Panic on the Schoolyard: The Merion midair collision (death of Senator John Heinz)
On the 4th of April 1991, a hired Piper Aerostar carrying Pennsylvania Senator John Heinz experienced a landing gear problem while on approach to Philadelphia. Unsure whether the landing gear was down and locked, the pilots asked for help, and the pilot of a nearby helicopter offered to fly underneath the plane and look at the landing gear. As the two aircraft flew in formation over the suburb of Lower Merion, something went horribly wrong: without warning, the helicopter struck the airplane from below, sending debris flying in all directions. As pieces of the aircraft rained over an area of several square blocks, the fuselage of the helicopter crashed to earth in the playground of an elementary school where recess was underway, killing two six-year-old schoolgirls along with both pilots. Simultaneously, the Piper Aerostar crashed on the school’s front lawn, killing Senator Heinz and the two crewmembers. The bizarre and tragic crash shocked the nation and left a school in mourning. But how could such an outlandish accident occur in the first place? It would be up to the NTSB to reveal the chain of bad decisions that led to the deaths of seven people at Merion Elementary.
For Senator John Heinz of Pennsylvania, April 4th 1991 was to be a day as busy as any other. It was Easter break and the United States Senate was on recess, but the work of a Senator stops for nothing, and today Heinz had a packed schedule. He was to meet with the editorial board of the Philadelphia Inquirer, attend a meeting of the town council in the Philadelphia suburb of Media, and attend a field hearing for the Senate Special Committee on Aging, where he was to speak about Medicare and telephone scams. During the 14 years following his election to the Senate in 1977, the moderate Republican had enjoyed strong popularity, and his presence was constantly in demand. A member of the famous Heinz family, heirs to the food company best known for Heinz ketchup, his real name was Henry John Heinz III, but he preferred to go by John.
Heinz started his day in the town of Williamsport in central Pennsylvania, where he briefed the media on his efforts to get funding for a local highway. To get from Williamsport to his scheduled events in Philadelphia, he hired the air charter company Lycoming Air Services, which was based at Williamsport-Lycoming County Airport. The small company offered mainly private charters using small planes, including the Piper Aerostar PA-60, a twin-engine single-pilot airplane with room for five passengers. Although the Aerostar could be flown by only one pilot, Heinz was a private pilot himself and always had an eye for safety, and he insisted on flying with two crewmembers in the cockpit whenever he flew with Lycoming Air Services (which was quite often). Today, the two pilots with Heinz were Captain Richard Schreck, a local Pennsylvanian; and First Officer Trond Stegen, who was from Norway. Schreck would be doing most of the flying while Stegen monitored the instruments. Schreck would need the monitoring: he had, at most, 114 hours on the Piper Aerostar, and this was only his second revenue flight. To his (probable) disappointment, the first one had been cut short by an engine failure.
The Aerostar departed Williamsport at 10:22 a.m. with only the two pilots and Senator Heinz on board. Approximately one and a half hours later, the flight was on approach to runway 17 at Philadelphia International Airport when the pilots encountered a problem: when Captain Schreck lowered the landing gear, the green light indicating that the nose gear was locked did not illuminate. He called air traffic control and informed them that he didn’t have a safe nose gear indication, and stated that he might need to cycle the gear. He presumably did this, to no effect.
Meanwhile, a Bell 412SP helicopter was preparing to depart a helipad at Philadelphia International Airport. The helicopter belonged to Sun Company Inc., formerly known as Sun Oil and later as Sunoco, a petroleum distribution company which owns the Sunoco gas station chain, among other facilities. The helicopter was used to transport company executives, and it had in fact just dropped off two executives to catch a flight out of Philadelphia; now the crew was ferrying the empty aircraft back to the Sun Company corporate headquarters. In command were two experienced helicopter pilots: Captain Charles Burke and First Officer Michael Pozzani, who both had over 8,000 flying hours.
Once the helicopter took off, air traffic control ordered the Aerostar to level off at 1,500 feet to let the helicopter pass underneath as it departed the airport. As the helicopter passed under the plane, the pilots decided to look up and check the status of the Aerostar’s landing gear, which they had heard might not be working. “That Aerostar that went past us, looks like the gear is down,” First Officer Pozzani reported over the ATC frequency.
But Captain Schreck on the Aerostar already knew that. On the Piper Aerostar, it was possible to see the nose gear reflected in the shiny propeller spinners, a trick which Aerostar pilots were taught from the beginning. “I can tell it’s down, but I don’t know if it’s locked,” Schreck clarified over the radio. “That’s the only problem.” Anticipating the possibility that the Aerostar’s nose gear could collapse on landing, the controller notified the fire trucks to stand by, and cleared the flight to land. But then he offered another suggestion: did the Aerostar pilots want to do a low fly-by of the control tower, so the controllers could check the status of the landing gear? Schreck agreed to the suggestion. But about 30 seconds later, Captain Burke on the helicopter chimed in with his own offer: “We could take a real close look at that if you wanted.” He began to turn the helicopter around in case the Aerostar requested his help inspecting the landing gear.
The problem with these suggestions was that the locking mechanism on the Piper Aerostar’s nose gear is not visible from the outside — the only way to see whether the gear is properly locked in place would be to stick one’s head up in the wheel well, something which obviously can’t be done in the air. As a qualified Aerostar captain, Schreck should have known this. But for whatever reason, he accepted the control tower’s offer anyway, and at around 12:05, he flew past the tower at low altitude. The controller informed him that the gear was down, to which Schreck again replied that he knew it was down but wanted to know if it was locked. In response, the controller relayed the helicopter crew’s offer to fly close to the Aerostar for a more thorough inspection, which Schreck accepted.
The Piper Aerostar now performed a 180-degree left turn onto a northwest-bound trajectory, paralleling the runway but headed away from the airport. The controller provided the helicopter with vectors to intercept the Aerostar, and shortly before 12:08 the two crews announced that they had each other in sight. The pilots agreed on a speed of 125 knots and an altitude of 1,100 feet for the interception, and the controller warned them to keep an eye out for some tall radio antennas about 11 kilometers ahead. “We’re going to come up behind you on your left side, so just hold your heading,” said Captain Burke on the helicopter. Captain Schreck on the Aerostar acknowledged, but stated that he would need to modify his course by 15 degrees to the left to avoid the radio antennas.
After about thirty seconds trailing slightly below, behind, and to the left of the Aerostar, the helicopter pilots announced, “Aerostar, we’re gonna pass around to your right side now, take a look at everything as we go by.”
“Okay,” replied Captain Schreck.
However, the helicopter pilots were having a hard time seeing the landing gear locking mechanism, for obvious reasons. Further complicating their task was that the helicopter’s “eyebrow windows” — a pair of windows above each pilot’s windscreen that would allow them to look nearly straight up — had been painted over. The Bell 412 initially hadn’t been certified for use at night and in clouds, and when it was undergoing examination to receive this certification, it was discovered that flickering lights reflected off the main rotor were being cast straight through the eyebrow windows and into the pilots’ eyes, inducing a nauseating sensation called “flicker vertigo.” Consequently, the eyebrow windows were painted over. This meant that the pilots of the helicopter had to look up through the top edge of their main windscreens to see the Aerostar’s landing gear, which forced them to move closer to the plane in order to get a good view. From this position, the Aerostar pilots were unable to see the helicopter trailing just a few meters behind and below them. The unusual formation flight caught the attention of witnesses on the ground, who began to watch as the two aircraft proceeded northwest over a suburban area in Lower Merion Township.
At 12:10, after a little under three minutes of formation flying, First Officer Pozzani on the helicopter reported that “everything looks good from here.”
“Okay, appreciate that,” replied Captain Schreck on the Aerostar. “We’ll start to turn in.”
But just seconds later, something went terribly wrong. Perhaps the Aerostar hit a pocket of turbulence caused by the helicopter’s rotor and descended slightly, or perhaps the helicopter began to climb away before the Aerostar had cleared the area. Who exactly hit whom is not known with any certainty. The consequences, however, were catastrophic: as the helicopter and the Aerostar came together, the plane was fed through the helicopter’s rotor blades like some kind of unholy blender. The blades first ripped off the landing gear, followed a fraction of a second later by large chunks of the right wing and lower fuselage. The Aerostar all but disintegrated in midair, throwing wreckage in every conceivable direction. The helicopter’s rotor blades quickly sheared off and launched themselves away through the blossoming debris cloud, while the powerless helicopter dropped like a rock out of the sky.
At the moment of the collision, the two aircraft were flying over Merion Elementary School, where 500 students were half way through their school day. On the school playground, several dozen first and second graders were enjoying their noon recess, unaware of the events unfolding in the sky above them. But then, volunteer supervisor Tho Oldham heard the sound of the helicopter followed by the noise of the collision — a noise that transported her back to her native Vietnam, where such sounds always heralded trouble. She instantly blew her whistle to call the kids in from recess, and the children began to run for the school building. But not fast enough: from 1,000 feet over the school, the crippled helicopter plunged directly onto the playground, triggering a massive explosion. The crash instantly killed two six-year-old girls and the helicopter pilots. Two more children were struck and injured by flying debris, while a young boy, his jacket showered in aviation fuel, ran burning into the school’s main hallway. The school custodian, without regard for his own safety, grabbed the boy and tore away the flaming jacket with his bare hands, saving his life.
The crash plunged the entire neighborhood into chaos. The helicopter was the center of attention, but the remains of the Piper Aerostar also crashed on the grounds of Merion Elementary, coming to rest on the front lawn. Both pilots and Senator John Heinz were killed instantly. Pieces of the two aircraft had also rained down over an area of several square blocks, coming down like grisly hail onto residents’ rooftops and yards. Upon seeing the crash, or hearing about it from others, parents rushed to the school to search for their children. The horror they felt cannot be described with words. Most parents arrived to tearful reunions with their kids, thankful that they were safe, but everyone knew that two families would not be so lucky.
As panic gripped the parents of Lower Merion Township, news of the death of Senator Heinz struck equally hard in America’s halls of government. The death of the popular senator at the age of just 52 was a shocking surprise; at his office in the capitol building, aides were seen leaving in tears. Both the local community and the nation at large wanted to know: how could this happen?
The National Transportation Safety Board didn’t have a lot to work with in its investigation: neither aircraft had a flight data recorder, and although the helicopter was equipped with a cockpit voice recorder, it hadn’t been installed properly and had only recorded incoming radio transmissions and background noise, without outbound transmissions or cockpit conversations. Like most accidents involving small planes, the cause had to be determined by examining the wreckage and listening to the air traffic control tapes.
From the first reports on the crash, it was already known that the plane and the helicopter had collided while attempting a close inspection of the Aerostar’s landing gear. The maneuver appeared to have gone without a hitch right up until the moment the two aircraft decided to part ways, at which point they collided. Markings on the wreckage showed that the helicopter’s rotor blades had impacted the plane from below, but witness statements were contradictory on whether the plane descended into the helicopter or the helicopter ascended into the plane. It was also possible that the answer was both: when one aircraft flies below another, it can cause aerodynamic interference which pushes the nose of the upper plane down and the nose of the lower plane up, potentially causing a collision if safe distance is not maintained or the pilots are not prepared to react. Based on the statements of witnesses, the two aircraft were indeed quite close together — close enough that a last-second avoidance maneuver by the helicopter pilots, which was picked up in the background noise on the CVR, proved unsuccessful.
But in the grand scheme of things, it didn’t really matter who hit whom. The real question was why the pilots of the two aircraft attempted this maneuver in the first place. Because the locking mechanism on the Aerostar’s nose gear is not visible from outside the plane, there was no point in doing a flyby or an intercept. Even on other aircraft types, the usefulness of such an inspection would have been doubtful. The crew of the Aerostar should have known this, and indeed the first officer on the helicopter should have known this as well, as he had previous experience on the Piper Aerostar. But even if they believed it was possible to see whether the gear was locked, the decision to let the helicopter look at the plane from close range made no sense from the standpoint of risk. Even if the nose gear were to collapse on landing, the nose of the Piper Aerostar sits less than a meter off the ground, so it would be hard to imagine anyone being injured in such an occurrence. In contrast, flying in formation with a helicopter comes with all kinds of hidden dangers. Aerodynamic interference can cause the two aircraft to suddenly collide, or someone could make a sudden move that results in a collision. Neither crew had any experience flying in formation with other aircraft (a risk factor in and of itself), but no such experience was required to imagine these dangers.
Once they made the questionable decision to go through with the mid-air inspection, the two crews could have followed some basic ground rules that would have minimized the safety risk associated with the maneuver. These included establishing a minimum safe distance, keeping within sight of each other at all times, designating one aircraft as the lead plane, and agreeing on all movements beforehand. The pilots observed none of these rules — they did not decide how close was too close, the helicopter flew where the Aerostar pilots couldn’t see it, and after the initial planning phase there was very little radio communication between the two crews. It would have been difficult or even impossible for the Aerostar crew to know where the helicopter was located during the entire maneuver, violating one of the basic principles of formation flying. Thus, Captain Schreck and First Officer Stegen completely handed over the safety responsibility to helicopter pilots Burke and Pozzani, who now bore sole responsibility for keeping a safe distance away from the airplane. However, they appeared not to recognize this responsibility, and they ultimately got far too close, probably in an attempt to see the landing gear through the forward windscreen, since the eyebrow windows were blocked.
All of this was doubly tragic because the Aerostar pilots had a foolproof way to check whether the gear was locked. According to the Piper Aerostar’s emergency gear extension procedures, it was possible to determine the status of the landing gear by throttling the engines back to idle and listening for the landing gear warning horn. If the gear isn’t locked, the warning horn will sound to alert the crew that the gear is not down; if it doesn’t sound, then the gear is properly locked. This procedure had been mentioned during training. But if the crew tried to find it on the accident flight, they almost certainly would have failed. Instead of being filed under the “emergency procedures” section in the flight operations manual, the procedure was buried under a chapter on the aircraft’s hydraulic system. The procedure was originally written as a way to verify that the gear had locked in place properly in the event of a hydraulic system failure, where the gear would have to drop into place under the force of gravity. It was apparently not considered that the procedure might be useful any time the pilots are unsure whether the gear is down and locked.
Moving on to operational factors, the NTSB found several items in the training history of both crews which shed some light on the events. Both pilots of the helicopter had plenty of experience with no major training issues, but Sun Company Aviation did have a history of being a “good neighbor” and using its helicopters to help others in need, especially controllers and other pilots. They had never attempted a mid-air inspection of another aircraft, but in anticipation of the possibility, the chief pilot had instructed crews to keep at least 300 feet away from the other aircraft during such a maneuver. Although Burke and Pozzani violated this rule, it was clear that offering to inspect another aircraft was not at all out of character for a Sun Company crew.
The history of Captain Schreck on the Aerostar was much more troubling. This was only his second revenue flight, and his first flight had already revealed some worrying tendencies. On that flight, he flew a single passenger who was an executive at the company that made the Aerostar’s engines, and who also happened to be a qualified Aerostar pilot with considerably more experience than Captain Schreck. This executive observed that Schreck grossly overcontrolled the aircraft using the nose wheel steering during the takeoff roll, to the point that the executive became concerned. After they reached cruising altitude, the engine began surging; having participated in the design of the engine, the executive suspected a mechanical failure, but Schreck appeared not to react, and he had to convince him to return to the airport. After landing, a serious malfunction was discovered. On top of this, at least 42 of his 114 total flight hours on the Aerostar had to be called into question. He acquired these hours while flying in the first officer position, but in practice an Aerostar first officer at Lycoming Air Services was basically a glorified passenger. Since a single pilot was the default configuration on the Piper Aerostar, captains tended to do everything by themselves, leaving little for the first officer. Any hours accrued in the first officer position were therefore of dubious value. Schreck’s useful time on the Aerostar might actually have been less than 72 hours.
This tendency to ignore the first officer may have played a role in the crash. On the accident flight, instead of splitting his duties across both crewmembers, Schreck probably continued to do everything that he would do if he were the only pilot — based on the evidence, he was most likely handling the radio, flying the plane, and troubleshooting the landing gear, all at the same time. He should have designated the secondary tasks to First Officer Stegen, and while it can’t be known with certainty what Stegen was doing during the flight, it was likely that he remained sidelined, just like the first officers on most two-pilot flights at Lycoming Air Services. But if there was ever a time to split the duties, it was on this flight. Distributing the workload would have allowed Schreck to think through his options more clearly and keep better tabs on the helicopter. It was this excessive workload, combined with his extreme inexperience, which probably led him to abdicate responsibility for maintaining a safe distance between his plane and the helicopter.
Interviews with the Federal Aviation Administration inspector assigned to Lycoming Air Services revealed that the problem wasn’t Schreck — it was the whole company. In December 1990, the inspector conducted check rides on two Lycoming pilots, and both failed. On the second attempt, one of the pilots passed, but the other one failed again. As a result of this sorry episode, the inspector audited the company’s paperwork and found numerous major discrepancies, which he gave the company a deadline of 30 days to fix. Later, the inspector rode along with the company’s chief pilot, who was conducting a check ride. The chief pilot’s performance was so bad that the inspector had to revoke his check airman certificate and send him to retraining. These events left serious questions about the quality of the pilots at Lycoming Air Services. But the FAA inspector had a lot on his plate: Lycoming was one of no less than 17 different air operator certificate holders under his purview, one of which was a scheduled commuter airline that needed a large amount of oversight. He didn’t even get a chance to visit Lycoming Air Services’ headquarters until four months after he was appointed, and he had no time to examine their operations beyond the surface level.
In its final report on the crash, the NTSB recommended that the FAA update the Airman’s Information Manual to describe the dangers of deliberately flying close to other aircraft; that the emergency gear extension procedures be moved to the “emergency procedures” section of the Piper Aerostar’s flight manual; and that the FAA work out how to reduce the workload on its inspectors. As a result of the findings, the FAA also issued a notice to the company that installed the helicopter’s cockpit voice recorder regarding the incorrect installation, and disseminated clearer installation instructions to all facilities that worked with this type of CVR.
At the end of the day, however, the main problem that led to the crash was poor judgment. In hindsight, it’s hard to understand how two qualified crews thought it would be a good idea to fly a helicopter underneath an airplane to try to see whether the nose gear was locked. Both crews massively overestimated their own skill levels and underestimated the risk to their own lives and the lives of people on the ground. However, no matter how it got into their heads in the first place, this half-baked idea could have been stopped in its tracks if the pilots of either aircraft had taken a moment to think critically about the situation and make an objective decision. This is a skill referred to in the industry as aeronautical decisionmaking. The FAA had already put out several very useful publications on aeronautical decisionmaking by the time of the crash, which were circulated widely among pilots at major airlines. But at a tiny charter company like Lycoming Air Services, these publications might as well have never existed. On top of the other recommendations already mentioned, the NTSB recommended that the FAA more aggressively distribute its articles on aeronautical decisionmaking to make sure they penetrate even the most overlooked corners of the commercial aviation industry. Today, this skill is an integral part of the training process at airlines around the world. And it’s not just useful for pilots: how many times in your life would it have been useful to step back and objectively assess the risks versus the rewards before you made a big decision (or even a small one)? If these pilots had done that, they, along with Senator Heinz and two innocent children, might still be alive.
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In memory of the two first graders, Lauren Freundlich and Rachel Blum, both taken much too soon. May they rest in peace.
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