N4BP

HISTORY OF FLIGHT

On July 22, 2015, about 0744 central daylight time, a Piper Malibu PA-46-310P single-engine airplane, N4BP, sustained substantial damage when it impacted runway 27 (6,179 ft by 150 ft, concrete) while landing at the Wittman Regional Airport (OSH), Oshkosh, Wisconsin. The pilot and two passengers sustained serious injuries and two passengers sustained minor injuries. The airplane was registered to DLM Holding Group LLC and operated by the pilot under the provisions of the 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed at the time of the accident and no flight plan was filed. The flight departed the Southwest Michigan Regional Airport (BEH), Benton Harbor, Michigan, about 0730 eastern daylight time.

The pilot reported that he departed BEH and overflew Kenosha, Burlington, Hartford, Ripon, and Fisk, Wisconsin. He then proceeded to fly the Fisk arrival procedures for runway 27 which were in use per the notice to airmen (NOTAM) for the EAA AirVenture 2015 air show at OSH. The pilot reported that he entered the right downwind leg for runway 27 at 1,800 ft and started to descend while maintaining 90 kts airspeed. He reported that he was instructed by air traffic control (ATC) to turn onto the base leg abeam the runway numbers and to land on the green dot (located about 2,500 ft from the runway 27 displaced threshold). After he started the base turn, he observed a twin-engine airplane taxi onto runway 27 and start its takeoff roll. (A passenger in the Malibu identified the airplane on the runway as a Cessna "high-wing 4-seater") The pilot was concerned about the airplane on the runway and was worried about a collision. The pilot reported that ATC instructed him to continue the approach and land on the orange dot (located about 1,000 ft from the runway 27 displaced threshold) instead of the green dot. The pilot considered doing a go-around, but decided to continue the approach. He reported that about 250 to 300 ft above ground level, he pulled back on the power which resulted in the airplane entering a stall. He attempted to recover by adding full power, but the airplane impacted the runway in a right wing low, nose down attitude. The right wing hit the runway which resulted in an explosion with fire and black smoke rising above the accident site. The right wing separated from the airplane and landed in the grass on the south side of the runway. The airplane skidded on its belly and came to rest on the left side of the runway about 278 ft from the initial impact point. The left wing was partially separated from the fuselage and there was a fire under the left wing.

The two passengers who were sitting in the middle, rear-facing seats, and the passenger sitting in the rear seat exited the airplane with assistance from the pilot and people who arrived at the site soon after the accident. The Crash Fire Rescue (CFR) personnel arrived at the scene and used foam to put out the fire. The passenger sitting in the copilot's seat was extracted from the wreckage by the CFR. All five survivors were taken to local hospitals for treatment.

Numerous witnesses reported that they saw the airplane on the base leg as it entered a steep right bank and impact the terrain in a steep nose down, right wing low attitude. One witness reported that he was located on the terminal ramp to the north of the approach end of runway 27. He heard an aircraft approaching from over the terminal building and observed that the airplane was very low – less than 200 ft above ground level (agl). The witness said that there was no indication that the airplane was in distress, such as a sputtering engine. He further reported that the airplane entered a steep right turn, with an estimated angle of bank of over 60 degrees and then impacted on its side with the right wing contacting the ground first.

AIR TRAFFIC CONTROL COMMUNICATIONS

Special procedures and staffing for ATC were in effect during the Experimental Aircraft Association's AirVenture event. The North Local Control (NLC) team was located in the control tower. The team consisted of five controllers: two spotters, one communicator, a team leader, and a front-line manager (FLM) overseeing the operation. At the time of the accident, the NLC team was responsible for issuing landing clearances on runway 27. The Itinerant Mobile (IM) team, who had overall responsibility for ATC departure operations on runway 27, was working from a Mobile Operations Communications Workstation (MOOCOW) located at the intersection of runway 27 and taxiway A. The IM team was responsible for clearing aircraft for takeoff on runway 27 and consisted of four controllers: an aircraft communicator (AC), one spotter/coordinator, and two "crossers" who work directly with aircraft holding for departure on the taxiway. Communication between the IM and NLC teams was conducted via portable FM (frequency modulation) radios used by the MOOCOW AC and the NLC FLM, although coordination was kept to a minimum. The IM team was responsible for ensuring separation between arrivals and departures by monitoring the inbound pattern traffic and releasing departures when there was sufficient time to do so before the next aircraft landed.

Instructions for the Fisk arrival contained in the AirVenture NOTAM direct pilots to minimize radio transmissions and not respond to ATC communications. Review of recorded transmissions from the NLC team and the IM team showed that at 0742:24, the NLC communicator instructed a Malibu on downwind for runway 27 to begin descent. At 0742:44, the Malibu pilot was told to, "…turn abeam the numbers, runway 27 green dot cleared to land."

Before and during the period the Malibu was operating in the traffic pattern, the IM team was clearing departures for takeoff from runway 27. Between 0730 and 0743 there were about 22 departures. The last departure before the accident was "Cessna 44Q", cleared for takeoff at 0743:03. The IM communicator then continued, "44Q roll it around the corner – scoot!"

At 0743:11, the NLC communicator transmitted, "Malibu I've got somebody on the runway – keep it coming around keep it coming around cleared to land runway 27 orange dot, land as soon as you can."

At 0743:23, the IM communicator transmitted, "Don't turn your back – don't turn your back!"

There were no further transmissions on the IM frequency.

The tower controllers notified airport firefighters to respond, extinguish the post-crash fire, and assist the aircraft's occupants.

The IM communicator reported that the Malibu looked "normal" on downwind over the gravel pit, but the next time he saw it, the aircraft looked unusually low for a runway 27 arrival. The Malibu was west of the terminal building and had not yet started to turn right base. The next departure was holding short between 125 and 250 feet from the runway. Traffic was very light, and there were no other aircraft waiting to depart. The communicator cleared the Cessna for takeoff. The communicator then observed that the Malibu was lower and "tighter" on base than he expected, so he went on frequency and told the Cessna pilot to hurry up. The Cessna pilot never stopped, and made a rolling takeoff as requested. The Malibu was over the terminal building and then turning toward the runway. The communicator reported that by then, the departing Cessna was rolling and approaching or beyond the green dot on the runway.

The communicator reported that the Malibu was on downwind west of the terminal building, and had not turned base yet when the Cessna was cleared for takeoff. He stated that controllers try to use minimum spacing during AirVenture, and to expedite traffic to avoid go-arounds. Because arriving aircraft were on the NLC frequency, the IM communicator could not directly instruct a pilot to go around. Should a go-around appear necessary, the IM team would contact the tower FLM via FM radio and the FLM would either override the tower frequency and send the aircraft around or ask the tower communicator to do so. The communicator stated that he had no reluctance to call for a go-around if he perceived an unsafe situation.

The communicator reported that while the Malibu was turning from downwind to base, it looked like it was making a continuous turn to final. Partway down the curving "base" leg, it briefly rolled wings level and was heading straight southbound. The Malibu was "very low" at that point. The communicator reported that the airplane overshot the final approach course and rolled into a very steep bank to try to line up with the runway. The wings looked almost perpendicular to the ground. He made the "don't turn your back" radio transmission, which was directed at one of the spotters, because the Malibu was in an unusual maneuver and the spotter needed to watch out for it.

Runway Separation

Under normal circumstances, controllers would be required to maintain at least 3,000 ft of separation between a departing Cessna and an arriving Malibu using the same runway. According to the reduced runway separation standards authorized during AirVenture, the minimum required distance between the arriving Malibu and the departing Cessna was 1,500 ft when the Malibu reached the runway threshold.

PERSONNEL INFORMATION

The 46-year-old pilot held a private pilot certificate with a single-engine land rating and an airplane instrument rating. He reported that he had 934 total hours of flight time with 130 hours in make and model. He held a third class medical certificate that was issued on December 3, 2014, with no limitations.

The pilot reported that he had flown to OSH during the EAA AirVenture Airshow numerous times and was familiar with the procedures for flying to OSH during the week of the airshow. He reported that on the morning of the accident, the airplane traffic was light and there was no other airplane on downwind when he was landing. He reported that he was s...