CEN18FA132

NTSB accident investigation · Cessna 150 · Marion, IN · April 2, 2018

Accident · FatalField investigationFinal report
Date
April 2, 2018, 15:09 local (19:09 UTC)
Place
Marion, IN
Injuries
2 fatal, 5 uninjured
Phase of flight
Takeoff
Aircraft
N5614ECessna 150N511ACCessna 525C
Defining events
Takeoff: Ground collisionLanding-landing roll: Collision during takeoff/land
Weather
Visual (VMC) · Day
Status
Completed · report April 13, 2020
Report
Approved by Office Director
NTSB office
Central Region
Parties
FAA FSDO, Cessna
Case key
96969

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The failure of both pilots to see and avoid the other airplane as they converged on intersecting runways. Contributing to the accident was the jet pilot's not monitoring the airport's traffic advisory frequency, known reduced visibility of the intersecting runways, and hazy weather condition.

Findings · 10

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

N5614E · Cessna 150

Action: lack of actionPersonnel issues › Action/decision · PilotCessna 150: 3 casesAll aircraft: 792 casesProbable cause
Action: lack of actionPersonnel issues › Action/decision · Pilot of other aircraftCessna 150: 3 casesAll aircraft: 792 casesProbable cause
Runway/land/takeoff/taxi surfaceEnvironmental issues › Physical environment · Contributed to outcomeCessna 150: 1 caseAll aircraft: 253 casesProbable cause
Ceiling/visibility/precipEnvironmental issues › Conditions/weather/phenomena · Contributed to outcomeCessna 150: 1 caseAll aircraft: 65 casesProbable cause
Communication (personnel): lack of communicationPersonnel issues › Task performance · Pilot of other aircraftCessna 150: 1 caseAll aircraft: 84 casesProbable cause

N511AC · Cessna 525C

Action: lack of actionPersonnel issues › Action/decision · PilotAll aircraft: 792 casesProbable cause
Action: lack of actionPersonnel issues › Action/decision · Pilot of other aircraftAll aircraft: 792 casesProbable cause
Runway/land/takeoff/taxi surfaceEnvironmental issues › Physical environment · Contributed to outcomeAll aircraft: 253 casesProbable cause
Ceiling/visibility/precipEnvironmental issues › Conditions/weather/phenomena · Contributed to outcomeAll aircraft: 65 casesProbable cause
Communication (personnel): lack of communicationPersonnel issues › Task performance · PilotAll aircraft: 84 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

N5614E · Cessna 150

N511AC · Cessna 525C

Analysis

A single-engine airplane was taking off from runway 15 about the same time that a multi-engine business jet landed on a nearly perpendicular runway (runway 22). The single-engine airplane, piloted by a private pilot, was departing on a local flight. The jet, piloted by an airline transport pilot, was rolling down the runway following a straight-in visual approach and landing. The single-engine airplane collided with the empennage of the jet at the intersection of the two runways. Witnesses in the airport lounge area heard the pilot of the single-engine airplane announce on the airport's universal communications (UNICOM) traffic advisory frequency a few minutes before the accident that the airplane was back-taxiing on the runway. The pilot of the jet did not recall making any radio transmissions on the UNICOM frequency and review of the jet's cockpit voice recorder did not reveal any incoming or outgoing calls on the frequency. The pilots of both airplanes were familiar with the airport, and the airport was not tower controlled. The airport had signage posted on all runways indicating that traffic using the nearly perpendicular runway could not be seen and instructed pilots to monitor the UNICOM. A visibility assessment confirmed reduced visibility of traffic operating from the nearly perpendicular runways. The reported weather conditions about the time of the accident included clear skies with 4 miles visibility due to haze. Both airplanes were painted white. It is likely that the pilot of the jet would have been aware of the departing traffic if he was monitoring the UNICOM frequency. Although the jet was equipped with a traffic collision avoidance system (TCAS), he reported that the system did not depict any conflicting traffic during the approach to the airport. Although the visibility assessment showed reduced visibility from the departing and arrival runways, it could not be determined if or at what point during their respective landing and takeoff the pilot of each airplane may have been able to see the other airplane. In addition to the known reduced visibility of the intersecting runways, both airplanes were painted white and there was reported haze in the area, which could have affected the pilots' ability to see each other.

Factual narrative

A small unmanned aircraft system was used to map and conduct viewpoint flights of the crossing runways, infield area, and impact area. About 1,400 high-resolution photos and videos were gathered and processed to create a visibility assessment. The assessment confirmed the visibility restrictions that were posted on airport signage at the approach and departure ends of the runways. The Cessna 150 was a two-seat, high-wing airplane manufactured in 1958. It was powered by a Continental O-200 engine equipped with a McCauley propeller. According to maintenance logbooks, its most recent annual inspection was completed on January 1, 2018, at a total airframe time of 4,035 hours. The pilot had recently purchased the airplane on January 25, 2018. The airplane was painted white. The Cessna 525 was a 10-seat, low-wing, business jet manufactured in 2012. It was powered by two Williams turbojet engines. According to maintenance logbooks, its most recent annual inspection was completed on March 9, 2018, at a total airframe time of 2,524 hours. The airplane was based at MZZ and was operated as a company airplane for Avis Industrial Corporation. The airplane was painted white. The airport was not tower-controlled. At the departure and arrival ends of runways 15/33, there was a sign posted, "Traffic Using Runway 4/22 Cannot Be Seen, Monitor Unicom 122.7." At the departure and arrival ends of runways 4/22, there was a sign stating, "Traffic Using 15/33 Cannot Be Seen, Monitor Unicom 122.7." On April 2, 2018, at 1709 eastern standard time, a Cessna 150 airplane, N5614E, collided with a Cessna 525 business jet, N511AC, at Marion Municipal Airport (MZZ), Marion, Indiana. The private pilot and one passenger onboard the Cessna 150 sustained fatal injuries, and the airplane was destroyed. The airline transport pilot and four passengers onboard the Cessna 525 were not injured, and the airplane was substantially damaged. Visual meteorological conditions prevailed in the area at the time of the accident. Both flights were being conducted under the provisions of Title 14 Code of Federal Regulations Part 91. The Cessna 525 flight originated from Jackson, Michigan, on an instrument flight rules (IFR) flight plan for the business flight and was performing a visual landing approach to runway 22; the Cessna 150 was departing runway 15 on a local visual flight rules personal flight. The pilot of the Cessna 525 stated that he cancelled his IFR flight plan with air traffic control about 5 to 10 miles from MZZ. He stated that he did not recall announcing his approach to land at MZZ on the airport's universal communications (UNICOM) frequency and that the airplane's traffic collision avoidance system did not show any traffic at the airport. He also stated that he did not see the Cessna 150 during the straight-in visual approach to runway 22 nor did he see it during the landing roll. He landed the airplane on runway 22 and while approaching the intersection with runway 15 during thelanding roll, the pilot thought that he saw something out of the right cockpit window; at the same time, he felt the airplane yaw. The pilot stopped the airplane, turned it around, taxied back toward intersection, and stopped. The four passengers aboard the Cessna 525 all reported that they did not see the Cessna 150 on the approach or during the landing roll. There were three witnesses to the accident, all located in the airport lounge within hearing distance of the base UNICOM radio. Two of the witnesses stated that they heard the pilot of the Cessna 150 announce on the UNICOM a few minutes before the accident that the airplane was back-taxiing on runway 15. Each witness reported that the Cessna 150 had just become airborne when it collided with the empennage of the Cessna 525 at the intersection of runways 15 and 22. The Cessna 525 was equipped with a cockpit voice recorder (CVR). The CVR recording did not reveal any incoming or outgoing radio transmissions on the MZZ UNICOM frequency. The Northeast Indiana Forensic Center, Fort Wayne, Indiana, performed an autopsy on the Cessna 150 pilot; the cause of death was multiple blunt force injuries. Toxicology testing was performed by the FAA. Tests were negative for carbon dioxide and alcohol; 50.33 (ug/ml, ug/g) Acetaminophen (Tylenol) was present, which was not considered impairing. The recorded weather at MZZ at 1655 included wind from 140° at 9 knots, 4 statute miles visibility with haze, clear skies, temperature 5°C, dew point -1°C, and an altimeter setting of 30.01 inches of mercury. The pilot of the Cessna 150 held a private pilot certificate with a rating for airplane single-engine land. His most recent third-class Federal Aviation Administration (FAA) medical certificate was issued on May 3, 2017. According to entries in his pilot logbook, he had a total flight experience of 71.9 hours, with 10.7 hours in the Cessna 150. The pilot of the Cessna 525 held an airline transport pilot certificate with ratings for airplane single- and multi-engine land and instrument airplane. He also held a flight instructor certificate with ratings for airplane single, and multi-engine. He reported a total flight experience of 35,437 hours, with 2,537 hours in the Cessna 525. The Cessna 150 came to rest on its right side in the grass adjacent to runway 15 on a 110º magnetic heading. The wreckage exhibited extensive fire damage. The left wing displayed leading edge crush damage along its span. All flight control surfaces were attached, and flight control cable continuity was established from the control surfaces to the cockpit. The wing flap and elevator trim positions could not be determined due to impact damage. The fuel selector handle and valve were found fire-damaged and their positions could not be determined. Both fuel tanks were compromised and fire-damaged. Impact damage prevented examination of the environmental systems, the transponder, and the emergency locator transmitter (ELT). The cabin sectionwas destroyed by the postimpact fire. The two lap belt buckles were found latched. The engine had severe fire damage. Examination revealed no evidence of any pre-impact abnormalities of the airframe or engine. The Cessna 525 was on runway 22 on a 40º magnetic heading. The empennage was separated from the fuselage and came to rest in the grass adjacent to runway 22. The rudder remained attached to the vertical stabilizer and the elevator remained attached to the horizontal stabilizer. The right engine nacelle displayed impact damage. Leading edge crush damage was observed on the vertical stabilizer. There was no damage to the rest of the airplane. Flight control cable continuity was established from the control surfaces to the cockpit. No pre-impact abnormalities were noted.

Aircraft · 2

Registration
N5614E
Reported as
Cessna 150 (UNDESIGNAT)
Category
Airplane
Serial number
17114
Built
1958
Airframe hours
4,035
Engine
Cont Motor O-200 SERIES, 100 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · January 1, 2018
Departed
MZZ · Marion, IN
Destination
MZZ · Marion, IN
Airport
MZZ · Marion Municipal Airport, runway 15, 3,456 × 100 ft, asphalt
Equipment
None

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Registration
N511AC
Reported as
Cessna 525C (C)
Category
Airplane
Serial number
525C0081
Built
2012
Airframe hours
2,537
Engines
Williams FJ44-4A, 3,621 lbs thrust, turbo jetWilliams FJ44-4A, 3,621 lbs thrust, turbo jet
Damage
Substantial damage
Flight
Business · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · March 9, 2018 · 13 hours before
Departed
JXN · Jackson, MI
Destination
MZZ · Marion, IN
Flight plan
IFR
Airport
MZZ · Marion Municipal Airport, runway 22, 6,011 × 100 ft, asphalt
Equipment
ADS-B, Stall warning system, Satellite tracking device, Onboard weather, Electronic primary flight display, Electronic multifunction display, Data recorder, Auto-pilot, Angle of attack indicator

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot, aircraft N5614E
Age
31
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Last flight review
October 18, 2017
Seat
Left
Restraint
Lap only
Toxicology
Performed
Flight hours
71.9 total · 10.6 in this make and model · 23.7 as pilot in command · 10.6 in the last 90 days · 8.6 in the last 30 days
Role
Pilot, aircraft N511AC
Age
70
Injuries
None
Certificate
Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
June 24, 2017
Seat
Left
Restraint
5-point
Flight hours
35,437 total · 2,537 in this make and model · 35,237 as pilot in command · 67 in the last 90 days · 12 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
140° at 9 knots
Visibility
4 statute miles
Lowest ceiling
None
Temperature
41 °F, dew point 30 °F
Altimeter
30.01 inHg
Observed at
MZZ

Docket · 23

The files NTSB released with the investigation on March 4, 2020, on NTSB’s docket system: statements, records, photos and specialists’ reports. 81.9 MB in all.

MZZ Safety Enhancement Letter to NTSBItem 1 · .PDF · 170 KBNTSB Form 6120 Pilot Operator Report Cessna 525Item 2 · .PDF · 3.7 MBMemorandum for the Record Cessna 525 Pilot Interview SummaryItem 3 · .PDF · 201 KBMemorandum for the Record Witness SummariesItem 4 · .PDF · 204 KBMemorandum for the Record Cessna 525 Passenger Interview SummariesItem 5 · .PDF · 193 KBPhoto array CEN18FA132ABItem 6 · .PDF · 6.2 MBUAS Aerial Imagery ReportItem 7 · .PDF · 2.3 MBUAS Aerial Imagery Att 1 CJ4 left side looking toward runway 15Item 8 · .PDF · 9.1 MBUAS Aerial Imagery Att 2 CJ4 tail and C150Item 9 · .PDF · 3.8 MBUAS Aerial Imagery Att 3 Fig 1 CJ with C150 in backgroundItem 10 · .PDF · 3.8 MBUAS Aerial Imagery Att 4 Fig 2 View along runway 22Item 11 · .PDF · 3.6 MBUAS Aerial Imagery Att 5 Fig 3 view along 15Item 12 · .PDF · 1.4 MBUAS Aerial Imagery Att 6 DSM GEOtiffItem 13 · ZIP · 43.1 MBUAS Aerial Imagery Att 8 Fig 6 View from above runway 15 toward runway 22Item 14 · .PDF · 2.5 MBUAS Aerial Imagery Att 9 FullGridKMZ CoverSheetItem 15 · .PDF · 71 KBUAS Aerial Imagery Att 10 Fig 8 Point cloud with viewpointItem 16 · .PDF · 201 KBUAS Aerial Imagery Att 11 Fig 9 DSM overlaid on topoItem 17 · .PDF · 177 KBUAS Aerial Imagery Att 12 Fig 10 ExplanatoryItem 18 · .PDF · 303 KBUAS Aerial Imagery Att 13 Fig 11 C150atTHItem 19 · .PDF · 243 KBUAS Aerial Imagery Att 14 Fig 12 C150CJMutualRollingItem 20 · .PDF · 239 KBToxicology Report Cessna 150 PilotItem 21 · .PDF · 190 KBCertificate of Party Representative CessnaItem 22 · .PDF · 279 KBCockpit Voice Recorder - Specialist's Factual ReportItem 23 · .PDF · 64 KB

FAA reports on this event · 2

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.