CEN10FA443

The pilot's decision not to advance the engines to takeoff power during the go-around, as stipulated by the airplane flight manual, which resulted in an aerodynamic stall at a low altitude.

The accident occurred during the Experimental Aircraft Association's Airventure 2010 fly-in convention. Because of the high density of aircraft operations during the fly-in, the Federal Aviation Administration implemented special air traffic control procedures to accommodate traffic demand and maximize runway capacity. Arriving aircraft were issued landing instructions and clearances by a tower controller using a specified tower radio frequency. Departing aircraft were handled by another team of controllers operating on a separate radio frequency that was associated with a mobile operations unit located near the runway. Air traffic control data indicated that the accident airplane established contact with the tower controller and entered a left traffic pattern for runway 18R. As the accident airplane was turning from downwind to base leg, the controller handling departures cleared a Piper Cub for an immediate takeoff and angled departure (a procedure used by slower aircraft to clear the runway immediately after liftoff by turning across the runway edge). The accident pilot was not monitoring the departure frequency, and, therefore, he did not hear the radio transmissions indicating that the departing Piper Cub was going to offset to the left of the runway after liftoff. The accident pilot reported that, while on base leg, he became concerned that his descent path to the runway would conflict with the Piper Cub that was on takeoff roll. He stated that he overshot the runway centerline during his turn from base to final, and, when he completed the turn, his airplane was offset to the 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 that was ahead and to the left of his position. 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. The airplane subsequently collided with terrain in a nose down, right wing low attitude. A postaccident review of available air traffic control communications, amateur video of the accident sequence, controller and witness statements, and position data recovered from the accident airplane indicated that the Piper Cub was already airborne, had turned left, and was clear of runway 18R when the accident airplane turned from base to final. The postaccident examination did not reveal any preimpact mechanical malfunctions or failures that would have precluded normal operation of the airplane. The airplane flight manual states that, in the event of a go-around, the pilot should first advance engine thrust to takeoff power and then establish Vref (reference landing approach speed). The pilot's decision not to select takeoff power during the go-around directly contributed to the development of the aerodynamic stall at a low altitude.

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. On July 27, 2010, about 1816 central daylight time, a Hawker Beechcraft model 390 (Premier IA) business jet, N6JR, collided with terrain while maneuvering to land on runway 18R at Wittman Regional Airport (OSH), Oshkosh, Wisconsin. The airline transport pilot and passenger sustained serious injuries. The airplane sustained substantial damage. The airplane was registered to and operated by Roush Fenway Racing, LLC, as a business flight under 14 Code of Federal Regulations Part 91. Day visual meteorological conditions prevailed at the time of the accident. The cross-country flight departed Willow Run Airport (YIP), Ypsilanti, Michigan, at 1729, with OSH as the intended destination. The pilot was flying to OSH to attend the Experimental Aircraft Association's Airventure 2010 fly-in convention. During the fly-in convention, a parallel taxiway east of runway 18 was used for takeoff and landings and was identified as runway 18L. The main runway, normally identified as runway 18, was denoted runway 18R and had a displaced threshold of 1,300 feet, leaving 6,700 feet of runway surface available for takeoffs and landings. During the fly-in convention, arriving aircraft were issued landing instructions and clearances by an air traffic control tower controller (tower controller) using a specified tower radio frequency. Departing aircraft were handled by another team of controllers operating on a separate radio frequency that was associated with a mobile operations/communications workstation (MOOCOW) located near the runway. Air traffic control (ATC) data indicated that the accident airplane entered the Oshkosh area under visual 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 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 a