NTSB Animation of Marlin Air Cessna Citation Accident Investigation Near Milwaukee Wisconsin

January 17, 2010

Video courtesy: NTSB

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:http://www.ntsb.gov/Publictn/2009/AAR0906.htm

Duration : 0:3:34


Comments

16 Responses to “NTSB Animation of Marlin Air Cessna Citation Accident Investigation Near Milwaukee Wisconsin”

  1. RobertGary1 on January 17th, 2010 1:51 am

    If the captain knew …
    If the captain knew the issue was runaway trim (we don’t know even today), then he could have simply reacted to that. I’m not sure about the 550 but in every aircraft I’ve flown, if the trim is commanded more than a certain amount there is an annunciator (“trim, in motion”) that clues you in. This captain at least didn’t receive such an annuciator (either because the 550 doesn’t have it or because the it wasn’t a runway trim issue). Some also make a loud clicking when moving that clues you in.

  2. amediastintas on January 17th, 2010 1:51 am

    yeah but if you …
    yeah but if you have a runaway trim speeding up only makes it worse. he shoudlve instinctively turned the damper off. damper is linked to the rudder.

  3. umahuma4 on January 17th, 2010 1:51 am

    The second officer …
    The second officer doesnt even know his own aircraft? such a shame.

  4. chipjumper on January 17th, 2010 1:51 am

    @jamesbooty That …
    @jamesbooty That makes sense. Well it appears that U of M purchased their own fixed wing aircraft and are back in the long distance business.

  5. jamesbooty on January 17th, 2010 1:51 am

    @chipjumper There …
    @chipjumper There was no FDR, which means there was no data on which to build the typical NTSB animation.

  6. RobertGary1 on January 17th, 2010 1:51 am

    Wow, that was …
    Wow, that was non-obvious. The NTSB faulted him for building speed while having a control problem. I would have done the exact same thing. I wouldn’t want to be slow with low control effectiveness. Its one of those damned-if-you-do damned if you don’t situations. 🙁

  7. EimantazzzWM on January 17th, 2010 1:51 am

    what happened with …
    what happened with the crew?

  8. JensLine on January 17th, 2010 1:51 am

    Second officer: …
    Second officer: Where is it?
    What a heck?

  9. chipjumper on January 17th, 2010 1:51 am

    Why did they end …
    Why did they end the video when the plane was still at 1900 feet? Why didn’t the NTSB do an animation like the other crashes? Ridiculous.

  10. pomrizzle09 on January 17th, 2010 1:51 am

    So did the patient …
    So did the patient ever get an organ?

  11. mikemike390 on January 17th, 2010 1:51 am

    yeah imagine if u …
    yeah imagine if u where on that plane

  12. innersilencedotcom on January 17th, 2010 1:51 am

    you idiots there’s …
    you idiots there’s nothing awesome about a plane crash.

  13. JustinnnnChannel on January 17th, 2010 1:51 am

    Very nice Animation …
    Very nice Animation 4/5Reaction :’D

  14. MrSolid95 on January 17th, 2010 1:51 am

    COOL..
    COOL..

  15. rsfan010 on January 17th, 2010 1:51 am

    awesome
    awesome

  16. L33tP1ckL on January 17th, 2010 1:51 am

    I enjoyed this very …
    I enjoyed this very much, ty AB!

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