# NTSB CHI95FA126: Cessna 150M, N45457, Oshkosh, WI, April 14, 1995 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: April 14, 1995, 14:25 local (19:25 UTC) - Place: Oshkosh, WI - Location: 43.9699° N, 88.5560° W: Placed by OpenAirDocs from NTSB’s distance and direction from WITTMAN RGNL (OSH), within about a mile (OpenAirDocs) - Nearby events: https://openairdocs.org/map.md?lat=43.9699&lon=-88.5560&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 4 fatal - Status: Completed, report March 25, 1997 - Report: Approved by Office Director - NTSB case key (mKey): 9729 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CHI95FA126 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/9729/pdf - Page: https://openairdocs.org/ntsb/CHI95FA126 ## Probable cause (aircraft 2) INADEQUATE VISUAL LOOKOUT BY THE PILOT OF THE BEECH V35B, RESULTING IN HIS FAILURE TO SEE-AND-AVOID THE CESSNA 150, WHICH WAS AHEAD AND BELOW HIM ON FINAL APPROACH; AND FAILURE OF THE TOWER CONTROLLER TO PROVIDE ADEQUATE SERVICE (FLIGHT ADVISORIES AND LANDING SEQUENCE) TO THE PILOTS OF THE CESSNA 150 AND BEECH V35B. FACTORS RELATING TO THE ACCIDENT WERE: INADEQUATE AIR-TO-GROUND COMMUNICATION BY THE BEECH V35B PILOT, BY FAILING TO NOTIFY THE TOWER THAT HE WAS ON FINAL APPROACH, AND BY FAILING TO OBTAIN A CLEARANCE TO LAND; FAILURE OF THE TOWER CONTROLLER TO VISUALLY IDENTIFY THE BEECH V35B; EXCESSIVE WORKLOAD FOR THE TOWER CONTROLLER; AND POSSIBLE GLARE FROM THE WINDOWS OF THE TOWER CAB (OTHER LIGHT CONDITION). ## Probable cause (aircraft 1) INADEQUATE VISUAL LOOKOUT BY THE PILOT OF THE BEECH V35B, RESULTING IN HIS FAILURE TO SEE-AND-AVOID THE CESSNA 150, WHICH WAS AHEAD AND BELOW HIM ON FINAL APPROACH; AND FAILURE OF THE TOWER CONTROLLER TO PROVIDE ADEQUATE SERVICE (FLIGHT ADVISORIES AND LANDING SEQUENCE) TO THE PILOTS OF THE CESSNA 150 AND BEECH V35B. FACTORS RELATING TO THE ACCIDENT WERE: INADEQUATE AIR-TO-GROUND COMMUNICATION BY THE BEECH V35B PILOT, BY FAILING TO NOTIFY THE TOWER THAT HE WAS ON FINAL APPROACH, AND BY FAILING TO OBTAIN A CLEARANCE TO LAND; FAILURE OF THE TOWER CONTROLLER TO VISUALLY IDENTIFY THE BEECH V35B; EXCESSIVE WORKLOAD FOR THE TOWER CONTROLLER; AND POSSIBLE GLARE FROM THE WINDOWS OF THE TOWER CAB (OTHER LIGHT CONDITION). ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Midair collision, approach - vfr pattern - final approach - air/ground communications - inadequate, pilot of other aircraft (contributing factor) - radar,brite - unavailable - excessive workload (task overload), atc personnel(lcl/gnd/clnc) - light condition - other (contributing factor) - identification of aircraft visually - not attained, atc personnel(lcl/gnd/clnc) (contributing factor) - control tower service - inadequate, atc personnel(lcl/gnd/clnc) (cause) - flight advisories - not issued, atc personnel(lcl/gnd/clnc) (cause) - visual lookout - inadequate, pilot of other aircraft (cause) - In flight collision with terrain/water, descent - uncontrolled - Midair collision, approach - vfr pattern - final approach - air/ground communications - inadequate, pilot in command (contributing factor) - radar,brite - unavailable - excessive workload (task overload), atc personnel(lcl/gnd/clnc) - light condition - other (contributing factor) - identification of aircraft visually - not attained, atc personnel(lcl/gnd/clnc) (contributing factor) - control tower service - inadequate, atc personnel(lcl/gnd/clnc) (cause) - flight advisories - not issued, atc personnel(lcl/gnd/clnc) (cause) - visual lookout - inadequate, pilot in command (cause) - In flight collision with terrain/water, descent - uncontrolled ## Analysis (aircraft 2) AT 1417:23 CDT, THE PILOT OF CESSNA 150, N45457, CONTACTED THE TOWER AND REPORTED THAT HE WAS 12 MILES SOUTHWEST OF THE AIRPORT AND INBOUND (FOR LANDING). THE TOWER CONTROLLER (CTLR) CLEARED THE PILOT TO ENTER A LEFT BASE FOR RUNWAY 36 AND TOLD HIM TO REPORT 3 MILES SOUTHWEST (OF THE AIRPORT). AT 1419:30, BEECH V35B, N1HK, CONTACTED THE TOWER AND REPORTED INBOUND, 18 MILES SOUTH (FOR LANDING). THE CTLR CLEARED THE V35B (TO CONTINUE) FOR A STRAIGHT-IN APPROACH TO RUNWAY 36 (BUT DID NOT CLEAR THE V35B TO LAND). ONE OF THE V35B PILOTS ACKNOWLEDGED THE CALL, THEN THERE WAS NO FURTHER COMMUNICATION WITH THE V35B. AT 1422:54, THE CESSNA PILOT REPORTED THAT HE WAS 3 MILES SOUTHWEST 'STARTING A BASE' AND WAS CLEARED TO LAND. THE TOWER WAS NOT EQUIPPED WITH A D-BRITE SCOPE (RADAR SCREEN REPEATER); BUT LATER, RADAR NTAP DATA AT THE GREEN BAY STATION REVEALED THAT THE TWO AIRPLANES CONVERGED AS THEY WERE ON FINAL APPROACH TO LAND. THE V35B WAS ABOUT 800' ABOVE AND SLIGHTLY BEHIND THE CESSNA AS THE CESSNA BEGAN ITS FINAL APPROACH. THE ACCIDENT OCCURRED AFTER THE AIRPLANES TRAVELED ABOUT 1500' BEYOND THE RUNWAY THRESHOLD. JUST BEFORE IMPACT, THE CESSNA BANKED RAPIDLY TO THE RIGHT, BUT ITS LEFT WING AND THE V35B'S LOWER FUSELAGE COLLIDED. THE TWO AIRPLANES THEN CRASHED. THE CTLR SAID THAT HE DID NOT SEE THE V35B AFTER CLEARING THE CESSNA TO LAND. A SECOND CTLR WAS ON DUTY, BUT WAS ON A RELIEF BREAK WHEN THE ACCIDENT OCCURRED. THE CTLRS SAID THAT THE TOWER CAB WINDOW HAD REFLECTIVE GLARE THAT CONSTITUTED A HINDRANCE. THE WORKING CTLR WAS HANDLING NINE AIRPLANES WHEN THE ACCIDENT OCCURRED. ## Analysis (aircraft 1) AT 1417:23 CDT, THE PILOT OF CESSNA 150, N45457, CONTACTED THE TOWER AND REPORTED THAT HE WAS 12 MILES SOUTHWEST OF THE AIRPORT AND INBOUND (FOR LANDING). THE TOWER CONTROLLER (CTLR) CLEARED THE PILOT TO ENTER A LEFT BASE FOR RUNWAY 36 AND TOLD HIM TO REPORT 3 MILES SOUTHWEST (OF THE AIRPORT). AT 1419:30, BEECH V35B, N1HK, CONTACTED THE TOWER AND REPORTED INBOUND, 18 MILES SOUTH (FOR LANDING). THE CTLR CLEARED THE V35B (TO CONTINUE) FOR A STRAIGHT-IN APPROACH TO RUNWAY 36 (BUT DID NOT CLEAR THE V35B TO LAND). ONE OF THE V35B PILOTS ACKNOWLEDGED THE CALL, THEN THERE WAS NO FURTHER COMMUNICATION WITH THE V35B. AT 1422:54, THE CESSNA PILOT REPORTED THAT HE WAS 3 MILES SOUTHWEST 'STARTING A BASE' AND WAS CLEARED TO LAND. THE TOWER WAS NOT EQUIPPED WITH A D-BRITE SCOPE (RADAR SCREEN REPEATER); BUT LATER, RADAR NTAP DATA AT THE GREEN BAY STATION REVEALED THAT THE TWO AIRPLANES CONVERGED AS THEY WERE ON FINAL APPROACH TO LAND. THE V35B WAS ABOUT 800' ABOVE AND SLIGHTLY BEHIND THE CESSNA AS THE CESSNA BEGAN ITS FINAL APPROACH. THE ACCIDENT OCCURRED AFTER THE AIRPLANES TRAVELED ABOUT 1500' BEYOND THE RUNWAY THRESHOLD. JUST BEFORE IMPACT, THE CESSNA BANKED RAPIDLY TO THE RIGHT, BUT ITS LEFT WING AND THE V35B'S LOWER FUSELAGE COLLIDED. THE TWO AIRPLANES THEN CRASHED. THE CTLR SAID THAT HE DID NOT SEE THE V35B AFTER CLEARING THE CESSNA TO LAND. A SECOND CTLR WAS ON DUTY, BUT WAS ON A RELIEF BREAK WHEN THE ACCIDENT OCCURRED. THE CTLRS SAID THAT THE TOWER CAB WINDOW HAD REFLECTIVE GLARE THAT CONSTITUTED A HINDRANCE. THE WORKING CTLR WAS HANDLING NINE AIRPLANES WHEN THE ACCIDENT OCCURRED. ## Factual narrative (aircraft 2) -See narrative on CHI-95-F-A126A- ## Factual narrative (aircraft 1) HISTORY OF FLIGHT On April 14, 1995, at 1425 central daylight time (cdt), a Cessna 150M, N45457, registered to the Vagabond Flying Service of Bartlett, Illinois, and piloted by a commercially certificated pilot, was involved in a midair collision with a Beech V35B, N1HK. N1HK was registered to Chudy Leasing, Incorporated, of Las Vegas, Nevada, and piloted by a private pilot. The midair collision occurred over the approach end of Runway 36 at the Wittman Regional Airport, Oshkosh, Wisconsin. Visual meteorological conditions prevailed at the time of the accident. Both airplanes were destroyed. N45457 was operating as a personal flight under 14 CFR Part 91. It was not operating on a flight plan. The pilot and passenger were fatally injured. N45457 departed West Chicago, Illinois, exact time unknown. N1HK was operating as a personal flight under 14 CFR Part 91. It was not operating on a flight plan. The pilot and pilot-rated passenger were fatally injured. N1HK departed Delevan, Wisconsin, exact time unknown. One witness, located about 800 feet east of runway 36's approach end, observed both airplanes on final approach to runway 36. He said the N45457 was about 75 feet above the runway threshold descending for a landing and that N1HK was behind N45457 at a higher altitude also descending. The witness said N1HK overtook N45457 about 1,500 feet beyond the runway threshold. He said N1HK was still descending and was about 10 feet above N45457 when N45457 made a "...violent right turn." He said N45457's right wing collided with the runway and the left wing struck N1HK's belly. The witness continued, "The forward flight stopped-- the V-35 [N1HK] pitched up and fell to the left, on top of [N45457]." He said he did not notice any increase or decrease in engine sound during this event. A second witness said he had landed shortly before observing an airplane approach for a landing on runway 36. While taxiing southbound on Taxiway "C" the pilot said the airplane was approaching runway 36 at a steep descent angle. He said, "Suddenly, the airplane pitched up into a straight up attitude. The plane rolled to the left starting to inverted and went straight down into the field." This witness said it was difficult to see due to the sun being in his eyes. FAA information showed N45457 12 miles southwest of the airport when its pilot contacted the tower at 1417:23 cdt. The tower controller instructed N45457 to turn onto a left base leg for runway 36 and to report when it was three miles southwest of the airport. N45457's pilot acknowledged the controller's instructions. At 1419:32 cdt, N1HK contacted the control tower and reported 18 DME nautical miles south of the airport. One of the pilots said they were inbound for landing. The tower controller instructed N1HK to proceed straight in for Runway 36 and issued the altimeter setting and surface wind conditions. One of the pilot's in N1HK's acknowledged the controller's transmission. At 1422:54 the pilot of N45457 reported his airplane was 3 miles southwest of the airport. The controller advised the pilot his airplane was not in sight. He told the pilot his airplane was number two for landing due to another airplane being on short final for runway 36. The controller advised the pilot of N45457 that his airplane was in sight and cleared N45457 to land on runway 36. There were no other contacts made between the control tower and pilot of N1HK. PERSONNEL INFORMATION The pilot of N45457 obtained his private pilot's certificate on July 2, 1945. He obtained his commercial pilot's certificate on April 12, 1970, and his airplane flight instructor certificate on December 18, 1975. The FAA's Airman's Medical Branch records showed his last pilot medical certificate was issued on January 7, 1992. At the time of its issuance the pilot stated he had 2,255 hours. The pilot's logbook showed he had a total time of 2,315.4 hours as of January 9, 1994. According to this logbook, he satisfactorily completed a biennial flight review on May 13, 1992. N45457's pilot had flown the Cessna 150 model airplane 5.2 hours during March 1995, according to flying club records. The pilot of N1HK possessed a private pilot's certificate issued on September 8, 1989. At the time of its issuance, the pilot stated he had a total flight time of 57 hours. FAA pilot records show he obtained his airplane instrument rating on September 24, 1990. At the time of its issuance the pilot stated he had accumulated a total flight time of 147 hours. His third class FAA pilot medical certificate was issued on November 11, 1994. The last entry in the pilot's logbook showed he had flown a Cessna 172 for .7 of an hour during January 1, 1995. His logbook showed he flew a total of 12.9 hours during 1994. According to his logbook, he had accumulated 6.5 hours in a Beech model 35. His last logged flight in the Model 35 was on June 29, 1992. His logbook showed this flight was a 4.2 hour cross country flight. His pilot logbook showed he had accumulated a total time of 92.3 hours in a Beech Model A-36 Bonanza. His last logged flight in the Model A-36 was on August 18, 1993. This flight was a 1.4 hour cross country flight according to his logbook. The pilot-rated passenger in N1HK obtained his multi-engine airline transport pilot's certificate on June 14, 1963. He obtained his airplane flight instructor certificate on May 22, 1964. At the time of this certificate's issuance he stated he had a total flight time of 2,970 hours. This pilot's logbook records were not located by family members. AIRCRAFT INFORMATION The airframe and powerplant logbooks for N1HK were essentially destroyed by the post-impact fire. Fragments of these records were found and showed N1HK had about six FAA STC's added to its airframe during its service life. The maintenance facility that did the annual on N1HK said it was done during the early part of April 1994. A representative of that facility said the inspection sheet related to the airplane's annual inspection showed it had an airframe total time of 2,638.06 hours. He said it recalled that the airplane was scheduled for its next annual during the last week of April 1995. N45457's maintenance records showed it had an annual inspection on April 1, 1994. According to its airframe logbook, N45457 had 5,827.9 hours total operating time. The last entry in its airframe logbook was on February 23, 1995. It showed a total airframe time of 6,019.7 hours. METEOROLOGICAL INFORMATION Weather conditions at the time of the accident were clear skies with 20 miles visibility. The sun's azimuth position relative to Wittman Regional Airport was 216 degrees, 50 minutes, and its position above the horizon was 50 degrees, 17 minutes according to an astronomer from the Adler Planetarium, Chicago, Illinois. AERODROME INFORMATION At the time of the accident, Wittman Regional Airport, Oshkosh, Wisconsin, was classified as a Level One airport by the FAA. According to the FAA, this type airport control tower is required to have a minimum of one controller in the tower cab. Runway 36 had an operating Precision Approach Path indicator (PAPI) operating at the time of the accident. The airport control tower was not equipped with a DBRITE Scope, a radar screen repeater. A representative from the FAA said this type of equipment had not been installed at the airport due to its incompatibility with the FAA's Chicago Air Route Traffic Control Center radar system. He said that the closest terminal radar site was at Green Bay, Wisconsin's, Austin-Straubel Airport's Air Traffic Control Tower. The representative said that due to the distance between Green Bay, Wisconsin, and Oshkosh, Wisconsin, the radar presentation near Oshkosh is not suitable to make a DBRITE usable to controllers at the Wittman Regional Airport's control tower. WRECKA ## Aircraft 1 - Registration: [N45457](https://openairdocs.org/deregistered/N45457-1997-03-24), registration cancelled 1997-03-24, S/N 15076932 (OpenAirDocs) - Reported make and model: CESSNA 150M - Registry model: [Cessna 150M](https://openairdocs.org/model/cessna-150m) (registry code 2071830) (OpenAirDocs) - Category: Airplane - Serial number: 15076932 - Engines: CONTINENTAL O-200 100 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Registered owner: Vagabond Flying Service - Airworthiness certificate: Standard, Utility; Standard, Normal - Last inspection: Annual, April 1, 1994 - Departed: DPA, WEST CHICAGO, IL - Airport: OSH, Wittman Regional, runway 36, 8,001 × 150 ft, concrete ## Aircraft 2 - Registration: [N1HK](https://openairdocs.org/deregistered/N1HK-1997-04-23), registration cancelled 1997-04-23, S/N D9960 (OpenAirDocs) - Reported make and model: BEECH V35B - Registry model: [Beech V35B](https://openairdocs.org/model/beech-v35b) (registry code 1151548) (OpenAirDocs) - Category: Airplane - Serial number: D-9960 - Engines: CONTINENTAL IO-520-BA 285 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Operator: John Kuranz - Registered owner: Chudy Leasing, Inc. - Airworthiness certificate: Standard, Normal - Last inspection: Annual, April 30, 1994 - Departed: C59, DELEVAN, WI - Airport: OSH, Wittman Regional, runway 36, 8,001 × 150 ft, concrete ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot, aircraft N45457; age 67; flight instructor, commercial; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, invalid medical for flight; seat: left; toxicology performed; flight hours: 2,315 total, 2,207 as pilot in command, 16 in the last 90 days - Pilot, aircraft N1HK; age 48; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, valid medical--w/ waivers/lim; seat: left; toxicology performed; flight hours: 319 total, 7 in this make and model, 272 as pilot in command ## Weather - Conditions: Visual (VMC), Day - Wind: 80° at 7 knots - Visibility: 20 statute miles - Lowest ceiling: none - Altimeter: 30.00 inHg - Observed at: OSH, 1 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). - [Accident 19950414007982A](https://openairdocs.org/incident/19950414007982A), Apr 14, 1995: Cessna 150M, Oshkosh, WI, Destroyed, 2 fatal. Turning final was overtook and collided with aircraft on straight in final. ATC failed to note. Failed report final (-23) Cessna 150, N45457, reported twelve… - [Accident 19950414007981A](https://openairdocs.org/incident/19950414007981A), Apr 14, 1995: Beech V35B, Oshkosh, WI, Destroyed, 2 fatal. On straight in final overtook and collided with aircraft on final. Failed to call on final for clearance to land. (-23) Cessna 150, N45457, reported twelve… 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.