1$1374J 4 MILE NOHPIFrlEST OF FAIRLAID, IIDIAIU smmm 9, 1969 An Allegheny Airlines, Inc., X-9, N988VJ, and a Forth Cowration, Piper PA-28, N737hJ, collided In flight e;)proximazely I+ miles northwest of Fairland, Indiana, at approxhately 1529 e.d.t., September 9, 1969. All 83 occupants, 78 passengers and four crehmenbers, aboard the E-S, and the pilot af the PA-28 were fatally injured. Both aircraft were destroyed by the collision and ground hpact. Allegheny 853 was wider positive radar control of the Federal Aviation Adninistration's 1nd.ianapolis P-pproach Control, descending from 6,000 feet to an assigned altitude of 2,530 feet at the ti::% of ' the coliision. N7'3743 has beir.g flown by a studenr pilot ~n a .:>lo cross-country in accorhnce h-ith a Visual Flight Rules (WR) flight plen'. The collision cccurred at an altitude of approxixately 3,gjO feet. ,i The'visihility in the area was at least 15 miles, hut there was an intervening cloud condition wbich precluded the crew of either aircraft from sighting the other until a few seconds prior to collision. Based in part upon this investigetion, the Board has submitted recommendations to the FAA concerning estabi.ishent of clizinum standards for radar reflectivity Of sniall. aircrcf't, and mandatory aircrew training programs on effective scanninc patteras and procedures. The Board Sl.so convened a pub1.ic hearing on the Midair Collision Problem in general, which was attended by all sepents of the aviation commu?itp. The material receivfd at that hearing will be the subject of a separate report. The Board determines the probable cause of this,eccident to be the deficiencies in the collision avoidance c'qability of the Air Traffic Control (ATC) system of the Federal Aviation Administration in a terminal area wherein there was mixed Instrment Flight Rules (IFR) and Visual Fllzht Fiules (VFII) txffic. '2t.e deficiencies in- cluded the Inadequacy of the see-and-avold conccpt under the circum- stances of this case; the txbnical limitations of radar in detecting all Rircraft; and the absence of Federal Aviation Regulations which would provide a system of odeq.'-te separeticn of mixed VFR and IFR tmffic in terminal arpa&. -3- 1. INVFSTIGATION 1.1 Ristory of the Flight Allegheny Airlines, Inc., Flight 853 (Allegheny 853), is a i regularly scheduled flight from Boston, Massachusetts, to St. Louis, Missouri, with intermediate stops at Baltimore, Maryland, Cincinnati, Ohio, and Indianapolis, Indiana. On September 9, 1969, the flight departed Eoston at 1200 1/ and proceeded routine1.y t3 Cincinnati. i Departure, at 1515, was in accordance with an Instrument Flight Rules (In) clearance to Indianapolis via V-97 at an altituae of 10,000 feet. There were 78 passengers and. four crewmembers aboard. At 1522:55, $he Indianapolis Air Route Traffic Control Center (ARXC) D-20 controller advised, "Allegheny eight fifty three is in radar contact, cross Shelbyrille (VOR) at and maintain six thousand and your position now thirty-two miles (unintelligible) . snutheast of Shelbyville." Approximately 3 minutes later, the flight reported leaving 10,000 feet, and during its descent, was instructed to contact InCianapolis ! Approach Control. At 1:i27:12, che approach control controller advised, "Allegheny eight five three roger, squawk ident heading two eight zero radar vector visual approach three one left." Allegheny 853 acknowl- edged the vector and bas almost immediately instructed to descend to 2,500 feet. The flixht acknowledged at 1527:29, "Eight five three cleared down two thousand five hundred and report reaching." This was the last recorded transnission from the flight. Piper PA-28, h-73745, ohlled and operated by tine Forth Corporation, was based at Brooks-ide Air,.ark, approximately 20 miles northeast of Indianapolis. On September 9, i969, the aircraft WES leased to a stutent pilot, who was to complete a solo cross-country flight. Although the pilot had intended to fly to Purdue University Airport, deteriorating weather had prompted a change in ple.ns, and he selected Zakalar AFB, approximatnly 40 miles south of Brookside. The preparation for the actual flight was checked by the general manager of tke airpark, and a Visual Flight Rules (VFR) flight plan was filed indicating a cruising altitude of 3,500 feet. The general manager reported that the pilot was-wearing glasses, had tuned 011 the aircraft's rot:.ting anti- collision beacon, and in a call on Brookside Unicorn, acknowledged by the general manager, said that he would depart on Runway 36. ?io witness obsel-ved the actual takeoff, but the pilot advised the Indianapolis Flight Service Statios at 1521 that he had d.eparted Brookside, and re- quested activation of his flight plan. This ms the last known comuci- cation with N7374.J. The D-20 controller in the AFrlCC who handed off Allegheny 6j3 to approach control stated that the target was approximately 10 miles south- east of che Shelbyville VOR on 17-97 at the tFne. He continued to observe -- lJAZ1 thes herein are easterll daylight, based o<Fhe 2lt-hour clock. '. -4- the target poceed to a point a?proximately 5 miles southeast of the ShelLyvil?.e VOR, execute a 45" left turn and proceed westbound for approximately 5 miles. At this point, be shifted his attention to other duties. He testified that he did not see any prbe.ry targets that were conflicting traffic for Allegheny 353. The AR-1 controller, who assumed responsibili:) for Allegheny 853 in the approach control facility, was aiso assigned the functional duties of the AX-2 position. He stated that he .>bserued the target of Allegheny 853 southeast of the Shelbyville VOR, heading approxi- mately 300". Following radar identification he, 'I. instructed him to turn left heading two eight zero degrees for radar vector for visual approach to runway three one left, descend and maintain two thousand five hundred feet ar.d report l?vel . .'I The flight acknowledged these instructions, and then the controller's attention was diverted to other duties, inclucling a radar handoff on Allegheny 820 which :ms arriving fron the southwest. At approximately the sane time, 1531, he noticed that the target of Allegheny 853 had disappeared. At no time did he observe any conflicting traffic i.n the vicinity of tke flight. The recorded comunications between the AR-1 controller and other flights under his direction. revealed. that he issued several traffic advisories of primary radar tarxets in the vicinity cf the flighzs ha was controlling. Statements were obtained frcm 22 witnesses in the area, cight of w%om sax tk!e collision. The statemcn'ts indicate that there was a broken-to-scattered cloEd cover in the area, bat both aircraft were below the clouls and could be seen clearly at the time uf the collision. .'illegheny 853 ifes westbound and IT7374J was heeding southeasterly, and neither aircraft attempted a collision avoidance maneuver according to the witnesses. There were many flights in the vicinity of Yndianapolis at the approxiuate ti2e of the accident. They all repcrted good visibility below the clouds, bxt varied in t'neir estimates of the cloud base from 3,000 to 4,000 feet m.s.1. There were three aircraft utiEzing the expanded radar semice of approach control between 1500 and 1600 that reported operating VFR at 3,500 feet. One of these aircraft, W666J, reported ir. the vicini.ty of Shelbyville approximately 10 minutes befgre the accident. 1.2 Injuries to Persons Injuries -Crew Passengers -Gthers Fats1 4 (E-?) 78 0 1 (PA-28) 0 0 Nonfatal 0 0 0 None 0 0 I -21 The Ai(-1 position is responsible fc,? traf3c arriving from the east and AR-2 is responsible for traffic arriving from the west. -5- 1.3 Demage to Aircraft Both aircraft were destroyed by the collision and ground impact. 1.4 Other Eamage A few mohiLe homes in the vicinity of the main cra;h site were slightly damaged. me soybean crop, which VBS growing in the field %here the E-9 impacted, was destroyed. 1.5 Crew 1nforn.ation The crews of both aircraft were properly certificated and qualified for the respective flights. (See Appendix B for details.) 1.6 Aircraft Information Both aircraft were proper% certificated and had been maiutained ir. ticcordance with existing regulations. The weight and renter of gravity of each were within the prescribed limits. The E-9 was serviced with kerosene and the PA-28 with 80/87 aviation fuel. (See Appendix C for details.