NTSB -- REVISED W/CORRECTED LINK - PILOT MISMANAGEMENT AND IMPROPER ACTIONS CAUSED MEDICAL FLIGHT CRASH NEAR MILWAUKEE, NTSB DETERMINES

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NTSB PRESS RELEASE

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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/AAR0906.htm

Media Contact: Keith Holloway (202) 314-6100

hollowk@xxxxxxxx

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