The Transportation Safety Board of Canada (TSB) released its investigation report Thursday into the mid-air collision between a Piper PA-28 and a Beechcraft Bonanza on May 28, 2012.
"This accident shows once again that the see-and-avoid principle is inadequate for preventing collisions between aircraft flying under visual flight rules (VFR)," said Jon Lee, TSB's Investigator-in-Charge. "Additional defenses must be put in place to prevent mid-air collisions among VFR aircraft."
The Piper (tail number N23C) was registered to and piloted by Federal Aviation Administration (FAA) employee Thomas Proven, and the Beechcraft (tail number N6658R) was registered to and piloted by National Transportation Safety Board (NTSB) employee James Duncan. Given the unique circumstances surrounding the ownership and operation of the aircraft, the TSB accepted delegation of the accident investigation from the NTSB in accordance with international convention.
The Beechcraft was in a shallow climb, headed southbound, being operated VFR for the purposes of a biennial flight review. The Piper was in level flight, under VFR, and was heading in a southeasterly direction. The aircraft collided at approximately 1,800 feet above sea level just after 4 p.m. EDT in the area of Warrenton, Va.
The Beechcraft broke up in flight and the pilot and flight instructor on board were fatally injured. Proven, the sole occupant of the Piper, conducted a forced landing in a pasture approximately six nautical miles south of the Warrenton-Fauquier Airport.
“The TSB remains concerned that yet again, the defenses available to avert a mid-air collision between VFR aircraft in congested airspace have failed,” the board said in their report. “As VFR traffic increases, additional lines of defense should be considered to reduce the risk of a mid-air collision. These include changes in airspace classification, increased air traffic control intervention, ground-based and on board technology.
“A meaningful improvement to the ability to see-and-avoid other VFR aircraft may require on board technology capable of directly alerting pilots to the proximity of conflicting traffic. A number of viable and economical on board alerting systems exist or are under development. Had one or both of these aircraft been equipped with some form of the technology, the risk of collision would have been reduced. The report identified that there is a high risk of mid-air collision in congested airspace when aircraft are not alerted to the presence of another aircraft and rely solely on the see-and-avoid principle.”