# NTSB CEN19LA188: Cessna 560, N318RW, Janesville, WI, June 27, 2019 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Class 3 · Limited · Final report - Date: June 27, 2019, 15:00 local (20:00 UTC) - Place: Janesville, WI - Coordinates: 42.644165, -88.960556 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=42.6442&lon=-88.9606&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Turbulence encounter](https://openairdocs.org/ntsb-events/360) - Highest injury: Serious injuries - Injuries: 1 serious, 1 minor, 2 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: FAA FSDO - NTSB case key (mKey): 99726 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN19LA188 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99726/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99726 - Page: https://openairdocs.org/ntsb/CEN19LA188 ## Probable cause The passenger’s decision to unbuckle her restraints during an in-flight turbulence event, resulting in serious injury. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Turbulence: clear air turbulence](https://openairdocs.org/ntsb-findings/03032015): Environmental issues › Conditions/weather/phenomena · Contributed to outcome (probable cause); cases with it: [Cessna 560, 1 case](https://openairdocs.org/ntsb-findings/03032015/cases.md?model=2076750), [All aircraft, 78 cases](https://openairdocs.org/ntsb-findings/03032015/cases.md) - [Action](https://openairdocs.org/ntsb-findings/02041000): Personnel issues › Action/decision · Passenger (probable cause); cases with it: [Cessna 560, 1 case](https://openairdocs.org/ntsb-findings/02041000/cases.md?model=2076750), [All aircraft, 111 cases](https://openairdocs.org/ntsb-findings/02041000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: Turbulence encounter](https://openairdocs.org/ntsb-events/360) (defining event); cases with it: [Cessna 560, 1 case](https://openairdocs.org/ntsb-events/360/sequence.md?model=2076750), [All aircraft, 423 cases](https://openairdocs.org/ntsb-events/360/sequence.md) ## 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](https://openairdocs.org/aircraft/N318RW), registered now, S/N 560-0051, built 1990 (OpenAirDocs) - Reported make and model: Cessna 560 (Undesignat) - Registry model: [Cessna 560](https://openairdocs.org/model/cessna-560) (registry code 2076750) (OpenAirDocs) - Registry engine: [Pratt & Whitney Canada JT15D 5 series](https://openairdocs.org/engine/pratt-whitney-canada-jt15d-5-series) (registry code 52113, turbo-fan) (OpenAirDocs) - Category: Airplane - Serial number: 560-0051 - Year built: 1990 - Airframe hours: 8957.5 - Engines: Pratt & Whitney JTD15-5A 2900 lbs thrust turbo jet; Pratt & Whitney JTD15-5A 2900 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 61; injuries: none; 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 ## 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 20190627008219A](https://openairdocs.org/incident/20190627008219A), Jun 27, 2019: Cessna 560, Janesville, WI, No damage. On June 27, 2019, at 1503 CDT, a Cessna 560, N318RW, encounter severe clear air turbulence at FL230 over kjvl, Janesville, Wisconsin. The air transport pilot… ## Docket (3 files) The files NTSB released with the investigation on November 30, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99726. 2.3 MB in all. - NTSB form 6120 pilot operator report CEN19LA188 (item 1, PDF, 9 pages, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11762177&FileExtension=pdf&FileName=NTSB%20Form%206120%20Pilot%20Operator%20Report%20CEN19LA188_Redacted-Rel.pdf - Airplane turbulance inspection CEN19LA188 (item 2, PDF, 2 pages, 222 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11762028&FileExtension=pdf&FileName=Airplane%20Turbulance%20Inspection%20CEN19LA188_Redacted-Rel.pdf - Pilot flight training record from flight safety international CEN19LA188 (item 3, PDF, 2 pages, 495 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11762595&FileExtension=pdf&FileName=PIlot%20Flight%20Training%20Record%20from%20Flight%20Safety%20International%20CEN19LA188_Redacted-Rel.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.