File 1 4 0 1 2

AIRCRAFT ACCIDENT REPORT

0 Adopted: June 30, 1969

OZARK AIR LINES, INC.,

DC-9, N970Z AND

INTERSTATE AIRMOTIVE, INC.,

CESSNA lSOF, N8669G

ST. LOUIS, MISSOURI

MARCH 27, 1968

NATIONAL TRANSPORTATION SAFETY BOARD

DEPARTMENT OF TRANSPORTATION
WASHINGTON D.C. 20591

For 8818 by Clearinghouse for Federal Scientiee and Technical InformatJon, W.S. Department oe
Commerce, Sprins3eid. Va. 22151. Annual subscription price $12.00 Domeatle; $16.00 ~oreign;
,-,
Single COPY $3.00: Microfiche $0.65. Order Number NTSB-AA&69-2
Lc--L \
-,
h .
f

OZARK AIR. LINES. INC.,

E-9. N ~ ~ O Z A N D
INTERSTATE A1F"WIVE. INC.,
.
CESSNA 150F. N8669G
sr LOUIS. MISSOURI
MARCH 27. 1968

TABLF: OF CONTENTS

Synopsis ...................... 1
Probable Cause................... 1
1
1.1
. Investigation. . . . .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..
History of the Flight
2
2
1.2 Injuries to Persons................ 5
1.3 Ismage to Aircraft................. 5
1.4 Other Emage ..................... 5
1.5 Crew Information.................. 5
1.6 Aircraft Information. . . .. .. .. .. .. .. .. .. .. .. .. .. ..
Meteorological Information
5
1.7 5
1.8 Aids to Navigation
Communications
.................
................... 5
1.9
1.10
1.11
Aerodrome and Ground Facilities
Flight Recorders..................
.......... 3
8
1.12
1.13
Wreckage
Fire
......................
. . . . . . ... .. .. .. .. ....... .. .. .. .. .. ...... . . 9
10
1.14 Survival Aspects 10
1.15 Tests and Research ................. 10
1.16 Pertinent Information ............... 11

. . . . . . . . . .. .. .. ....... .. .. .. .. .. .. . .
2 . Analysis and Conclusions 13
2.1 Analysis 13
2.2 Conclusions .................... 17
(a) Findings . . . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. 17
(b) Probable Cause 18
3 . Recommendations .................. 19
Appendices
 F i l e No. 1-0012

NATIONAL TRANSPORTATION SAFETY BOARD

DEPARTMENT OF TRANSPORTATION
AIR- ACCIDENT REPORT

OZARK AIR LINES, INC.,

X!-9, N970Z AND
INTERSTATE AIRMOTIVE, INC.,
CESSNA 150F, Ii8669G
ST. LOUIS, MISSOURI
MARCH 27, 1968

SYNOPSIS

An Ozark A i r Lines, Inc., X!-9, N9702, and an I n t e r s t a t e Airmotive, Inc.,

Cessna 150F, N8669G, c_sllided_inffAight approximately 1 . 5 miles north of
lambert F i e l d , S t . Louis, Missouri, at approximately 1757 c . s . t . , March 27,
1968. Both a i r c r a f t were in t h e l a n d L n m t t m . n . . f o r Runway 17, under t h e
j u r i s d i c t i o n of t h e S t . Louis Tower, when t h e accident occurred. The Cessna
was demolished by t h e c o l l i s i o n and ground impact, and both occupants were
f a t a l l y injured. The DC-9 sustained l i g h t damage and was a b l e t o e f f e c t a
s a f e landing. None of t h e 44 passengers o r f i v e crewmembers was i n j u r e d .

A t t h e time of t h e c o l l i s i o n t h e weather was high, t h i n , broken clouds,

with 1 5 miles v i s i b i l i t y . Eaylight weather conditions e x i s t e d .
The Safety Board determines t h a t t h e probable cause of t h i s midair
c o l l i s i o n was t h e combination of: t h e ___.. inadequacyLf current .. VFR- .seEr-ation-
..
standards i n controlled airspace, t h e crew of t h e X!-9 not s i g h t i n g t h e
Cessna n if m
l
' et o avoid it, t h e absence of VFR t r a f f i c p a t t e r n procedures
t o enhance an o r d e r l y flow of landing a i r c r a f t , t h e l o c a l c o n t r o l l e r not
assuring t h a t important landing information issued t o t h e Cessna, was
received and understood under t h e circumstances of a heavy t r a f f i c s i t u a t i o n
without radar a s s i s t a n c e , and t h e Cessna, crew's deviation from t h e i r t r a P f i c
p a t t e r n i n s t r u c t i o n s and/or t h e i r continuation t o a c r i t i c a l point i n t h e
t r a f f i c p a t t e r n without informing t h e l o c a l c o n t r o l l e r of t h e progress of
the f l i g h t .
 - 2 -

1. INVESTIGATION

1.1 History of t h e F l i g h t

An Ozark A i r Lines, Inc., (Ozark) E - 9 , NgTOZ, and an I n t e r s t a t e

Airmotive, Inc., Cessna 150F, ~ 8 6 6 9 ~collided , i n f l i g h t approximately
1-1/2 miles north of h b e r t Field, S t . Louis, Missouri, on March 27,
1968, a t approximately 1757 11 c . s . t . Both a i r c r a f t were i n t h e landing
t r a f f i c p a t t e r n f o r Runway 17,under t h e c o n t r o l of t h e S t . Louis Tower,
when t h e accident occurred. Following t h e c o l l i s i o n , t h e E - 9 continued
i t s approach and landed s a f e l y on Runway 17. Damage t o t h e Ozark a i r c r a f t
was l i g h t and no i n j u r i e s were sustained by t h e passengers o r crew. The
Cessna f e l l t o t h e ground immediately a f t e r t h e c o l l i s i o n and both occu-
pants received f a t a l i n j u r i e s . The a i r c r a f t was demolished. The col-
l i s i o n occurred during daylight conditions, a t 38"45' North Latitude and
5 ~ 3 ~ 2 2West
' Longitude.

Ozark 965

Ozark 965, a E-9, N970Z, was a r e g u l a r l y scheduled passenger f l i g h t

which originated i n Chicago, I l l i n o i s , and terminated at S t . Louis,
Missouri, w i t h an en route s t o p a t Peoria, I l l i n o i s .

Ozark 965 departed from Peoria at approximately 1731 with 44 passen-

gers and a crew of f i v e . 2/ , The f l i g h t proceeded r o u t i n e l y t o t h e S t . Louis
a r e a i n accordance with ixs Instrument F l i g h t Rules (IFR) clearance and,
at approximately 1749, radar c o n t r o l of t h e a i r c r a f t was t r a n s f e r r e d from
Kansas City A i r Route T r a f f i c Control Center (ARTCC) t o S t . Louis Approach
Control. The f l i g h t was advised t h a t it was i n radar contact and was
cleared t o descend from 6,000 f e e t t o 2,600 f e e t on a heading of 190°,
with radar vectors t o t h e outer marker (LOM), for an ILS approach t o Run-
way 1 2 r i g h t ( R ) .

The first o f f i c e r was f l y i n g t h e a i r c r a f t from t h e c o p i l o t ' s s e a t

during t h e approach.

P r i o r t o reaching t h e LOM, Ozark 965 reported t h a t it had t h e

airport i n s i g h t . Approach Control t h e n advised, "OK, you can start a
l e f t t u r n then f o r one seven if you l i k e , you're cleared f o r a one two
r i g h t ILS approach o r a contact approach, contact t h e tower now one one

-1/ Al times herein a r e c e n t r a l standard based on t h e 24-hour clock.

-2/ A check captain occupied t h e jumpseat, b u t was not conducting any

o f f i c i a l check on t h i s f l i g h t .
 - 3-
eight point five." Ozark 965 responded, "OK, ah now runway's one seven
you say?" Approach Control confirmed that t h e a c t i v e mnway was 17 and
reported t h e winds t o be 170" a t 1 5 t o 20 knots. Ozark 965 acknowledged
t h i s transmission a t 1755:20. Approach Control then observed t h e air-
c r a f t ' s t a r g e t on t h e radarscope beginning a l e f t t u r n . This t u r n was
comenced a t a point estimated by t h e c o n t r o l l e r t o be about 1 mile north
of t h e LOM. (See Attaclment No. 1.)

A t 1756:09, t h e f l i g h t reported t o t h e S t . Louis Tower, "Ozark 965

on a r i g h t base." The tower c o n t r o l l e r v i s u a l l y observed t h e f l i g h t on
a r i g h t base l e g t o Runway 17 and also observed a l i g h t a i r c r a f t i n t h e
proximity of t h e DC-4which a l s o appeared t o be on a r i g h t base l e g t o
Runway 17. Ozark 965 was cleared t o land on Runway 17 following a Cessna
which was on a short f i n a l and at t h i s time (1756:31) was advised,
'I. .. t r a f f i c i s a Cessna looks l i k e ahead and t o your r i g h t maybe t o
your l e f t t h e r e northeast bound." 31 Although t h e statements of t h e crew-
members do not r e f e r t o t h i s t r a f f y c advisory, t h e y d i d hear it. One
member comented, "I don't see it (out t h e r e ) a t all," -and another r e p l i e d
"Naw." 41 Another t r a f f i c advisory was given t o t h e f l i g h t a t 1757:06
(approxFmately 6 seconds p r i o r t o t h e c o l l i s i o n ) , "Ozark nine six f i v e
t r a f f i c ' s t h a t Cessna off t o your r i g h t looks l i k e h e ' s eastbound."

According t o t h e cockpit crewmembers, a l l looked t o t h e r i g h t at t h i s

time and observed t h e bulk of an a i r c r a f t a b e q t h e cockpit area. The
captain r o l l e d h i s c o n t r o 1 s ~ a A e ; t and added power i n an attempt t o
avoid t h e other a i r c r a f t . A thump of impact was then heard and f e l t .
Following t h e c o l l i s i o n , t h e a i r c r a f t proved t o be c o n t r o l l a b l e and t h e
approach was continued t o a normal landing on Runway 17 a t approximately
1758.
I n t e r s t a t e Airmotive Cessna l5OF

Cessna 1 5 0 ~ ,N8669G, was scheduled f o r an i n s t r u c t o r - t r a i n i n g f l i g h t

of 1-1/2 hours duration from 1630 t o 1800. Records of t h e S t . Louis
Tower i n d i c a t e t h a t ~ 8 6 6 9 ~ o f f a t 1623. No information i s a v a i l a b l e
took
concerning t h e conduct or t h e whereabouts of t h e f l i g h t u n t i l 1754:OO
when t h e f l i g h t reported t o S t . Louis Tower, "Six nine golf S t . Charles

-3/ Al radio communications between S t . Louis Tower, Ozark Flight.

and Cessna ~ 8 6 6 9a r~e included i n Section 1.9 Communications.
965,

A t r a n s c r i p t of p e r t i n e n t conversation from t h e cockpit voice recorder

i s contained i n Appendix C.
 -4-
with golf." 51 Tower frequency congestion r e s u l t e d i n a s h o r t handling
delay, and azout 1755, Cessna ~ 8 6 6 was 9 ~ cleared t o r e p o r t r i g h t downwind
l e g f o r landing Runway 17. This transmission was not acknowledged by t h e
Cessna.61 The next communication with N8669G by t h e Tower was at 1756:43,
"Six nif;e golf if that's you out t h e r e about t o t u r n final p u l l out t o
your a h well j u s t proceed s t r a i g h t on across t h e final and e n t e r on a
l e f t base l e g f o r runway one seven. Y o u ' l l b e following an Ozark E - 9
turning f i n a l about two out, maybe t o your l e f t and above you, you have
him?" Cessna N8669G r e p l i e d , "Six nine golf roger . I ' The c o l l i s i o n oc-
curred s e v e r a l seconds l a t e r and t h e Cessna f e l l t o t h e ground about
1-1/2 miles north of t h e approach end o f Runway 17.

Evidence indicated that, a t t h e time of t h e c o l l i s i o n , t h e i n s t r u c t o r -

p i l o t was i n t h e lef% p i l o t ' s s e a t and t h e i n s t r u c t o r - t r a i n e e was occupying
the right p i l o t ' s seat.

The a i r c r a f t were not observed by eyewitnesses on t h e ground except

during approximately t h e last 1-1/2 miles of f l i g h t before t h e c o l l i s i o n .
Witnesses generally agreed that t h e E - 9 was i n a descending r i g h t t u r n
and overtaking t h e Cessna which was below and t o t h e r i g h t of t h e E - 9 .
The witnesses s t a t e d that t h e Cessna was i n l e v e l f l i g h t proceeding towards
t h e southeast when t h e c o l l i s i o n occurred.

The l o c a l c o n t r o l l e r and o t h e r c o n t r o l l e r s i n t h e tower v i s u a l l y I

observed t h e Ozark DC-9 and Cessna ~ 8 6 6 %f o r approximately 50 seconds,

during t h e last approximate 1-1/2 t o 2 miles of t h e i r f l i g h t p a t h s p r i o r
t o t h e c o l l i s i o n . T r a f f i c a d v i s o r i e s were given t o each a i r c r a f t , r e l a t i v e
t o t h e other, based on t h e v i s u a l observations of t h e l o c a l c o n t r o l l e r .
Radar i n s t a l l e d i n t h e tower cab was not u t i l i z e d i n t h e c o n t r o l of t h e
a i r c r a f t as i t s scope presentation was not s u i t a b l e f o r i n t e r p r e t a t i o n
under t h e e x i s t i n g daylight conditions.

-5/ Automatic TermindL'Information Service (ATIS) i s a v a i l a b l e i n S t . Louis,

Missouri. The information current a t t h i s time was designated "Golf"
and consisted o f t h e following: "Thin broken cirroform, v i s i b i l i t y 15,
temperature 79" wind 180" a t 20. Altimeter 3004. Runway 12 ILS approach
i n use. C i r c l e t o land Runway 17. Departure, on Runways 17 and 1 2 IF'R
frequency 119.9 IF'Fi transponder equipped squawk 1,000 j u s t before de-
parture. Inform S t . Louis approach control, tower, o r ground c o n t r o l
you have received information Golf."

-61 W i n g t h i s time period, S t . Louis Tower was attempting t o c o n t r o l a

considerable number o f f l i g h t s i n t h e S t . Louis c o n t r o l zone. Multiple
i n s t m c t i o n s were being issued i n t h e same transmission t o d i f f e r e n t
f l i g h t s . I n s t r u c t i o n s or a d v i s o r i e s were not acknowledged v e r b a l l y i n
a number of instances.
 i
i

1 1.2 Injuries t o Persons

Injuries
Fatal
Nonfatal
-
Crew
2
0
(N8669G)
- 5 -

Wssengers
0
0
Others
0
0
None 5 44
1.3 Damage t o A i r c r a f t
Ozark 965 sustained damage confined t o t h e lower s i d e of t h e r i g h t
wing and r i g h t landing f l a p .

N8699G was demolished.

1.4 Other Dmage

The CeSSna wreckage f e l l i n an open parking l o t , i n f l i c t i n g n e g l i g i b l e

damage t o ground property.

1.5 Crew Information

The crews of both a i r c r a f t were properly

- -
t o conduct t h e i r respective f l i g h t s . (For d e t a i l e d information see
-
c e r t i f i c a t e d and a u a l i f i e d
~~

Appendix A. )

Both a i r c r a f t were properly c e r t i f i c a t e d and maintained i n accordance

with e x i s t i n g requirements. (See Appendix B.)

1.7 Meteorological Information

The surface weather observation taken a t t h e time of t h e accident
by t h e Weather Bureau a t S t . Louis was: 1801, Special, high t h i n broken
clouds, v i s i b i l i t y 1 5 miles, temperature 69"F., dew point 45"F., wind
170" at 18 knots, gusts 24 knots, a l t i m e t e r s e t t i n g 30.06 inches.
Information obtained from t h e U. S. Naval Observatory i n d i c a t e d a
sun angle azimuth 271' from t r u e north, 3" above t h e horizon. O f f i c i a l
sunset was 1819.

1.8 Aids t o Navigation

Not involved.

1.9 Communications
There were no reported d i f f i c u l t i e s with air/ground communications
between t h e S t . Louis Tower and any of t h e f l i g h t s operating i n t h e S t . Louis
area during t h e s i g n i f i c a n t time period of t h i s accident.
 - 6 -
with
dela: The tape recording of radio communications between t h e l o c a l c o n t r o l l e r 1
leg 1 and t h e crews of those a i r c r a f t on t h e ground and i n t h e air shows t h a t t h e r e
Cessr were numerous voice transmissions made on t h e Tower frequency during t h e 3-
“Six minute.time period preceding t h e c o l l i s i o n . This recording f u r t h e r r e v e a l s
your t h a t , within t h i s time period, t h e l o c a l c o n t r o l l e r was involved i n communi-
le0 cations with approximately seven a i r c r a f t on t h e a i r p o r t and e i g h t a i r c r a f t
turni t h a t were inbound f o r landing. Voice transmissions on t h e Tower frequency i 1
him? ’ presented a p a t t e r n of near-continuous speech. I n s t r u c t i o n s t o as many as
curre four f l i g h t s were given by t h e c o n t r o l l e r i n a s i n g l e transmission and
1-11; verbal acknowledgment f o r t h e i n s t r u c t i o n s was not received i n a number of
instances. The communications t a p e shows t h a t departure and a r r i v a l . b p e r a -
t i o n s were being conducted t o Runway 17, w i t h both l e f t and r i g h t t r a f f i c
pilot p a t t e r n s being u t i l i z e d . Runway 12R was a l s o being u t i l i z e d f o r departures
the r and a r r i v a l s f o r those who e l e c t e d t o use it.

Pertinent Transmissions and Times

durin
Witne mm:
and o
The w
t h e st
STL A/C
OZ 965 -
- St.
Louis Tower Approach Control
Ozark A i r Lines F l i g h t 965, E - 9
STL L/C - St.
Louis Tower Local Control
I -
~ 6 9n8669~,
~ Cessna 150
obser
durinl (1749:OO approximate start of t a p e recording)
t o thf
t o thf St. Louis Approach Control
Radar
aircrz 1749: 37 oz 965 Ozark nine s i x t y f i v e l e v e l at s i x with g o l f .
under
1749: 41 STL A/C Ozark nine s i x t y f i v e S t . Louis approach c o n t r o l
-7 7 G i n radar contact descend t o two thousand s i x hundred
m heading of about one nine zero, be vectors runway
aI one two r i g h t .
t€
ir 1749: 52 oz 965 Out of s i x f o r twenty s i x and ah one nine zero.
fi
Pa 1749: 59 STL ALC Roger and t h a t ’ s ah one two r i g h t IIS ah vector t h e r e .
YC
1750: 02 02 965 okay.
g h
co 1751: 53 STL A/C Ozark nine s i x t y f i v e t r a f f i c a t one o’clock t h r e e
in miles southbound.
fl
a oz 965 Nine s i x t y f i v e no contact.

STL A/C Roger.

 - 7-
11 c o n t r o l l e r
II 1752:25 oz 965 Nine s i x t y f i v e has t h e t r a f f i c .
)Ws t h a t t h e r e
wing t h e 3- 1752: 29 STL A/C Roger.
;her reveals
t i n comuni- 1752: 32 oz 965 He's a t twenty f i v e hundred.
:ht a i r c r a f t
. frequency 1752: 34 STL A/c Okay.
as many as
.on and 1754: 32 STL A/C Ozark nine s i x t y f i v e t r a f f i c two o'clock two miles
1 number of northbound.
'opera-
I t traffic 1754: 37 oz 965 Got him.
' departures
1754: 51 STL A/C Ozark nine s i x t y f i v e I'll t u r n you on r i g h t at t h e
marker.

1754: 55 oz 965 Okay,.we've got t h e a i r p o r t i n s i g h t .

1754: 59 STL A/C Okay, you can start a l e f t t u r n then ah f o r one

seven i f you l i k e , you're cleared f o r a one two
r i g h t ILS approach o r a contact approach, contact
t h e tower now one one e i g h t point f i v e .

1755: 08 oz 965 Okay, ah now runways one seven you say?

5TL A/C Yeah, t h e a c t i v e runway i s one seven, t h e wind i s

oae seven zero degrees one f i v e t o two zero.

If. 1755: 20 oz 965 Okay.

ontrol S t . Louis Tower Frequency

i x hundred
runway 1754: 00 ~ 6 9 ~ ( U n i n t e l l i g i b l e ) s i x nine golf S t . Charles with
golf.

zero. 1754:Ob STL L/C Six niner golf stand by I'll get t o you i n a
moment. F r o n t i e r four seventy 'six a r i g h t t u r n off
ector there. cross one two contact ground control. Cessna one
seven yankee runway one two r i g h t i s cleared f o r
takeoff. Eastern t h r e e e i g h t y s i x you gonna land
twelve o r seventeen?
ck t h r e e
1754:43 STL L/C 'I Okay, two two lima I have you i n s i g h t , and s i x
n i n e r golf r e p o r t r i g h t downwind runway one seven,
and who's t h e o t h e r a i r c r a f t a t S t . Charles?

'
IJBetween t h i s transmission and t h e one at 1756:43, t h e r e were 24 t o t a l -
airlground transmissions on Tower frequency.
 -8-
oz 965 Ozark nine sixty five on a right base.

STL L/C x r , Cessna six four delta cleared for takeoff

runway one seven.

STL L/C Aircraft southeast for one seven roger, Cessna

seven zero fox is cleared to land runway one seven
and Ozark nine sixty five that you on the base?

oz 965 Yes Sir.

STL L/C Okay, you're number two to follow a Cessna on a

real short final for one seven and traffic is a
Cessna looks like ahead and to your right maybe to
your left there northeastbound.

STL L/C Six nine golf if that's you out there about to turn
final pull out to your ah well just proceed straight
on across the final and enter on a left base leg for
runway one seven. You'llbe following an Ozark Dc
nine turning final about two out maybe to your left
and above you, you have him?

~ 6 9 ~ Six nine golf

- roger.
-

STL L/C Ozark nine sixty five traffic's that Cessna off to
your right looks like he's wa eastbound.

1.10 Aerodrome and Ground Facilities

Not involved. (See Attachment No. 1 for runway and tower layout of
W b e r t Field.)

1.11 Flight Recorders

Ozark Flight 965 was equipped with a Fairchild Model 5424-502flight
data recorder. A readout of the last 4 minutes of flight showed that the
aircraft approached the outer marker in accordance with its clearance and
that, at approximately 2 minutes 8 seconds before the collision, a descend-
ing left turn from an altitude of 2,600 feet m.s.l., was commenced. The
left turn and descent continued until 1 minute 3 seconds before impact
when the heading stabilized at approximately looo, with the airspeed decreas-
ing from 194 knots to 172 knots. At this point, the aircraft was passing
through an altitude of 2,200 feet m.s.l., descending at approximately
800 feet per minute. Approximately 23 seconds prior to the collision, a
 - 9 -
r i g h t t u r n of about 2.3' per second was i n i t i a t e d and was continued u n t i l
j u s t seconds before t h e c o l l i s i o n . A t t h e time of c o l l i s i o n , t h e DC-9
was a t an a l t i t u d e of approximately 1,100 f e e t m.s.l., on a heading of
160" and a t an indicated airspeed of 135 knots. The a l t i t u d e t r a c e r i s e s
and f a l l s sharply and t h e v e r t i c a l a c c e l e r a t i o n t r a c e r i s e s t o a plus
2.4 "g" and decreases t o 0 "g" during t h e same period. (These excursions
c o r r e l a t e with t h e captain's statement t h a t , i n an attempt t o avoid N8669G,
he added power, banked sharply t o t h e l e f t and then leveled t h e wings. )
Following these excursions, t h e recording shows that t h e a i r c r a f t then
continued i t s descent t o touchdown.

Ozark 965 was a l s o equipped with a United Control model V557 cockpit
voice recorder. Recordings found on t h e cockpit area microphone (CAM)
channel revealed that t h e cockpit speaker was being u t i l i z e d by t h e crew
and that t h e radio transmissions on tower frequency (118.5 MHz) emanating
from t h i s speaker were of s u f f i c i e n t volume t o be c l e a r l y heard by t h e
crew. h r i n g t h e period of time from t h e f i r s t advisory u n t i l t h e f i n a l
advisory t h e r e was no discussion o r checklist a c t i v i t y taking place i n t h e
cockpit. (See Appendix C.)

G3669G was not equipped with f l i g h t recorders and none were required.
1.12 Wreckage

The wreckage of ~ 8 6 6 was 9 ~ separated in two sections. The e n t i r e

fuselage and l e f t wing were located 6,500 f e e t from t h e approach end and
on t h e extended c e n t e r l i n e of -way 17. The r i g h t wing of t h e a i r c r a f t
was found approximately 500 f e e t north of t h e main wreckage.

Examination of t h i s wreckage revealed no evidence of pre-impact m a l -

functions o r d i s t r e s s i n t h e a i r c r a f t powerplant, s t r u c t u r e , o r systems.
The propeller blades were bent andobroken, with one blade end missing.
The f l a p s were i n t h e "up" p o s i t i o n . Several s c r a t c h marks were evident
on t h e upper portion of t h e Cessna's l e f t wing leading-edge s e c t i o n a t t h e
wing root a r e a . These marks ran forward and inboard on a 45" angle t o t h e
l a t e r a l axis.

b a g e t o t h e Ozark 965 was confined t o t h e underside of t h e r i g h t

wing i n l i n e with t h e v o r t i l o n and t h e r i g h t wing f l a p s . A f u e l tank
access p l a t e on t h e lower wing was cut open. Black and yellow p a i n t smears
were evident on t h e access p l a t e and on t h e adjacent a r e a s . Red paint
smears were evident on t h e lower surface of t h e damaged r i g h t wing f l a p .
(The Cessna was trimmed i n red; t h e p r o p e l l e r was painted black and yellow.)
Scratch and s c a r marks i n t h e a r e a forward of t h e DC-9 center spar extended
aft and inboard on a 60" angle t o t h e l a t e r a l axis of t h e a i r c r a f t .
 a

- 10 -
The W-9 flightcrew s t a t e d that, at t h e time of t h e c o l l i s i o n , t h e tin
aircraf't was i n a landing configuration with f l a p s s e t at 50" and t h e of
landing gear down. in(
OZl

1.13 -
Fire st1
fet
Wii
There was no f i r e on e i t h e r a i r c r a f t p r i o r t o or subsequent t o t h e
collision.
COI
1.14 Survival Aspects
M:
Following t h e c o l l i s i o n , t h e I S 9 continued i t s approach and landed PhI
on Runway 17. After touchdown, t h e tower advised t h e flight t h a t f u e l was Po
leaking from t h e r i g h t s i d e of t h e a i r c r a f t . The r i g h t engine was shut
down immediately a f t e r engine reverse and t h e l e f t engine was secured de
later during t h e r o l l o u t . The a i r c r a f t was brought t o a s t o p adjacent t o im
a taxiway and a l l passengers and t h e crew deplaned through t h e forward ha
airstair door. No d i f f i c u l t y o r s i g n i f i c a n t delays were reported during 17
t h e evacuation. ca
fo
Airport f i r e equipnent responded t o t h e emergency and was standing th
by t h e a i r c r a f t throughout t h e evacuation. se
The Cessna crash was nonsurvivable.
ta
1.15 Tests and Research tt
Ol:
A cockpit v i s i b i l i t y study was conducted by t h e Safety Board t o ti
determine t h e physical l i m i t a t i o n t o v i s i b i l i t y from t h e f l i g h t c r e w s e a t s be
i n each a i r c r a f t involved and t o reconstruct t h e f l i g h t p a t h o f each i n t?
order t o f i n d if those physical l i m i t a t i o n s would hinder e i t h e r crew i n K
t h e detection and observations of t h e o t h e r a i r p l a n e . fj
tl
The data developed by t h e f l i g h t recorder group was u t i l i z e d t o
e s t a b l i s h t h e f l i g h t p a t h of Ozark 965. The f l i g h t p a t h o f ~ 8 6 6 was
9~ 1.
e s t a b l i s h e d u t i l i z i n g t h e information obtained from eyewitnesses, operational
data, radio communications, and c o l l i s i o n s c r a t c h marks. The s c r a t c h marks
indicated t h a t t h e angle of impact between t h e two a i r c r a f t was 15", and t h e fl
respective headings of t h e E€!-9 and Cessna were approximately 162' and 147". W:
h:
By method of vector diagram, t h e heading and airspeed of t h e Cessna tl
a t impact were determined t o be 147" and 94.5 knots, respectively. W:
(:
Ground t r a c k s f o r both a i r c r a f t were p l o t t e d , from which ranges and a:
bearings between t h e two were obtained f o r t h e last 2 minutes 21 seconds
p r i o r t o t h e c o l l i s i o n . Flight recorder data shows that Ozark 965 was i n
a l e f t t u r n divergent t o ~ 8 6 6 9 ~ 2 minutes 10 seconds u n t i l approxi-
from
3
mately 1 minute p r i o r t o t h e c o l l i s i o n . From 1 minute before until t h e
 - 11 -
time of t h e c o l l i s i o n , t h e Dc-9 ( i n a r i g h t t u r n and descending at a rate
of 920 feet per minute) was overtaking t h e Cessna. The a v a i l a b l e d a t a
indicates t h a t ~866%was maintaining a constant heading and a l t i t u d e below
h a r k 965 f o r at least 1 minute p r i o r t o t h e c o l l i s i o n . A t 1754:51 ( t h e
s t a r t i n g point of t h e study) t h e two a i r c r a f t were estimated t o be 16,926
f e e t a w t , and t h e t a r g e t source represented by t h e Cessna was w e l l
within t h e detectable range of v i s i o n f o r t h e Dc-9 crew.

I n order t o determine t h e physical l i m i t a t i o n s t o v i s i o n from each

cockpit, binocular photographs were taken of a Cessna 150 and a Douglas
DC-9 by t h e FAA's National Aviation F a c i l i t i e s Experimental Center. These
photographs u t i l i z e d a f i x e d p o s i t i o n corresponding t o t h e design eye
position f o r t h e flightcrews.

The visual angles 8/ of t h e crewmembers from each a i r c r a f t were

3
determined from approxiiiately 1minute before c o l l i s i o n t o t h e time of
impact. Based on these computations, it was determined that N8669G could
have been detected by t h e first o f f i c e r during t h e time period between
1756:Og and 1757:07, f o r a t o t a l of 58 seconds p r i o r t o t h e c o l l i s i o n . The
captain could have sighted N8669G during t h e time period 1756:45 t o 1757:07,
f o r a t o t a l of 22 seconds. The observer could have seen t h e Cessna during
the periods 1756:39 t o 1756~45,and 1756:57 t o 1757:03, f o r a t o t a l of 12
seconds.

Each a i r c r a f t had some physical r e s t r i c t i o n s t o v i s i o n of a point

1;
target source of t h e o t h e r a i r c r a f t . From t h e normal eye p o s i t i o n s of
the captain, c o p i l o t , and observer of t h e nC-9, N8669G would be partial1
obscured by t h e windshield posts and lower cockpit fuselage at various
time periods during t h e closure of t h e a i r c r a f t . Ozark 965 would not have
been v i s i b l e t o t h e crew of ~ 8 6 6 9 at~ any time during t h i s period due t o
the high wing p o s i t i o n of t h e Cessna 150. [AS was s t a t e d previously,[the
paths of t h e point source t a r g e t s p l o t t e d on t h e windshields were based on
fixed-eye reference points. If t h e crewmembers s h i f t e d t h e i r head p o s i t i o n
these paths would have changed2 ,.'
,,"
1.16 Pertinent Information
The A r r i v a l Radar (AR) Controller was t h e first person i n t h e S t . Louis
f a c i l i t y t o provide c o n t r o l s e r v i c e s t o Ozark 965. He had n e i t h e r contact
with ~ 8 6 6 %nor knowledge of t h a t a i r c r a f t ' s operation. The l o c a t i o n of
h i s position of operation was i n t h e IFB room below t h e tower cab. He s t a t e d
t h a t t h e f a c i l i t y radar was operating s a t i s f a c t o r i l y and that radar contact
with Ozark 965 was established i n t h e v i c i n i t y of F i d e l i t y i n t e r s e c t i o n
(approximately 24 miles northeast of t h e STL MM). When advised that t h e
a i r p o r t was i n s i g h t , t h e f l i g h t was given t h e option o f making e i t h e r a

-
8/ Targets r e f e r r e d t o are point sources. It should be noted t h a t as t h e
a i r c r a f t converged t h e v i s u a l angles of t h e t a r g e t s would increase.
 - 12 -
contact approach t o Runway 17 or an ILS approach t o Runway la, and was
i n s t r u c t e d t o contact t h e tower on t h e l o c a l c o n t r o l frequency. The AR
c o n t r o l l e r s t a t e d that the a i r c r a f t ' s p o s i t i o n at t h a t time was approxi-
mately 1 t o 1.5 miles northwest of t h e LOM, and he d i d not r e c a l l observing
t h e radar t a r g e t of Ozark 965 a f t e r t h e a i r c r a f t i n i t i a t e d a t u r n toward
t h e a i r p o r t . A t t h i s point, Ozark 965 had, i n e f f e c t , entered t h e VFR
t r a f f i c pattern f o r t h e S t . Louis Airport and was under t h e c o n t r o l of t h e
l o c a l c o n t r o l l e r . Arriving and departing t r a f f i c was u t i l i z i n g Runways 17
and 12R. Runway 17 was considered t h e a c t i v e runway because o f t h e s t r o n g
surface winds; however, l a r g e a i r c r a f t which were l e s s a f f e c t e d by t h e
crosswind component were using Runway 12R.

A t t h e time of t h e accident, t h e r e were s i x c o n t r o l l e r s i n t h e tower

cab, including t h e watch supervisor. They included:

Local Controller -
who i s s u e s information and clearances t o
air and vehicular t r a f f i c operating on t h e landing area, t o
VFR t r a f f i c operating i n t h e c o n t r o l zone, and IFR t r a f f i . c
released t o l o c a l c o n t r o l j u r i s d i c t i o n .

Ground Controller - who assists other operating p o s i t i o n s by

handling t a x i i n g a i r c r a f t and vehicular t r a f f i c on t h e landing
area.

F l i g h t k t a Controller -
who receives, posts, and r e l a y s f l i g h t
data concerning IFR t r a f f i c and, as directed, assists i n t h e
operation of t h e f a c i l i t y .

Cab Coordinator -
who coordinates and d i r e c t s t h e a c t i v i t i e s
of designated p o s i t i o n s of operation i n t h e tower cab.

Watch Supervisor -
who supervises all phases of work on a watch
i n t h e tower cab and delegates supervisory functions- t o subordi-
nates, as required.

Relief Local Controller - who was preparing t o assume d u t i e s of

the l o c a l c o n t r o l l e r .

The general functions of t h e l o c a l c o n t r o l l e r a r e f u r t h e r amplified

i n t h e FAA F a c i l i t y Operation Handbook 7230.1 as follows: "A c o n t r o l l e r
i s responsible f o r formulating and i s s u i n g clearances and c o n t r o l i n s t r u c t i o n s
t o provide separation between a i r c r a f t and vehicular t r a f f i c operating under
t h e j u r i s d i c t i o n of t h e f a c i l i t y , effecting coordination with appropriate
positions of operation and other f a c i l i t i e s , providing f l i g h t a s s i s t a n c e
service t o a i r c r a f t as required. . . ." The procedures t o be u t i l i z e d i n
t h e execution of these functions a r e s e t f o r t h i n FAA Handbook 7110.8
e n t i t l e d , "Terminal A i r T r a f f i c Control." This manual does not s p e c i e any

!
 - 13 -
i n - f l i g h t separation minima f o r VFR operations within t h e c o n t r o l zone.
In practice, t h e l o c a l c o n t r o l l e r provides a d v i s o r i e s and/or i n s t r u c t i o n s
based on t h e p o s i t i o n s of observed or known t r a f f i c , contingent upon air-
port conditions. The c o n t r o l l e r e s t a b l i s h e s t h e sequence of a r r i v i n g and
departing a i r c r a f t by requiring various adJustments i n t h e f l i g h t o r ground
operations t o achieve proper spacing. There i s no reguired o r f i x e d di-
mension t o such spacing as it p e r t a i n s t o a i r c r a f t i n f l i g h t .

2. ANALYSIS AND CONCLUSIONS

2.1 Analysis

A t t h e time of t h e accident, v i r t u a l l y i d e a l f l y i n g weather with

unrestricted v i s i b i l i t y e x i s t e d at t h e S t . Louis Airport. However, strong
southerly winds were present, and t h i s r e s u l t e d i n t h e designation of
Runway 17 as t h e primary runway. Since t h e r e were no radar sequencing
procedures for Runway 17, t h e AR c o n t r o l l e r simply cleared Ozark 965 f o r
an ILS approach t o Runway 1 R or a contact approach t o Runway 17, and
2
instructed t h e f l i g h t t o contact t h e l o c a l c o n t r o l l e r on t h e tower frequency.
Such i n s t r u c t i o n s a r e normally given t o IFR f l i g h t s p r i o r t o reaching t h e
LQM (located 5.3 miles northwest of t h e a i r p o r t ) and i n t h i s instance were
issued approximately 1 . 5 miles north of t h e LOM.

Meanwhile, VFR a r r i v i n g t r a f f i c was required t o r e p o r t p r i o r t o e n t e r i n g

the control zone (a 5-mile r a d i u s ) , and all a r r i v i n g a i r c r a f t were then
being cleared t o land on Runways 17 and 12R. Departing t r a f f i c was a l s o
being interspersed on both runways. This "manual" mixing o f a i r c r a f t from
random reporting points, without t h e systematic sequencing o r s u r v e i l l a n c e
normally provided by t h e AR c o n t r o l l e r , g r e a t l y increased t h e workload of
the l o c a l c o n t r o l l e r t o t h e point t h a t he was u t i l i z i n g both l e f t and r i g h t
landing p a t t e r n s f o r Runway 17 i n a d d i t i o n t o t h e o t h e r approaches t o Run-
way 12R. Aside from t h e need t o s i g h t and i d e n t i f y a l l t r a f f i c , he faced
the d i f f i c u l t task of judging r e l a t i v e speeds and distances t o provide
sequence and spacing. Although t h i s required a m a x i m u m amount of p i l o t /
controller coordination through communication, t h e volume of t r a f f i c required
almost continuous use of t h e l o c a l c o n t r o l frequency. The c o n t r o l l e r , of
necessity, was i s s u i n g i n s t r u c t i o n s t o s e v e r a l a i r c r a f t i n each transmission,
and there was l i m i t e d opportunity for acknowledgments from t h e p i l o t s t o
whom t h e i n s t r u c t i o n s were issued. Thus, t h e e f f e c t i v e n e s s of timely comuni-
c a t i o n which, under t h e circumstances, was t h e c o n t r o l l e r ' s p r i n c i p a l means
ns of maintaining an o r d e r l y flow of mixed vFR/IFR t r a f f i c , began t o d e t e r i o r a t e .
This was demonstrated a t 1754:OO when N8669G reported over S t . Charles with
information "golf ." The tower's r e p l y was: "Six n i n e r golf s t a n d by I'll
get t o you i n a moment. F r o n t i e r four seventy s i x a r i g h t t u r n off c r o s s one
two contact ground control. Cessna one seven yankee runway one two r i g h t i s
cleared f o r t a k e o f f . Eastern t h r e e eighty s i x you gonna land twelve or
seventeen?"
 - 14 -
A t 1754:43, t h e l o c a l c o n t r o l l e r advised, "Okay, two two l
i
m a I have 026
you i n s i g h t , and s i x niner golf r e p o r t r i g h t downwind runway one seven, ha\
and who's t h e o t h e r aircraft at S t . Charles?" No acknowled@plent of e i t h e r 96:
transmission was received from N8669G, and it i s obvious that t h e r e was loc
l i m i t e d opportunity f o r t h e crew t o do so. of
the
A t 1756:09, Ozark 965 made i t s first contact on t h e tower frequency, mol
"Ozark nine s i x t y - f i v e on a r i g h t base." Although N8669G could have heard (NL
t h i s call, t h e p i l o t s would have had no way of knowing which runway was
involved. Indeed, they may have l o g i c a l l y assumed that t h e l a r g e r a i r c r a f t
was approaching Fxnway 12R. The l o c a l c o n t r o l l e r s t a t e d that, a f t e r con- pat
firming t h e l o c a t i o n of Ozark 965 and observing t r a f f i c i n i t s v i c i n i t y , he laf
advised at 1756:31, "Okay, you're number two t o follow a Cessna on a r e a l N&
short f i n a l f o r one seven and t r a f f i c i s a Cessna looks l i k e ahead and t o thc
your r i g h t maybe t o your l e f t t h e r e northeastbound." The l o c a l c o n t r o l l e r shc
assumed t h a t t h e Cessna i n question was N8669G s i n c e it was t h e only air- fil
craft under h i s j u r i s d i c t i o n whose p o s i t i o n had not s p e c i f i c a l l y been ac- be6
counted for. After a few seconds pause, he transmitted, "Six nine golf i f sit
t h a t ' s you out t h e r e about t o t u r n f i n a l pull out t o your ah w e l l j u s t por
proceed s t r a i g h t on across t h e f i n a l and e n t e r on a l e e base l e g for runway bec
one seven. You'll be following an Ozark DC nine t u r n i n g final about two out ou1
maybe t o your l e f t and above you, you have him?" A t 1756:58, N8669~r e p l i e d , Otl
"Six nine golf roger." The l o c a l c o n t r o l l e r s t a t e d t h a t , at t h i s time, ret
~ 8 6 6 9appeared
~ t o be across t h e f i n a l approach course, and approximately ha1
112 mile from Ozark 965. A t t h i s point, 14 seconds p r i o r t o c o l l i s i o n , both
crews had been advised t h a t they were mutual t r a f f i c f o r each other.
of
Unfortunately, while t h e crew of Ozark 965 was a b l e t o s i g h t t h e tht
"Cessna on a r e a l short final (WOF)" they were unable t o d e t e c t ~ 8 6 6 9 ~
which was, a t t h a t time, s l i g h t l y over 3,500 f e e t o f f t h e i r r i g h t . f r o n t
quarter, according t o t h e v i s i b i l i t y study. F'urther, it appears that while ne1
t h e crew of E3669 heard t h e i n s t r u c t i o n t o proceed across t h e final approach tht
course, they e i t h e r did not hear t h e t r a f f i c advisory warning of t h e Do9 OPf
or they attached no urgent s i g n i f i c a n c e t o it and ignored it temporarily. ad
sel
The l o c a l c o n t r o l l e r again issued a t r a f f i c 'warning t o Ozark 965 at net
1757:06, "Ozark nine s i x t y - f i v e t r a f f i c ' s that Cessna off t o your r i g h t of
looks l i k e h e ' s wa eastbound." Although no verbal acknowledgment from t h e ell
crew was recorded, they s t a t e d t h a t t h e y d i d receive t h i s transmission, b u t f rt
it was t o o l a t e t o avoid t h e c o l l i s i o n which occurred a t 1757:12. me]
mol
The cockpit v i s i b i l i t y study attempted t o e s t a b l i s h as a c c u r a t e l y as bet
possible what physical r e s t r i c t i o n s t o v i s i o n may have hindered each crew in8
i n t h e observation of t h e other aircraft. NE36696 was apparently between thl
Ozark 965 and t h e a i r p o r t throughout t h e period t h a t both were operating ca:
i n t h e c o n t r o l zone. Accordingly, t h e a t t e n t i o n of t h e p i l o t s of N8669G t rI
would have been focused toward t h e a i r p o r t on t h e i r r i g h t and away from to
 - 15 -
Ozark 965. Additionally, t h e high-wing construction of t h e Cessna would
have prevented all but t h e most concerted e f f o r t s of t h e crew t o see Ozark
965 i f they had looked up and t o t h e l e f t . It i s presumed t h a t , l i k e t h e
l o c a l c o n t r o l l e r , t h e crew of N8669G must have assumed that they were c l e a r
of Ozark 965, and intended t o spot t h a t a i r c r a f t af%er they had completed
t h e i r t u r n t o a l e f t base. Another p o s s i b i l i t y i s t h a t they may have been
more immediately engrossed i n t h e i r closure with another l i g h t a i r c r a f t
(NhQZT), which was already on a l e f t base f o r Runway 17.

Ozark 965 executed a gentle l e f t t u r n , divergent t o t h e general f l i g h t -

path o f ~ 8 6 6 9 ~ ,
between 1 and 2 minutes p r i o r t o c o l l i s i o n and, during t h e
l a s t minute p r i o r t o t h e accident, it was i n a descending r i g h t t u r n toward
N866gG. Throughout most of t h i s period, t h e crew should have been aware of
the c o n f l i c t i n g t r a f f i c which was i n t h e general d i r e c t i o n that t h e i r a t t e n t i o n
should have been focused. Eased on a fixed-eye reference point, only t h e
f i r s t o f f i c e r had a p r o t r a c t e d length of time during which ~ 8 6 6 would 9 ~ have
been v i s i b l e i n t h e last minute before c o l l i s i o n . However, t h e amount of
sighting time a v a i l a b l e t o each crewmember, based on fixed-eye reference
points, cannot be considered v a l i d because a l l of t h e crewmembers should have
been a c t i v e l y engaged i n scanning t h e a i r s p a c e ahead of t h e a i r c r a f t through-
out t h e approach and, therefore, each could have detected t h e Cessna at times
other than s p e c i f i e d i n t h e study. Thus, t h e Board concludes t h a t with a
reasonable degree o f vigilance on t h e i r part, t h e crew of Ozark 965 should
have sighted t h e Cessna i n time t o avoid t h e c o l l i s i o n .

The preceding portion of t h e a n a l y s i s has d e a l t mainly with t h e dynamics

of the c o l l i s i o n ; however, i n properly evaluating all of t h e circumstances of
the accident, o t h e r p e r t i n e n t f a c t o r s must a l s o be considered.
r
F i r s t , it must be remembered t h a t t h e l o c a l c o n t r o l l e r was operating
near t h e maximum of h i s c a p a b i l i t i e s i n terms o f t r a f f i c load. Although
there was no requirement f o r him t o provide i n - f l i g h t separation of a i r c r a f t
operating i n t h e c o n t r o l zone, he was responsible f o r providing p e r t i n e n t
advisory information t o p i l o t s and for e s t a b l i s h i n g an o r d e r l y landing
sequence. Accomplishment of t h i s t a s k required two-way communication. P i l o t s
need t o report t h e i r positions, and receive i n s t r u c t i o n s i n r e t u r n . The tempo
of transmissions had increased t o t h e point t h a t s c a r c e l y 3 t o 4 seconds
elapsed between necessary r e p o r t s from p i l o t s and subsequent i n s t r u c t i o n s
from t h e l o c a l c o n t r o l l e r , and t h e r e was v i r t u a l l y no time f o r acknowledg-
ment. Although verbal acknowledgment i s not required, s i n c e r e c e i p t of’
most i n s t r u c t i o n s becomes evident i n t h e movement of t h e a i r c r a f t , it
becomes necessary f o r t h e c o n t r o l l e r t o monitor each f l i g h t more c l o s e l y t o
insure t h a t h i s i n s t r u c t i o n s a r e being c a r r i e d o u t . I n t h e i n s t a n t case,
the l o c a l c o n t r o l l e r d i d not have assurance t h a t h i s i n s t r u c t i o n s were being
carried out, and i n f a c t t h e y were not. I n view of t h e r a p i d l y i n c r e a s i n g
t r a f f i c s i t u a t i o n , it can be seen t h a t it was important f o r t h e c o n t r o l l e r
t o know t h a t t h e Cessna had, indeed, received t h e i n s t r u c t i o n s t o r e p o r t
 - 16 -
downwind as t h i s would be t h e only method by which he would have ample
time t o see t h e a i r c r a f t and e s t a b l i s h a proper landing sequence with
o t h e r a i r c r a f t i n t h e p a t t e r n . It appears that, on t h e contrary, he simply
dismissed N8669G from h i s mind u n t i l such time as he would receive t h e
requested c a l l "entering t h e downwind." Consequently h i s next conscious
awareness of N8669G occurred when he observed t h e as y e t u n i d e n t i f i e d Cessna
i n t h e v i c i n i t y of Ozark 965, on t h e base l e g f o r Runway 17.

It can be argued t h a t first e s t a b l i s h e d radio contact between t h e

tower .and N8669G d i d not occur u n t i l 14 seconds p r i o r t o impact. A t t h i s
time, t h e c o n t r o l l e r ' s concern f o r t h e r a p i d l y developing c o n f l i c t i n
t r a f f i c i s indicated by t h e f a c t that he i n s t r u c t e d ~ 8 6 6 9 t o~ f l y s t r a i g h t
across t h e final approach course, which was also a r i s k because N b 2 T was
already i n a l e f t hand p a t t e r n f o r Fiunway 17. It i s perhaps moot whether
t h e c o n t r o l l e r forgot about t h e q t h e r t r a f f i c , o r simply considered t h i s
course of a c t i o n as t h e l e s s e r of two e v i l s , because it i s c l e a r t h a t he
was not a b l e t o e s t a b l i s h landing sequence i n an o r d e r l y manner. The
crew of N b 2 T estimated t h a t t h e y were l e s s than 112 mile from t h e c o l l i s i o n
point. However, because of t h e distance and p o s i t i o n of t h e Cessna and
t h e nC-9 from t h e Tower Cab,the c o n t r o l l e r could not v i s u a l l y determine t h e
p o s i t i o n of ~ 8 6 6 9 i n~ r e l a t i o n t o t h e extended c e n t e r l i n e of Runway 17, and
was probably r e l u c t a n t t o i s s u e evasive maneuver i n s t r u c t i o n s t o e i t h e r
a i r c r a f t because o f t h e d i f f i c u l t y i n ' j u d g i n g t h e i r r e l a t i v e p o s i t i o n s .

With a daylight radar d i s p l a y (brLght display) it is possible even

a t that juncture t h a t t h e c o n t r o l l e r could have issued e f f e c t i v e c o l l i s i o n
avoidance i n s t r u c t i o n s t o t h e p i l o t . More importantly, t h e equipment would
have enabled him t o prevent developlent of t h e s i t u a t i o n t o t h i s c r i t i c a l
point. 91 -
Second, t h e crew of ~ 8 6 6 9 e i~t h e r d i d not hear t h e tower's i n s t r u c t i o n s
regarding t r a f f i c p a t t e r n e n t r y and entered t h e c o n t r o l zone without two-
way radio comunic e r , o r simply f a i l e d t o comply with t h e
instructions issu n t , t h e f l i g h t d i d not s u f f i c i e n t l y inform
t h e tower of t h e e s s i n t o t h e a i r p o r t landing t r a f f i c p a t t e r n .
Time-distance computations a t e t h a t t h e aircraft d i d not e n t e r on a
downwind, b u t proceeded ow e c t course from S t . Charles t o t h e c o l l i s i o n
point. If t h e p i l o t d i d not receive t h e i n s t r u c t i o n s , he should have at-
tempted further contact with t h e tower before e n t e r i n g t h e t r a f f i c p a t t e r n .
Instead t h e flight v i r t u a l l y reached t h e final approach course and still
had no sequence t o land. I n f a c t t h e i r only transmission, p r i o r t o t h e
acknowledgment of i n s t r u c t i o n s t o e n t e r a l e f t base, was t h e i n i t i a l contact
a t S t . Charles when t h e y entered t h e c o n t r o l zone. Notwithstanding t h e f a c t
t h a t information "golf" had provided them with t h e necessary landing informa-
t i o n , it must be concluded that t h e crew of N8669G d i d not conform with
established operating p r a c t i c e s i n conducting t h e approach i n t h e manner t h e y
did without at l e a s t informing t h e tower of t h e i r progress.

See Recommendations (Section 3).

 - 17 -
Third, the failure of the crew of Ozark 965 to sight ~ 3 6 6 must
9 ~ be
considered crucial, if only because it was the final opportunity to avoid
the collision. There were three crewmembers aboard the flight instead of
the n o d two. This constituted an exbra set of eyes and yet they failed
S to see the conflicting traffic. It would seem that the subsequent instruc-
essna tions to N8669G relative to the final approach course would have served as
additional impetus to increase their vigilance as they continued in a de-
scending right turn. However, there was no further apparent concern until
the controller again pointed out the Cessna with less than 6 seconds to
is react.

Sht Finally, and of equal imprtance, the Board believes that this accident
ZS shows that the basic philosophy of VFR procedural control used in the air
?r traffic control system must be re-evaluated for adequacy for present and
3 future air traffic operations. It is believed that separation criteria for
3. aircraft operating within a control zone must be established and the air
traffic control system must assume a major responsibility for the safe
ision sepwation of aircraft under jurisdiction of the tower within this air-
space. The facts of this accident and others demonstrate that the pilot's
the v i s u a l ability to effect his own separation is not of itself sufficient to
and assure the level of safety demanded for present and future air operations.

2.2 Conclusions

(a) Findings
.on
1uld 1. Both aircraft were properly certificated and airworthy.
.1
2. All flight crewmembers were properly certificated.

ions 3. There is no evidence of any malfunction of either air-

craft prior to collision.
the
nform 4. Both aircraft were operating VFR in the control zone.
ttern.
5. The weather was clear and visibility good.
sion
- 6.. At the time of the accident, Runways 17 and 12R were
m . being utilized by the local controller for arriving and
departing aircraft. Both left and right landing traffic
patterns were in use for Runway 17 which was the primary
tact runway.
eact
)ma- 7. Lambert Field has no published VFR traffic pattern
procedures.
they
8. Communications were almost continuous on the local control
- frequency, and multiple instructions were being issued to
different flights in the same transmission.
 - 18 -
9. Verbal acknowledgment for instructions was not received
by the local controller on a number of occasions.

10. Time and distance calculations indicate that the Cessna

proceeded directly from over St. Charles to a right base
leg entry f o r the Landing traffic pattern.
11. The Cessna crew either did not receive the instruction to
enter the traffic pattern downwind and entered the control
zone without establishing two-way radio communications, or,
failed to comply with the issued instructions.

12. The tower issued a traffic advisory to the I S 9 regarding

N8669G approximately 41 seconds prior to the collision.
13. Traffic information concerning the I S 9 was given to N8669G
by the tower approximately 29 seconds prior to the collision.

14. Ozark pilots, if exercising reasonable vigilance, could

have sighted the Cessna in time to avoid the collision. The
Cessna crew could not have been expected to see and avoid
the E-9.

15. The local controller was unable to determine accurately by

visual observation the position of'each aircraft with respect
to the other.

16. With a daylight radar display, it is possible that the

controller could have issued effective collision avoidance
instructions.

(b) Probable Cause

The Safety Board determines that the probable cause of this mid-
air collision was the combination of: the inadequacy of current VFFi
separation standards in controlled airspace, the crew of the E-9 not
sighting the Cessna in time to avoid it, the absence of VFR traffic pattern
procedures to enhance an orderly flow of landing aircraft, the local con-
troller not assuring that important landing information issued to the Cessna
was received and understood under the circumstances of a heavy traffic
situation without radar assistance, and the Cessna crew's deviation from
their traffic pattern instructions and/or their continuation to a critical
point in the traffic pattern without informing the local controller of the
progress of the flight.
i

- 19 -

3. RECOMMENMTIONS

On June 14, 1968, t h e Board s e n t a l e t t e r t o t h e Federal Aviation

Administration recommending t h a t :

(a) Daylight radar display equipnent be i n s t a l l e d i n t h e

Lambert Field Tower Cab at t h e e a r l i e s t possible d a t e .

(b) Greater u t i l i z a t i o n of t h e f a c i l i t y radar be made so

as t o provide radar sequencing, monitoring, and
advisory s e r v i c e on a t'ull-time b a s i s u n t i l Phase I1
of t h e National T e r m i n a l Radar Service Program can be
implemented a t S t . Louis.

( c ) VFFi p a t t e r n s ( e n t r y points, t r a c k s , and a l t i t u d e s ) be

established f o r t h e Lambert F i e l d c o n t r o l zone t o be
u t i l i z e d by those a i r c r a f t not p a r t i c i p a t i n g i n a radar
program.

(a) A l l of t h e above recommended a c t i o n s be considered f o r

t h e i r a p p l i c a b i l i t y t o o t h e r l o c a t i o n s similar t o
S t . Louis.

On June 28, 1968, t h e Administrator i n r e p l y t o t h e foregoing

recommendations advised t h a t :

(a) The i n s t a l l a t i o n of daylight b r i g h t tube radar displays

has been completed a t t h e S t . Louis Airport.

(b) Stage I1 of t h e National Radar Program, which will involve

radar sequencing, monitoring and advisory s e r v i c e t o air-
c r a f t , was scheduled December 1, 1968.

(c) The FAA had under consideration t h e e s t a b l i s h i n g of VFR

e n t r y and departure routes f o r Lambert F i e l d . It was
s t a t e d , however, that t h e use of VFR t r a f f i c c o r r i d o r s
w i l l not eliminate t h e "mixing bowl" s i t u a t i o n somewhere
i n t h e a i r p o r t t r a f f i c p a t t e r n p a r t i c u l a r l y where multiple
runways a r e i n use simultaneously.
 - 20 -

(d) All of the above recommended actions are being con-

' sidered for applicability at other locations which
have problems similar to Lambert Field.

BY THE NATIONAL TRANSPORTATION SAFETY B

OAR
D:

JOHN H. REED
Chairman

OSCAR M. LAUREL
Member

FRANCIS H. Mc
A-
Member

LOUIS M. THAYER
Member
 APPENDIX A

Captain R. J. Fitch, aged 53, held airline transport certificate

No. 26107-40 with ratings in E-3, E-4, E-9, L 18, C 46, F 271227,
CV 240/340/440, M 2021404. He had accumulated 24,127 total flying hours
of which 800 hours were in the E- 9. His last proficiency check was
completed November 17, 1967, and his FAA first-class medical certificate.
was issued September 27, 1967, with the limitation that corrective glasses
(near vision) must be worn while flying. He had been off duty for 12
hours 42 minutes prior to this flight.

First Officer W. C. Oltman, aged 43, held airline transport pilot

certificate No. 354408 with ratings in Dc-3 and airplane single and
multiengine land. He had accumulated 9,805 total flying hours of which
1,188 hours were in the E-9. His last proficiency check was completed
August 19, 1967, and his FAA first-class medical certificate was issued
January 16, 1968, with the limitation that glasses must be worn while
flying. He had been off duty for 12 hours 42 minutes prior to this flight.

Captain R. W. Traub, aged 46, held airline transport pilot certi-

ficate No. 333086 with ratings in E-3, E - 9 , CV 240/340/440, F-27,
M m2/404. He had accumulated 18,402 total flying hours of which 51 hours
were in the D.7-9. His last proficiency check was completed March 26, 1968,
and his FAA first-class medical certificate was issued November 29, 1967,
with no limitations. He had been off duty 1 5 hours prior to this flight.

Hostess Shirley Waggoner, aged 30, was hired on September 29, 1958.
She completed her last emergency procedures training on July 7, 1967.

Hostess Marilyn Schroepfer, aged 27, was hired on July 1, 1965.

She completed her last emergency procedures training on July 12, 1967.

Instructor Pilot B. L. Allen, aged 31, held commercial pilot certi-

ficate No. 1617257 with ratings for airplane single engine land and
flight instructor. He had accumulated 380.7 total flying hours. His last
proficiency check was completed on March 26, 1968, in a Cessna 172, and
his FAA second-class medical certificate was issued October 31, 1967,
with no limitations. He was employed as a part-time instructor by Inter-
state Airmotive, Inc.

Instructor Pilot-Trainee John Brooks, aged 34, held comercial pilot

certificate No. 1795 with a rating for airplane single engine land. He
had accumulated 174 total flying hours. His last proficiency check was
completed March 13, 1968, and his FAA second-class medical certificate
was issued December 11, 1967, without limitations.
 APPENDIX B

Aircraft Information

N9702, a Douglas E-9, SIN 45772, was manufactured b y 5, 1966.

At the time of the accident the aircraft had a total time of 5172:5& hours.

Aircraft records indicate that N970Z had been maintained in accordance

with all company procedures and FAA directives.

The Cessna 150FJ N8669GJ was owned by Interstate Airmotive, Inc. , and
had accumulated a total aircraft time of 1392:24 hours at the time of the
accident.

A review of all available aircraft records indicates that the aircraft

was maintained in accordance with approved procedures and directives.

- i -
 PSPENDIX c
LEGEND
Cockpit Area Microphone Circuit

Three men on flight deck. Identity of speaker unknown

Voice assumed to be the Captain's

Voice assumed to be the Copilot's

Voice assumed to be the additional crewmember's

Radio transmission from Ozark 965

Radio transmission from St. Louis local controller

Radio transmission on tower frequency 118.5 MHz emanating from

PC-9 cockpit speaker system
Recorded sounds or times of significant interest

Unintelligible conversation

Words enclosed within parentheses are not clearly understood and

are subject to interpretation. Those shown represent the best
interpretation o f what the person said.

Underlined portions o f the transcript are intended to assist the

reader to more easily identify crew conversation and pertinent
radio transmissions to or from the flight.

CONTENT

Ozark 965 radio tuned to St. Louis local control frequency.

Tower transmissions are emanating from the aircraft's cock-
pit speaker system and recorded on CAM channel

SRCR Okay, I ' m going to (the terminal)

SEXR -
Okay, six four data change your ah transmitter to tower
frequency one eighteen point five. Cherokee zero two juliet
taxi into position and hold, Delta three sixty five taxi
into position and hold on one two F755:4V -
1755:39 W#? (You want t h e o t h e r runway)

You want - - - - - you want - --- one two?

1755:a W#? There's one two a i n ' t it?

1 7 5 5 : a SPKR Okay, t h r e e s i x t y f i v e

1755:46 CAM#? -
Yeah

1755:47 SPXR Cherokee two two lima runway one seven cleared f o r take-
o f f . Who's t h e Cessna

p o u n d similar t o t h a t of landing gear being l o w e r e d 7 -

Sp141 Up t h e r e a t one seven f o r takeoff?
(cont.)
-
B o u n d of gear warning horn7

Six four d e l t a i s that you that j u s t t a x i i e d on t h e

runway? I ' m not hearing you on tower frequency one
eighteen point f i v e change your t r a n s m i t t e r r1755:587 -
-
w

Ah - roger do you read me now?

Gotcha now s i x four d e l t a hold i n position. Eastern -

ah - t h r e e e i g h t y s i x a r i g h t t u r n o f f contact ground
control

OK

Roger

Ozark nine s i x t y f i v e on a r i g h t base

Roger, Cessna s i x four d e l t a cleared f o r takeoff

runway one seven

(You got t h i r t y . )

Gee southeast t u r n i n g downwind f o r one seven

A i r c r a f t southeast f o r one seven roger, Cessna seven

zero fox i s cleared t o land runway one seven and Ozark
nine s i x t y f i v e t h a t you on t h e base?

Yes sir.

- ii -
 Okay, you're number two t o follow a Cessna on a r e d
s h o r t final f o r one seven and t r a f f i c i s a

( B e t t e r slow down)

Tlm
(cont a) Cessna looks l i k e ahead and t o your r i g h t , maybe t o your
l e f t t h e r e northeastbound

I don't see it (out t h e r e ) a t all

:e-
-
Naw. f1756: 47-7
Six nine golf i f t h a t ' s you out t h e r e about t o t u r n final
pull out t o your ah - -
well j u s t proceed s t r a i g h t on
across t h e final and e n t e r on a l e f t base l e g for r u n w a ~ ~
one seven. Y o u ' l l b e following an Ozaxk DC nine t u r n i n g
final about two out maybe t o your l e f t and above you, you
have him?

S i x nine golf - roger.

( U n i n t e l l i g i b l e ) has got Ozark i n s i g h t can we follow

him i n we're crossing t h e double highways

Ozark nine s i x t y f i v e t r a f f i c ' s that Cessna off t o your

r i g h t looks l i k e h e ' s wa eastbound /1757:0g/ -
Look out!

,@ollision7 -
S t . Louis tower ( U n i n t e l l i g i b l e )

(Keep t h e power on)*

(It's on)

S t Louis tower t h a t ah Ozark h i t that l i t t l e one ah - -

zero two T c a l l i n g Ozark o r - ah - S t . Louis tower.

Ozark nine s i x t y f i v e you OK.

Better c a l l t h e (*)
We're OK get t h a t a i r p l a n e off t h e ground o f f t h e runway

Seven zero fox c l e a r t h e runway t o t h e r i g h t immediately

- iii -
Ah (this) h i t him p r e t t y hard

Now ease it back. ,

St Louis tower Cessna t h r e e nine one e i g h t j u l i e t over t h e

r i v e r north with g o l f .

Fzark 965 touchdown on runwaJ

p o u n d of reverse t h r u s g

Ozark nine s i x t y f i v e t h e equipment i s on t h e w a y if you

w a n t t o s t o p on t h e runway.

We're experiencing no d i f f i c u l t x

1'11 t a k e it.

Ozark nine s i x t y f i v e roger, t h e r e i s fuel looks l i k e

leaking from your r i g h t side.

-
* x *

Take your f e e t off t h e brake

I ' m off

-
* x *

(We gonna t a k e em o f f here)

-
Yeah

*Nan I sure didn't see him

E l e c t r i c a l power removed from recorder. End of

recording p e r t a i n i n g t o f l i g h t .

- iv -
 ATTACHMENT No. 1

/
Y I I

ST. CHARLES

i
.i