LAX04FA037

Aircraft 2 the failure of the pilot of the R22 to comply with an ATC clearance. --- Aircraft 1 the student pilot in the R22's failure to comply with an ATC clearance.

A Robinson R22 Beta II and a Robinson R44 collided in midair while in the traffic pattern. The R22 pilot did not broadcast that he was a student pilot, and the controller did not think that the R22 pilot was a student pilot based on the quality of his radio transmissions. The R22 pilot had been practicing at a helipad north of runway 29R, and was returning to his parking area on the ramp south of runway 29L. The R44 pilot was departing from runway 29L on a touch-and-go. The R22 was above the R44, and descending to the southwest while the R44 was climbing straight ahead on runway 29L at the time of the collision. A tower controller instructed the R22 pilot to hold when he requested to go from the helipad to parking. After traffic passed, the controller advised him that he could proceed in right traffic flying a downwind traffic pattern for runway 29R to the helipad. The R22 pilot requested takeoff to land at his parking area. The controller instructed him to fly westbound. A few seconds later, the controller cleared the R44 pilot for the touch-and-go option on runway 29L, and in the same transmission cleared the R22 pilot to make a right turn to the downwind on runway 29R. About 45 seconds later, the controller informed the R22 pilot that he could expect a clearance to cross midfield when the controller got a chance. About 20 seconds later, the controller instructed the R22 pilot to turn right. About 30 seconds after that, he cleared the R22 pilot to land on runway 29R; the R22 pilot acknowledged about 5 seconds later with his call sign. The controller immediately transmitted for him to turn right, and cleared him to land on runway 29R. There was no further communication from the R22 pilot. The R22 was still in a position to turn and land on runway 29R. It began a right turn, but then instead of landing on the runway, it crossed 29R and continued descending toward 29L at a continuously reducing angle. The controller had looked away to work other traffic. As he turned to inform the R44 of the R22 landing on the parallel runway, he observed the collision. Reconstruction of the collision geometry placed the R22 above and slightly forward of the R44, and on a similar track. Based on a visibility study, once the R22 pilot turned toward his pad while he was north of runway 29R, he was not in a position to see the R44. During the takeoff, the R44 pilot was not in a position to see the R22 prior to impact.

HISTORY OF FLIGHT On November 6, 2003, at 1528 Pacific standard time, a Robinson R22 Beta II, N206TV, and a Robinson R44, N442RH, collided in midair while in the traffic pattern at Zamperini Field, Torrance, California. Pacific Coast Helicopters was operating the R22 under the provisions of 14 CFR Part 91. Robinson Helicopter Company was operating the R44 under the provisions of 14 CFR Part 91. The solo student pilot in the R22 sustained serious injuries. The certified flight instructor (CFI) and the private pilot undergoing instruction (PUI) in the R44 sustained fatal injuries. Both helicopters were destroyed; a post crash fire partially consumed the R44. The R22 departed on a local instructional flight about 1442. The R44 departed on a local instructional flight about 1449. Visual meteorological conditions prevailed, and no flight plans had been filed. The R22 came to rest between runways 29R and 29L; approximate global positioning system (GPS) coordinates of the primary wreckage were 33 degrees 48.275 minutes north latitude and 118 degrees 20.536 minutes west longitude. The R44 came to rest on the departure end of runway 29L; approximate global positioning system (GPS) coordinates of the primary wreckage were 33 degrees 48.277 minutes north latitude and 118 degrees 20.584 minutes west longitude. The instructor for the solo student had been watching him during his flight. The student flew the R22 from its parking area between taxiways D and E to a helipad north of runway 29R. The student practiced on the helipad, and then completed several touch-and-go landings to the helipad. He requested a return to his parking area. Upon hearing this request, the instructor turned the volume of his radio down, and turned away to talk to a bystander. One witness reported that the R44 was speeding up and increasing in altitude as it took off straight ahead on runway 29L. He first observed the R22 when it was over runway 29R, or slightly north of it. The R22 was starting to descend as it was transiting across the left runway to the southwest, and appeared to be heading toward its landing area. Other witnesses pointed out that the R22 was above the R44. The R44 seemed to increase its climb rate just before the collision. The two helicopters collided about 50 feet in the air over runway 29L. The R22 spun left several times before it contacted the ground. A National Transportation Safety Board specialist interviewed the controllers, and obtained recorded radar data. He prepared a factual report, and pertinent parts follow. Because of technical difficulties with the recordings of the ATC voice channels, times in this report prior to 1523:02 are based on draft transcripts provided early in the investigation. Times after that are valid times. The R22 pilot first called the LC1 controller at 1442 requesting to fly from the Pacific Coast Helicopters parking area to the North Pad. He did not indicate that he was a student pilot; the controller did not think that he was a student, because his radio technique was good. He flew to the North Pad, which is a helicopter-only practice landing point that is at midfield on the north side of runway 29R. Pilots operating at the North Pad typically fly right closed traffic patterns at 600 feet msl. They are required to keep their pattern within the lateral confines of the runway 29R displaced thresholds. They are required to contact the LC1 controller for each circuit around the pattern, or if they wish to extend their pattern beyond the 29R threshold limits. The R44 pilot contacted the LC1 controller at 1449, and requested a northeast departure from the "antennae site," which is at the intersection of the ramp area and taxiway G. The LC1 controller cleared him for takeoff from runway 29R, and the pilot departed the airport area to the northeast. The R44 pilot returned at 1505; he reported 6 miles north of the airport, and requested to operate on the North Pad. The controller advised him that the pad was in use (by the R22), and asked the pilot if he wanted to use the runway instead. The pilot accepted, and the controller instructed him to report a 2-mile right base entry. At 1507, the controller provided a traffic advisory of a departing helicopter, cleared him for the option on runway 29R, and told him to enter right closed traffic. The pilot continued routine traffic pattern operations until 1525, including landings on runway 29L. At 1523:14, the R22 pilot requested a North Pad takeoff and landing at PCH parking. PCH parking referred to the parking area used by Pacific Coast Helicopters. It is west of the tower, on the ramp between taxiways D and E. The controller instructed him to hold, and the pilot acknowledged holding. At 1524:33, the controller advised him that he could proceed in right traffic to the North Pad after a Cessna passed off his left. At 1524:56, the R22 pilot transmitted, "<unintelligible> takeoff and land PCH parking." At 1524:59, the LC1 controller responded, "Helicopter six tango victor fly westbound." Between 1525:18 and 1525:52, there was some confusion caused by the pilot of a departing helicopter (29M) who incorrectly used the call sign 2RH when requesting departure from the ramp area. The controller resolved the confusion. At 1526:01, the controller cleared the pilot of the R44 to, "make your base your discretion two niner left cleared for the option", and at 1526:15, in the same transmission, continued, "helicopter six tango victor make a right turn to the downwind." At 1526:19, the R22 pilot acknowledged, but only with his call sign. At 1526:32, the controller again cleared the R44 for the option on runway 29L, and the pilot acknowledged. At 1526:59, the controller advised the pilot of the R22, "ah you're gonna cross midfield as soon as I get a chance." At 1527:17, the controller instructed the R22 pilot to, "turn right," and the pilot acknowledged with his call sign. At 1527:49, the controller transmitted, "Helicopter six tango victor runway two niner right cleared to land." At 1527:53, the R22 pilot acknowledged with his call sign. At 1527:54, the controller transmitted, "turn right helicopter six tango victor runway two niner right cleared to land." There was no communication from the R22 pilot. At 1528:12, the LC1 controller advised the R44 pilot, "robinson two romeo hotel caution for the helo oh." A review of recorded radar data showed a target that turned off the right downwind leg, crossed runway 29R, and approached runway 29L in the immediate area of the accident. The last target for this track was at 1528:10, approximately 2 seconds before the collision. A plot of this track on a street map indicated that it was perpendicular to the runways at 1527:49, and the target was between Lomita Boulevard and Skypark Drive. At 1527:54, this target was still approaching Skypark Drive and north of runway 29R. After crossing Skypark about 5 seconds later, the target appeared to turn toward the southwest, and the last two targets were approaching runway 29L at a shallow angle. Another target turned from right downwind to base to final for runway 29L. Its last target appeared at 1527:15; its track lined up with runway 29L, and was westbound abeam the approach end of runway 29R. PERSONNEL INFORMATION R22 Pilot A review of Federal Aviation Administration (FAA) airmen records revealed that the R22 pilot held a student pilot certificate, and a first-class medical certificate issued in September 2003. An examination of the student pilot's logbook indicated that his first flight occurred on September 7, 2003. He had an estimated total flight time of 32 hours. He logged 16 hours in the last 30 days. He had solo time on two previous flights that totaled about 1.5 hours. R44 CFI A review of FAA airman records revealed that the pilot held a commercial pilot certificate with ratings for rotorcraft helicopter