Pilot error blamed in aeromed Citation crash

By: Curt Epstein

November 1, 2009
Accidents

The NTSB has issued its findings in the June 4, 2007 crash of a Cessna Citation II into Lake Michigan, which killed the two crewmembers and four passengers. The Board cited “the pilot’s 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” as the probable cause of the crash.

Operated by Marlin Air under Part 135, the aircraft was transporting a human organ for a transplant operation when it crashed shortly after takeoff from General Mitchell International Airport in Milwaukee. The Board stated the likely initiating event for the accident was either a runaway trim or the unintentional engagement of the autopilot rather than the yaw damper on takeoff, as ATC transmissions and transcripts from the recovered CVR indicate the pilot reported difficulties in operating the aircraft flight controls. The twinjet did not have a data recording system.

According to the report, the PIC allowed the problem with the flight controls to escalate by not decreasing airspeed and the resulting control forces while the crew attempted to troubleshoot the problem. The Board concluded that at a reduced airspeed the pilots should have been able to maintain control of the aircraft long enough to solve the problem or return to the airport.

Also noted as contributing factors were deficiencies in the operator’s safety procedures, including inadequate checkrides administered by the company’s chief pilot and the FAA’s failure to detect and correct those deficiencies, allowing an ill-prepared pilot to fly in Part 135 operations.

The investigation indicated that the accident pilot did not adhere to procedures or comply with regulations and regularly abbreviated checklists. The report 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 the situation experienced during the flight.

As a result of the investigation, the NTSB 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.

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