Aviation Accident Final Report

flight rules. The pilot reported being on the Turbine/Warbird Arrival, a published arrival procedure used by jets and other high-performance aircraft during the fly-in convention. At 1811:18, the tower controller asked the pilot which runway he would like to use for landing. The pilot replied, "Uh, 18 or 27 would be okay." The tower controller told the pilot to expect a left base to runway 18R and to report over Warbird Island (a geographic reference point used for the approach procedure). At 1813:31, the pilot reported being over Warbird Island. The tower controller cleared the pilot to land on runway 18R and to make his base turn abeam the control tower. The pilot read back the landing clearance correctly. At 1815:23, the tower controller told the pilot to turn northbound, onto a left downwind for the runway. At 1815:54, the controller handling departing aircraft told the pilot of a yellow Piper Cub to taxi in position and hold on runway 18R. The pilot of the yellow Piper Cub acknowledged and requested an "... angled departure to stay clear of faster traffic." An angled-departure is a procedure used by slower aircraft to clear the runway immediately after liftoff by turning across the runway edge. At 1816:10, the controller handling departures transmitted, "Cub uh 18R cleared for takeoff as requested ... cleared for immediate takeoff." (A postaccident review of the cockpit voice recorder [CVR] indicated that the accident pilot was not monitoring the departure frequency, and therefore did not hear the radio Page 4 of 10 CEN10FA443 transmissions made to the departing yellow Piper Cub.) Position data obtained from the accident airplane's enhanced ground proximity warning system (EGPWS) was synchronized with ATC communications. The synchronized data indicated that the accident airplane was turning to base leg when the yellow Piper Cub was cleared for immediate takeoff. At 1816:19, the accident pilot transmitted to the tower controller, "Is ... is 6JR gonna be okay with this?" The tower controller responded, "Affirmative," to which the accident pilot replied, "I don't think so." The EGPWS position data indicated the accident airplane was still turning onto a base leg. At 1816:21, the controller handling departures transmitted, "Cub as soon as you're airborne offset off the runway," and at 1816:33, told the pilot of the yellow Piper Cub to, "... turn left off the runway, traffic short final behind you." At 1816:36, the controller handling departures continued, "Thank you sir, doing a good job." A review of an amateur video synchronized with ATC voice recordings and the EGPWS data indicated that the accident airplane was turning from base to final when the controller transmitted the "good job" comment to the pilot of the yellow Piper Cub. The final segments of the accident flight were below available radar coverage; as a result, radar track data could not be used to establish separation between the accident airplane and the departing yellow Piper Cub. At 1816:35, the CVR recorded the EGPWS announcing "bank angle" five times until 1816:40. During the same time period, the CVR recorded a rapid increase in engine sound. At 1816:40, the accident pilot transmitted "Going around" as the engine sound peaked. Review of the synchronized amateur video showed that the accident airplane had pitched up at that time. Beginning at 1816:41, the CVR recorded a decrease in engine sound over a period of 6 seconds. During the same time period, the EGPWS announced "bank angle" two additional times. At 1816:46, the tower controller acknowledged the go-around stating, "Alright premier jet uh use caution for the uh traffic ahead on the upwind and uh..." During this controller transmission, the CVR recorded an incremental increase of engine sound over 6 seconds until 1816:54. At 1816:54 the EGPWS announced "bank angle" two more times. The engine sound remained steady until the CVR recorded a sound similar to impact at 1816:57. A continuous high-pitched tone was recorded by the CVR immediately before impact. The airplane was equipped with a stall warning horn. A review of available EGPWS position data depicted the accident airplane turning from downwind in a continuous left turn to final for runway 18R. During the final portion of the turn, the recorded bank angles were between 32 and 43 degrees left-wing-down (LWD). The airplane overshot the runway during that turn. The EGPWS data also showed that the airplane descended from 185 feet to 37 feet above the ground (radar altitude) during the turn to final. After the overshoot, the airplane momentarily leveled its wings before entering a climb for about 6 seconds. The airplane climbed from 37 feet to 117 feet above the ground, as it entered a left bank (reaching 30 degrees LWD). The airplane then entered a descending right turn, at an increasingly higher angle-of-attack and rate-of-descent. The maximum bank angle was 44 degrees right-wing-down during the 5 seconds before impact. The angle-of-attack was between 11 and 16 degrees and the maximum descent rate was 1,972 feet per minute during the same time period. The accident airplane's flight path depicted on the amateur video was consistent with the available EGPWS data. During the final descent the airplane's pitch appeared to increase until the airplane entered Page 5 of 10 CEN10FA443 a right bank and struck the grass area west of the runway in a nose down, right wing low attitude. The video showed a yellow Piper Cub appearing after the accident airplane had overshot the final approach. At that time, the wing profile of the yellow Piper Cub was consistent with a southeasterly heading, away from runway 18R. The pilot was interviewed on August 30, 2010, by an Operational Factors investigator with the National Transportation Safety Board (NTSB). The pilot reported that he had departed YIP on an instrument flight rules (IFR) flight plan to Milwaukee, Wisconsin; however, he canceled the flight plan while en route and continued to OSH under visual flight rules. He stated that he flew the Turbine/Warbird Arrival and that the tower controller told him to expect runway 18R. He noted that he was not given an option of available runways. While on base and during his turn to final, he identified two airplanes operating from runway 18R. One of the airplanes was already airborne and approaching the departure end of the runway. The other airplane, a yellow Piper Cub, was on takeoff roll. The accident pilot reported that while on base leg, he became concerned that his descent path to the runway would conflict the Piper Cub that was on takeoff roll. He stated that he overshot the runway during his turn from base to final, and when he completed the turn the accident airplane was right of the runway. The pilot stated that at this point he decided not to land because of a perceived conflict with the departing Piper Cub (which was flying ahead and to the left of the accident airplane). He recalled seeing the yellow Piper Cub over the runway 18R centerline. The pilot reported that he initiated a go-around, increasing engine power slightly, but not to takeoff power, as he looked for additional traffic to avoid. He estimated that he advanced the throttle levers "probably a third of the way to the stop" and, as he looked for traffic, the stall warning stick-shaker and stick-pusher systems activated almost simultaneously as the right wing stalled. He did not recall hearing a stall warning horn sound. He stated that there were no preimpact mechanical malfunctions or failures that would have precluded normal operation of the airplane. The air traffic controllers working the final portion of the accident flight were interviewed on July 28, 2010, by a NTSB Air Traffic Control Investigator. The MOOCOW aircraft spotter/coordinator stated that he was made aware of an inbound Premier IA jet via notification by the control tower supervisor over an FM radio link used for coordination between the control tower and the MOOCOW. The control tower supervisor made two status calls; one as the Premier IA jet was on downwind, and another when it turned onto left base. The aircraft spotter/coordinator stated that in response to the first status call he directed the aircraft communicator (for departing aircraft) to clear the yellow Piper Cub for an immediate takeoff and to sidestep off the runway after liftoff. At that time, the Premier IA jet was in a turn from downwind to base. The aircraft spotter/coordinator reported that the yellow Piper Cub was airborne and clear of the runway before the Premier IA jet turned inbound onto final. The other MOOCOW controllers gave similar statements about the flight path of the Premier IA jet and remarked that it appeared to be going around before it impacted terrain. The tower controller responsible for communicating with arriving aircraft reported that when the accident pilot announced "Going around" the yellow Piper Cub was already airborne and offset from the runway. Several witnesses recalled seeing the yellow Piper Cub offset from runway 18R when the accident occurred. One witness reported that the Piper Cub performed a short-field takeoff and offset after liftoff. The same witness reported that the Piper Cub was between runways 18R and 18L as the Premier jet was turning base to final. Page 6 of 10 CEN10FA443 Pilot Information Certificate: Airline transport Age: 68,Male Airplane Rating(s): Single-engine land; Multi-engine land Seat Occupied: Left Other Aircraft Rating(s): None Restraint Used: Instrument Rating(s): Airplane Second Pilot Present: No Instructor Rating(s): None Toxicology Performed: No Medical Certification: Class 2 With waivers/limitations Last FAA Medical Exam: January 17, 2010 Occupational Pilot: No Last Flight Review or Equivalent: December 9, 2009 Flight Time: 9095 hours (Total, all aircraft), 1406 hours (Total, this make and model), 8464 hours (Pilot In Command, all aircraft), 62 hours (Last 90 days, all aircraft), 17 hours (Last 30 days, all aircraft), 2 hours (Last 24 hours, all aircraft) According to Federal Aviation Administration (FAA) records, the accident pilot, age 68, held an airline transport pilot certificate, issued on May 4, 2007, with airplane single and multi-engine land ratings. The pilot was type-rated in the Cessna 525 (Citation) and the Hawker Beechcraft model 390 (Premier). He also had FAA authorization to fly North American P-51 (Mustang) with an experimental classification. His last aviation medical examination was completed on January 17, 2010, when he was issued a second-class medical certificate with a restriction for corrective lenses. The pilot reported having accumulated 9,095 hours total flight time, of which 8,464 hours were as pilot- in-command. He had accumulated 2,165 hours in single-engine airplanes, 6,930 hours in multi-engine airplanes, 1,641 hours at night, and 857 hours in actual instrument conditions. He had flown approximately 1,425 hours in the accident airplane make/model. The pilot had flown 62 hours during last 90 days, 17 hours during in the 30 days, and 1.5 hours during the previous 24 hours. The pilot's most recent flight review was completed in the accident airplane on December 9, 2009. Page 7 of 10 CEN10FA443 Aircraft and Owner/Operator Information Aircraft Make: Hawker Beechcraft Registration: N6JR Model/Series: 390 Aircraft Category: Airplane Year of Manufacture: Amateur Built: No Airworthiness Certificate: Normal Serial Number: RB-161 Landing Gear Type: Retractable - Tricycle Seats: 8 Date/Type of Last Inspection: February 16, 2010 AAIP Certified Max Gross Wt.: 12500 lbs Time Since Last Inspection: Engines: 2 Turbo fan Airframe Total Time: 1265 Hrs at time of accident Engine Manufacturer: Williams International ELT: Installed, activated, did not aid in locating accident Engine Model/Series: FJ44-2A Registered Owner: Rated Power: 2300 Lbs thrust Operator: Operating Certificate(s) Held: None The accident airplane was a 2006 Hawker Beechcraft model 390 (Premier IA) business jet, serial number (s/n) RB-161. Two Williams International model FJ44-2A turbofan engines powered the airplane. The airplane had a certified maximum takeoff weight of 12,500 pounds. The airplane was equipped for operation under instrument flight rules and in known icing-conditions. The accident airplane was issued a standard airworthiness certificate on September 20, 2006. Roush Fenway Racing, LLC, purchased the airplane on June 22, 2007. The current FAA registration certificate was issued on July 18, 2007. As of July 25, 2010, the airframe and both engines had accumulated a total service time of 1,264.8 hours and 930 takeoff-and-landing cycles. The airplane was maintained under the provisions of a manufacturer inspection program. The last inspection of the airplane was completed on February 16, 2010, at 1,163.1 hours (847 cycles). The static system, altimeter system, automatic pressure altitude reporting system, and transponder were also tested during that inspection. The last recorded maintenance was performed on July 17, 2010, when both main tires were replaced. A postaccident review of the maintenance records found no history of unresolved airworthiness issues. The airplane flight manual provides procedures for a balked landing (go-around) under the Normal Procedures section. The listed procedure requires pilots to first advance engine thrust to takeoff power and establish Vref (reference landing approach speed). After a positive climb is established the pilot should select flaps 10-degrees, landing gear UP, and yaw damp ON. The final checklist items were to select flaps UP, ensure the lift dump handle was LOCKED, and turn the landing light OFF. Page 8 of 10 CEN10FA443 Meteorological Information and Flight Plan Conditions at Accident Site: Visual (VMC) Condition of Light: Day Observation Facility, Elevation: OSH,808 ft msl Distance from Accident Site: 0 Nautical Miles Observation Time: 18:15 Local Direction from Accident Site: Lowest Cloud Condition: Clear Visibility 9 miles Lowest Ceiling: None Visibility (RVR): Wind Speed/Gusts: 11 knots / 16 knots Turbulence Type Forecast/Actual: / Wind Direction: 200° Turbulence Severity Forecast/Actual: / Altimeter Setting: 29.88 inches Hg Temperature/Dew Point: 29°C / 23°C Precipitation and Obscuration: No Obscuration; No Precipitation Departure Point: Ypsilanti, MI (YIP ) Type of Flight Plan Filed: VFR/IFR Destination: Oshkosh, WI (OSH ) Type of Clearance: VFR Departure Time: 17:29 Local Type of Airspace: Class D At 1815, the Wittman Regional Airport (OSH) automated weather observation system reported the following weather conditions: wind from 200 degrees true at 11 knots, gusting to 16 knots; visibility 9 miles; sky clear below 12,000 feet; temperature 29 degrees Celsius; dew point 23 degrees Celsius; altimeter 29.89 inches-of-mercury. The weather observation station also recorded the following 1-minute wind data: At 1815, wind from 196 degrees at 11 knots; peak wind from 205 degrees at 14 knots At 1816, wind from 198 degrees at 10 knots; peak wind from 211 degrees at 13 knots At 1817, wind from 197 degrees at 9 knots; peak wind from 201 degrees at 11 knots At 1818, wind from 196 degrees at 9 knots; peak wind from 214 degrees at 14 knots Airport Information Airport: Wittman Regional Airport OSH Runway Surface Type: Concrete Airport Elevation: 808 ft msl Runway Surface Condition: Dry Runway Used: 18R IFR Approach: None Runway Length/Width: 6700 ft / 150 ft VFR Approach/Landing: Traffic pattern Page 9 of 10 CEN10FA443 Wreckage and Impact Information Crew Injuries: 1 Serious Aircraft Damage: Substantial Passenger Injuries: 1 Serious Aircraft Fire: None Ground Injuries: N/A Aircraft Explosion: None Total Injuries: 2 Serious Latitude, Longitude: 43.975276,-88.558052 The initial point-of-impact (POI) was about 4,300 feet north of the departure end of runway 18R, in a grass drainage ditch between taxiway P and a temporary taxiway used during the fly- in convention. Recovered debris found at the POI was associated with the right wingtip. The wreckage debris path was about 250 feet long, orientated on a 215-degree magnetic heading. The main wreckage consisted of the fuselage, both wings, and empennage. The fuselage was fractured immediately forward of the engines. The wing remained partially attached to the fuselage. All flight control surfaces remained attached to their respective hinges. The wing flaps were found fully extended. The landing gear was extended. The wreckage debris path and accident site were surveyed before the airplane was eventually recovered to a secured area for further examination. No preimpact malfunctions or anomalies were noted during the on-scene examinations of the airframe structure, flight control systems, or two turbofan engines. Injuries to Persons The pilot and passenger were assisted out of the aircraft and transported to the hospital for treatment of their serious, but non-life-threatening injuries. There were no ground injuries. Flight recorders The cockpit voice recorder (CVR), manufactured by L-3 Communications, s/n 352608, was removed from the accident aircraft and sent to the NTSB's laboratory in Washington, D.C., for readout and evaluation. The CVR had not sustained any heat or appreciable impact damage. The CVR contained 30- minutes of digital audio that was stored in solid-state memory modules. The extracted recording consisted of four channels of audio information. Two of the channels were assigned to the captain and first officer audio panels. One channel was assigned the cockpit area microphone. The remaining fourth channel did not contain audio, nor was it required by law to do so. The accident airplane was not equipped with a flight data recorder; however, the airplane was equipped with an enhanced ground proximity warning system (EGPWS) that recorded numerous flight parameters Page 10 of 10 CEN10FA443 after a warning message was issued. The accident flight triggered several recorded warnings while the accident airplane maneuvered toward the runway; as a result, the EGPWS recorded 52 seconds of flight parameter data before impact. The EGPWS also continued to record various parameters for an additional 10 seconds after impact. Administrative Information Investigator In Charge (IIC): Fox, Andrew Additional Participating Persons: Jan Gerstner; FAA - Milwaukee FSDO; Milwaukee, WI Christine Soucy; FAA - Accident Investigation and Prevention; Washington, DC Mike Gibbons; Hawker Beechcraft - Air Safety Investigation; Wichita, KS Robert Ramey; Hawker Beechcraft - Air Safety Investigation; Wichita, KS Original Publish Date: June 12, 2012 Note: The NTSB traveled to the scene of this accident. Investigation Docket: https://data.ntsb.gov/Docket?ProjectID=76778 The National Transportation Safety Board (NTSB), established in 1967, is an independent federal agency mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The NTSB makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of any part of an NTSB report related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report. A factual report that may be admissible under 49 U.S.C. § 1154(b) is available here.