# NTSB CEN11CA128: Cessna 340A, N233DS, Madison, WI, December 21, 2010 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: December 21, 2010, 12:30 local (18:30 UTC) - Place: Madison, WI - Coordinates: 43.13972, -89.337501 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=43.1397&lon=-89.3375&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-IFR final approach: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report May 16, 2011 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 78058 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN11CA128 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/78058/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=78058 - Page: https://openairdocs.org/ntsb/CEN11CA128 ## Probable cause The pilot's failure to maintain adequate airspeed during the approach, which resulted in an aerodynamic stall. Contributing to the accident was the pilot's failure to check the de-ice fluid level prior to takeoff, which resulted in the failure of the de-ice system to clear the windshield of ice. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: airspeed](https://openairdocs.org/ntsb-findings/01062010): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cessna 340A, 4 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=2076405), [All aircraft, 1,681 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna 340A, 10 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2076405), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach-IFR final approach: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Cessna 340A, 8 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=2076405), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Approach-IFR final approach: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cessna 340A, 14 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2076405), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) - [Landing: Runway excursion](https://openairdocs.org/ntsb-events/300); cases with it: [Cessna 340A, 6 cases](https://openairdocs.org/ntsb-events/300/sequence.md?model=2076405), [All aircraft, 3,643 cases](https://openairdocs.org/ntsb-events/300/sequence.md) ## Analysis According to the pilot, he attempted two landings at the original destination airport; however, due to the weather, the pilot elected to return to the departure airport. While on the instrument approach to the runway, the windshield became covered with ice and the de-ice system could not de-ice the windshield. The pilot then attempted the landing by looking out the left window. At 15 feet above the runway, the pilot noticed the airspeed was approximately 85 knots and the airplane stalled. The pilot added engine power; however, the airplane experienced a hard landing on the runway. Examination of the airplane revealed the forward fuselage was buckled and the de-ice fluid tank was empty. No mechanical anomalies were noted with the airplane. The pilot stated that he did not check the fluid level in the de-ice tank during the preflight inspection. ## Factual narrative According to the pilot, he attempted two landings at the original destination airport; however, due to the weather conditions, the pilot elected to return to the departure airport. While on the instrument approach to the runway, the windshield became covered with ice and the de-ice system could not de-ice the windshield. The pilot then attempted the landing by looking out the left window. At 15 feet above the runway, the pilot noticed the airspeed was approximately 85 knots and the airplane stalled. The pilot added engine power; however, the airplane experienced a hard landing on the runway. Examination of the airplane revealed the forward fuselage was buckled and the de-ice fluid tank was empty. No mechanical anomalies were noted with the airplane. The pilot stated that he did not check the fluid level in the de-ice tank during the pre-flight inspection. ## Aircraft - Registration: [N233DS](https://openairdocs.org/deregistered/N233DS-2013-08-07), registration cancelled 2013-08-07, S/N 340A0420, built 1977 (OpenAirDocs) - Reported make and model: CESSNA 340A - Registry model: [Cessna 340A](https://openairdocs.org/model/cessna-340a) (registry code 2076405) (OpenAirDocs) - Registry engine: [Continental TSIO-520 series](https://openairdocs.org/engine/continental-tsio-520-series) (registry code 17040, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 340A0420 - Airframe hours: 10050 - Engines: CONT MOTOR TSIO-520 SER 310 horsepower reciprocating; CONT MOTOR TSIO-520 SER 300 horsepower reciprocating - Damage: Substantial damage - Flight: Positioning, Part 91 - Operator: Wisconsin Aviation Inc - Registered owner: Wisconsin Aviation Inc - Airworthiness certificate: Standard, Normal - Last inspection: Annual, May 7, 2010 - Departed: MSN, Madison, WI - Destination: MSN, Madison, WI - Flight plan: IFR - Airport: MSN, Dane County Regional Airport, runway 18, 9,005 × 150 ft, concrete ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 70; injuries: none; airline transport, commercial; airplane ratings: single-engine land, single-engine sea, multi-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review September 1, 2010; seat: left; flight hours: 11,421 total, 200 in this make and model, 11,078 as pilot in command, 44 in the last 90 days, 18 in the last 30 days ## Weather - Conditions: Instrument (IMC), Day - Wind: 170° at 5 knots - Visibility: 1 statute miles - Lowest ceiling: 300 ft overcast - Temperature: 30 °F, dew point 28 °F - Altimeter: 29.93 inHg - Observed at: MSN ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20101221053669A](https://openairdocs.org/incident/20101221053669A), Dec 21, 2010: Cessna 340A, Madison, WI, Substantial damage. On December 21, 2010 at 12:45 CT on approach to runway 18 Madison WI the pilot of Cessna 340A, N233DS, experienced windshield icing and lost visual contact… ## Docket (1 files) The files NTSB released with the investigation on January 25, 2011, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=78058. 2.3 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40341746&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.