# NTSB CEN10IA447: Piper PA-32R-301, N8159B, Ripon, WI, July 27, 2010 - Type: NTSB incident investigation - Classification: Incident · No injuries · Incident investigation · Final report - Date: July 27, 2010, 12:15 local (17:15 UTC) - Place: Ripon, WI - Coordinates: 43.840557, -88.840103 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=43.8406&lon=-88.8401&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining events: [Approach: Midair collision](https://openairdocs.org/ntsb-events/250); [Approach: Midair collision](https://openairdocs.org/ntsb-events/250) - Highest injury: No injuries - Injuries: 3 uninjured - Status: Completed, report April 7, 2011 - Report: Approved by Office Director - NTSB office: Central Region - Parties: FAA Flight Standards District Office - NTSB case key (mKey): 76803 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN10IA447 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/76803/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=76803 - Page: https://openairdocs.org/ntsb/CEN10IA447 ## Probable cause (aircraft 1) The inability of either pilot to see the other airplane due to the blind spot created by their respective airplane's wings. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Attention/monitoring: monitoring other aircraft](https://openairdocs.org/ntsb-findings/02021540): Personnel issues › Psychological · Not specified (probable cause), aircraft 1; cases with it: [All aircraft, 231 cases](https://openairdocs.org/ntsb-findings/02021540/cases.md) - [Attention/monitoring: monitoring other aircraft](https://openairdocs.org/ntsb-findings/02021540): Personnel issues › Psychological · Not specified (probable cause), aircraft 2; cases with it: [Piper PA-11, 1 case](https://openairdocs.org/ntsb-findings/02021540/cases.md?model=7101102), [All aircraft, 231 cases](https://openairdocs.org/ntsb-findings/02021540/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach: Midair collision](https://openairdocs.org/ntsb-events/250) (defining event), aircraft 1; cases with it: [All aircraft, 196 cases](https://openairdocs.org/ntsb-events/250/sequence.md) - [Approach: Midair collision](https://openairdocs.org/ntsb-events/250) (defining event), aircraft 2; cases with it: [Piper PA-11, 1 case](https://openairdocs.org/ntsb-events/250/sequence.md?model=7101102), [All aircraft, 196 cases](https://openairdocs.org/ntsb-events/250/sequence.md) ## Analysis (aircraft 1) According to the pilot of the PA-11, a high-wing airplane, prior to entering the arrival route he performed a visual check to look for traffic in the area and then crossed Ripon, WI, at 90 knots and at an altitude of 1,800 feet. According to the pilot of the PA-32, a low-wing airplane, prior to entering the arrival route at Ripon he performed a visual check to look for traffic in the area, slowed to 90 knots, and descended to 1,800 feet. He increased his airspeed to between 95 and 100 knots upon hearing controllers advise pilots to keep their speed up. The pilot of the PA-11 observed the PA-32 come from above him, impact his propeller, and continue past him. Both airplanes landed without further incident. Examination of both airplanes revealed damage indicating a collision between the propeller blade of the PA-11 and the left main landing gear tire of the PA-32. No other damage was noted; an examination of the airframe and systems on both airplanes revealed no preexisting anomalies. ## Factual narrative (aircraft 1) On July 27, 2010, approximately 1215 central daylight time, N8159B, a low-wing Piper PA-32R-301, collided with N78659, a high-wing Piper PA-11, while both airplanes were maneuvering over Ripon, Wisconsin, to fly the FISK visual flight rules (VFR) arrival to Oshkosh (KOSH), Wisconsin. Visual meteorological conditions prevailed at the time of the accident. Both flights were being conducted under the provisions of 14 Code of Federal Regulations Part 91 without flight plans. The commercial pilot aboard the Piper PA-32R-301 and the commercial pilot and passenger aboard the Piper PA-11 were not injured. The Piper PA-32R-301 departed Juneau, Wisconsin, and the Piper PA-11 departed Fort Wayne, Indiana. Both airplanes were en route to KOSH. According to a verbal statement taken from the pilot of N8159B, he was monitoring the frequency for FISK Approach and heard the controllers advise the airplanes to “keep their speed up.” He had joined the arrival route just west of Ripon and was at 1,800 feet mean sea level (msl). Upon hearing the advisory to keep their speeds up, he increased his airspeed to between 95 and 100 knots. He observed a Cessna one mile ahead of him and followed that Cessna. Approximately two miles east of Ripon he heard a soft “thud.” Shortly thereafter he heard another airplane transmit that an airplane had just hit them. He responded that he had hit the other airplane. N8159B continued to KOSH and landed on runway 18 right. During the landing roll, the pilot was not able to maintain directional control and departed the runway to the left. The pilot’s written statement confirmed the verbal statement provided the day of the incident. In addition, he elaborated that prior to arriving at Ripon, he performed S-turns in order to scan for other traffic in the area, and it was at this time that he observed the Cessna. He did not perform any S-turns after Ripon to look for traffic, as the NOTAM prohibits this activity. He also elaborated that he was at 90 knots while approaching Ripon and only increased his airspeed when the controller advised aircraft to “keep their speed up.” He also stated that after passing Ripon his altitude was constant at 1,800 feet msl and was neither climbing or descending prior to or at the time of the impact. He never observed N78659 prior to the impact. When asked to elaborate on what he heard or understood regarding the controller’s statement to “keep their speed up,” he stated that it was not an announcement such as that made when an airport terminal information system (ATIS) is updated but rather a general statement of keeping the speed up to the field. He stated that it was not associated with a specific airplane description and was stated several times during the 15 minutes he had been monitoring FISK prior to the impact. An examination of N8159B revealed damage to the left main landing gear tire and wheel. An examination of the remaining systems revealed no further impact damage and no anomalies. According to averbal statement taken from the pilot of N78659, he was just east of FISK when an airplane struck his airplane from above. The other airplane continued to fly past him to the east and he reported the collision on the FISK frequency. The pilot noted a vibration in the engine; however, he was able to reduce power and continue to KOSH. The pilot performed a straight in landing to runway 09 without further incident. The pilot’s written statement confirmed the verbal statement provided the day of the incident. In addition, he elaborated that prior to flying the required procedure he performed a 360 degree turn to clear for traffic. An examination of N78659 revealed damage to one propeller blade. An examination of the remaining systems revealed no further impact damage and no anomalies. Both aircraft were inbound to KOSH to attend the 2010 AirVenture. At the time, special flight procedures were in effect which were communicated to the aviation community through the Federal Aviation Administration Notice to Airman (NOTAM). This NOTAM was effective from July 23, 2010, through August 2, 2010. The procedures for the FISK VFR arrival to KOSH required pilots to approach Ripon at 1,800 feet or 2,300 feet msl. Aircraft at 1,800 feet were to maintain 90 knots or maximum cruise speed (if slower than 90 knots). After arriving at Ripon, aircraft were to follow the railroad tracks to FISK and then follow air traffic control (ATC) instructions from that point. Both pilots confirmed that they had the NOTAM. The NOTAM is very specific that pilots shall “maintain a minimum of ½ mile in-trail spacing behind the aircraft” they are following. In addition, the NOTAM prohibits S-turns. The EAA AirVenture website page "Understanding Air Traffic Control at EAA AirVenture Oshkosh" states that there may be times when air traffic volume is low and Fisk controllers request pilots to keep their speed up. The page states that if an airplane receives permission to increase their speed, they must remember to reduce their speed back to 90 knots upon passing Fisk. According to an Air Traffic Control Manager, when aircraft receive the instruction to increase speed, they are not expected to climb up to the higher altitude. ## Aircraft 1 - Registration: N8159B (not matched to a registry record) - Reported make and model: PIPER PA-32R-301 - Category: Airplane - Serial number: 32R-8013061 - Airframe hours: 4268 - Engines: LYCOMING IO-540 SER 300 horsepower reciprocating - Damage: Minor damage - Flight: Personal, Part 91 - Operator: Heitzmann Donald F - Registered owner: Heitzmann Donald F - Airworthiness certificate: Standard, Normal - Last inspection: Annual, June 9, 2010 - Departed: KUNU, Juneau, WI - Destination: KOSH, Oshkosh, WI - Airport: runway 18R ## Aircraft 2 - Registration: [N78659](https://openairdocs.org/aircraft/N78659), registered now, S/N 11-1420 (OpenAirDocs) - Reported make and model: PIPER PA-11 - Registry model: [Piper PA-11](https://openairdocs.org/model/piper-pa-11) (registry code 7101102) (OpenAirDocs) - Registry engine: [Continental C90 series](https://openairdocs.org/engine/continental-c90-series) (registry code 17009, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 11-1420 - Airframe hours: 5997.8 - Engines: CONT MOTOR C90 SERIES 95 horsepower reciprocating - Damage: Minor damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, July 1, 2010 - Departed: KDKB, De Kalb, IL - Destination: KOSH, Oshkosh, WI - Airport: runway 09 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot, aircraft N8159B; age 61; injuries: none; commercial; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; last flight review May 10, 2010; seat: left; flight hours: 1,669 total, 1,076 in this make and model, 1,484 as pilot in command, 13 in the last 90 days, 10 in the last 30 days, 1 in the last 24 hours - Pilot, aircraft N78659; age 76; injuries: none; flight instructor, airline transport; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; last flight review September 29, 2009; seat: rear; flight hours: 20,756 total, 5,000 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: 220° at 8 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 82 °F, dew point 70 °F - Altimeter: 29.98 inHg - Observed at: KOSH, 16 nm away ## FAA reports on this event (2) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Incident 20100727039132I](https://openairdocs.org/incident/20100727039132I), Jul 27, 2010: Piper PA-32R-301, Fisk, WI, Minor damage. Pilot stated that he departed msn through juneau (unu). He passed unu 15 min prior to impact. He checked duats last night and did not file a flight plan. He… - [Incident 20100727043192I](https://openairdocs.org/incident/20100727043192I), Jul 27, 2010: Piper PA-11, Fisk, WI, Minor damage. Fisk arrival past ripon, 1800 MSL. Felt impact. Saw plane go ahead of him appeared to be descending. 10 seconds later after controls check, set 1800 RPM.… ## Docket (4 files) The files NTSB released with the investigation on November 30, 2010, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=76803. 5.8 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 - N8159B (item 1, .PDF, 4.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40335279&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1%20-%20N8159B-Redacted.PDF - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 - N78659 (item 2, .PDF, 319 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40338349&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1%20-%20N78659-Redacted.PDF - FAA NOTAM (item 3, .PDF, 159 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40337287&FileExtension=.PDF&FileName=FAA%20NOTAM-Master.PDF - Understanding Air Traffic Control at EAA AirVenture Oshkosh (item 4, .PDF, 682 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40338340&FileExtension=.PDF&FileName=Understanding%20Air%20Traffic%20Control%20at%20EAA%20AirVenture%20Oshkosh-Master.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.