WPR16FA172

The pilot's selection of a landing runway which, given the wind and traffic conditions, was susceptible to high crosswinds and the translation of wake turbulence across its approach path, and the controller's and pilot's failure to ensure separation from the B757 and its wake, which resulted in a low-altitude encounter with wake vortices that the pilot was unable to recover from.

The 73-year-old commercial pilot was on the fourth and final leg of a 950-mile round trip same day flight. As the airplane neared the airport, the pilot was told by the air traffic controller to expect runway 25 for landing. After the controller informed him of a delay for that runway, the pilot stated that he could accept runway 16L; the pilot was told to proceed for runway landing, but the runway was not specified, an instruction which he acknowledged. Shortly after establishing contact with the tower controller, who instructed the pilot to continue for runway 25, the pilot reported that the airplane was on a downwind leg for landing on runway 16L. The controller acknowledged and, rather than correcting the pilot, instructed him to continue inbound for 16L. At the time, runway 16R was being used for landing by two Boeing 757 (B757) airplanes in sequence, separated from each other by about 7 miles. The controller advised the accident pilot that a B757 was on a 9-mile final for runway 16R and cautioned him about wake turbulence, then cleared the accident airplane to land. Shortly thereafter, the pilot reported that he had "the airliner" in sight. At this time, one of the B757s was on a short final approach for 16R, about 4.5 miles ahead of and below the accident airplane. The other B757, which was the potential conflict, was about 5 miles away from the accident airplane at its 2-to-3-o'clock position. Given that the pilot's attention was likely focused toward the runway during this portion of the approach, it is likely that he misidentified the ATC-reported traffic as the B757 on short final, which landed soon after and likely resulted in the pilot relaxing his vigilance in looking for traffic. Shortly thereafter, the controller issued an all-aircraft advisory that the wind was from 250° at 17 knots with gusts to 20 knots. Although these wind conditions met or exceeded the airplane's maximum demonstrated crosswind capability for a landing on 16L, and the airplane was still well-positioned to revert to an approach to runway 25, the pilot continued toward 16L. About 70 seconds after the pilot reported sighting the traffic, just after turning the airplane onto the base leg of the traffic pattern, the B757 passed about 1 mile ahead of and about 100 ft below the accident airplane. The investigation was unable to determine whether the pilot saw that B757, or if he did, whether he was cognizant of the potential for a wake vortex encounter and the flight path alterations necessary to avoid such an encounter. The pilot made no radio communications or flight path adjustments to indicate that he saw the B757 or tried to avoid its wake. According to witnesses, the airplane's flightpath appeared normal as it approached the runway for landing. When the airplane was on about a 1/2-mile final approach, at an altitude of less than 200 ft above ground level, it suddenly rolled and descended to the ground. Ground scars and debris distribution was consistent with a near-vertical descent and impact. Examination of the wreckage did not reveal any evidence of pre-impact mechanical deficiencies or malfunctions that would have precluded normal operation. A wake vortex analysis study revealed that the airplane most likely encountered the wake vortices that were generated by a B757 landing on the parallel, upwind runway. The vortices were of sufficient size and strength to radically upset the airplane at an altitude too low to recover. Had the controller informed the pilot that there were two B757s on final approach for 16R, it is likely that the pilot's traffic situational awareness would have been more complete. The pilot likely would have altered his traffic scan or questioned ATC further to ensure that he had identified the correct B757. The pilot's radio communications did not indicate any doubt about whether he had properly identified his traffic, and in postaccident interviews, the controller stated that he was certain that the pilot had correctly identified it. Had either the controller or the pilot specified the location of the traffic once the pilot reported it in sight, that information would have significantly improved the likelihood of detecting the pilot's identification error. The safety of the approach sequence was dependent on assured separation of the airplane from the B757 and its wake. In this case, because both airplanes were being controlled by ATC in a radar environment, aircraft and wake turbulence (vortex) separation was the responsibility of the controller until explicitly transferred to the accident pilot. Although ATC requirements to apply pilot-based visual separation had been satisfied and it was the controller's intent to have the accident pilot maintain visual separation from the B757, the controller relinquished his separation responsibility without explicitly transferring that responsibility to the accident pilot. As a result, no separation services were being provided by the controller. The accident pilot's likely misidentification of his traffic, the controller's lack of awareness of that apparent error, and the controller's failure to monitor, detect, or intervene in a situation conducive to a wake vortex encounter enabled the accident to occur. At the time of the accident, the pilot had been awake about 14.5 hours and had flown about 8.5 hours that day. Given the pilot's experience level, it is unlikely that he was not aware of the effect of either the extreme landing crosswinds or wake vortex behaviors and hazards, but for reasons that could not be not determined during the investigation, the pilot nevertheless continued his approach to land on 16L. Investigators were also unable to determine the effect of the pilot's long duty day on his mental acuity or explain the reasons behind several of his actions and decisions, including his vague communications with ATC regarding the landing runway, his decision to forego landing on a runway more favorable to the wind conditions, and his misidentification of the conflicting traffic.

Flying Start Aero According to its website, "Flying Start Aero is a full-service flight school and aviation resource center" that specialized "in flight training from student pilot to Airline Transport Pilot." Flying Start Aero also offered "scenic-photo flight over Lake Tahoe and the surrounding points of interest." The web site stated that the Bonanza (the accident airplane) was "perfectly suited for commercial pilot training and/or fast and comfortable trips to faraway places for our renters." As of the date of the accident, Flying Start Aero did not hold an FAA Part 135 operating certificate, which would enable them to offer chartered transportation of passengers for hire. Airplane Sign-out/Dispatch Records A common practice of flight schools or fixed base operators (FBOs) is to utilize systems of electronic or paper sign out/dispatch records to track the times that students or renters accrue on the aircraft. The information is then principally utilized for both billing and maintenance scheduling purposes. In response to an NTSB request for the accident airplane's dispatch records, the Flying Start Aero attorney stated that the "rental book records containing…copies of the dispatch [paperwork] of N985CA were in the aircraft at the time of the accident and destroyed in the fire." This attorney-cited practice of keeping the rental records onboard the airplane was not consistent with typical FBO business practices. In addition, the attorney's response was dated September 21, 2016; as of that date, the wreckage had not been released by the investigation, and therefore neither Flying Start Aero nor its attorney had any access to, or any knowledge of, the recovered airplane components or contents. FAA Regulations re Non-Instructional Flights FAA regulations set the requirements and limitations for pilots and operators to be reimbursed for carrying passengers. Because Flying Start Aero did not hold a Part 135 operating certificate, any carriage of persons for compensation, for purposes other than flight instruction, must comply with either paragraph 91.146 and 91.147, which delineate the applicable requirements and limitations for such flights. Paragraph 91.146 permits limited operations for carriage of passengers for "charitable, non-profit, and community events." The guidance defines those events, and imposes strict limits in terms of calendar frequency, departure and landing airports, flight distance, and overflight areas. Specifically, the flight must be nonstop, begin and end at the same airport, and must be conducted within a 25-statute mile radius of that airport. There was no evidence that the accident flight was in support of any charitable, non-profit, or community event. In addition, the accident flight did not comply with the 91.146 airport or distance limitations. Paragraph 91.147 permits the carriage of persons for profit, but the flights are subjected to strict limitations, and the Operator must be granted a Letter of Authorization (LOA) by the FAA Flight Standards District Office (FSDO) "nearest [the operator's] principal place of business." That LOA would be very specific regarding the applicable conditions for those flights. In the case of Flying Start Aero, the nearest FSDO was Reno. Flying Start Aero had never applied for, and was never granted, any such LOA by the Reno FSDO. An FAR Part 135 operating certificate would have permitted Flying Start Aero to carry passengers for hire. For fatigue avoidance and flight safety reasons, FAR Part 135 specifies flight- and duty-time limits for pilots. FAR 135.265 imposed limits on planned flights to 1,200 hours in any calendar year, 120 hours in any calendar month, 34 hours in any 7 consecutive day, and 8 hours during any 24 consecutive hours for a flight crew consisting of one pilot. Flight Arrangements Although some initial information indicated that the flight was an instructional flight, and because Flying Start Aero did not hold a Part 135 certificate, the investigation attempted to determine the exact nature of the flight. The investigation found that, although the passenger who was the owner of the local company had taken one or two flight lessons the year before the accident, he did not posses an FAA student pilot certificate. Furthermore, the passenger who deplaned in HND stated that there did not appear to be any flight instruction occurring during the time that he was on board the airplane, and that the pilot conducted all activities associated with the operation of the airplane, including radio communications. In response to an NTSB inquiry, the Flying Start Aero attorney stated that he believed that company owner passenger "intended to become an active student" pilot, and that the flight was to be fully paid for by the passenger and/or his company. The attorney noted that subsequent to the accident, there was "never any billing" for the flight. The accident airplane owner's representative stated that the owner was normally not kept apprised of the airplane flight types or related payment specifics. Several subsequent inquiries to representatives of the passengers and the company the passengers worked for regarding the nature of the flight, and particularly how it was to be paid for, were not answered. General and RNO ATCT Staffing Approaching RNO, the flight first communicated with Northern California Terminal Radar Approach Control (NCT), and then with the RNO ATCT local controller A segment of the ATC recording was provided to a flight instructor at Flying Start Aero who knew the accident pilot well; he was asked whether he could identify the person on the radio in the accident airplane. It was his determination that the person on the radio was his colleague, the accident pilot. According to the RNO ATCT personnel and position logs, at the time of the accident, there were 2 controllers on duty in the RNO ATCT. One controller was assigned to the local control position 1 (LC1) and the other was assigned to operational supervisor 1 (OS1) and ground control (GC) positions. Multiple position assignments for 1 individual during a work shift is normal operational practice. The LC1 controller was the individual who communicated with the accident airplane from the time the pilot contacted the RNO ATCT until the accident. According to an NTSB interview the LC1 controller began working for the FAA in July 2010, and transferred to the RNO ATCT in May 2015. He was qualified on all operating positions within the ATCT and was designated a controller in charge (CIC). The LC1 controller started his work shift at 1030, and ended it at 2300, for a total "on duty" time of 12 hours, 30 minutes. The Position Logs indicated that his "Position Duties" time was 5 hours, 16 minutes, and his "Non-Position Duties" time was 4 hours, 27 minutes. After returning from his second break period, the controller was assigned to the LC1 position, and about 21 minutes later, the accident pilot made his initial contact with RNO ATCT, with the LC1 controller. ATC Communications and Ground Track About 1744, when the accident airplane was about 35 miles south-southeast of RNO, the pilot checked on with NorCal approach control (NCT) and advised the LC1 controller that he had RNO ATIS information Juliet. The LC1 controller asked for the pilot's runway preference, and the pilot stated that he wanted runway 25. About 1751, the NCT controller issued a heading vector of 350°, and restricted the minimum altitude to 8,500 ft. The NCT controller advised the pilot to expect runway 25. At that time, the airplane's flight track was approximately perpendicular to, and about 7 miles east of, runway 25; this position and heading were consistent with a wide left base leg for runway 25. About 1754, the NCT controller advised the pilot that there would be a "slight delay for runway 25," that he was "number four now for the airport," and advised that "traffic on a fifte