# NTSB CEN17CA114: Cessna 340A, N255BC, Waukesha, WI, February 25, 2017 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: February 24, 2017, 18:15 local (Feb 25, 2017, 00:15 UTC) - Place: Waukesha, WI - Coordinates: 43.04111, -88.236946 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=43.0411&lon=-88.2369&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 April 4, 2017 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 94793 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN17CA114 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/94793/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=94793 - Page: https://openairdocs.org/ntsb/CEN17CA114 ## Probable cause The pilot’s decision to fly in in conditions conducive to structural icing and her subsequent failure to maintain airplane control during the instrument approach. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Ceiling/visibility/precip: freezing rain/sleet](https://openairdocs.org/ntsb-findings/03035040): Environmental issues › Conditions/weather/phenomena · Effect on equipment (probable cause); cases with it: [Cessna 340A, 1 case](https://openairdocs.org/ntsb-findings/03035040/cases.md?model=2076405), [All aircraft, 26 cases](https://openairdocs.org/ntsb-findings/03035040/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) - [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: [Cessna 340A, 1 case](https://openairdocs.org/ntsb-findings/03031025/cases.md?model=2076405), [All aircraft, 103 cases](https://openairdocs.org/ntsb-findings/03031025/cases.md) - [Performance/control parameters](https://openairdocs.org/ntsb-findings/01062000): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cessna 340A, 3 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md?model=2076405), [All aircraft, 1,269 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Cessna 340A, 7 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=2076405), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Pilot; cases with it: [Cessna 340A, 2 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=2076405), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/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) ## Analysis Before the positioning flight, the airline transport pilot monitored the weather and noticed the weather conditions were deteriorating near the time of the planned departure. The weather conditions included low visibility, freezing drizzle, and mist. In an effort to reduce the time in the deteriorating weather conditions, the pilot performed some before takeoff checks while the airplane was in the hangar. During the pilot's "haste" to preflight and take off, she inadvertently selected the wrong switch for windshield heat. While on the instrument approach to the runway in night conditions, the pilot had no forward visibility due to ice accumulation on the windshield. The pilot executed a missed approach and contacted an instructor pilot at the departure airport to confirm the location of the windshield heat switch. The pilot then activated the windshield heat switch and enough ice had melted for the pilot to conduct another approach. During the approach, the pilot increased the airspeed due to "carrying a lot of ice." On short final approach, the airplane descended below the glidepath due to the ice accumulation. Subsequently, the airplane contacted the terrain short of the runway and then "skipped" onto the runway. The airplane came to rest upright and off the runway surface. Examination of the airplane revealed substantial damage to the left wing. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airframe or engine that would have precluded normal operation. ## Factual narrative Prior to the positioning flight, the pilot monitored the weather and noticed the weather conditions were deteriorating near the time of the planned departure. The weather conditions included low visibility, freezing drizzle, and mist. In an effort to reduce the time in the deteriorating weather conditions, the pilot performed some before takeoff checks while the airplane was in the hangar. During the pilot's "haste" to preflight and takeoff, she inadvertently selected the wrong switch for windshield heat. While on the instrument approach to the runway in night conditions, the pilot had no forward visibility due to ice accumulation on the windshield. The pilot executed a missed approach and contacted an instructor pilot at the departure airport to confirm the location of the windshield heat switch. The pilot then activated the windshield heat switch and enough ice had melted for the pilot to conduct another approach. During the approach, the pilot increased the airspeed due to "carrying a lot of ice." On short final approach, the airplane descended below the glide path due to the ice accumulation. Subsequently, the airplane contacted the terrain short of the runway, and "skipped" onto the runway. The airplane came to rest upright and off the runway surface. Examination of the airplane revealed substantial damage to the left wing. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airframe or engine that would have precluded normal operation. ## Aircraft - Registration: [N255BC](https://openairdocs.org/deregistered/N255BC-2019-05-06), registration cancelled 2019-05-06, S/N 340A0908, built 1979 (OpenAirDocs) - Reported make and model: CESSNA 340A (A) - 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: 340A0908 - Year built: 1979 - Airframe hours: 5644 - Engines: CONT MOTOR TSIO-520 NB 335 horsepower reciprocating; CONT MOTOR TSIO-520 NB 335 horsepower reciprocating - Damage: Substantial damage - Flight: Positioning, Part 91 - Operator: Signicast LLC - Registered owner: Signicast LLC - Airworthiness certificate: Standard, Normal - Last inspection: Annual, August 12, 2016 - Departed: UNU, Juneau, WI - Destination: UES, Waukesha, WI - Flight plan: IFR - Airport: UES, Waukesha County Airport, runway 10, 5,849 × 100 ft, asphalt - Equipment: Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 55; injuries: none; flight instructor, airline transport; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, with waivers/limitations; last flight review August 5, 2016; seat: left; restraint: 3-point; flight hours: 10,200 total, 200 in this make and model, 10,200 as pilot in command, 60 in the last 90 days, 4.5 in the last 24 hours ## Weather - Conditions: Instrument (IMC), Dusk - Wind: 320° at 8 knots - Visibility: 2.5 statute miles - Lowest ceiling: 700 ft overcast - Temperature: 28 °F, dew point 28 °F - Altimeter: 29.54 inHg - Icing: Rime - Observed at: UES ## 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 20170224002979A](https://openairdocs.org/incident/20170224002979A), Feb 24, 2017: Cessna 340A, Waukesha, WI, Substantial damage. Significant icing event departing juneau, WI landing at Waukesha, WI. Pilot received weather info via internet for freezing drizzle. She pre-flighted the… ## Docket (1 files) The files NTSB released with the investigation on March 16, 2017, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=94793. 381 KB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 381 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449999&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-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.