CEN19LA188

NTSB accident investigation · Cessna 560 · Janesville, WI · June 27, 2019

Accident · Serious injuriesClass 3 · LimitedFinal report
Date
June 27, 2019, 15:00 local (20:00 UTC)
Place
Janesville, WI
Injuries
1 serious, 1 minor, 2 uninjured
Damage
Minor damage
Phase of flight
Enroute
Aircraft
N318RWCessna 560
Defining event
Enroute-cruise: Turbulence encounter
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
FAA FSDO
FAA report
20190627008219A
Case key
99726

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

On this page

Probable cause

The passenger’s decision to unbuckle her restraints during an in-flight turbulence event, resulting in serious injury.

Findings · 2

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.

Turbulence: clear air turbulenceEnvironmental issues › Conditions/weather/phenomena · Contributed to outcomeCessna 560: 1 caseAll aircraft: 78 casesProbable cause
ActionPersonnel issues › Action/decision · PassengerCessna 560: 1 caseAll aircraft: 111 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.

Analysis

The pilot had anticipated some turbulence along the route of flight, briefed his three passengers, and turned on the seat belt sign. At flight level (FL) 240, the flight encountered turbulence, and the pilot requested clearance to deviate from air traffic control (ATC), which ATC provided. Using on-board weather radar, the pilot determined that he needed a greater deviation and made several urgent requests for a clearance to deviate. ATC was not able to approve the deviation but instructed the pilot to descend from FL 240 to FL 200. During the descent, the airplane encountered the first of four 15- to 20-second severe turbulence events, with a 5- to 10-second interval between events. During the events, the pilot made several urgent requests for a deviation, but ATC was not able to approve the requests. As far as the pilot was aware, all the passengers were in their seats with seat restraints on during the turbulent portion of the flight. One of the passengers was an elderly man, and one passenger was his caregiver. The caregiver reported that she had gotten out of her seat to assist the elderly man in adjusting his restraints more firmly. During the time she had gotten up to assist, she was thrown about the cabin during the turbulence. The pilot landed the airplane as soon as possible, and the caregiver was treated at a local hospital for bone fractures to her right arm.

Factual narrative

On June 27, 2019, about 1500 central daylight time, a Cessna 525, N318RW, sustained minor damage when it was involved in an accident near Janesville, Wisconsin. One passenger sustained serious injuries, the pilot sustained minor injuries, and two passengers were not injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 business flight. The pilot had anticipated some turbulence along the route of flight, briefed the three passengers, and had the seat belt sign turned on. At flight level (FL) 240, due to turbulence, the pilot requested a deviation from air traffic control (ATC) on the south side of a squall line, which ATC provided. Using on-board weather radar, the pilot determined that he needed a greater deviation to the south and made several urgent requests for a clearance to deviate. ATC was not able to approve the deviation requests. ATC instructed the pilot to descend to from FL 240 to FL 200. During the descent, the airplane encountered the first of four 15- to 20-second severe turbulence events, with a 5- to 10-second interval between events. During the events, the pilot made several urgent requests for a deviation, but ATC was not able to approve the requests. As far as the pilot was aware, all the passengers were in their seats with seat restraints on during the turbulent portion of the flight. One of the passengers was an elderly man, and one was his caregiver. The caregiver reported that she had gotten out of her seat to assist the elderly man to adjust his restraints more firmly. During the time she had gotten up to assist, she was thrown about the cabin during the turbulence. The pilot landed the airplane as soon as possible in Madison, Wisconsin, and the caregiver was treated at a local hospital for bone fractures to her right arm.

Aircraft

Registration
N318RW
Reported as
Cessna 560 (Undesignat)
Category
Airplane
Serial number
560-0051
Built
1990
Airframe hours
8,957.5
Engines
Pratt & Whitney JTD15-5A, 2,900 lbs thrust, turbo jetPratt & Whitney JTD15-5A, 2,900 lbs thrust, turbo jet
Damage
Minor damage
Flight
Business · Part 91
Operator
Mueller Aero Inc
Registered owner
Mueller Aero Inc
Airworthiness certificate
Standard, Normal
Last inspection
Continuous airworthiness · January 30, 2018
Departed
LAS · Las Vegas, NV
Destination
91C · Prairie du Sac, WI
Flight plan
IFR
Equipment
ADS-B, Stall warning system, Onboard weather, Electronic primary flight display, Angle of attack indicator, Electronic multifunction display, Data recorder, Auto-pilot

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.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
61
Injuries
None
Certificate
Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
June 10, 2018
Seat
Left
Restraint
5-point
Flight hours
11,663 total · 1,292 in this make and model

Weather

Conditions
Visual (VMC) · Day
Visibility
10 statute miles
Lowest ceiling
None
Turbulence
Severe

Docket · 3

The files NTSB released with the investigation on November 30, 2021, on NTSB’s docket system: statements, records, photos and specialists’ reports. 2.3 MB in all.

FAA reports on this event · 1

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