ERA15FA025

The failure of the helicopter pilots and the airplane pilot to maintain an adequate visual lookout for known traffic in the traffic pattern, which resulted in a midair collision. Contributing to the accident were the airplane pilot's descent below the published airplane traffic pattern altitude (TPA) and the helicopter pilot's climb above the proper helicopter TPA as prescribed in the Federal Aviation Administration's Aeronautical Information Manual for airports without published helicopter TPAs. Also contributing to the accident were the lack of a published helicopter TPA, the absence of radar equipment in the tower, and the controller's inadequate task prioritization.

The private airplane pilot was conducting a personal cross-country flight, and the commercial helicopter pilot and flight instructor were conducting a local instructional flight. A review of radar and voice communications revealed that the accident airplane pilot first contacted the nonradar-equipped tower when the airplane was 10 miles from the airport and that the local controller (LC) then acknowledged the pilot's transmission and instructed him to contact the tower when he was 3 miles from the airport. At this time, the LC was also handling two helicopters in the traffic pattern, one airplane conducting practice instrument approaches to a runway that intersected the runway assigned to the accident airplane, another airplane inbound from the southeast, and a business jet with its instrument flight rules (IFR) clearance on request. About 1 minute after the accident airplane pilot first contacted the LC, the LC began handling the accident helicopter and cleared it for takeoff. One minute later, the controller issued the business jet pilot an IFR clearance. When the accident airplane was 3 miles from the airport, the pilot reported the airplane's position to the controller, but the controller missed the call because she was preoccupied with the clearance read-back from the business jet pilot. About 1 minute later, the controller instructed the accident airplane pilot to enter the left downwind leg of the traffic pattern on a 45-degree angle and issued a landing clearance. She advised that there were three helicopters "below" the airplane in the traffic pattern, and the pilot replied that he had two of the helicopters in sight. Data downloaded from the airplane and witnesses on the ground and in the air indicated that, as the airplane entered the downwind leg of the traffic pattern, it flew through the accident helicopter's rotor system at the approximate point where the helicopter would have turned left from the crosswind to the downwind leg. Because of a specific advisory transmitted on the tower radio frequency advising of traffic on the downwind, the pilot of each accident aircraft was or should have been aware of the other. A witness in the helicopter directly behind the accident helicopter had a similar field of view as the accident helicopter, and he reported that he acquired both accident aircraft in his scan before the collision. Given this statement and that the accident helicopter had two commercial pilots in the cockpit, the pilots should have had the situational awareness to understand the conflict potential based on the airplane's position reports. Although the airplane was equipped with a traffic advisory system, its capabilities could have been limited by antenna/airframe obstruction or an inhibition of the audio alert by the airplane's flap position. The airplane's data indicated that the collision occurred at an altitude of about 1,100 ft mean sea level (msl). The published traffic pattern altitude (TPA) for light airplanes was 1,300 ft msl. Although several different helicopter TPAs were depicted in locally produced pamphlets and posters and reportedly discussed at various airport meetings, there was no published TPA for helicopters in the airport/facility directory or in the tower's standard operating procedures. According to the Federal Aviation Administration's Aeronautical Information Manual, in the absence of a published TPA, the TPA for helicopters was 500 ft above ground level; therefore, the appropriate TPA for helicopters at the accident airport was about 800 ft msl. The lack of an official helicopter TPA, which was published after the accident, significantly reduced the potential for positive traffic conflict resolution. Review of the airport procedures, tower capabilities, and the controller's actions revealed no specific departure from proper procedures. Because the tower was not equipped with radar equipment, all of the sequencing and obtaining of traffic information had to be done visually. This would have been especially difficult at the accident airport due to the local terrain and tree lines that extend above the pattern altitudes from the tower controllers' view, which can cause aircraft to easily blend in with the background. Further, the controller spent a lengthy amount of time on the task of issuing the IFR clearance to the business jet while handling multiple aircraft in the traffic pattern. It is likely that the lack of radar equipment in the tower and the controller's inadequate task management also significantly reduced the potential for positive traffic conflict resolution.

Aircraft 2 HISTORY OF FLIGHT **This report was modified on 6/2/2016. Please refer to the public docket for this accident to view the original report.** On October 23, 2014, about 1537 eastern daylight time, a Cirrus SR22 airplane, N122ES, operated by a private individual, and a Robinson R44 II helicopter, N7518Q, operated by Advanced Helicopter Concepts, collided in midair approximately 1 mile southwest of the Frederick Municipal Airport (FDK), Frederick, Maryland. The airplane departed controlled flight after the collision, the ballistic parachute system was deployed, and the airplane landed nose-down in a thicket of low trees and brush. The helicopter also departed controlled flight, descended vertically, and was destroyed by impact forces at ground contact. The private pilot on board the airplane was not injured, and his passenger sustained a minor injury. The flight instructor, commercial pilot, and a passenger in the helicopter were fatally injured. Visual meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan was filed for the airplane, which departed Cleveland, Tennessee, on a personal flight about 1247. No flight plan was filed for the helicopter, which departed FDK on an instructional flight about 1535. The flights were conducted under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91. Witnesses on the ground watched the aircraft approach each other at the same altitude and saw the collision. One witness said the helicopter appeared to be in a stationary hover as the airplane closed on it and the two collided. She said neither aircraft changed altitude as they approached each other. A flight instructor for the helicopter operator in a company Robinson R22 helicopter followed the accident helicopter in the traffic pattern for landing abeam runway 30 in the infield sod at FDK. He said his helicopter had just completed the turn onto the crosswind leg of the traffic pattern when the accident helicopter came into his view to his front at about the point where it would turn to the downwind leg of the pattern. At the same time, the airplane appeared in his field of view as it "flew through the rotor system" of the helicopter. Radar and voice communication information from the Federal Aviation Administration (FAA), as well as interviews conducted with air traffic controllers, revealed the following: At 1534:10, the accident airplane first contacted the FDK tower and was about 10 miles west of the field at 3,000 feet. The local controller (LC) acknowledged the pilot's transmission and instructed him to report 3 miles west for a left downwind to runway 30. At 1534:31, the pilot of the accident airplane acknowledged and read back the controller's instructions. At the time the accident airplane contacted the LC, other traffic being handled by the tower included two helicopters ( two company helicopters N2342U and N444PH) in the VFR traffic pattern, one airplane conducting practice instrument approaches to runway 23, another airplane inbound from the southeast, and a business jet (N612JD) with its IFR clearance on request. At 1535:02, the LC then cleared the accident helicopter for take-off from alpha taxiway as requested and issued the current winds, and the call was acknowledged. At 1536:02, the LC contacted the pilot of N612JD and advised she was ready to issue the airplane's instrument clearance. From 1536:06 to 1536:49 (43 seconds), the controller issued the clearance. At 1536:49, the pilot of N612JD read back his clearance as required. Also at 1536:49, during the read back from N612JD, the pilot of the accident airplane reported on local frequency that he was 3 miles out on a 45-degree entry for runway 30, which the LC did not hear because she was listening to the read back from N612JD on ground control frequency. At 1537:09, the LC transmitted to helicopter N444PH, "…four papa hotel option to the grass at your own risk use caution and on uh next go around stay at a thousand feet. I have traffic in the downwind." At 1537:22, the LC instructed the accident airplane to report midfield left downwind for runway 30 and said "I have three helicopters below ya in the uh traffic pattern". At 1537:30, the pilot of the accident airplane acknowledged the request to report midfield downwind and stated he had two of the helicopters in sight. Immediately after that transmission, at 1537:34, the LC said "Alright uh two echo sierra, I have ya in sight runway three zero, maintain your altitude to…until turning base, cleared to land." At 1537:41, cries were heard over the local frequency, and, at 1537:49, the pilot of a helicopter in the traffic pattern reported that an airplane and helicopter were both "down." The pilot of the accident airplane was interviewed and provided written statements. His recollection of the flight was consistent with voice, radar, and aircraft data. The pilot stated that as he descended and slowed for the traffic pattern entry, he set the flaps to 50 percent. The pilot stated that, about the time the airplane entered the downwind leg of the traffic pattern, the tower controller issued a landing clearance, and, "out of nowhere…I saw a helicopter below me and to the left…" The pilot initiated an evasive maneuver, but he "heard a thump," and the airplane rolled right and nosed down. The pilot deployed the ballistic recovery system, and the airplane's descent was controlled by the parachute to ground contact. PERSONNEL INFORMATION The airplane pilot held a private pilot certificate with ratings for airplane single-engine land and instrument airplane. His most recent FAA second-class medical certificate was issued April 31, 2014. He reported 959 total hours of flight experience, of which 804 hours were in the accident airplane make and model. The flight instructor on board the helicopter held commercial pilot and flight instructor certificates with ratings for rotorcraft-helicopter and instrument helicopter. His most recent FAA second-class medical certificate was issued April 31, 2014. Examination of his logbook revealed 832 total hours of flight experience, of which 116 hours were in the accident helicopter make and model. The helicopter pilot held commercial pilot and flight instructor certificates with ratings for airplane single-engine land, multiengine land, rotorcraft-helicopter and instrument helicopter. His most recent FAA second-class medical certificate was issued April 29, 2013, and he reported 2,850 total hours of flight experience on that date. Excerpts of a pilot logbook for his helicopter time revealed 1,538 total hours of helicopter experience. A review of records revealed that he stopped flying as a helicopter tour pilot in 1994. During the years following, he logged five or fewer helicopter flights per year. Between 2004 and 2011, he logged one flight per year, none in 2011, and one in 2012. In 2014, he logged two flights in September, and two in October prior to the accident flight. AIRCRAFT INFORMATION According to FAA records, the airplane was manufactured in 2006. Its most recent annual inspection was completed June 13, 2014, at 1,289.8 total aircraft hours. The helicopter was manufactured in 2004. Its most recent 100-hour inspection was completed October 2, 2014, at 1,758 total aircraft hours. METEOROLOGICAL INFORMATION The 1553 weather observation at FDK included scattered clouds at 4,800 feet, 10 miles visibility, and wind from 330 degrees at 16 knots gusting to 21 knots. The was 26 degrees above the horizon, and the sun angle was from 225 degrees. AIR TRAFFIC CONTROL The air traffic control (ATC) group was formed on October 23, 2014. The group consisted of the group chairman from operational factors and a representative from the FAA compliance services group. The group reviewed radar data provided by the FAA from Potomac TRACON (PCT), ATC voice recordings, controller training and qualifi --- Aircraft 1 HISTORY OF FLIGHT **This report was modified on 6/2/2016. Please refer to the public docket for this accident to view the original report.** On October 23, 2014, about 1537 eastern daylight time, a Cirrus SR22 airplane, N122ES, operated by a private individual, and a Robinson R44 II helicopter, N7518Q, operated by Advanced Helicopter Concepts, collided in midair approximately 1 mile southwest of the Frederick Municipal Airport (FDK), Frederick, Maryland. The airplane departed controlled flight after the collision, the ballistic parachute system was deployed, and the airplane landed nose-down in a thicket of low trees and brush. The helicopter also departed controlled flight, descended vertically, and was destroyed by impact forces at ground contact. The private pilot on board the airplane was not injured, and his passenger sustained a minor injury. The flight instructor, commercial pilot, and a passenger in the helicopter were fatally injured. Visual meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan was filed for the airplane, which departed Cleveland, Tennessee, on a personal flight about 1247. No flight plan was filed for the helicopter, which departed FDK on an instructional flight about 1535. The flights were conducted under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91. Witnesses on the ground watched the aircraft approach each other at the same altitude and saw the collision. One witness said the helicopter appeared to be in a stationary hover as the airplane closed on it and the two collided. She said neither aircraft changed altitude as they approached each other. A flight instructor for the helicopter operator in a company Robinson R22 helicopter followed the accident helicopter in the traffic pattern for landing abeam runway 30 in the infield sod at FDK. He said his helicopter had just completed the turn onto the crosswind leg of the traffic pattern when the accident helicopter came into his view to his front at about the point where it would turn to the downwind leg of the pattern. At the same time, the airplane appeared in his field of view as it "flew through the rotor system" of the helicopter. Radar and voice communication information from the Federal Aviation Administration (FAA), as well as interviews conducted with air traffic controllers, revealed the following: At 1534:10, the accident airplane first contacted the FDK tower and was about 10 miles west of the field at 3,000 feet. The local controller (LC) acknowledged the pilot's transmission and instructed him to report 3 miles west for a left downwind to runway 30. At 1534:31, the pilot of the accident airplane acknowledged and read back the controller's instructions. At the time the accident airplane contacted the LC, other traffic being handled by the tower included two helicopters (two company helicopters N2342U and N444PH) in the VFR traffic pattern, one airplane conducting practice instrument approaches to runway 23, another airplane inbound from the southeast, and a business jet (N612JD) with its IFR clearance on request. At 1535:02, the LC then cleared the accident helicopter for take-off from alpha taxiway as requested and issued the current winds, and the call was acknowledged. At 1536:02, the LC contacted the pilot of N612JD and advised she was ready to issue the airplane's instrument clearance. From 1536:06 to 1536:49 (43 seconds), the controller issued the clearance. At 1536:49, the pilot of N612JD read back his clearance as required. Also at 1536:49, during the read back from N612JD, the pilot of the accident airplane reported on local frequency that he was 3 miles out on a 45-degree entry for runway 30, which the LC did not hear because she was listening to the read back from N612JD on ground control frequency. At 1537:09, the LC transmitted to helicopter N444PH, "…four papa hotel option to the grass at your own risk use caution and on uh next go around stay at a thousand feet. I have traffic in the downwind." At 1537:22, the LC instructed the accident airplane to report midfield left downwind for runway 30 and said "I have three helicopters below ya in the uh traffic pattern". At 1537:30, the pilot of the accident airplane acknowledged the request to report midfield downwind and stated he had two of the helicopters in sight. Immediately after that transmission, at 1537:34, the LC said "Alright uh two echo sierra, I have ya in sight runway three zero, maintain your altitude to…until turning base, cleared to land." At 1537:41, cries were heard over the local frequency, and, at 1537:49, the pilot of a helicopter in the traffic pattern reported that an airplane and helicopter were both "down." The pilot of the accident airplane was interviewed and provided written statements. His recollection of the flight was consistent with voice, radar, and aircraft data. The pilot stated that as he descended and slowed for the traffic pattern entry, he set the flaps to 50 percent. The pilot stated that, about the time the airplane entered the downwind leg of the traffic pattern, the tower controller issued a landing clearance, and, "out of nowhere…I saw a helicopter below me and to the left…" The pilot initiated an evasive maneuver, but he "heard a thump," and the airplane rolled right and nosed down. The pilot deployed the ballistic recovery system, and the airplane's descent was controlled by the parachute to ground contact. PERSONNEL INFORMATION The airplane pilot held a private pilot certificate with ratings for airplane single-engine land and instrument airplane. His most recent FAA second-class medical certificate was issued April 31, 2014. He reported 959 total hours of flight experience, of which 804 hours were in the accident airplane make and model. The flight instructor on board the helicopter held commercial pilot and flight instructor certificates with ratings for rotorcraft-helicopter and instrument helicopter. His most recent FAA second-class medical certificate was issued April 31, 2014. Examination of his logbook revealed 832 total hours of flight experience, of which 116 hours were in the accident helicopter make and model. The helicopter pilot held commercial pilot and flight instructor certificates with ratings for airplane single-engine land, multiengine land, rotorcraft-helicopter and instrument helicopter. His most recent FAA second-class medical certificate was issued April 29, 2013, and he reported 2,850 total hours of flight experience on that date. Excerpts of a pilot logbook for his helicopter time revealed 1,538 total hours of helicopter experience. A review of records revealed that he stopped flying as a helicopter tour pilot in 1994. During the years following, he logged five or fewer helicopter flights per year. Between 2004 and 2011, he logged one flight per year, none in 2011, and one in 2012. In 2014, he logged two flights in September, and two in October prior to the accident flight. AIRCRAFT INFORMATION According to FAA records, the airplane was manufactured in 2006. Its most recent annual inspection was completed June 13, 2014, at 1,289.8 total aircraft hours. The helicopter was manufactured in 2004. Its most recent 100-hour inspection was completed October 2, 2014, at 1,758 total aircraft hours. METEOROLOGICAL INFORMATION The 1553 weather observation at FDK included scattered clouds at 4,800 feet, 10 miles visibility, and wind from 330 degrees at 16 knots gusting to 21 knots. The was 26 degrees above the horizon, and the sun angle was from 225 degrees. AIR TRAFFIC CONTROL The air traffic control (ATC) group was formed on October 23, 2014. The group consisted of the group chairman from operational factors and a representative from the FAA compliance services group. The group reviewed radar data provided by the FAA from Potomac TRACON (PCT), ATC voice recordings, controller training and qualific