# NTSB CHI02FA200: Piper PA-20, N1592A, Oshkosh, WI, July 21, 2002 - Type: NTSB accident investigation - Classification: Accident · No injuries · Field investigation · Final report - Date: July 21, 2002, 15:20 local (20:20 UTC) - Place: Oshkosh, WI - Coordinates: 43.984165, -88.556945 - Nearby events: https://openairdocs.org/map.md?lat=43.9842&lon=-88.5569&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report April 18, 2003 - Report: Approved by Office Director - Parties: FAA, Milwaukee, WI FSDO - NTSB case key (mKey): 55284 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CHI02FA200 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/55284/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=55284 - Page: https://openairdocs.org/ntsb/CHI02FA200 ## Probable cause Inadequate visual lookout by both the accident pilot and the pilot of the other airplane. An additional cause is the arrival procedure used which resulted in a congested traffic pattern and the subsequent inadequate visual separation of the airplanes. Factors associated with the accident are the gusty crosswind, the pilot of the other aircraft landed longer than ATC expected, and the stall/spin encountered during the pilot's attempted remedial action. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Near collision between aircraft, landing - visual lookout - inadequate, pilot in command (cause) - visual lookout - inadequate, pilot of other aircraft (cause) - proper touchdown point - exceeded, pilot of other aircraft (contributing factor) - traffic pattern procedure - congested (cause) - visual separation - inadequate, faa(other/organization) (cause) - Abrupt maneuver, landing - flare/touchdown - remedial action - attempted, pilot in command - Loss of control - in flight, landing - weather condition - crosswind (contributing factor) - weather condition - gusts (contributing factor) - stall/spin - encountered (contributing factor) - In flight collision with terrain/water, descent - uncontrolled ## Analysis The PA-20 collided with the runway following an abrupt maneuver to avoid another airplane. The accident occurred during EAA AirVenture 2002, at Oshkosh, Wisconsin. The PA-20 pilot was cleared to land on the "orange dot" (1,500 from the threshold) on runway 27. A Cessna 172 was cleared to land on the numbers of runway 27. The PA-20 pilot reported that during his landing flare, he saw the Cessna 172 underneath his airplane. He pulled up and to the right to avoid a collision with the other Cessna 172. He stated he added full throttle and leveled the nose, but a strong wind from the left rolled the airplane to the left and "without enough airspeed for effective aileron" he could not reverse the roll. The airplane stalled and spun into the runway from an altitude of about 120 feet. The pilot of the Cessna 172 reported that there was a fairly strong left crosswind and that his airplane floated a little on the runway before touching down. Neither pilot reported seeing the other. The Cessna 172 pilot reported that he was unaware that an accident had occurred. Winds at the time of the accident were from 230 degrees at 12 knots gusting to 22 knots. As announced on the airport terminal information service (ATIS), the VFR Oshkosh Arrival, Yellow Flow procedures were in effect at the time of the accident. The Yellow Flow instructs pilots to join the other traffic over over a VFR checkpoint. The traffic then travels around the northwest side of the airport, entering a right base leg for either runway 18L or 18R. In addition to landing VFR traffic on runway 18L and 18R, air traffic control (ATC) was landing VFR traffic on runway 27. This was accomplished by having the VFR traffic extend their base leg for the 18 runways, putting them on a right downwind for runway 27. The VFR landings on runway 27 were not outlined as part of the Yellow Flow procedures. The only landings on runway 27 that are a part of the procedure were IFR arrivals approaching the airport from the east and warbirds who were to approach the airport from the southeast. Neither airplane was issued go-around procedures from ATC. The PA-20 pilot reported that his passenger recalled hearing an ATC transmission about an airplane underneath them, but by this time he had already pulled up and it was too late. T ## Factual narrative On July 21, 2002, at 1520 central daylight time, a Piper PA-20, N1592A, collided with the runway following an abrupt maneuver and loss of control while avoiding another airplane during a landing on runway 27 (6,178 feet by 150 feet, dry asphalt) at Wittman Regional Airport (OSH), Oshkosh, Wisconsin. The private pilot and a passenger on board were not injured. The airplane was substantially damaged. The Title 14 CFR Part 91 flight was operating in visual meteorological conditions and a visual flight rules flight plan had been filed. The purpose of the flight was for the pilot to attend Experimental Aircraft Association (EAA) AirVenture 2002, Oshkosh, Wisconsin. The pilot reported the last stop on the cross-country flight was at Mount Pleasant, Michigan. He reported that they departed there about 1315 for OSH. He reported he entered the OSH traffic at Rippon where he was identified as the "high wing tail dragger." He was instructed to follow a Bonanza along the tracks to Fisk. At Fisk, he was instructed to change to the tower frequency and to follow the Bonanza for a landing on runway 27. The pilot stated he flew the approach at 1,800 feet mean sea level at an airspeed of 90 knots. The pilot reported that while on final approach, he had to "roll hard left" to avoid a twin-engine airplane that was landing on runway 18. The pilot reported he was cleared to land on the "orange dot" on runway 27. He stated, "I was preparing to land on orange dot with full flaps, throttle back when an all metal tricycle geared plane possibly a 172 Cessna appeared directly under my nose." The pilot reported that he pulled up and to the right to avoid a collision with the other airplane. He added full throttle and leveled the nose, but a strong wind from the left rolled the airplane to the left and "without enough airspeed for effective aileron" he could not reverse the roll. The pilot reported the airplane stalled and spun into the runway from an altitude of about 120 feet above the runway. The pilot reported that the airplane that appeared under him was already on the runway, and that he did not hear any radio calls regarding this airplane. He was on the tower frequency of 118.5. The pilot reported that his passenger later stated that he recalled a radio transmission about an airplane being underneath them, but by that time he already had pulled up and it was too late. He stated that it was his impression that this airplane that appeared underneath him had landed on the numbers. Weather conditions reported at OSH, 27 minutes prior to the accident, consisted of clear skies with the winds from 230 degrees at 12 knots gusting to 22 knots. A transcript of the OSH Air Traffic Controller Tower communications is attached to this report. It should be noted that during EAA AirVenture VFR aircraft are not identified by N-number. They are identified by make and model, color, wing configuration, or any combination thereof. IFR aircraft are identified by N-number or a portion thereof. The color of N1592A is a yellowish cream with dark blue strips. The controller who was responsible for working runway 27 at the time of the accident was designated as the south local controller (SLC). The transcript states in part: At 1515:33 SLC cessna one sierra papa you're following a twin cessna runway runway two seven cleared to land on the ah green dot. At 1515:38 N1SP cleared to land green dot we're following we're looking one sierra papa. At 1516:03 SLC november one sierra papa you're going to be following a cherokee ah just turning base ah just around the terminal building at this time. At 1516:10 N1SP following the cherokee one sierra papa. At 1517:16 SLC aircraft on the the cessna on a two mile final ah traffic off your right side we're not talking to him. At 1517:22 SLC vee tail to the (unintelligible) ah to the numbers to the numbers runway two seven cleared to land. At 1517:28 N1SP cleared to land one sierra papa At 1517:43 SLC cessna on final cessna one sierra papa your cleared to land on the numbers runway two seven. At 1517:47 N1SP on the numbers two seven one sierra papa At 1517:49 SLC and be ah be advised you do have traffic coming in off your right we're not talking to him At 1517:56 SLC yellow and black tail on the base follow the cessna mile and a half final rock your wings At 1518:04 SLC all aircraft landing two seven exit ah into the grass the left side as soon as feasible. At 2018:12 SLC red and white low wing on the right base ah enter a mile and a half final and rock you're wings At 2018:19 SLC ok cessna you're following traffic on ah on about a half mile final additional traffic is a black tail dragger off your right side we're not talking to him At 2018:27 Cessna roger At 2018:28 SLC the black ah tail dragger on final for two seven rock your wings At 2018:33 SLC vee tail keep it going keep it going down to the green dot you're cleared to land on the green dot At 2018:37 SLC vee tail bonanza on two seven keep it up and go down to the green dot cleared to land At 2018:43 SLC one sierra papa do you have the tail dragger off your right side ahead and to your right At 2018:48 SLC one sierra papa do you have the tail dragger ahead and to your right At 2018:51 N1SP one sierra papa has the tail dragger At 2018:53 SLC ok we're not talking to him and follow him if he lands two seven you're cleared to land on the numbers the ah black tail dragger we're not talking to I've got three other aircraft inbound to two seven At 2019:07 SLC the ah high wing cessna on a right base your following a cessna low a cessna low on runway two seven At 2019:17 SLC twin cessna you're cleared to land on the numbers runway two seven At 2019:20 SLC tail dragger if you're listening land on the orange dot you've got traffic landing on the numbers two seven underneath you At 2019:49 SLC cessna on the ah cessna one sierra papa exit immediately to the left if feasible At 2019:54 N1SP one sierra papa At 2019:55 SLC thank you At 2019:56 SLC the tail dragger you're ah At 2020:01 SLC twin Cessna go around AIRPORT INFORMATION Runways 09/27 and 18/36 are the main runways used at the OSH during AirVenture. In addition to these runways, taxiway Alpha that parallels runway 36 is also used for takeoffs and landings. This surface is designated as runway 18L/36R. The permanent runway 18/36 is designated as runway 18R/36L. The Federal Aviation Administration (FAA) institutes special air traffic control procedures for the AirVenture fly-ins. These procedures are published in a notice to airmen (NOTAM). The NOTAM states in part: Enter transition over Ripon. Maintain 90 knots (or maximum cruise speed if below 90 knots) and 1,800 MSL. If unable, maintain 135 knots and 2,300 MSL. Proceed single file over the railroad tracks toward FISK (FISK can be identified by railroad track/road intersection and white strobe lights.) Fly over the railroad tracks; do not fly over the strobe lights. Listen for controller instructions as you approach FISK. Controller will use color and type of aircraft at FISK. Pilots should vigorously rock wings to acknowledge ATC instructions and refrain from verbal responses unless requested. Controller will advise your assigned runway and when to monitor Oshkosh Tower on 118.5 or 126.6. As announced on the airport terminal information service (ATIS), the VFR Oshkosh Arrival, Yellow Flow procedures were in effect at the time of the accident. These procedures show VFR traffic arriving from the west over FISK. The traffi ## Aircraft - Registration: [N1592A](https://openairdocs.org/aircraft/N1592A), registered now, S/N 20-829 (OpenAirDocs) - Reported make and model: Piper PA-20 - Registry model: [Piper PA-20](https://openairdocs.org/model/piper-pa-20) (registry code 7102002) (OpenAirDocs) - Registry engine: [Lycoming 0-290 series](https://openairdocs.org/engine/lycoming-0-290-series) (registry code 41506, 4 cycle) (OpenAirDocs) - Category: Airplane - Serial number: 20-829 - Airframe hours: 2258 - Engines: Lycoming O-290-D2 135 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Registered owner: Bruce M. Clark - Airworthiness certificate: Standard, Normal - Last inspection: Annual, October 18, 2001, 100 hours before - Departed: MOP, Mount Pleasant, MI - Destination: OSH, Oshkosh, WI - Flight plan: VFR - Airport: OSH, Oshkosh, runway 27, 6,178 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 73; injuries: none; private; airplane ratings: single-engine land; medical: class 3, valid medical--w/ waivers/lim; last flight review September 16, 2000; seat: left; flight hours: 3,800 total, 300 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: 230° at 12 knots, gusting 22 - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 95 °F, dew point 91 °F - Altimeter: 29.80 inHg - Observed at: OSH ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20020721038009A](https://openairdocs.org/incident/20020721038009A), Jul 21, 2002: Piper PA20, Oshkosh, WI, Substantial damage. (-23) Pilot was following traffic to land on runway 27. Pilot abruptly pulled up from flare, when his pax warned of imminent collision with another aircraft.… ## Other investigations on N1592A (1) 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. - [NTSB OAK77DVA24](https://openairdocs.org/ntsb/OAK77DVA24), Mar 11, 1977: Piper PA-20 (N1592A), Mariposa, CA, substantial damage ## Docket (6 files) The files NTSB released with the investigation on February 27, 2003, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=55284. 2.1 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1 photo, 750 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40463536&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Record of Interview and Witness Statements (item 2, .PDF, 252 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40463537&FileExtension=.PDF&FileName=Record%20of%20Interview%20and%20Witness%20Statements-Master.PDF - ATC Information and Transcripts (item 3, .PDF, 607 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40463538&FileExtension=.PDF&FileName=ATC%20Information%20and%20Transcripts-Master.PDF - NOTAM (item 4, .PDF, 243 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40177516&FileExtension=.PDF&FileName=NOTAM-Master.PDF - Photo 1. Left Front View of Damage To N1592A (item 5, .PDF, 122 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40177517&FileExtension=.PDF&FileName=Photo%201.%20%20Left%20Front%20View%20of%20Damage%20To%20N1592A-Master.PDF - Photo 2. Right Front View of Damage To N1592A (item 6, .PDF, 115 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40177518&FileExtension=.PDF&FileName=Photo%202.%20%20Right%20Front%20View%20of%20Damage%20To%20N1592A-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.