Chicago-Midway

On November 30, 2018, about 1028 central standard time, a Cessna 525A (Citation) airplane, N525EG, was destroyed when it was involved in an accident near Memphis, Indiana. The pilot and two passengers were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 business flight. The cross-country flight originated from Clark Regional Airport (JVY), Jeffersonville, Indiana, and was en route to Chicago Midway International Airport (MDW), Chicago, Illinois. The airplane was equipped with automatic dependent surveillance–broadcast (ADS-B), which recorded latitude and longitude from GPS, pressure and geometric altitude, and selected altitude and heading. The airplane was also equipped with a cockpit voice recorder (CVR), which recorded the accident flight and annunciations from the enhanced ground proximity warning system (EGPWS). It was not equipped with a flight data recorder (FDR) nor was it required to be. Review of the CVR transcript showed that the pilot operated as a single pilot but verbalized his actions as he configured the airplane before departure. He referenced items from the Before Taxi checklist and included in his crew briefing that in the event of a problem after takeoff decision speed, he would handle it as an in-flight emergency and “fly the airplane, address the problem, get the autopilot on, talk on the radios, divert over to Stanford.” The air traffic controller provided initial clearance for the pilot to fly direct to the STREP intersection and to climb and maintain 3,000 ft mean sea level. Before the departure from JVY, the pilot announced on the common traffic advisory frequency that he was departing runway 36 and verbalized in the cockpit “this is three six” before he advanced the throttles. The flight departed JVY about 1024:36 into instrument meteorological conditions. The CVR recorded the pilot state that he set power to maximum cruise thrust, switched the engine sync on, and turned on the yaw dampers. The pilot also verbalized his interaction with the autopilot, including navigation mode, direct STREP, and vertical speed climb up to 3,000 ft. According to the National Transportation Safety Board’s (NTSB) airplane performance study, the airplane climbed to about 1,400 ft msl before it turned left onto a course of 330° and continued to climb. The CVR recorded the pilot state he was turning on the autopilot at 1025:22. At 1025:39, the pilot was cleared up to 10,000 ft and asked to “ident,” and the airplane was subsequently identified on radar. The pilot verbalized setting the autopilot for 10,000 ft and read items on the After Takeoff/Climb checklist. The performance study indicated that the airplane passed 3,000 ft about 1026, with an airspeed between 230 and 240 kts, and continued to climb steadily. At 1026:29, while the pilot was conducting the checklist, the controller instructed him to contact the Indianapolis Air Route Traffic Control Center; the pilot acknowledged. At 1026:38, the pilot resumed the checklist and stated, “uhhh lets seeee. Pressurization pressurizing anti ice de-ice systems are not required at this time.” The performance study indicated that, at 1026:45, the airplane began to bank to the left at a rate of about 5° per second and that after the onset of the roll, the airplane maintained airspeed while it continued to climb for 12 seconds, consistent with engine power not being reduced in response to the roll onset. At 1026:48, the CVR recorded the airplane’s autopilot disconnect annunciation, “autopilot.” The performance study indicated that about this time, the airplane was in about a 30° left bank. About 1 second later, the pilot stated, “whooooaaaaah.” Over the next 8 seconds, the airplane’s EGPWS annunciated six “bank angle” alerts. At 1026:57, the airplane reached its maximum altitude of about 6,100 ft msl and then began to descend rapidly, in excess of 11,000 ft per minute. At 1026:58, the bank angle was about 70° left wing down, and by 1027:05, the airplane was near 90° left wing down. At 1027:04, the CVR recorded a sound similar to an overspeed warning alert, which continued to the end of the flight. The performance study indicated that about the time of the overspeed warning, the airplane passed about 250 kts calibrated airspeed at an altitude of about 5,600 ft. After the overspeed warning, the pilot shouted three expletives, and the bank angle alert sounded two more times. According to the performance study, at 1027:18, the final ADS-B data point, the airplane was about 1,000 ft msl, with the airspeed about 380 kts and in a 53° left bank. At 1027:11, the CVR recorded the pilot shouting a radio transmission, “mayday mayday mayday citation five two five echo golf is in an emergency descent unable to gain control of the aircraft.” At 1027:16, the CVR recorded the EGPWS annunciating “terrain terrain.” The sound of impact was recorded about 1027:20. The total time from the beginning of the left roll until ground impact was about 35 seconds. The accident site was located about 8.5 miles northwest of JVY.

The commercial pilot was conducting an on-demand cargo charter flight. Shortly after takeoff, the pilot informed the tower controller that he wanted to "come back and land" because he was "having trouble with the left engine." The pilot chose to fly a left traffic pattern and return for landing. No further transmissions were received from the pilot. The accident site was located about 0.50 mile southeast of the runway's displaced threshold. GPS data revealed that, after takeoff, the airplane entered a left turn to a southeasterly course and reached a maximum GPS altitude of 959 ft (about 342 ft above ground level [agl]). The airplane then entered another left turn that appeared to continue until the final data point. The altitude associated with the final data point was 890 ft (about 273 ft agl). The final GPS data point was located about 135 ft northeast of the accident site. Based on GPS data and the prevailing surface winds, the airspeed was about 45 knots during the turn. According to the airplane flight manual, the stall speed in level flight with the wing flaps extended was 59 knots. Postaccident examination and testing of the airframe, engines, and related components did not reveal any preimpact mechanical failures or malfunctions that would have precluded normal operation; therefore, the nature of any issue related to the left engine could not be determined. Based on the evidence, the pilot failed to maintain adequate airspeed while turning the airplane back toward the airport, which resulted in an aerodynamic stall/spin.

The flight encountered light rime icing during an instrument approach to the destination airport. The copilot was the pilot flying at the time of the accident. He reported that the airframe anti-icing system was turned off upon intercepting the instrument approach glide slope, which was shortly before the airplane descended below the cloud layer. He recalled observing light frost on the outboard wing and tip tank during the approach. The stick shaker activated on short final, and the airplane impacted left of the runway centerline before it ultimately departed the right side of the runway pavement and crossed a slight rise before coming to rest in the grass. The cockpit voice recorder transcript indicated that the pilots were operating in icing conditions without the wing anti- ice system activated for about 4 1/2 minutes prior to activation of the stick shaker. A postaccident examination of the airplane did not reveal any anomalies consistent with a preimpact failure of the flight control system or a loss of anti-ice system functionality. A performance study determined that the airplane’s airspeed during the final 30 seconds of the flight was about 114 knots and that the angle of attack ultimately met the stick shaker threshold. The expected stall speed for the airplane was about 93 knots. The airplane flight manual stated that anti-ice systems should be turned on prior to operation in icing conditions during normal operations. The manual warned that even small accumulations of ice on the wing leading edge can cause an aerodynamic stall prior to activation of the stick shaker and/or stick pusher.

On February 2, 2005, about 0718 eastern standard time, a Bombardier Challenger CL-600-1A11, N370V, ran off the departure end of runway 6 at Teterboro Airport (TEB), Teterboro, New Jersey, at a ground speed of about 110 knots; through an airport perimeter fence; across a six-lane highway (where it struck a vehicle); and into a parking lot before impacting a building. The two pilots were seriously injured, as were two occupants in the vehicle. The cabin aide, eight passengers, and one person in the building received minor injuries. The airplane was destroyed by impact forces and postimpact fire. The accident flight was an on-demand passenger charter flight from TEB to Chicago Midway Airport, Chicago, Illinois. The flight was subject to the provisions of 14 Code of Federal Regulations (CFR) Part 135 and operated by Platinum Jet Management, LLC (PJM), Fort Lauderdale, Florida, under the auspices of a charter management agreement with Darby Aviation (Darby), Muscle Shoals, Alabama. Visual meteorological conditions prevailed for the flight, which operated on an instrument flight rules flight plan.

The airplane was on an on-demand air-taxi flight operating under 14 CFR Part 135 and was destroyed when it impacted trees and terrain while circling to land during a non-precision instrument approach at night. The airplane came to rest 1.74 nautical miles and 226 degrees magnetic from the intended airport. A weather briefing was obtained and instrument meteorological conditions were present along the route of flight at the time of the briefing. Weather conditions for the two reporting stations closest to the destination were obtained by the airplane prior to executing the approach. The weather reports listed ceilings and visibilities as 400 to 500 feet overcast and 5 to 7 statute miles. The airport elevation is 669 feet and the minimum descent altitude for the approach was listed as 1,240 feet. There was no weather reporting station at the destination airport at the time of the accident. According to the operators General Operations Manual, the pilot was responsible for the dispatch of the airplane including flight planning, and confirming departure, en-route, arrival and terminal operations compliance. The manual also states, "For airports without weather reporting, the area forecast and reports from airports in the vicinity must indicate that the weather conditions will be VFR [visual flight rules] at the ETA so as to allow the aircraft to terminate the IFR operations and land under VFR. (Note: a visual approach is not approved without weather reporting)." For 14 CFR Part 135 instrument flight operations conducted at an airport, federal regulations require weather observations at that airport. Furthermore, the regulations state that, for 14 CFR Part 135 operations, an instrument approach cannot be initiated unless approved weather information is available at the airport where the instrument approach is located, and the weather information indicates that the weather conditions are at or above the authorized minimums for the approach procedure. The commercial pilot held a type rating for the accident airplane. The right seat occupant was a commercial pilot employed by the operator and did not hold an appropriate type rating for the accident airplane. The pitch trim selector switch was found set to the co-pilot side. The regulations state that 14 CFR Part 135 operators cannot use the services of any person as an airman unless that person is appropriately qualified for the operation for which the person is to be used. The circling approach was made over primarily unlit land and water. An FAA publication states that during night operations, "Distance may be deceptive at night due to limited lighting conditions. A lack of intervening Page 2 of 17 CHI01FA083 references on the ground and the inability of the pilot to compare the size and location of different ground objects cause this. This also applies to the estimation of altitude and speed. Consequently, more dependence must be placed on flight instruments, particularly the altimeter and the airspeed indicator." No anomalies were found with respect to the airframe, engines, or systems that could be associated with a pre-impact condition.

While loading a patient & his personal gear in the aircraft for an air ambulance flight, the aircraft tipped onto its tail. As a result, the tail bumper was forced upward into the belly of the empennage. The pilot refused the offer to have a mechanic look at the damage, and remarked 'this has happened before.' after takeoff, the pilot radioed to the tower that he had a jammed elevator, and was coming around to land. While maneuvering on a base leg, control was lost & the airplane was observed to crash with one wing perpendicular to the ground. Another airplane was in the takeoff position on the runway. The airplane was configured with a hospital litter/stretcher and oxygen bottle on the right side of the cabin. There was no record for the approval for, or installation of, the stretcher. In addition, there was no weight & balance record for the airplane with the stretcher installation. All three occupants were killed.

A lineman noted parking brake (p/b) was set before flight. Pilots began takeoff on 5,147 feet runway with 10 knots crosswind. A witness said aircraft rotated for takeoff about 4,500 feet down runway and lifted off about 50 feet later. Reportedly, it remained low and slow (20-60 feet agl) after lift-off, then banked (rocked) left and right in nose high attitude, settled, hit trees and crashed abt 200 feet beyond runway. One person said aircraft went out of control before impact; another said it was 'in or on the edge of stalled flight.' Examination showed rotational damage occurred in both engines during impact. The braking systems had evidence that p/b control valve was partially on; brake torque tube contained heat blueing. On this early model (Learjet 23/sn: 23-45a), p/b had to be released by depressing brake pedals first; pilot handbook did not address this. On later models (sn: 23-050 and up), p/b needed only to be moved 'off.' Investigations showed left seat pilot had training in later models (Learjet 24/25); but only a biennial flight review was noted in the model 23. Company dispatcher said no training would have been performed on accident flight (with passenger aboard). Aircraft was about 430 lbs over max weight limit. All three occupants were killed.

The first takeoff was aborted due to a perceived engine problem. Six minutes later on second takeoff, the aircraft climbed to 50 feet, drifted to the right, rolled right and impacted in the infield. This was a single pilot operation in a complex aircraft. Winds exceeded the demonstrated crosswind limitation of the aircraft. There was no evidence that the pilot was using the seat belt or shoulder harness. Post crash investigation of both engines and props determined that there were no operational defects and that both were producing power at the time of impact. Strong gusty winds varying in intensity from 15 to 30 knots and varying in direction from southwest to northwest were prevalent at the airport on the day of the accident. The prop condition levers were found in the taxi position and the power levers were set with the left engine near flight idle position and the right engine at the takeoff position. The pilot, sole on board, was killed.

Scheduled domestic part 121 flight could not get landing gear to extend on approach to Chicago-Midway Airport. After missed approach, crew tried unsuccessfully to extend gear manually using procedures in cockpit checklist and flight operations manual. Emergency gear-up landing was made at Chicago-O'Hare International Airport. Investigation revealed a disconnected gear selector actuating rod from the normal landing gear retract/extension actuating assembly. Crew damaged manual gear extension mechanism in manual extension attempts. FAA approved procedural checklist had omitted critical step in manual gear extension procedure.

On initial climb the pilot reported 'just lost one', followed by a loss of control and descent into a residential area. Subsequent investigation revealed a loose connection between the left engine throttle serrated washer and the serrated shaft. The engine had been removed and reinstalled a few flight hours prior to the occurrence. The pilot, sole on board, was killed.