Woodruff, WI, USA
N193BS
Cirrus Design Corporation SR22
The pilot was attempting a non-precision instrument approach at dusk in instrument meteorological conditions (IMC) that were below the required approach minimums without an alternate airport. Near the missed approach point, the airplane entered a climb and the airspeed decreased. The airplane gave a stall warning and it subsequently crashed. Recorded flight data revealed that pilot was utilizing the autopilot intermittently and then about two minutes before the accident he turned it off, indicating that he was either not proficient in flying in IMC in the accident airplane make and model and/or utilizing its autopilot. This was further supported by the pilot previously failing his initial airman examination flight and his lack of experience in non precision approaches in such conditions. Furthermore, the postaccident investigation determined that the Part 135 certificate holder had used an unapproved airplane training program paid for by the airplane owner and had falsified air carrier records in order to meet air carrier flight training requirements. The assignment of the flight shows a loss of operational control due to the attempted approach in below approach minimums; the lack of an alternate airport; the assignment of a pilot that lacked proficiency and/or experience in the weather conditions that were encountered during the flight; and pilot’s lack of explicit authorization for use of an autopilot in lieu of a second-in-command, which was due to the Federal Aviation Administration (FAA) Principal Operation Inspector's (POI) failure to complete the appropriate form. Additionally, the airplane’s registered owner had placed their airplanes on a previous Part 135 certificate but that certificate holder removed those airplanes from the certificate after the owner improperly exercised operational control instead of the certificate holder. The airplanes were then placed on the current certificate holder’s certificate during which time there are indications that the airplane owner was exercising operation control. At least one inspector from the FAA’s Flight Standard District Office (FSDO) was aware of the history of improper exercise of operational control of flights by the airplane owner (not the certificate holder) and no action was taken to stop this practice. Additionally, the FAA FSDO surveillance records revealed that the certificate holder was rated as satisfactory with no comments noted, although throughout the investigation numerous discrepancies were found that within the company that did not comply with Part 135 operations. A postaccident examination revealed no mechanical anomalies that would have precluded normal airplane operation.
HISTORY OF FLIGHT On September 11, 2008, approximately 1915 central daylight time, a Cirrus Design Corporation SR22, N193BS, sustained substantial damage when it impacted terrain during a nonprecision instrument approach to runway 36 at the Lakeland Airport/Noble F. Lee Memorial Field (ARV), Minocqua-Woodruff, Wisconsin. Instrument meteorological conditions prevailed at the time of the accident. The Title 14 Code of Federal Regulations (CFR) Part 135 on-demand passenger flight was operating on an instrument flight rules (IFR) flight plan. The pilot and two revenue passengers received fatal injuries. The flight departed from General Mitchell International Airport (MKE), Milwaukee, Wisconsin, at 1745, and was en route to ARV. According to available documentation, the airplane was registered to Bluesky Taxi Inc. (BST), Lincolnshire, Illinois, and was listed on Midwest Air Transport, Inc's (MAT) Part 135 operating certificate. Earlier on the day of the accident, the pilot had flown his airplane to Lafayette, Indiana, and arrived about 1045 eastern daylight time to meet a friend. The friend stated that the pilot was in “fine” condition, in a “great mood,” and “relaxed.” The pilot told his friend that the Bluesky Taxi (BST) operating certificate was owned by a private individual, but that individual did not operate the flights. The pilot also told him that the owners of BST were the operators and that they assigned the flights. The pilot also told his friend that there was no dispatcher and that the pilots dispatch themselves and would try to fly under visual flight rules (VFR) as much as possible to minimize the cost to the customers as much as possible. The pilot further told him that he would get a call from the chief pilot of BST if he flew IFR and did not absolutely have to. The pilot then departed from Lafayette in the afternoon to return to his home in Illinois. The president of MAT stated that the accident flight was originally scheduled with a pilot who could only fly under VFR; however, IMC conditions prevailed to the north along the intended route of flight, so the MAT president called the accident pilot via telephone and asked if he was available. The pilot said he was available and was provided flight itinerary information. The pilot was dispatched from DuPage Airport (DPA), West Chicago, Illinois, in N193BS because the airplane was closer to the accident pilot’s home. The president stated that he believed that he talked to the originally scheduled pilot and the accident pilot before 1500, a couple of hours before the scheduled pick-up at 1700. The pilot left his house about 1600 to pick up the airplane at DPA. At 1627:58, a caller representing himself as the pilot of N193BS called Kankakee automated flight service station (AFSS) and filed two IFR flight plans from MKE to ARV and ARV to DPA. The caller filed the first flight plan for N193BS and specified the airplane equipment capability as “slash golf” (Global Navigation Satellite System (GNSS), including GPS or WAAS, with en route and terminal capability). The proposed departure time from MKE was 1700, at an altitude of 8,000 feet, destination ARV, time en route of 1 hour 15 minutes, and 3 hours 30 minutes of fuel on board. The caller filed a return flight plan with a proposed departure time from ARV to DPA at an altitude of 8,000 feet, with a proposed arrival time of 2330. The FSS specialist asked the caller if he had the latest information on weather conditions, to which the caller responded by saying, “yes I do since (unintelligible).” The specialist then provided the caller with convective Significant Meteorological Information (SIGMET) for thunderstorms and an Airmen's Meteorological Information (AIRMET) for IFR. At 1631:16, the call to Kankakee AFSS was concluded. A credit card receipt from Signature Flight Support at MKE shows a charge for 30 gallons of 100 low lead fuel for N193BS and the customer listed is “Bluesky Taxi LLC.” The following is a chronological summary of voice communications of the airplane and airplane flight data extruded from the airplane flight instruments. At 1742:13, N193BS requested and was issued an IFR clearance to ARV by MKE Air Traffic Control (ATC). The clearance to ARV was via the Brew Three departure direct to Oshkosh, and to maintain 5,000 feet. At 1743:36, N193BS requested and received a taxi clearance from Signature Flight to runway 19R by MKE ground control. At 1745:00, N193BS was issued a takeoff clearance by MKE local control. At 1831:50, Minneapolis Air Route Traffic Control Center (ARTCC), Sector 4 Radar Controller (ZMP04) transmitted, “tango November one niner three bravo sierra advise when you have the current arbor vitae weather---and the arbor vitae altimeter’s two nine eight niner.” At 1831:57, N193BS transmitted, “yea we’ve got the weather.” At 1831:59, ZMP04 transmitted, “and (your) tango november one niner three bravo sierra a couple notams at arbor vitae n d b is out of service runway three six i l s d m e is out of service.” [A Notice to Airmen (NOTAM) was issued on September 3, 2008, stating that the ARV nondirectional radio beacon (NDB) was out of service. A second NOTAM was issued on September 8, 2008, stating that the ARV runway 36 instrument landing system (ILS) distance measuring equipment (DME) was out of service.] At 1832:10, N193BS transmitted, “ah the i l s completely out or is it just the d m e.” At 1832:16, ZMP04 transmitted, “tango november one niner three bravo sierra say again.” At 1832:19, N193BS transmitted, “is the i l s completely out or is it just the d m e.” At 1832:22, ZMP04 transmitted, “and i am just showing three six i l s d m e is out of service.” At 1832:27, N193BS transmitted, “o k well ah that may be a problem for us to get in then i’ve got to figure something out and get back to you.” At 1834, ZMP04 instructed N193BS to contact Minneapolis ARTCC with a frequency change. N193BS then initiated contact with the Minneapolis ARTCC, Sector 03 Radar Controller (ZMP03) and reported an altitude of 8,000 feet. At 1835:55, N193BS transmitted, and Minneapolis three bravo sierra so for planning purposes uh (unintelligible) we are going to get radar vectors to the localizer three six.” At 1836:01, ZMP03 transmitted, “november three bravo sierra affirmative.” At 1904:49, ZMP03 transmitted, “a november three bravo sierra’s four south of dougy maintain three thousand five hundred til on a published portion of the approach cleared for the localizer three six approach arbor vitae.” At 1905:07, N193BS transmitted, “ah i got all that ah three thousand five hundred till on a published segment (unintelligible) cleared three six approach.” At 1905:13, ZMP03 transmitted, “November three bravo sierra roger and are you going to be able to shoot the approach from a couple south of the marker there.” At 1905:19, N193BS transmitted, “i’m sorry what.” At 1905:20, ZMP03 transmitted, “are you going to be able to make the approach from fifty two hundred from a couple south of the marker.” At 1905:29, the autopilot (AP) was selected OFF at a pressure altitude of 5,033 feet and a heading of 359 degrees magnetic. At 1906, N193BS transmitted, “yea i’m going to need to go back around three bravo sierra if i can just do one oval i should be o k.” ZMP03 approved a left 360 degree turn. At 1906:07, the active waypoint transitioned from DOUGY to runway 36 at a pressure altitude of 4,509 feet and a heading of 354 degrees. The airplane started a descending left hand 360 degree turn without the AP selected ON. At 19:07:04, 190 degrees into the turn the AP was selected ON and the turn continued using the heading bug selection. The autopilot altitude reference selected was initially set at 3,500 feet and adjusted to 3,200 feet during the descent. At 1907:30, ZMP03 transmitted, “november three bravo sierra let me know when uh you’re reestablished inbound on the loc.” At 1907:34, N193BS transmitted, “yea we are starting to turn back now.” At 1910:05, ZMP03 transmitted, “o k show you right over the marker now you can change to advisory cancellation or down time um ah with me or forward it through flight service.” At 1910:11, N193BS transmitted, “wilco three bravo sierra.” There were no further recorded transmissions from N193BS. At 1910:11, the final recorded altitude and heading bug settings were 1,900 feet and 0 (360) degrees. At 1910:24, the AP was selected OFF. The AP remained OFF for the remainder of the recording. The final descent into ARV began just after the AP OFF selection. At 1910:42, the flap setting changed from 0 percent to 50 percent. At 1912:06, the engine RPM was at 1,670 rpm. At 1912:07, the Horizontal Deviation Indication started to indicate a fly right command and the altitude rate, indicating a descent, began a transition to a climb. At 1912:12, the engine RPM increased to 2,590 rpm. At 1912:14, a maximum pitch of 45.5 degrees was recorded. The indicated airspeed was 73.2 knots and a roll attitude of 15 degree left wing down. Prior to a stall warning discrete, the Recoverable Data Module (RDM) recorded an increase in engine manifold pressure, fuel flow, and engine speed. At 1912:16, the stall warning discrete was set on the RDM. The indicated airspeed was 60 knots, ground speed 61 knots, pitch attitude 39 degrees, and a roll attitude of 32 degrees left wing down. At 1912:24, the recorded data ends. WITNESSES The pilot of a Piper PA-32R-301, which preceded N193BS on the approach, stated that he held a private pilot certificate with an instrument rating and accumulated 5,018 hours of flight time of which 1,017 hours was instrument flight time. The pilot was en route from Dubuque, Iowa, to ARV. The ARV automated weather observing system (AWOS) was reporting ceiling height of 400 feet and a visibility of 3 miles the entire time he was en route. He stated that the cloud tops were about 5,000 feet, but he did not recall the sky condition above the tops. He heard Minneapolis Air Traffic Control Center (ATCC) transmit to N193BS that N193BS was number two for the approach and that his Piper was lower or faster. The Piper pilot said that N193BS was at 7,000 feet and his Piper was at 5,000 feet. ATCC then gave N193BS a vector, cleared the Piper for the approach, and asked the Piper to close his flight plan through N193BS because it would take too long through flight service due to the Piper's low altitude. The Piper pilot stated that he flew the localizer 36 approach at an approach speed of 90 knots due to a tailwind from 180 degrees at 9-10 knots. The Piper pilot monitored the ARV AWOS until reaching the outer marker and then descended to the minimum descent altitude. The Piper pilot then turned the runway lights on high at an altitude of about 400 feet above ground level. The Piper pilot said that he was on the final approach segment about 20 minutes before sunset, it was “getting dark,” and the visibility was a “little hazy.” He saw the approach lights “clear as a bell” off his left wing so he descended a “little.” He had “good” visibility and could see the runway. The Piper touched down a “few minutes” after 1900. He transmitted to N193BS to close the flight plan for his Piper. N193BS then called back and said ATCC had his cancellation. The Piper pilot then transmitted that he was clear of the active runway and the ceilings were “pretty” low. There was no response from N193BS to that transmission and a few seconds later the Piper pilot heard N193BS respond to ATCC by transmitting “cleared for the approach.” The N193BS pilot sounded “fine, alert, calm,” and “matter of fact.” About 3-5 minutes after touchdown and while taxiing to his hangar, the Piper pilot checked the ARV AWOS, which reported ceiling and visibility 200 feet and 2 miles. He taxied to his hangar, got out of the airplane, and was standing outside about 100 yards east of runway 36, talking on his cell phone when he heard the engine of N193BS. The Piper pilot could not see the runway lights from his position, but heard engine noise in the distance, which he said was “normal” and “constant.” He stated that the engine noise was “throttled back” when it changed to “full power.” The intensity of the noise increased by twofold to what he assumed was full throttle for about 4-5 seconds. He then heard a “thud” and the cessation of engine noise. He judged the position of the airplane when he heard it based upon engine noise as being south and west of the runway 36 and never heard the airplane overhead or pass over the runway. He didn’t think that N193BS performed more than one approach attempt. The Piper pilot said that he met a couple in a car at the airport who were waiting for a passenger from Milwaukee, who was “running late.” They had also heard the “thud.” The Piper pilot called Flight Service and asked if they lost somebody. He took the people to the accident site. The Piper pilot stated that he did not have any concerns regarding his approach or the airport. PERSONNEL INFORMATION Accident Pilot Background According to airman records, the pilot held a commercial pilot certificate with single-engine land and instrument airplane ratings. As of September 8, 2008, he accumulated a total flight time of 2,212.5 hours, 233.7 hours of night flight, 140.7 hours of actual instrument time, and 118.9 hours of simulated instrument time. He was last issued a second class airman medical certificate on March 10, 2008, with no limitations. On March 22, 1975, he was issued a private pilot certificate with an airplane single-engine land rating at a total instruction time of 64.7 hours and a total pilot-in-command time of 48.2 hours. On December 2, 1990, he was issued an instrument airplane rating at a total flight time of 401 hours. On October 18, 1995, he was issued an airplane single-engine sea rating at a total flight time of 776 hours. On April 9, 2007, he was issued a commercial pilot certificate at a total flight time of 1,847 hours. The pilot had no previous record of accidents, incidents, or enforcement actions. Employment and Training The accident pilot’s representative stated that the accident pilot was enthused to fly and that he flew about 100 hours in August, which equaled his total flight time in the previous year. He pursued employment flying BST flights because he “loved” to fly and it gave him different “opportunities” to fly. The representative had never heard of MAT since the accident pilot always used the name of BST when he referred to his flying. His other flying, which was concurrent with BST flights, was WBBM Shadow Traffic out of Illinois Aviation Academy on Mondays and Fridays. He also flew Angel Flights. According to MAT’s Training Program and Employment Data records, the accident pilot did not have a date next to his “Preemployment pilot safety background information verification.” A background check in accordance with the Pilot Records Improvement Act (PRIA) was not performed by MAT. The MAT president stated that he was unaware of the “official notification” that had to be made to the FAA until the National Transportation Safety Board (NTSB) Investigator-In-Charge (IIC) told him about the Act. The MAT president said that the only checks he performed were premployment and that nobody made him aware that it was a statutory requirement and that it was not a Federal Aviation Regulation requirement. FAA Order 8000.88, PRIA Guidance for FAA Inspectors, effective March 14, 2006, states that an air carrier cannot place a pilot into service until after it obtains and reviews the last 5 years of the pilot’s records specified in the Act. Furthermore, the primary responsibilities of the FAA’s principal operations inspector (POI) includes, in part: a. Be knowledgeable concerning PRIA. b. Promote the assigned air carrier’s awareness of and compliance with PRIA. c. Conduct regularly scheduled reviews of the assigned air carrier’s PRIA records. d. Be prepared to conduct an investigation upon receipt of a report
The pilot’s failure to maintain airspeed during a missed approach leading to the inadvertent stall. Contributing to the accident were the pilot’s lack of experience in the type of operation conducted, the certificate holder’s loss of operational control, and the lack of adequate oversight of the operation by the Federal Aviation Administration.
Source: NTSB Aviation Accident Database
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