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The Hudson River midair collision NTSB Report

It’s been more than a year since the tragic midair collision over the Hudson River that claimed the lives of 9 people and it has been on my mind ever since. I for one love the scenic flight up the Hudson River. It was my first destination in a small airplane back in the spring of 2001 and I even flew down the Hudson during my introductory flight a few weeks later.

A number of years ago I ran across an article posted by our former flying club president describing his method of using the class Bravo airspace just above the Hudson River VFR corridor. This afforded him ATC services and some additional views of the City such as flying over Central Park and down the East River (restricted since the Cory Lidle crash). After trying this method I made the decision to avoid the VFR corridor from that point. As I am sure is the case for many of my fellow pilots one of my biggest fears is a midair collision. Engine failure on takeoff being a close second, but you can train for the engine failure, you simply cannot prepare for a midair collision. After flying for a while in my friends TAS (Traffic Advisory System) equipped Cirrus SR22 it only made my awareness increase to the point that I have decided to do something about it.

There is some good news. The technology has improved and the cost has come down so much that it is now affordable to have effective traffic detection aboard our airplanes. I for one am looking at the Zaon Portable Collision Avoidance System.

Of course no level of technology or ATC assistance should replace the “see and avoid” method of traffic avoidance. These are all tools at our disposal and it remains true that the best tool is our god given sight and smart flight planning with a mindset that we all share the sky.

The FAA has an online training course, New York City Special Flight Rules Area (SFRA), to familiarize pilots with the requirements for flying within the corridor and the SFRA. The course includes a simulation of how a flight in the exclusion is conducted, along with the visual reporting points and audio examples of position reporting calls. (To receive FAA Wings credit, log in to the FAA’s website to take the course.) There is also a quiz to test your understanding of the information and a kneeboard summary of requirements for the exclusion.

Animation Courtesy: NTSB

This animation consists of a two-dimensional (2-D) depiction of preliminary radar flight path information of the August 8, 2009 mid-air collision of a Piper 32 aircraft with a Eurocopter helicopter. The animation begins after the Pipers departure from Teterboro airport, and continues until the collision. The radar ground tracks for both aircraft are displayed on a satellite photo illustration of the area. The 2-D animation is followed by a three-dimensional (3-D) representation of the collision. The 3-D animation is a thirty second, chase view of the Piper 32 depicting the closure of the helicopter with the Piper, ending at the collision. After the 3-D representation, post-collision photographs obtained from witnesses are shown as still images.

Selected comments from the Teterboro and Newark air traffic control (ATC) preliminary transcript are displayed as text, and the animation audio consists of portions of the recorded air traffic control communications. The animation does not depict the weather or visibility conditions at the time of the accident.


The following is the NTSB report on the incident found at http://ntsb.gov/Publictn/2010/AAR1005.html

NATIONAL TRANSPORTATION SAFETY BOARD

Public Meeting of September 14, 2010

(Information subject to editing)

Aircraft Accident Report

Midair Collision Over Hudson River, Piper PA-32R-300, N71MC,

And Eurocopter AS350BA, N401LH

Near Hoboken, New Jersey

This is a synopsis from the Safety Board’s report and does not include the Board’s rationale for the conclusions, probable cause, and safety recommendations. Safety Board staff is currently making final revisions to the report from which the attached conclusions and safety recommendations have been extracted. The final report and pertinent safety recommendation letters will be distributed to recommendation recipients as soon as possible. The attached information is subject to further review and editing.

EXECUTIVE SUMMARY

On August 8, 2009, at 1153:14 eastern daylight time, a Piper PA-32R-300 airplane, N71MC, and a Eurocopter AS350BA helicopter, N401LH, operated by Liberty Helicopters, collided over the Hudson River near Hoboken, New Jersey. The pilot and two passengers aboard the airplane and the pilot and five passengers aboard the helicopter were killed, and both aircraft received substantial damage from the impact. The airplane flight was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 91, and the helicopter flight was operating under the provisions of 14 CFR Parts 135 and 136. No flight plans were filed or were required for either flight, and visual meteorological conditions prevailed at the time of the accident.

CONCLUSIONS

Both pilots were properly certificated and qualified in accordance with applicable federal regulations.

Available evidence suggested that the airplane pilot was not likely affected by fatigue at the time of the accident. The helicopter pilot had an opportunity to obtain sufficient sleep before the day of the accident, but it is unknown if he did so; as a result, no assessment about fatigue could be made for the helicopter pilot.

Both aircraft were properly certified, equipped, and maintained in accordance with federal regulations, and the recovered components showed no evidence of any preimpact structural, engine, or system failures.

Weather was not a factor in this accident, and sun glare would not have interfered with the pilots’ ability to detect and track the other aircraft.

The accident was not survivable.

The Teterboro Airport local controller unnecessarily delayed transferring communications for the accident airplane from Teterboro to Newark Liberty International Airport (EWR), which prevented the EWR controller from turning the airplane away from Hudson River traffic and having the airplane climb directly into class B airspace.

The Teterboro Airport local controller did not provide continual traffic advisories to the airplane pilot, as required; such advisories would have heightened the pilot’s awareness of traffic over the Hudson River.

The airplane pilot may have believed that no other potential traffic conflicts existed because he had not received additional traffic advisories, but the pilot was still responsible for seeing and avoiding other traffic.

The Teterboro Airport local controller did not correct the airplane pilot’s read back of the Newark Liberty International Airport tower frequency because of the controller’s nonpertinent telephone conversation and other transmissions that were occurring.

The airplane pilot’s incorrect frequency selection, along with the Teterboro Airport controller’s failure to correct the read back prevented the Newark Liberty International Airport controller from issuing instructions to the airplane pilot to climb and turn away from traffic.

Because the airplane pilot had requested traffic advisories, was attempting to contact the Newark Liberty International Airport air traffic control tower, and did not anticipate operating in the Hudson River class B exclusion area, the pilot was not expected or required to monitor common traffic advisory frequency position reports, including those made by the helicopter pilot.

The helicopter’s climb above 1,000 feet was not consistent with company procedures and decreased the vertical separation between the aircraft.

The helicopter would not have been obscured from the airplane pilot’s view but would likely have been difficult for him to detect until the final seconds before the collision because, before that time, the helicopter would have appeared as a relatively small and stationary object against a complex background of buildings.

The airplane pilot appeared to have started an evasive maneuver immediately before the collision to avoid the helicopter.

The airplane would likely have been in the helicopter pilot’s field of view until 32 seconds before the collision, after which time the airplane was above and behind the helicopter and was outside the pilot’s field of view.

Neither pilot effectively used the information available on his aircraft’s electronic traffic advisory system to assist in maintaining awareness of nearby aircraft.

The local controller’s nonpertinent telephone conversations distracted him from his air traffic control duties.

The local controller’s nonpertinent telephone conversation during the time of the accident flight might not have occurred if the front line manager had corrected the controller’s performance deficiency involving an earlier nonpertinent telephone conversation.

The Teterboro Airport front line manager, who was not present in the air traffic control tower at the time of the accident, exercised poor judgment by not letting staff know how he could be reached while he was away from the tower and by not using an available staffing asset to provide an additional layer of oversight at the tower during his absence.

The local controller’s and the front line manager’s noncompliance with existing procedures and best practices demonstrated a lack of professionalism, which increased the opportunity for errors.

The air traffic control transfer-of-communications procedures applied to the accident airplane might have inadvertently caused the pilot not to follow the traffic awareness procedures established for flights through the area, thereby increasing the chance for a collision.

Pilots operating air tour helicopters to and from the Downtown Manhattan Heliport may not be fully aware of other aircraft operating over the Hudson River because the common traffic advisory frequency used for such flights is for the adjacent East River area.

Current Federal Aviation Administration regulations do not provide adequate vertical separation for aircraft operating in the Hudson River special flight rules area because the regulations do not include specific operating altitudes for local aircraft.

The guidance in Advisory Circular (AC) 90-48C, “Pilots’ Role in Collision Avoidance,” could better assist pilots’ efforts to establish effective see-and-avoid skills if the AC were to recognize current challenges that pilots encounter in managing their see-and-avoid responsibilities, including complex, high-density airspace and the increasing presence of technology in the cockpit.

Because the Federal Aviation Administration’s current technical standard orders for electronic traffic advisory systems do not distinguish between the different flight characteristics of helicopters and fixed-wing airplanes, the effectiveness of these systems aboard helicopters is limited.

The traffic alerting function of helicopter electronic traffic advisory systems is limited because the parameters used to trigger alerts do not consider frequent maneuvering in congested areas, resulting in nuisance alerts.

Electronic traffic advisory systems installed on helicopters operated for passenger revenue flight would enhance a pilot’s capability to detect other aircraft operating in the same area by providing aural annunciations and visual displays of the traffic.

PROBABLE CAUSE

The National Transportation Safety Board determines that the probable cause of this accident was (1) the inherent limitations of the see-and-avoid concept, which made it difficult for the airplane pilot to see the helicopter until the final seconds before the collision, and (2) the Teterboro Airport local controller’s nonpertinent telephone conversation, which distracted him from his air traffic control duties, including correcting the airplane pilot’s read back of the Newark Liberty International Airport (EWR) tower frequency and the timely transfer of communications for the accident airplane to the EWR tower. Contributing to this accident were (1) both pilots’ ineffective use of available information from their aircraft’s electronic traffic advisory system to maintain awareness of nearby aircraft, (2) inadequate Federal Aviation Administration (FAA) procedures for transfer of communication among air traffic control facilities near the Hudson River class B exclusion area; and (3) FAA regulations that did not provide adequate vertical separation for aircraft operating in the Hudson River class B exclusion area.

RECOMMENDATIONS

New Recommendations

The National Transportation Safety Board recommends the following to the Federal Aviation Administration:

Redefine the boundaries of the East River common traffic advisory frequency (CTAF) so that the Downtown Manhattan Heliport will be located in the area that uses the Hudson River CTAF.

Revise 14 Code of Federal Regulations 93.352 to specify altitudes of use for aircraft conducting local operations in the Hudson River special flight rules area so that the regulation includes required operating altitudes for both local and transiting aircraft, and incorporate the altitude information for local operations onto published visual flight rules aeronautical charts for the area.

Update Advisory Circular 90-48C to reflect current-day operations, including (1) a description of the current National Airspace System and airspace classifications, (2) references to air tour operational areas as high-volume traffic environments, and (3) guidance on the use of electronic traffic advisory systems for pilots operating under the see-and-avoid concept.

Develop standards for helicopter cockpit electronic traffic advisory systems that (1) address, among other flight characteristics, the capability of helicopters to hover and to fly near other aircraft at lower altitudes, slower airspeeds, and different attitudes than fixed-wing airplanes; (2) reduce nuisance alerts when nearby aircraft enter the systems’ alerting envelope; and (3) consider the different types of operations conducted by helicopters, including those in congested airspace. (Supersedes Safety Recommendation A-09-04 and is classified “Open—Unacceptable Response”)

Once standards for helicopter electronic traffic advisory systems are developed, as requested in Safety Recommendation [4], require electronic news gathering operators, air tour operators, and other operators of helicopters used for passenger revenue flight to install this equipment on their aircraft. (Supersedes Safety Recommendation A‑09‑05)

Previously Issued Recommendations Resulting From This Accident Investigation

The National Transportation Safety Board issued the following recommendations to the Federal Aviation Administration on August 27, 2009:

Revise standard operating procedures for all air traffic control (ATC) facilities, including those at Teterboro airport, LaGuardia airport, and Newark Liberty International airport, adjoining the Hudson River class B exclusion area in the following ways:

establish procedures for coordination among ATC facilities so that aircraft operating under visual flight rules and requesting a route that would require entry into class B airspace receive ATC clearance to enter the airspace as soon as traffic permits,

require controllers to instruct pilots with whom they are communicating and whose flight will operate in the Hudson River class B exclusion area to switch from ATC communications to the common traffic advisory frequency (CTAF) and to self-announce before entering the area,

add an advisory to the Automatic Terminal Information Service broadcast, reminding pilots of the need to use the CTAF while operating in the Hudson River class B exclusion area and to self-announce before entering the area, and

in any situation where, despite the above procedures, controllers are in contact with an aircraft operating within or approaching the Hudson River class B exclusion area, ensure that the pilot is provided with traffic advisories and safety alerts at least until exiting the area. (A-09-82)

Brief all air traffic controllers and supervisors on the air traffic control (ATC) performance deficiencies evident in the circumstances of this accident and emphasize the requirement to be attentive and conscientious when performing ATC duties. (A-09-83)

Amend 14 Code of Federal Regulations Part 93 to establish [a] special flight rules area (SFRA) including the Hudson River class B exclusion area, the East River class B exclusion area, and the area surrounding Ellis Island and the Statue of Liberty; define operational procedures for use within the SFRA; and require that pilots complete specific training on the SFRA requirements before flight within the area. (A-09-84)

As part of the special flight rules area procedures requested in Safety Recommendation A-09-84, require vertical separation between helicopters and airplanes by requiring that helicopters operate at a lower altitude than airplanes do, thus minimizing the effect of performance differences between helicopters and airplanes on the ability of pilots to see and avoid other traffic. (A-09-85)

Conduct a review of all class B airspace to identify any other airspace configurations where specific pilot training and familiarization would improve safety, and, as appropriate, develop special flight rules areas and associated training for pilots operating within those areas. (A-09-86)

Previously Issued Recommendations Reclassified in This Report

Safety Recommendation A-09-04, which was issued to the Federal Aviation Administration (FAA) on February 9, 2009, is reclassified “Closed—Unacceptable Action/Superseded” in section 3.4 of this report. The recommendation is superseded by Safety Recommendation [4].

Develop standards for helicopter cockpit electronic traffic advisory systems so that pilots can be alerted to the presence of other aircraft operating in the same area regardless of their position. (A-09-04)

Safety Recommendation A-09-05, which was issued to the FAA on February 9, 2009, is reclassified “Closed—Acceptable Action/Superseded” in section 3.4 of this report. The recommendation is superseded by Safety Recommendation [5].

Once standards for helicopter cockpit electronic traffic advisory systems are developed, as requested in Safety Recommendation A-09-04, require electronic news gathering operators to install this equipment on their aircraft. (A-09-05)

August 8, 2009

NTSB/AAR-10/0

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  • Frank Convertini

    Very nice presentation Mike.
    To this day, the closest call in an airplane I have ever encountered was in the Hudson River Corridor in 1992. I was flying northbound and was instructed to cross the Hudson at 40th Street to position for a northbound landing on Runway 1 at TEB. The next thing I knew (after announcing my intentions and vigilantly scanning for traffic, was the tail of a Bonanza whipping by my right window. I don't think we had 25 feet of separation. I almost bought the farm that day for sure.

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Amanda Michelle (Younkin) Franklin 3/14/1986 – 5/27/2011 Click for information on Amanda