Cresco, IA, USA
N636SE
Cessna 560
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 crewmembers. 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.
HISTORY OF FLIGHT On July 19, 2006, at 1104 central daylight time, a Cessna 560, N636SE, received substantial damage on impact with terrain during an aborted landing on runway 33 (2,949 feet by 50 feet, concrete) at Ellen Church Field Airport (CJJ), Cresco, Iowa. The airplane was located in a cornfield about 1,751 feet north of the departure end of runway 33. Visual meteorological conditions prevailed at the time of the accident. The 14 CFR Part 91 flight was operating on an instrument flight rules (IFR) flight plan. Flight crew services were provided by Jackson Air Charter, Inc (JAC). The left seat pilot and right seat pilot received fatal injuries, and the two passengers received serious injuries. The flight last departed from University-Oxford Airport (UOX), Oxford, Mississippi, at 0920, and was en route to Rochester International Airport (RST), Rochester, Minnesota, when it diverted to CJJ. The JAC Trip Sheet Information lists the following itinerary for four passengers, including the passengers aboard the accident flight. --------------------------------------- Depart from Jackson at 0600; Arrive Gulfport-Biloxi at 0639 Depart from Gulfport-Biloxi at 0700; Arrive at Destin-Ft. Walton, Fla. at 0739 Depart Destin-Ft. Walton at 0745; Arrive at Meridian, Miss. at 0830 Depart from Key Field, Miss. at 0845; Arrive at Oxford, Miss., at 0924 Depart from Oxford, Miss. at 1000; Arrive at Rochester, Minn. At 1151 Depart from Rochester, Minn. at 1300; Arrive at Oxford, Miss. at 1445 Depart from Oxford, Miss. at 1730; Arrive at Meridian, Miss. at 1809 Depart from Meridian, Miss. at 1830; Arrive at Destin-Ft. Walton, Fla. at 1915 Depart from Destin-Ft. Walton, Fla. at 1930; Arrive at Jackson at 2027 ------------------------------ One of the four passengers is designated as the "primary passenger" on the Trip Information Sheet, which also lists the primary passenger's corporation as the customer. According to JAC and the primary passenger, the flights on the day of the accident were 14 CFR Part 91 flights. The Trip Sheet Information also provides a quote and list of charges. The left front second row seat (#5) passenger stated that he had not flown in N363SE prior to the accident but has flown on similar airplanes with 8-12 seats but did not recall whether they were in Cessna 560 airplanes. The right front seat (#4) passenger called the left front seat passenger and asked him to accompany him to Mayo Clinic to undergo medical tests. They both boarded the airplane at Gulfport, Mississippi, and flew to Destin, Florida, where the primary passenger boarded the airplane. They then flew to Meridian, Mississippi, where they dropped off the primary passenger. They then flew to Oxford, Mississippi, where the dropped off the primary passenger's wife. The primary passenger stated that he boarded the airplane with his wife at Destin-Ft. Walton Beach, Destin, Florida, where he met his friend who was the #4 passenger and the other passenger who was the #5 passenger. They departed a few minutes after 0715 en route to Key Field Airport, Meridian, Mississippi, where the primary passenger deplaned and his wife continued onto University-Oxford, Oxford, Mississippi, where she then deplaned. The primary passenger stated that his wife overheard the pilots saying that they were going to top off the fuel and the remaining passengers could get some coffee or something to eat. The #5 passenger stated that he had lunch with the right seat pilot (viewed looking forward from within the airplane). The right seat pilot was a "great guy" and was alert. During lunch, the right seat pilot ate a biscuit and drank a nonalcoholic beverage, but the left front seat passenger could not recall if it was coffee. The right seat pilot was a "young good looking healthy guy." The left seat pilot remained with the airplane. He stated that it was a "beautiful day" on the coast. The #5 passenger stated that the crew obtained fuel for the airplane in University-Oxford, Oxford, Mississippi (a credit card receipt for 527 gallons of Jet A time stamp with a time stamp of 0846 at University-Oxford, Oxford, Mississippi, was found at the accident site). He stated that the cockpit door was left open during the flight and they did not talk to the flight crew because the noise level was "loud," and they were "far" from the flight crew. According to Flight Service Station information, an IFR flight plan for N636SE was filed for a flight from UOX to RST at flight level (FL) 380 with no alternate airport. The #5 passenger stated they were flying north toward Rochester, Minnesota, when they made a "hard u-turn" and started "dropping down" to Cresco, Iowa. He stated that it was a "pretty aggressive drop," and the descent was "more aggressive" than a "commercial airliner." He said he had "no fears what so ever." The descent was so steep that he could see the runway through the pilot windshield at an altitude of 5,000 feet. The airplane then felt as if it got "jarred" and a couple of overhead panels opened. The flight crew recovered and lined themselves up for landing. He stated alarms were "going on," and he heard a "beeping" and "pull-up pull-up." He stated that it looked like the flight crew was going to make a "picture perfect" landing. The cockpit voice recorder (CVR) was read out by the National Transportation Safety Board's Recorders Laboratory. The CVR begins as the airplane is on final approach to University-Oxford airport in Oxford, Mississippi. The crew states the items in the landing checklist and the sound of touchdown, followed by in an increased background noise (similar to thrust reverser) is recorded. The CVR stops recording followed immediately by the sound of a CVR power-up tone. It is unknown how much local time actually elapsed between the shut down and power up of the CVR. However, eight minutes and thirty-two seconds elapsed from the beginning of the recording to the shut down/power-up of the CVR. The second part of the recording began at the power-up tone on the CVR at 09:09:20 (approximately 8 minutes, 32 seconds after the start of the recording). About 09:11:54, the crew discusses the weather between Oxford, Mississippi, and Rochester, Minnesota. The crew states items in the before taxi and the before takeoff checklists and about 09:17:52, the right seat pilot states within the crew briefing that he will be flying the airplane. About 09:18:36, the sound of increased engine RPM is recorded. The airplane is issued an IFR clearance, as filed, from Memphis Center about 09:21:58. The airplane is subsequently issued clearance to climb to FL 380 and about 09:47:31, the airplane is transferred to Kansas City Center, where they are given clearance to climb to FL 400. About 10:20:00, the airplane is transferred to Chicago Center and about 11 minutes later reports light chop. About 10:32:19, the airplane is transferred to another Chicago Center controller. At 10:33:14, the crew requests a lower altitude, which the center controller approves to FL 350. About 10:42:33, the airplane is transferred to Minneapolis Center. About 10:43:13, the left seat pilot relays to Minneapolis Center that they are deviating from weather (but direct to Rochester), and additionally are not able to pick up automatic terminal information service (ATIS) at Rochester. The controller then relays the weather information to the airplane. About 10:45:54, the left seat pilot radios Center stating, "we're just gonna' keep kinda' heading this direction stay on the west side of the weather 'til we get north of Rochester and then turn around and take a look at it." The controller asks for clarification that he means "on the east side of the weather" and the left seat pilot replies, "affirmative." After, the airplane is transferred to another Minneapolis Center controller, the controller states at 10:51:57, "it's heck of a bow hook we got going on there… but ah you'd have to go about a hundred miles or more north to get around the very northern edge of it. Ah if you go around the south side um it's about eighty miles to get around the south side." The crew discusses it and decides to "pick [their] way through it." About 10:54:54, the airplane is continuing its descent and is transferred to Rochester Approach. Approximately 8 seconds later, a partial ATIS recording for Rochester is recorded on the crew channels. At 10:55:26, the left seat pilot checks in with the Rochester Approach descending from 14,700 feet to 10,000 feet with ATIS information Victor. At 10:55:42, Rochester Approach states, "Citation six three six Sierra Echo Rochester approach and expect vectors for the ah loca- well wind three four zero at six gusts two four that would favor the I-L-S to three one but right now the area of weather that we've got is all along that final and we're showing weather echoes along that final approach course. say your intentions" The left seat pilot replies that they will continue for another 20 miles on their present heading of 240 degrees and "take a look at it on the radar." 10:56:25, the right seat pilot states, "probably what I'm going to do is go here to this hole then work my way up around that way." 10:56:27, the left seat pilot states, "yep yeah." 10:56:32, Rochester Approach clears the clears the airplane to descend and maintain 9,000 feet which the left seat pilot acknowledges. 10:57:00, the left seat pilot states, "so we're just going through the localizer right right now… about you have to go up and come back." 10:57:22, the left seat pilot states "yeah that's the only hole this is what he was talking about for the final yeah." 10:57:28, ATIS, "…Rochester Tower information Victor one five three eight Zulu special observation wind three two zero at two niner gusts three niner visibility one half thunderstorm heavy rain **." 10:57:43, the right seat pilot states, " (teah) couldn't get there at a worse time." 10:58:01, the left seat pilot states, "I'm wondering if that hole's (blinking) if that red's (blinking) that spot (out right there). 10:58:04, the right seat pilot states, "yeah yeah I'm curious about that too." 10:58:07, the right seat pilot states, "we're gonna know here in a minute I'm gonna go this way." 10:58:10, the left seat pilot transmits, "and Sierra Echo we're gonna turn a little bit further to the south, " and Rochester Approach acknowledges the transmission. 10:58:20, the left seat pilot states, "this little airport right here C-C-J-J." 10:58:33, the left seat pilot states, "don't see it on the map here." 10:58:49, the right seat pilot states, "what airport is that?" 10:58:51, the left seat pilot states, "uhh I'm gonna have to look it up heeere… C-C-J-J." 10:59:18, [sound of tone similar to altitude alerter] 10:59:19, the right seat pilot states, "I've got that airport right there." 10:59:22, the left seat pilot states, "yep ah." 10:59:31, the left seat pilot states, "how long's the runway look?" 10:59:32, the right seat pilot states, "ah I'm guessing five thousand feet at least." 10:59:44, the left seat pilot transmits, "yeah the airport below us to the left has got an identifier of Charlie Juliet Juliet what's what's that airport" to which Rochester Approach responds by stating that it "Cresco Iowa Cresco." 10:59:58, the right seat pilot states, "I guess worse case scenario we could set here until it clears." 11:00:00, the left seat pilot states, "yeah." 11:00:04, the right seat pilot states, "what do you think?" 11:00:05, the left seat pilot states, "Cresco yeah I mean I'm okay with that." 11:00:06, the right seat pilot states, "let's do that." 11:00:10, [sound of tone similar to autopilot disconnect] 11:00:11, the left seat pilot states, "…ah we're just gonna land at Cresco and l-l-look at the weather on the ground and ah." 11:00:15, RST approach transmits, "attention all aircraft Rochester information Whiskey's current altimeter three zero one zero." 11:00:21, the left seat pilot states, "he's got you at nine you're going through nine. 11:00:23, the right seat pilot states, "oh I'm sorry." 11:00:25, the right seat pilot states, "ah I'm trying to stay below this weather and tell him we want to get down here." 11:00:28, the left seat pilot transmitted to RST approach that they were going to land at Cresco, had the it in sight, and were subsequently cleared from the visual approach to CJJ. 11:00:43, the right seat pilot states, "see if you can get me s-see if you can get me some numbers for the thing at all or well the landing numbers would be okay." 11:00:49, the right seat pilot states, "I'm gonna have to put us down here hang on." 11:00:54, the left seat pilot transmits to Rochester Approach and asks if they had the common traffic advisory frequency for Cresco to which the controller responds that he doesn't. 11:01:03, the right seat pilot states, "you didn't find it in the book at all?" 11:01:04, the left seat pilot states, "do what?" 11:01:05, the right seat pilot states, "even in the Ac-u-kwik?" 11:01:09, the left seat pilot states, "let's see." 11:01:16, the left seat pilot states, "crit-." 11:01:19, the left seat pilot transmits, "is it Cres-ton Iowa?" 11:01:26, [sound of clunk] 11:01:28, [sound of increased background noise] 11:01:35, RST Approach transmits, "and Citation six Sierra Echo that common traffic advisory frequency at Cresco one two two point eight" to which the left seat pilot replied with "…thank you." 11:01:47, [sound of tone similar to altitude alert] 11:01:48, the right seat pilot states, "whenever I slow down to flap speed I'll let you just go ahead and give them to me." 11:01:59, the left seat pilot states, "we're probably five miles south." 11:02:01, RST Approach states, "Citation six Sierra Echo report canceling the I-F-R." The left seat pilot responds by canceling the IFR clearance. Approximately 24 seconds later, the left seat pilot issued a traffic advisory, "ah Creston Iowa traffic Citation six three six Sierra Echo we're checking in for a we're turning final landing to the ah north." 11:02:35, the right seat pilot states, "whatever runway it is. [sound of laughing] 11:02:35, the right seat pilot states, "yeah." 11:02:38, the left seat pilot states, "improvise." 11:02:38, the right seat pilot states, "flaps land." 11:02:04, the right seat pilot states, "okay how we looking for landing got ignition got gear got flaps and speed brake still out." 11:02:45, the left seat pilot states, "***crew brief***." 11:02:49, the right seat pilot states, "don't let me land with the speed brake." 11:02:50, the left seat pilot states, "passenger advisory * safe passenger*." 11:02:52, the left seat pilot states, "fuel crossfeed antiskid is checked and on ground idle switch is coming to normal." 11:02:56, the right seat pilot states, "okay." 11:02:57, the left seat pilot states, "pressurization is down." 11:02:58, the right seat pilot states, "speed brake up please." 11:02:59, the left seat pilot states, "flaps **is checked." 11:03:03, the left seat pilot states, "annd engine sync is off a-approach. Before landing landing gear verify down and three green." 11:03:08, the right seat pilot states, "checked." 11:03:09, the right seat pilot states, "great." 11:03:09, the left seat pilot states, "landing lights on. Ignition?" 11:03:11, the right seat pilot states, "they're up." 11:03:11, the left seat pilot states, "normal or on?" 11:03:12, (flaps). 11:03:12, GPWS, "terrain. terrain. [male synthetic voice]" followed by "pull up [male synthetic voice] two seconds later. 11:03:15, the right seat pilot states, "get rid of that guy or one of those guys." Over the next five seconds there were additional "pull up" statements by the GPWS. 11:03:24, the left seat pilot states, "all right you're in good shape ***." 11:03:24, the copilot states, "I don't see anything." 11:03:26, the left seat pilot states, "I don't either." 11:03:26, GPWS, "pull up… pull up. [male synthetic voice] and continued until the end of the recording. 11:03:28, the left seat pilot states, "and it's a wet runway too so." 11:03:30, the right seat pilot states, 'kay." 11:03:35, the left seat pilot states, "looks like it's long enough for you?" 1103:35, the right seat pilot states, "it's the descent rate." 1103:36, GPWS,
The flight crew's inadequate aeronautical decision-making and poor crew resource management (CRM), including the inadequate use of the on-board sources (such as the flight management system and navigation charts), to get critical information about Ellen Church Field Airport, including runway direction and length. Contributing factors to the accident were the flight crew's failure to consider and understand indications that the runway length was insufficient and inadequate CRM training for pilots at Part 135 on-demand operators.
Source: NTSB Aviation Accident Database
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