Iowa

The noninstrument-rated private pilot was conducting a visual flight rules (VFR) cross-country flight while receiving VFR flight following services from air traffic control. Radar data and voice
communication information indicated that the airplane was in cruise flight as the pilot deviated around convective weather near his destination. The controller issued a weather advisory to the pilot concerning areas of moderate to extreme precipitation along his route; the pilot responded that he saw the weather on the airplane's NEXRAD weather display system and planned to deviate around it before resuming course. About 3 minutes later, the pilot stated that he was around the weather and requested to start his descent direct toward his destination. The controller advised the pilot to descend at his discretion. Radar showed the airplane in a descending right turn before radar contact was lost at 2,900 ft mean sea level. There were no eyewitnesses, and search personnel reported rain and thunderstorms in the area about the time of the accident. The distribution of the wreckage was consistent with an in-flight breakup. Examination of the airframe revealed overload failures of the empennage and wings. No pre-impact airframe structural anomalies were found, and the propeller showed evidence of rotation at the time of impact. Further, there was no evidence of pilot impairment or incapacitation. Review of weather information indicated that the pilot most likely encountered instrument meteorological conditions as the airplane descended during the last several minutes of flight. During this time, it is likely that the pilot became disoriented while attempting to maneuver in convective, restricted visibility conditions, and lost control of the airplane. The transition from visual to instrument flight conditions would have been conducive to the development of spatial disorientation; the turning descent before the loss of radar contact and the in-flight breakup are also consistent with a loss of control due to spatial disorientation.

The instrument-rated private pilot was returning to his home airport after flying to another location to attend a meeting. At the departure airport, the pilot filed an instrument flight rules flight plan, had it activated, and then departed for his home airport. After reaching his assigned altitude, the pilot requested clearance directly to his destination with air traffic control, and he was cleared as requested. Before arriving at his airport, he requested off frequency to get the NOTAMs and weather conditions for his destination. The weather conditions at the arrival airport included a 200-ft overcast ceiling and 5 miles visibility with light rain and mist. The pilot then requested the instrument landing system (ILS) approach for landing. An air traffic controller issued vectors to the ILS final approach course and cleared the pilot to change off their frequency. Witnesses at the airport reported hearing and seeing the airplane break out of the clouds, fly over the runway about 100 ft above ground level (agl), and then disappear back into the clouds. Two witnesses stated that the engine sounded as if it were at full power and another witness stated that he heard the engine "revving" as if flew overhead. Shortly after the airplane was seen over the airport, it struck a line of 80-ft tall trees about 3,600 ft north-northwest of the airport and subsequently impacted the ground and a large tree near a residence. The published missed approach procedures required the pilot to climb the airplane to an altitude of 2,000 ft mean sea level (msl), or about 900 ft agl, while flying the runway heading. Upon reaching 2,000 ft msl, the pilot was required to begin a left turn to the northwest and then continue climbing to 3,300 ft msl. An examination of the airplane, the engine, and other airplane systems revealed no anomalies that would have precluded the airplane from being able to fully perform in a climb during the missed approach. It is likely that the pilot lost airplane control after initiating a missed approach in instrument meteorological conditions. Although it is possible that the pilot may have experienced spatial disorientation, there was insufficient evidence to conclude that spatial disorientation contributed to the accident.

A witness reported that the multi-engine turboprop airplane was on final approach to land when it suddenly veered to the left and entered a rapid descent. The witness stated that he heard the "whine of the engines" before the airplane impacted terrain about 1/2 mile south of the runway threshold. In the days preceding the accident flight, the airplane had been at a maintenance facility to resolve a vibration in the rudder system while the autopilot system was engaged. There were no anomalies reported with the autopilot system during a test flight completed immediately before the accident flight. However, anomalies with the rate gyro were noted by a mechanic who recommended replacing it, but the pilot departed on the accident flight without the recommended repair having been completed. Further, examination of the autopilot annunciator panel indicated that the autopilot was likely not engaged at the time of impact, likely because the airplane was on a short final approach for landing. Accordingly, any existing autopilot faults would not have affected the flight as the autopilot system was likely not in use. There were no failures identified with the primary flight controls, engines, or propellers that would have prevented the pilot from maintaining control of the airplane manually. Toxicological testing revealed the presence of Zolpidem in the pilot's blood (Zolpidem, the trade name for Ambien, is used for short-term treatment of insomnia); however, the reported levels would likely not have resulted in any impairment.

The pilot of the Part 91 business flight filed an instrument-flight-rules (IFR) flight plan with the destination and alternate airports, both of which were below weather minimums. The pilot and
copilot departed from the departure airport in weather minimums that were below the approach minimums for the departure airport. While en route, the destination airport's automated observing system continued to report weather below approach minimums, but the flight crew continued the flight. The flight crew then requested and were cleared for the instrument landing system (ILS) 31 approach and while on that approach were issued visibilities of 1,800 feet runway visual range after changing to tower frequency. During landing, the copilot told the pilot that he was not lined up with the runway. The pilot reportedly said, "those are edge lights," and then realized that he was not properly lined up with the runway. The airplane then touched down beyond a normal touchdown point, about 2,800 feet down the runway, and off the left side of the runway surface. The airplane veered to the left, collapsing the nose landing gear. Both flight crewmembers had previous experience in Part 135 operations, which have more stringent weather requirements than operations conducted under Part 91. Under Part 135, IFR flights to an airport cannot be conducted and an approach cannot begin unless weather minimums are above approach minimums. The accident flight's departure in weather below approach minimums would have precluded a return to the airport had an emergency been encountered by the flight crew, leaving few options and little time to reach a takeoff alternate airport. The company's flight procedures allow for a takeoff to be performed as long as there is a takeoff alternate airport within one hour at normal cruise speed and a minimum takeoff visibility that was based upon the pilot being able to maintain runway alignment during takeoff. The company's procedures did not allow flight crew to depart to an airport that was below minimums but did allow for the flight crew, at their discretion, to
perform a "look-see" approach to approach minimums if the weather was below minimums. The allowance of a "look see" approach essentially negates the procedural risk mitigation afforded by requiring approaches to be conducted only when weather was above approach minimums.

The private pilot arrived at the accident airport as part of an Angel Flight volunteer program to provide transportation of a passenger who had undergone medical treatment at a local hospital. About 0937, the airplane landed on runway 30 (3,900 feet by 150 feet) with winds from 073-080 degrees and 5-6 knots, which continued to increase due to an atmospheric pressure gradient. The pilot met the passengers and departed the terminal about 1003, with winds at 101-103 degrees and 23-36 knots. About 1005 the airplane was near the approach end of runway 30 with wind from 089-096 degrees and 21-31 knots. The pilot stated that he began rotating the airplane about 3,000 feet down the runway. About 1006, the airplane was approximately 3,553 feet down the runway while flying about 30 feet above the runway. The airplane experienced an aerodynamic stall, and the left wing dropped before it impacted the ground. No mechanical anomalies that would have precluded normal operation of the airplane were noted during the investigation. The fatally injured passenger, who had received medical treatment, was 2 years and 10 months of age at the time of the accident. She was held by her mother during the flight, as she had been on previous Angel Flights, but was otherwise unrestrained. According to 14 CFR 91.107(3), each person on board a U.S.-registered civil aircraft must occupy an approved seat with a safety belt properly secured during takeoff, and only unrestrained children who are under the age of 2 may be held by a restrained adult. Although the accident was survivable (both the pilot and the adult passenger survived with non-life-threatening injuries), an autopsy performed on the child revealed that the cause of death was blunt force trauma of the head.

The flight was on a VHF Omni Range (VOR) instrument approach to the destination airport at the time of the accident. Radar track data indicated that the airplane passed the VOR at 2,800 feet. After passing the VOR, it turned right, becoming established on an approximate 017- degree magnetic course. The published final approach course was 341 degrees. The airplane subsequently entered a left turn, followed immediately by a right turn, until the final radar data point. Altitude returns indicated that the pilot initiated a descent from 2,800 feet upon passing the VOR. The airplane descended through 2,000 feet during the initial right turn, and reached a minimum altitude of 1,400 feet. The altitude associated with the final data point was 1,600 feet. The initial impact point was about 0.18 nautical miles from the final radar data point, at an approximate elevation of 1,235 feet. The minimum descent altitude for the approach procedure was 1,720 feet. Review of weather data indicated the potential for moderate turbulence and low-level wind shear in the vicinity of the accident site. In addition, icing potential data indicated that the pilot likely encountered severe icing conditions during descent and approach. The pilot obtained a preflight weather briefing, during which the briefer advised the pilot of current Airman's Meteorological Information advisories for moderate icing and moderate turbulence along the route of flight. The briefer also provided several pilot reports for icing and turbulence. A postaccident inspection of the airframe and engines did not reveal any anomalies associated with a preimpact failure or malfunction.

The airplane was managed by and listed on the certificate of Jackson Air Charter, Inc. (JAC), a 14 Code of Federal Regulations (CFR) Part 135 on-demand operator; however, because the owner of the airplane was using it for personal use, the accident flight was flown under 14 CFR Part 91 regulations. The right-seat pilot, who was the chief pilot for JAC, was the flying pilot for the flight. The right-seat pilot had about 13,312 total flight hours, 833 hours of which were in Cessna 560 airplanes. The left-seat pilot, who was the nonflying pilot for the flight and had only worked for JAC for a little over a month, had not yet completed the company's Part 135 training but was scheduled to do so. The left-seat pilot had about 11,607 total flight hours, 557 hours of which were in Cessna 560 airplanes. The flight was planned to land at Rochester International Airport (RST), Rochester, Minnesota. The flight crew attempted to circumnavigate severe weather conditions and continue the planned descent for about 15 minutes even though a Minneapolis Air Route Traffic Control Center controller stated that the flight would have to deviate 100 miles or more to the north or 80 miles to the south to do so. The RST approach controller subsequently told the flight crew that there was "weather," including wind gusts, along the final approach course, and on-board radar and weather advisories also showed severe thunderstorms and wind gusts in the area. Given the overwhelming evidence of severe weather conditions around RST, the flight crew exhibited poor aeronautical decision-making by attempting to continue the preplanned descent to RST despite being aware of the severe weather conditions and by not diverting to a suitable airport earlier in the flight. The cockpit voice recorder (CVR) recorded the flight crew begin discussing an alternate destination airport about 3 minutes after contacting RST approach; however, the CVR did not record the left-seat pilot adequately communicate to air traffic control that the flight was going to divert. CVR evidence also showed that neither pilot took a leadership role during the decision-making process regarding the diversion. As a result, the flight crew chose an alternate airport, Ellen Church Field Airport (CJJ), Cresco, Iowa, from either looking at a map or seeing it out the cockpit window. The flight crew was not familiar with the airport, which did not have weather reporting capabilities. CVR evidence indicates that the flight crew did not use the on-board resources, such as the flight management system and navigational charts, to get critical information about CJJ, including runway direction and length. Further, the flight crew did not use on-airport resources, such as the wind indicator located on the left side of runway 33. During the approach and landing, the enhanced ground proximity warning system (EGPWS) alerted in the cockpit. However, the flight crew did not recognize or respond to the EGPWS warning, which alerted because the EGPWS did not recognize the runway since it was less than 3,500 feet long. CVR evidence indicated that the flight crew incorrectly attributed the warning to the descent rate. Further, the runway was not depicted on an on-board non-navigational publication, which only contained runways that were 3,000 feet or more long, and this was referenced and noted by the flight crew. In addition, the flight crew visually recognized during the final approach that the runway was shorter than the at least 5,000 feet they originally believed it to be (as stated by the right-seat pilot earlier in the flight). Despite all of these indications that the runway was not long enough to land safely, the flight crew continued the descent and landing. (After the accident, Cessna computed the landing distance for the accident conditions, which indicated that about 5,200 feet would have been required to stop the airplane on a wet runway with a 10-knot tailwind. Runway 33 is only 2,949 feet long. Further, the Cessna Aircraft Flight Manual does not recommend landing on precipitation covered runways with any tailwind component.) Because the flight crew did not look up the runway length and did not heed indications that the runway was too short, both of which are further evidence of the flight crew's poor aeronautical decision-making, they landed with inadequate runway length to either land the airplane on the runway or abort the landing. Subsequently, the airplane exited the runway and continued about 1,700 feet beyond its end. The airplane had sufficient fuel to have proceeded to an airport with a suitable runway length. In addition to the poor decision-making, the flight crew did not exhibit adequate crew resource management (CRM) throughout the flight. For example, the flight crew exhibited poor communication and decision-making skills, did not effectively use the available on-board resources to get information about the landing runway, and neither pilot took a leadership role during the flight. JAC did not have and was not required to have an approved CRM training program although, according to company pilots, some CRM training was incorporated into the company's simulator training. On December 2, 2003, the National Transportation Safety Board issued Safety Recommendation A-03-52, which asked the Federal Aviation Administration (FAA) to require that 14 CFR Part 135 on-demand charter operators that conduct dual-pilot operations establish and implement an FAA-approved CRM training program for their flight crews in accordance with 14 CFR Part 121, subparts N and O. On May 2, 2006, Safety recommendation A-03-52 was reiterated and classified "Open-Unacceptable Response" pending issuance of a final rule. Although the accident flight was operated under Part 91, if JAC, as an on-demand Part 135 operator, had provided all of its pilots CRM training, the benefits of such training would extend to the company's Part 91 flights. In November 2007, the Safety Board placed Safety Recommendation A-03-52 on its Most Wanted List of Transportation Safety Improvements because of continued accidents involving accident flight crew members. As a result of this accident, the Safety Board reiterated Safety Recommendation A-03-52 on May 1, 2008. The right-seat pilot had in his possession multiple prescription and nonprescription painkillers, nonprescription allergy and anti-acid medications, and one prescription muscle relaxant. None of these medications are considered illicit drugs and would not have been reportable on drug testing required under 49 CFR Part 40. The right-seat pilot was known to have problems with back pain, although no medical records of treatment for the condition could be located. On his most recent application for airman medical certificate, the pilot had reported no history of or treatment for any medical conditions and no use of any medications. Toxicology testing revealed recent use of a prescription muscle relaxant, which might have resulted in impairment. It is also possible that the right-seat pilot was impaired or distracted by the symptoms for which he was taking the muscle relaxant; however, it could not be determined what role the muscle relaxant or the physical symptoms might have played in this accident.

The twin-engine airplane was destroyed by impact with terrain about 2.5 miles northeast of the airport while returning to the airport with an engine problem. A witness reported that the FAR Part 135 on-demand passenger flight had been scheduled for a 0900 departure, but because the flight had not been confirmed, a pilot was not scheduled to fly the flight. The accident pilot arrived at the airport about 1005. A witness reported that the pilot was not in the office for more than two minutes when he "grabbed the status book," walked straight to the airplane, and boarded. A lineman serviced both engines at 0930 with oil, but failed to put the dipstick back in the right engine oil filler tube. Witnesses reported that they did not see the pilot perform a preflight. The pilot was unaware that the dipstick was left on the right wing of the airplane. The pilot taxied the airplane forward about 5 feet and abruptly stopped and shut down both engines. The pilot got out of the airplane. The lineman reported that he approached the pilot and asked what was wrong. The lineman reported that the pilot closed the oil flap door on the right engine, and said that the oil flap door had been left open. The pilot restarted the engines and departed about 1008. About three minutes after takeoff, the pilot informed departure control that he needed to return to the airport due to an oil leak. The pilot reported over the Unicom radio frequency that he was returning because he was having trouble with the right engine. Radar track data indicated that about 1013, the airplane's position was about 1.5 miles directly north of the airport about 1,800 feet msl, heading south at 126 knots calibrated airspeed (CAS). The airplane continued to fly south directly to the airport. The radar track data indicated that instead of landing on runway 18, the airplane flew over the airport, paralleling runway 18. About 1014, the airplane's position was over the airport at an altitude of about 1,460 feet msl (550 feet above ground level), heading south at about 97 knots CAS. The airplane continued to fly south past the airport, entered a left turn, and turned back to the north. The last radar return was recorded about 1016. The airplane's position was approximately 1.5 miles east of the approach end of runway 18 at an altitude of about 1,116 feet msl (344 feet agl), heading north at about 99 knots CAS. The impact site was located about 2.5 miles north of the last radar return. A witness, located about 1/4 mile from the accident site, observed the airplane flying "really low." He reported, "The motor on the plane wasn't cutting out or sputtering." Another witness reported, "The plane lifted up over power lines then went across a field about 50 to 80 ft off ground." The airplane impacted a harvested cornfield in a Page 2 of 11 CHI06FA026 steep nose-down attitude, and traveled 45 feet before stopping. The inspection of the airplane revealed that the landing gear was down, flaps were found in a 20-degree down position, and neither propeller was feathered. The post accident inspection of the airplane's engines and airframe revealed no preexisting anomalies that could be associated with a pre-impact condition.

The airplane collided with a berm following a loss of directional control while landing. The airplane was on a 14 CFR Part 91 positioning flight at the time of the accident. The pilots reported that they encountered what they thought were rough spots on the runway during the takeoff roll. The captain reported that after takeoff, he called for the co-pilot to raise the gear and engage the yaw damper. The crew then noticed an unsafe gear indication for the nose gear. The captain stated they leveled off at 5,000 feet and decreased the airspeed so they could recycled the landing gear. Cycling the landing gear did not resolve the problem. The crew then requested to return to the departure airport for landing. The landing gear was extended and a gear down and locked indication for all three landing gear was observed. The captain stated that on touchdown, the co-pilot extended the spoilers and armed the thrust reversers. He stated that after the nose wheel touched down the airplane made a sharp left turn and traveled off the side of the runway through the grass. The airplane contacted a four-foot high berm prior to coming to a stop on another runway. The captain stated he attempted to taxi the airplane only to discover that they did not have any nose wheel steering. Post accident inspection revealed the seal on the nose gear strut had failed which prevented the nose gear from centering.

The pilot said he was on the glide slope for an ILS approach. The pilot said, "The autopilot was coupled on to the approach. The autopilot also coupled on to the Glide slope. Approximately 2-1/2 to 3 miles out, we visually had approach lights and runway lights. I then disconnected the autopilot and yaw damper, and hand flew a visual approach using the glide slope indicator as a cross check for a correct glide path to the airport. Continuing visually on the approach, I checked the GS (glide slope) and it indicated we were slightly above glide path, but was corrected, and seconds later hit a pole going through electrical wires, coming to rest short of the approach lights and to the right." An examination of the airplane revealed no anomalies. An examination of the ILS approach to the runway showed the facility operated satisfactorily.