The NTSB is out with its report on the tragic crash of a medical flight near Milwaukee and it's a familiar pattern. If a pilot flies the airplane, everyone lives.
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National Transportation Safety Board
Washington, DC 20594
FOR IMMEDIATE RELEASE: October 14, 2009
SB-09-57
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PILOT MISMANAGEMENT AND IMPROPER ACTIONS CAUSED MEDICAL
FLIGHT CRASH NEAR MILWAUKEE, NTSB DETERMINES
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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.
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A summary of the findings of the Board's report is available
on the NTSB's website at: http://www.ntsb.gov/Publictn/2009/PAR0901.htm
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An archive of press releases is available at
http://www.ntsb.gov/pressrel/pressrel.htm
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