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NTSB investigation record

CEN14FA399

Completed

Zimmerman Breezy· N3AZ

Date
July 31, 2014
Location
Oshkosh, WI
Conditions
VMC
Record
Published September 25, 2020

Primary finding

Probable cause

The pilot’s failure to maintain airplane control during landing while the air traffic controller was simultaneously coordinating the landing of three airplanes on the same runway, which resulted in the airplane exiting the runway and impacting a parked ground vehicle.

Investigator assessment

Analysis narrative

The accident pilot flew a passenger on a 10-minute flight during the Experimental Aircraft Association Airventure Oshkosh 2014. During landing, the pilot lost airplane control and subsequently struck a parked ground vehicle. A pilot in another airplane that had been cleared to land reported that he saw two airplanes in front of his airplane: a light-colored high-wing airplane that was turning from the right base to the final leg of the traffic pattern, and a high-wing airplane, which was the accident airplane, directly in front of him on the right downwind leg. The pilot of the trailing airplane stated that the air traffic controller was providing instructions to the pilots of the other two airplanes simultaneously and that it appeared that the controller was concerned about the spacing between the two airplanes ahead of him and the fact that his airplane was a faster airplane than the other two airplanes. The pilot heard the controller tell the accident airplane pilot while he was on short final to "pick it up a bit" and inform hit that a faster airplane was behind him. The accident airplane touched down and then become airborne again, and the controller subsequently stated to the accident pilot that "he could set it down." The airplane landed again and veered left on the runway. The pilot appeared to correct the airplane's ground track back on the centerline for a short time before the airplane veered right off the runway and onto the grass. The airplane then became airborne again and was in a nose-high, right-wing-low attitude; the pilot was likely attempting to clear a row of vehicles parked in the grass outside of the safety area. However, the airplane's tail hit one of the vehicles, and a small ground fire ensued. The pilot of the trailing airplane did not see any debris on the runway nor anything fall off the accident airplane before it hit the parked vehicle, and no debris or separated parts were found on the runway. An examination of the wreckage did not reveal any preimpact anomalies that would have precluded normal operation. The tower communications were consistent with the air traffic controller simultaneously coordinating the landing of three airplanes on the same runway. Photographs revealed that, after the accident airplane landed behind the first airplane, the separation between the two airplanes decreased before the accident airplane exited the runway. It is likely that after the accident pilot landed the airplane, he observed that the separation between his airplane and the airplane ahead of him was decreasing, which led to his loss of airplane control.

Source record

Factual narrative

The airplane's right wing and a ground vehicle's rear passenger side exhibited discoloration, charring, and deformation consistent with a ground fire. Witness statements confirmed the fire was consistent with a ground fire. A GoPro camera, belonging to the passenger, was found in the wreckage. It was shipped to the National Transportation Safety Board Vehicle Recorder Laboratory. The camera video files were corrupt and were recovered. The recovered camera files did not contain data associated with the accident. A transcription, which covered the OSH Airport Traffic Control Tower (ATCT) radio communications for the time period from July 31, 2014 , 0847, to July 31, 2014 ,0909 was reviewed. The transcript, in part, stated: Agencies Making Transmissions Abbreviations Breezy N3AZ Local Control South LCS ... 0852:44 N3AZ breezy ready papa three 0852:47 LCS breezy ah roger hold short of runway three six left 0852:50 N3AZ breezy 0853:57 LCS breezy runway three six left ah line up and wait 0854:00 N3AZ line up 0854:28 LCS breezy cleared for takeoff runway three six left 0857:08 N3AZ breezy turning base ah following the tail dragger 0857:12 LCS okay breezy thank you sir you're going to follow that taildragger runway three six right you are cleared to land 0857:16 N3AZ breezy 0857:29 LCS mooney left base ah you're cleared to land you're following the breezy just turning the ah base for runway three six right mooney three six right you're cleared to land mooney 0858:14 LCS aeroshell ah runway three six left you're cleared to land breezy go ahead and set it down now that that tail dragger's going to set it down here shortly 0858:31 LCS cirrus or mooney type go ahead and ah keep a high speed taxi you're following that breezy ahead breezy go ahead and set it down now taildragger on the runway keep it ah keep the speed up for me please sir keep the speed up for me please 0858:41 N3AZ (unintelligible) 0859:00 LCS okay ah ford go around for me ah mooney ah just keep it ah just keep it goin down the taxiway for me please ford go around and ah aeroshell team go around for me p lease all aircraft inbound from fisk ah we're going to be ah ah you're we' re going to have to turn back up to ripon for me all aircraft inbound from fisk turn to ripon for me please ah big ford ah go ahead and take it ah take it south ah just continue on the upwind now and ah you turn right abeam the tower for me please 0859:31 LCS cher cherokee in the aeroshell team there cherokee just sidestep to the right for me please and go around keep the up wind turn ah just keep the upwind for me OSH, located approximately two miles south of downtown Oshkosh, Wisconsin, was a towered airport, owned by Winnebago County, with a surveyed field elevation of 808 feet above mean sea level. The airport's primary runways are runway 9/27 (6,178 feet by 150 feet, asphalt) and runway 18/36 (8,002 feet by 150 feet). However, during AirVenture, permission has been granted to allow the use of its parallel taxiway as a runway. Runway 18/36 becomes 18R/36L and taxiway A becomes 18L/36R under special flight procedures that were effective from 0600 on July 25 to Noon on August 4, 2014. The temporary runway was about 50 feet wide and was about 5,500 feet in length from its threshold to the A2 intersection. The temporary runway was about 2,750 feet in length from its threshold to the A3 intersection and was about 1,325feet in length from its threshold to the A4 intersection. The EAA website, www.airventure.org, provided pilots with information about air traffic control procedures and aircraft movement on the ground. The website listed approximate available runway lengths associated with colored dots on runway 36L. The website did not list the approximate runway lengths associated with intersections on temporary runway 36R. Pictures supplied to the NTSB investigator in charge revealed that there was a high wing airplane, which was landing in front of the Breezy airplane. The images revealed the separation between the high wing airplane and the Breezy was decreasing prior to the Breezy exiting the runway. During the interview, the rear seat passenger stated that she did not see anything fall off the airplane and did not see anything break. She said that the pilot did not do preflight inspections between flights. He shut down the engine, the passenger would get off the airplane, and the next would get on the airplane. She did not recall an airplane in front of the Breezy during the landing. She stated that the engine did not sputter or have any unusual sounds. The passenger asked if there is "any way to get these parked trucks moved?" She said a Mooney previously hit similarly parked trucks in a prior accident at OSH. The impacted vehicles were parked outside of the safety area associated with the temporary runway. The information provided to pilots on the EAA website, in part, stated: Change of Plans Be prepared! The control instructions may change from what you were initially told. For instance you may have been instructed to "land on the numbers". This would have been issued if there was another aircraft ahead of you landing at the Purple Dot, however by the time you reach the runway… The other aircraft has exited the runway, therefore the controller may now instruct you to "land on the Purple Dot" which will allow for another aircraft to land behind you (on the numbers) and still provide for allowable runway separation. These "last minute" adjustments will probably occur no matter what runway you land on. The only difference will be the description of the touchdown point ("the numbers" or Purple Dot). Stay alert for traffic ahead of you on final and also for any potential traffic that may be sequenced from the right base. An autopsy was performed on the pilot by the Winnebago County Coroner's Office. The autopsy listed multiple blunt force injuries as the cause of death. The FAA Civil Aerospace Medical Institute prepared a Final Forensic Toxicology Accident Report. The report was negative for the tests performed. The airplane fuselage was found resting on its right side on the rear section of an armored Oshkosh vehicle parked in a grass area east of runway 36R and north of the A4 taxiway. This armored vehicle's rear passenger-side tire and chassis was charred and discolored. Other armored Oshkosh vehicles parked south of this vehicle exhibited witness marks that were oriented in the direction of the resting fuselage. Debris, consisting of pieces of fuselage frame tubing, a section of left main landing gear structure, and laminated wood shards, were located between the other armored vehicles and the airplane fuselage. The airplane's right wing, engine, and right main landing gear structure were found resting on the ground behind the charred rear passenger-side tire. The right wing was fabric was consumed by fire and its aileron control cables were traced to its bellcrank. The engine throttle linkage was intact and the mixture control was safety wired in the full rich position. The carburetor heat linkage was intact on the intake bracket. The wooden propeller hub remained attached to the engine propeller flange. However, its blades were not in place. The left wing separated from the fuselage and was found about 25 feet north of the fuselage. Its aileron control cable ends were found outside the wing, separated in a broomstraw appearance consistent with overload. The aileron moved when the separated cables were pulled by hand. The empennage separated from the fuselage and the empennage was found about 55 feet north of the fuselage. Flight control cables were traced and all observed breaks were consistent with overload. Examination of the engine controls cables revealed no pre-impact anomalies. An examination of runway 36R revealed no debris or separated parts on the runway. The grass infiel

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