Pilot Mismanagement and Improper Actions Caused Medical Flight Crash Near Milwaukee, NTSB Determines

Washington, D.C. - The National Transportation Safety Board today determined that the probable cause of an aircraft that lost control and impacted water was the pilots' mismanagement of an abnormal flight control situation through improper actions, including lack of crew coordination, and failing to control airspeed and to prioritize control of the airplane.

On June 4, 2007, about 4:00pm CST, a Cessna Citation 550, N550BP, impacted Lake Michigan shortly after departure from General Mitchell International Airport, Milwaukee, Wisconsin (MKE). The two pilots and four passengers were killed, and the airplane was destroyed. The airplane was being operated by Marlin Air under the provisions of Part 135. The aircraft was carrying a human organ for a transplant operation in Michigan. At the time of the accident, marginal visual meteorological conditions prevailed at the surface, and instrument meteorological conditions prevailed aloft; the flight operated on an instrument flight rules flight plan.

Due to the lack of a data recording system, the Board could not determine the exact nature of the initiating event of the accident. However, the evidence indicated that the two most likely scenarios were a runaway trim or the inadvertent engagement of the autopilot, rather than the yaw damper, at takeoff.

The Board further noted that the event was controllable if the captain had not allowed the airspeed and resulting control forces to increase while he tried to troubleshoot the problem. By allowing the airplane's airspeed to increase while engaging in poorly coordinated troubleshooting efforts, the pilots allowed an abnormal situation to escalate to an emergency.

Therefore, the NTSB concluded that if the pilots had simply maintained a reduced airspeed while they responded to the situation, the aerodynamic forces on the airplane would not have increased significantly. At reduced airspeeds, the pilots should have been able to maintain control of the airplane long enough to either successfully troubleshoot and resolve the problem or return safely to the airport.

Contributing to the accident were Marlin Air's operational safety deficiencies, including the inadequate checkrides administered by Marlin Air's chief pilot/check airman, and the Federal Aviation Administration's (FAA) failure to detect and correct those deficiencies, which placed a pilot who inadequately emphasized safety in the position of company chief pilot and designated check airman and placed an ill-prepared pilot in the first officer's seat.

Results from the Board's investigation indicated that the captain did not adhere to procedures or comply with regulations, and that he routinely abbreviated checklists. Subsequently, the NTSB concluded that the pilots' lack of discipline, lack of in-depth systems knowledge, and failure to adhere to procedures contributed to their inability to cope with anomalies experienced during the accident flight. Thus, the Board also concluded that Marlin Air's selection of a chief pilot/check airman who failed to comply with procedures and regulations contributed to a culture that allowed an ill-prepared first officer to fly in Part 135 operations.

The report adopted today by the Board, points out that FAA guidance regarding appointment of check airmen requires Principal Operations Inspectors (POI) to verify the check airman candidate's "certificates and background." Additionally, all required training must be completed, and the airman's training records must show satisfactory completion of initial, transition, or upgrade training, as applicable. The guidance does not specifically address POI actions when the background evaluation discloses negative information. This lack of guidance can result in the appointment of check airmen who do not adhere to standards and who possibly jeopardize flight safety.

As a result of this accident investigation, the Safety Board issued recommendations to the FAA, and the American Hospital Association regarding airplane and system deficiencies, FAA oversight, and the safety ramifications of an operator's financial health.

A summary of the findings of the Board's report is available on the NTSB's website at: www.ntsb.gov/Publictn/2009/AAR0906.htm

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