# NTSB CEN15LA021: Raytheon 58, N345PG, Dixon, IL, October 4, 2014 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: October 4, 2014, 10:28 local (15:28 UTC) - Place: Dixon, IL - Coordinates: 41.83934, -89.470825 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=41.8393&lon=-89.4708&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Inflight upset](https://openairdocs.org/ntsb-events/271) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report March 17, 2015 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Federal Aviation Administration; DPA FSDO - NTSB case key (mKey): 90283 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN15LA021 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/90283/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=90283 - Page: https://openairdocs.org/ntsb/CEN15LA021 ## Probable cause The pilots’ improper decision to continue flight in icing conditions after the deicing boots could not shed accumulated ice, which resulted in a temporary loss of airplane control. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Temp/humidity/pressure: conducive to structural icing](https://openairdocs.org/ntsb-findings/03031025): Environmental issues › Conditions/weather/phenomena · Effect on equipment (probable cause); cases with it: [Raytheon 58, 2 cases](https://openairdocs.org/ntsb-findings/03031025/cases.md?model=7150003), [All aircraft, 103 cases](https://openairdocs.org/ntsb-findings/03031025/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Raytheon 58, 4 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=7150003), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Instructor/check pilot (probable cause); cases with it: [Raytheon 58, 4 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=7150003), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-climb to cruise: Structural icing](https://openairdocs.org/ntsb-events/210); cases with it: [Raytheon 58, 2 cases](https://openairdocs.org/ntsb-events/210/sequence.md?model=7150003), [All aircraft, 102 cases](https://openairdocs.org/ntsb-events/210/sequence.md) - [Enroute-cruise: Inflight upset](https://openairdocs.org/ntsb-events/271) (defining event); cases with it: [Raytheon 58, 1 case](https://openairdocs.org/ntsb-events/271/sequence.md?model=7150003), [All aircraft, 74 cases](https://openairdocs.org/ntsb-events/271/sequence.md) - [Enroute-cruise: Loss of control in flight](https://openairdocs.org/ntsb-events/240); cases with it: [Raytheon 58, 7 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=7150003), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Uncontrolled descent: Attempted remediation/recovery](https://openairdocs.org/ntsb-events/060); cases with it: [Raytheon 58, 1 case](https://openairdocs.org/ntsb-events/060/sequence.md?model=7150003), [All aircraft, 1,422 cases](https://openairdocs.org/ntsb-events/060/sequence.md) ## Analysis The two pilots, one of whom was a flight instructor, were conducting a cross-country flight in instrument meteorological conditions. The pilot reported that, during the climb to 8,000 ft mean seal level (msl), light ice accumulated on the wings' leading edges. Activation of the deicing boots eliminated about 30 to 40 percent of the ice. The airplane then climbed to and leveled off at 10,000 ft msl, at which point, the engine speed "fluttered" and the airplane then rolled "quickly to the left" and entered a descending spin. The flight instructor applied control inputs, and the spin was arrested about 2,500 ft msl. The pilot landed the airplane without further incident. Postaccident examination and testing of the airplane revealed no mechanical anomalies that would have precluded normal operation. The examination revealed substantial damage to the right wing and elevator control surface, which was consistent with forces sustained from excessive accelerations; radar data showed that the airplane descended 7,500 ft in about 30 seconds. A weather briefing for the flight showed that an airmen's meteorological information for moderate icing conditions was in effect and that light showers, rain, and snow were forecast throughout the area about the time of the accident. The deicing boots were unable to shed the accumulated ice, which adversely affected the airplane's performance and resulted in the temporary loss of airplane control. The pilot reported that he did not fly in such weather conditions unless accompanied by an experienced pilot. ## Factual narrative On October 4, 2014, about 1028 central daylight time, a Raytheon 58, N345PG, entered an uncontrolled descent from cruise flight near Dixon, Illinois. The pilot recovered the airplane and it was landed without further incident. Both pilots were not injured and the airplane sustained substantial damage. The airplane was owned and operated by the pilot as a 14 Code of Federal Regulation Part 91 as a personal flight. Instrument meteorological conditions prevailed for the cross-country flight that was operating on an instrument rules flight plan. The flight originated from Chicago Executive Airport (PWK), Wheeling, Illinois, and was originally destined to University of Illinois-Willard Airport (CMI), Savoy, Illinois, but diverted to Dixon Municipal Airport-Charles R. Walgreen Field (C73), Dixon, Illinois. The airplane entered an uncontrolled descent after attaining a cruise altitude of 10,000 feet mean sea level (MSL), about 10 nautical miles southwest of C73. The airplane was piloted by the aircraft owner (first pilot) and a Windy City Flyers flight instructor (second pilot). The pilot reported that during a climb to 8,000 feet MSL, light ice accumulated on the deicing boots. Activation of the boots eliminated about 30-40 percent of the ice climbing through instrument meteorological to attain an initial altitude of 8,000 feet MSL, prior to a second climb to 10,000 feet MSL. Upon level off, the there was a "flutter" in engine speed followed by the airplane rolling "quickly to the left." The pilot stated that the flight instructor applied control inputs, and the airplane's spin was arrested about 2,500 MSL. The airplane landed without further incident, following the recovery, at C73. The airplane sustained substantial damage to the right wing and elevator control surfaces, which was consistent with forces from excessive accelerations (over-g). Radar data showed that the airplane descended from its cruise to recovery altitude in about 30 seconds. A weather briefing for the flight showed an AIRMET for moderate icing conditions was in effect and light showers, rain, and, snow were forecast. The pilot stated that he did not fly in such weather conditions unless accompanied by an experienced pilot. The pilot stated that he assumed that ice accumulation, which was not visually evident, resulted in the airplane departing controlled flight. Postaccident examination/testing of the airplane revealed no mechanical anomalies that would have precluded normal operation. The flight instructor was provided with, but did not return a National Transportation Safety Board Pilot/Operator Accident/Incident Report. ## Aircraft - Registration: [N345PG](https://openairdocs.org/aircraft/N345PG), registered now, S/N TH-2016, built 2001 (OpenAirDocs) - Reported make and model: RAYTHEON 58 (NO SERIES) - Registry model: [Raytheon 58](https://openairdocs.org/model/raytheon-58) (registry code 7150003) (OpenAirDocs) - Registry engine: [Continental IO-550 series](https://openairdocs.org/engine/continental-io-550-series) (registry code 17042, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: TH2016 - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Pilot - Registered owner: Cto Aero Leasing Corp - Airworthiness certificate: Standard, Normal - Departed: PWK, Wheeling, IL - Destination: CMI, Savoy, IL - Flight plan: IFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 54; injuries: none; private; airplane ratings: multi-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; last flight review June 19, 2013; seat: left; restraint: 3-point; flight hours: 750 total, 156 in this make and model, 750 as pilot in command, 0 in the last 90 days, 0 in the last 30 days, 0 in the last 24 hours - Flight instructor; age 20; injuries: none; commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: unknown; seat: right ## Weather - Conditions: Instrument (IMC), Day - Wind: 270° at 17 knots, gusting 22 - Visibility: 5 statute miles - Lowest ceiling: 1,200 ft overcast - Temperature: 39 °F, dew point 37 °F - Altimeter: 29.72 inHg - Observed at: SQI, 15 nm away ## 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 20141004018169A](https://openairdocs.org/incident/20141004018169A), Oct 4, 2014: Raytheon Aircraft Company 58, Dixon, IL, Substantial damage. [privacy data omitted] Was pilot in command of N345PG. At approximately 15:28Z on 10/04/2014, N345PG experienced a loss of control. The aircraft descended from… ## Docket (8 files) The files NTSB released with the investigation on January 28, 2015, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=90283. 12.9 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 - Pilot (item 1, .PDF, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40421757&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1%20-%20Pilot-Redacted.PDF - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 Letter– Flight Instructor (item 2, .PDF, 39 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40421758&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1%20Letter%E2%80%93%20Flight%20Instructor-Redacted.PDF - FAA Statements of Personnel (item 3, .PDF, 19 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40421759&FileExtension=.PDF&FileName=FAA%20Statements%20of%20Personnel-Redacted.PDF - Re-recording of N345PG - Oct. 4, 2014 (item 4, .PDF, 89 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40421760&FileExtension=.PDF&FileName=Re-recording%20of%20N345PG%20-%20Oct.%204,%202014-Master.PDF - FAA Airman Blue Ribbon Report - Pilot (item 5, .PDF, 3.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40421761&FileExtension=.PDF&FileName=FAA%20Airman%20Blue%20Ribbon%20Report%20-%20Pilot-Redacted.PDF - FAA Airman Blue Ribbon Report – Flight Instructor (item 6, .PDF, 6.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40421762&FileExtension=.PDF&FileName=FAA%20Airman%20Blue%20Ribbon%20Report%20%E2%80%93%20Flight%20Instructor-Redacted.PDF - N345PG-10-4-14 1332Z Briefing History (item 7, .PDF, 663 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40421763&FileExtension=.PDF&FileName=N345PG-10-4-14%201332Z%20Briefing%20History-Master.PDF - N345PG 10-4-14 ForeFlight Flight Plan (item 8, .PDF, 144 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40421764&FileExtension=.PDF&FileName=N345PG%2010-4-14%20ForeFlight%20Flight%20Plan-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.