# NTSB CEN16LA288: Cessna 208B, N7581F, Baldwin, WI, July 21, 2016 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: July 21, 2016, 14:00 local (19:00 UTC) - Place: Baldwin, WI - Coordinates: 44.966388, -92.387496 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=44.9664&lon=-92.3875&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing-landing roll: Runway excursion](https://openairdocs.org/ntsb-events/300) - Highest injury: No injuries - Injuries: 15 uninjured - Status: Completed, report September 6, 2017 - Report: Approved by Office Director - NTSB office: Central Region - Parties: FAA FSDO MSP - NTSB case key (mKey): 93696 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN16LA288 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/93696/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=93696 - Page: https://openairdocs.org/ntsb/CEN16LA288 ## Probable cause The pilot's decision to land the fully loaded parachutist drop airplane on a wet grass runway that had insufficient length for the landing in high temperature conditions, which resulted in a runway overrun, when a more suitable longer runway was available at a nearby airport. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Cessna 208B, 18 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=2073701), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Aircraft capability: landing distance](https://openairdocs.org/ntsb-findings/01061030): Aircraft › Aircraft oper/perf/capability · Capability exceeded (probable cause); cases with it: [Cessna 208B, 3 cases](https://openairdocs.org/ntsb-findings/01061030/cases.md?model=2073701), [All aircraft, 68 cases](https://openairdocs.org/ntsb-findings/01061030/cases.md) - [Temp/humidity/pressure: high temperature](https://openairdocs.org/ntsb-findings/03031015): Environmental issues › Conditions/weather/phenomena · Effect on equipment; cases with it: [Cessna 208B, 1 case](https://openairdocs.org/ntsb-findings/03031015/cases.md?model=2073701), [All aircraft, 30 cases](https://openairdocs.org/ntsb-findings/03031015/cases.md) - [Runway/land/takeoff/taxi surface: wet surface](https://openairdocs.org/ntsb-findings/03023010): Environmental issues › Physical environment · Effect on operation; cases with it: [Cessna 208B, 1 case](https://openairdocs.org/ntsb-findings/03023010/cases.md?model=2073701), [All aircraft, 141 cases](https://openairdocs.org/ntsb-findings/03023010/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Landing-landing roll: Runway excursion](https://openairdocs.org/ntsb-events/300) (defining event); cases with it: [Cessna 208B, 8 cases](https://openairdocs.org/ntsb-events/300/sequence.md?model=2073701), [All aircraft, 3,643 cases](https://openairdocs.org/ntsb-events/300/sequence.md) ## Analysis Before the accident flight, the commercial pilot had conducted three flights, during which parachutists were successfully dropped. After each flight, he returned the empty airplane to a dry grass airstrip (1,950 ft long) and conducted full-stop landings. Because the temperature was over 90° with high humidity, the pilot requested that his manifests allow only up to 14 parachutists and a longer time between shutdowns to ensure sufficient time for adequate engine cooling before the next flight. The pilot reported that pop-up rain showers had been passing north and south of his base airport throughout the morning but that they never came closer than 10 to 15 miles. While preparing for the accident flight, the pilot noted that clouds were over the intended drop zone but that there was no rain and that the clouds were moving away from the northern edge of the drop zone, so the pilot decided that it was worth attempting the flight. While climbing through 4,000 ft, an air traffic controller advised the pilot that light-to-moderate precipitation was in the area. The pilot continued to climb toward the drop zone, and the flight encountered light rain. The pilot advised the 14 parachutists that they were returning to land because of the weather. The approach was a stabilized, power-on approach, which was much flatter than the previous approaches with an empty airplane. The pilot used flaps incrementally to 30° (full flaps), initiated a flare over the threshold, and touched down at 65 knots. He used full-reverse propeller and retracted the flaps during the landing roll. When the pilot started to apply the brakes, he discovered that the braking action was null. The grass runway was wet because of a recent rain shower. Because of the hot temperature, humidity, full load of parachutists, and trees at the end of the runway, the pilot decided not to attempt a go-around. The pilot held full aft on the control yoke for aerodynamic braking, stayed in full-reverse propeller, and braked as much as possible without locking the wheels up. Just before coming to a complete stop (about 5 to 10 mph), the airplane rolled into a ditch before a road beyond the departure end of the runway, which resulted in substantial damage to the empennage. According to the airplane manufacturer, the applicable Pilot's Operating Handbook (POH) tables did not provide distances for landing on wet grass runways. However, for landing on dry grass runways, 40% distance was added to the normal landing roll distance chart figures. The pilot reported that the airplane weighed 8,010 lbs, and the nearest weather reporting station to the accident site, located at an airport about 16 miles to the north, reported that the temperature was 30°C at the time of the accident. According to the POH chart, the minimum required landing distance would have been about 2,265 ft. The published length of the runway was 1,950 ft. The closest airport had an available runway that was 5,507 ft long, which would havebeen well within the safe stopping distance for the fully loaded airplane. The pilot's decision to land the fully loaded airplane on the wet grass runway that had insufficient length for the landing led to the runway overrun. If he had chosen to land at the nearby airport that had sufficient length for the landing, the accident may have been avoided. ## Factual narrative On July 21, 2016, about 1400 central standard time, a Cessna 208B air drop configured airplane, N7581F, registered to Desert Sand Aircraft Leasing Company, Inc., of Carson City, Nevada, sustained substantial damage during a runway excursion after landing on runway 18 at the Baldwin Airport (WI14), Baldwin, Wisconsin. The commercial pilot and 14 passengers were not injured. The air drop flight was being operated by Skydive Twin Cities, of Baldwin, Wisconsin, and conducted under the provisions of Federal Code of Regulations Part 91. No flight plan was filed and local traffic advisory was requested by the pilot. Visual meteorological conditions with light rain showers prevailed throughout the area. The flight originated from WI14 about 1350. According to the pilot, he had ferried the airplane from Forest Lake, Wisconsin, to WI14 on the morning of the accident. The airplane had just completed its 100-hour inspection at Forest Lake. After flying three air drops without incident, he prepared for his fourth flight of the day. He stated that all the previous 3 flights had successfully deployed the parachutists and were full stop landings in an empty airplane. Due to the temperatures of 90+ degrees and high humidity, the pilot requested his manifests limit to 14 parachutists and allow a longer time between shutdowns to allow for adequate cooling before the next flight. The pilot reported that pop-up rain showers had been passing north and south of Baldwin throughout the morning, but never coming closer than 10-15 miles. While preparing for the fourth flight of the day (accident flight) the pilot discussed the weather with an experienced parachutist. Clouds were currently over the intended drop zone but there was no rain and the clouds were moving away from the northern edge of the drop zone. The pilot and parachutist agreed that it was worth attempting the drop considering the cloud movement away from the drop zone. The 14 parachutists were loaded and the airplane took off. Climbing through 3,000 feet MSL, the pilot checked in with ATC for traffic advisory and a radio check. Climbing through 4,000 feet, ATC advised the pilot that light to moderate precipitation was in the area. The pilot continued to climb toward the drop zone to see if there was any rain over the area and about 1-1.5 miles from the zone, light rain was encountered. The pilot advised the parachutists that they were returning to Baldwin to land because of the weather. After descending, the pilot set up a base leg to runway 18, and about two miles from the airport, turned on final. The approach was a stabilized, powered-on approach which was much flatter than the standard descent with an empty airplane. The pilot used flaps incrementally to 30-degrees (full flaps), initiated a flare over the threshold, and touched down at 65 knots. Full reverse propeller was used and the flaps retracted during the landing rollout. When the pilot started to apply brakes, he discovered that the brakingaction was null. The 1,950-foot-long grass runway was wet because of a recent rain shower. Because of the elevated temperature, humidity, full load, and trees at the end of the runway, the pilot decided to not attempt a go around. The pilot held full aft on the control yoke for aerodynamic braking, stayed in full propeller reverse, and braked as much as possible without locking the wheels up. Just before coming to a complete stop (about 5-10 mph), the airplane rolled into a ditch before a road beyond the departure end of the runway, resulting in substantial damage to the empennage. The pilot secured the engine and all the occupants exited the airplane. According to Cessna, the applicable 208B Pilot Operating Handbook (POH) tables do not provide for landing on WET grass runways. However, for landing on DRY grass runways, 40% distance is added to the normal landing roll distance chart figures. On NTSB Form 6120, the pilot reported an aircraft weight 8,010 pounds at the time of the accident. The nearest weather reporting station to the accident site, located about 16 miles to the north, reported the temperature at 30 degrees C. According to the POH chart, with an estimated airplane weight of 8,010 pounds, and temperature of 30 degrees C, the minimum landing distance would have been about 2,265 feet. The published length of runway 18 at the Baldwin Airport was 1,950 feet. New Richmond Municipal Airport (RNH) was located about 16 miles to the north of Baldwin Airport. The length of runway 14 at RNH was 5,507 feet. In an interview and email correspondence with the owner/operator (Skydive Twin Cities), he stated that the company's SOP would be updated to include the following language: If landing on a grass runway shorter than 3000' while fully loaded, the aircraft should be taken to the nearest airport that meets or exceeds safe landing requirements. He also stated that they also discussed the accident with their contract pilots and gave them a reminder of their training to use their best judgement in situations like what happened in Baldwin, Wisconsin. They discussed avoiding flying in situations where weather may become an issue and erring on the side of caution in all situations. Skydive Twin Cities had 17 pilots, most of whom were contractors and used seasonally. The company fleet was comprised of 4 Cessna Grand Caravans, 1 Short Body 114A Cessna Caravan, 1 King Air 90, and 1 SC7 Skyvan. ## Aircraft - Registration: [N7581F](https://openairdocs.org/aircraft/N7581F), registered now, S/N 208B0389, built 1994 (OpenAirDocs) - Reported make and model: CESSNA 208B (B) - Registry model: [Cessna 208B](https://openairdocs.org/model/cessna-208b) (registry code 2073701) (OpenAirDocs) - Registry engine: [Pratt & Whitney PT6A series](https://openairdocs.org/engine/pratt-whitney-pt6a-series) (registry code 52032, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: 208B0389 - Year built: 1994 - Airframe hours: 10660 - Engines: Honeywell TPE331 650 horsepower turbo prop - Damage: Substantial damage - Flight: Skydiving, Part 91 - Operator: Sky Dive Twin Cities - Registered owner: Desert Sand Aircraft Leasing Co Inc - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, July 20, 2016, 1 hours before - Departed: WI14, Baldwin, WI - Destination: WI14, Baldwin, WI - Airport: WI14, Baldwin Airport, runway 18, 1,950 × 120 ft, grass/turf - Equipment: Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 36; injuries: none; commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review June 15, 2015; seat: left; restraint: 4-point; flight hours: 1,012 total, 301 in this make and model, 2 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 280° at 5 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 86 °F, dew point 72 °F - Altimeter: 29.95 inHg - Observed at: RNH, 16 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 20160721011399A](https://openairdocs.org/incident/20160721011399A), Jul 21, 2016: Cessna 208B, Baldwin, WI, Substantial damage. On landing the aircraft ran off the end of the runway and hit the prop on a small hill striking the propeller. As the nose of the aircraft went up the small… ## Other investigations on N7581F (1) 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. - [NTSB WPR22FA197](https://openairdocs.org/ntsb/WPR22FA197), Jun 3, 2022: Cessna 208B (N7581F), Oceanside, CA, substantial damage, 1 fatal. Probable cause: The right-seated pilot’s failure to correct the left-seated pilot’s mismanagement of the engine thrust, which resulted in undesired speed and thrust oscillations during the final approach and a… ## Docket (7 files) The files NTSB released with the investigation on June 29, 2017, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=93696. 2.8 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40453867&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Photo Accident Site (item 2, .PDF, 1 photo, 363 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40453868&FileExtension=.PDF&FileName=Photo%20Accident%20Site-Master.PDF - Airport and Runway Information for WI14 and RNH (item 3, .PDF, 845 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40453869&FileExtension=.PDF&FileName=Airport%20and%20Runway%20Information%20for%20WI14%20and%20RNH-Master.PDF - Memorandum for the Record - Cessna Performance Information (item 4, .PDF, 135 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40453870&FileExtension=.PDF&FileName=Memorandum%20for%20the%20Record%20-%20Cessna%20Performance%20Information-Master.PDF - Memorandum for the Record - Operator Interview (item 5, .PDF, 66 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40453871&FileExtension=.PDF&FileName=Memorandum%20for%20the%20Record%20-%20Operator%20Interview-Master.PDF - Operator SOP Changes Email (item 6, .PDF, 22 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40453872&FileExtension=.PDF&FileName=Operator%20SOP%20Changes%20Email-Master.PDF - Aircraft Annual Inspection Log Sheet August 20, 2016 (item 7, .PDF, 65 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40453873&FileExtension=.PDF&FileName=Aircraft%20Annual%20Inspection%20Log%20Sheet%20August%2020,%202016-Master.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.