BOMBARDIER INC CL-600-2C10PSA Airlines

the air boss’s and air show event organizer’s lack of an adequate, prebriefed aircraft separation plan for the air show performance, relying instead on the air boss’s real-time deconfliction directives and the see-and-avoid strategy for collision avoidance, which allowed for the loss of separation between the Boeing B-17G and the Bell P-63F airplanes. Also causal was the diminished ability of the accident pilots to see and avoid the other aircraft due to flight path geometry, out-the-window view obscuration by airc…

The failure of both pilots to see and avoid the other airplane. Contributing to the accident were (1) the PA-12 pilot’s decision to fly with a known severe vision deficiency that had resulted in denial of his most recent application for medical certification and (2) the Federal Aviation Administration’s absence of a requirement for airborne traffic advisory systems with aural alerting among operators who carry passengers for hire.

(1) the inherent limitations of the see-and-avoid concept, which made it difficult for the airplane pilot to see the helicopter until the final seconds before the collision, and (2) the Teterboro Airport local controller’s nonpertinent telephone conversation, which distracted him from his air traffic control (ATC) duties, including correcting the airplane pilot’s read back of the Newark Liberty International Airport (EWR) tower frequency and the timely transfer of communications for the accident airplane to the EWR…

The limitations of the see-and-avoid concept as a method for self-separation of aircraft, which resulted in an inflight collision. Contributing to the accident was the absence of collision avoidance technology on both aircraft.

The approach controller's failure to provide an appropriate resolution to the conflict between the F-16 and the Cessna. Contributing to the accident were the inherent limitations of the see-and-avoid concept, resulting in both pilots' inability to take evasive action in time to avert the collision.