State: Confusion in tower and cockpit led to crash

Confusion among pilots and air traffic controllers contributed to the collision of two small airplanes at Sarasota-Bradenton International Airport in March, killing all four people aboard, according to the National Transportation Safety Board.

Several controllers, including one supervisor, were confused about where aircraft were on the field.

One pilot, who was not involved in the accident but contributed to the confusion that preceded it, completely misidentified the single-engine Cessna Cutlass he was flying as a Piper twin-engine Seneca.

And the system the tower used to track planes on the ground left critical gaps in the controllers' information. That system has since been revised.

Although the NTSB report did not assign blame for the accident, it occurred, the report said, because the pilot of a Cessna 172 was instructed to taxi onto the runway, which put him in front of a Cessna 152 that had been cleared and was on its takeoff roll.

The 152 got airborne and turned sharply to avoid the 172. Witnesses said the 152 stalled and dove into the 172, killing Lori Bahrenburg, a flight instructor aboard the 152, and her student pilot, Charles Heffner. It also killed both occupants of the 172, Julius Taubman and David Mouckley.

Heffner, Taubman and Mouckley died of burns and carbon monoxide poisoning, and Bahrenburg died from burns and chest injuries.

As events unfolded, the NTSB report says, two sets of controllers were juggling at least seven aircraft. Ground controllers supervise taxi clearances and local controllers handle takeoffs.

On the morning of March 9, takeoffs were starting at two points along the northwest-southeast Runway 14. Three aircraft, including the 152, waited in line for takeoff at the beginning of the runway. Three other aircraft, including the 172, were lined up for takeoff farther down, where taxiway Foxtrot intersects the runway.

About 10:31 a.m., the pilot of the 152 reported, "ready for takeoff." That plane's tail number was N89827. At taxiway Foxtrot, the Cutlass waited at the front of the line. Its tail number was N5287V.

Typically, after initial contact with controllers, pilots use only the last three digits of their N-numbers as identification. The similarity between "827" and "287" might have added to controller confusion, the NTSB said.

Just after 10:31, a local controller asked, "Who's at the approach end of runway (14) ready to depart?" The pilot of the 152 replied, "8-2-7."

"I show you at Foxtrot," the controller replied.

The pilot of the Cessna Cutlass responded, "No, Sir, that's eight-seven-victor at Foxtrot."

"I show you as a Seneca," the controller said. "You're not a Seneca, are you?"

"No," the pilot said. "I'm used to flying a Seneca."

Just before 10:33, the pilot of the 172 announced that he was ready for takeoff and was No. 2 in line. He was at Foxtrot. But the strip of paper created by the ground controller who supervised the 172's taxi was incomplete. It said only "14" on it, suggesting to the local controller that the 172 was up at the beginning of Runway 14. The paper strip should have said "14/F," specifically to indicate Foxtrot.

Another problem with the system at the time was that ground controllers didn't always pass off the paper strips in the same order that planes lined up. So the local controller not only had misinformation about the 172's takeoff point, he didn't know where it was in line, either.

At 10:34, the local controller told the 152 to taxi onto the runway and stop to wait for traffic taking off down field. Seconds later, he gave the Cutlass permission to take off.

He then cleared the 152 to take off, and believing the 172 was behind the 152, instructed the 172 to enter the runway and hold, a maneuver which put it squarely in the 152's path.

Two controllers were placed on leave after the crash, and the airport's highest-ranking controller was reassigned.

Although there was confusion in the tower, FAA regulations require pilots to make sure controllers know their positions and, when weather conditions permit, pilots are ultimately responsible to see and avoid other aircraft.

The weather on March 9 was clear.

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Lucy Morgan

From the Times state desk