CEN20LA028

NTSB accident investigation · BAE BAE125 · Detroit, MI · December 3, 2019

Accident · No injuriesClass 3 · LimitedFinal report
Date
December 3, 2019, 08:33 local (13:33 UTC)
Place
Detroit, MI
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N469RJBAE BAE125
Defining event
Landing-flare/touchdown: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
FAA, East Michigan FSDO, Textron Aviation, Honeywell Aerospace, L3 Harris Aviation Products
FAA report
20191203021089A
Case key
100651

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 pilots’ failure to increase approach speed as recommended for flight in icing conditions, which resulted in an aerodynamic stall and subsequent impact with terrain. Contributing to the accident was the failure of the stall warning system to advise the crew of the approaching stall.

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.

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 airline transport pilot rated crew was conducting an instrument landing system (ILS) approach. The air traffic controller at the departure airport advised them of the icing conditions present so the crew turned on the anti-ice system. The airplane did not have any airspeed oscillations during the approach. The flying pilot reported that the right wing "dropped" and a stall occurred as they approached the runway. He stated, “Although flight crew selected the correct Vref speed for the aircraft weight, they failed to add 10 kts for the ‘operation in icing conditions’ statement, per the aircraft checklist.” The stick shaker should have alerted the crew of the approaching stall. However, the flying pilot said that there was no shaker activation during the flight. The non-flying pilot felt the shaker was activated after the airplane came to rest. The reason for the lack of a stick shaker warning was not determined during the investigation. However, the cockpit voice recording confirmed the pilots’ statements. The accident is consistent with the airplane stalling on approach due to ice buildup, and the accident likely would not have occurred had the pilot’s flown the higher approach speed recommended for flight in icing conditions.

Factual narrative

The airplane’s ice detection system was equipped with a rotary-cutter type ice detector, two warning annunciators and a left-wing inspection spotlight. The system will automatically detect the formation of ice after takeoff; however, manual selection of the detector is available for operation on the ground. A TKS fluid airframe anti-icing system is provided for the leading edges of the wings and the horizontal stabilizers. The system is controlled by a timer switch and a warning chime, which will sound when the system setting times out and switches off. Anti-icing fluid for the system is stored in a tank with a total capacity of 5.55 US gallons, which provides priming and protection for about 61 minutes. The airplane came to rest upright on the infield grass near the airport control tower. Ice was observed on the leading edge of the left wing and on the ground beneath the wing. The outboard portion of the airplane’s left wing was bent upward. The CVR was shipped to the NTSB Recorder Laboratory. A CVR Factual Report was produced. The report confirmed the facts of the accident pilots’ statements. On December 3, 2019, about 0833 eastern standard time, a BAE 125 800A airplane, N469RJ, was substantially damaged when it was involved in an accident near Detroit, Michigan. The airline transport pilot and copilot were uninjured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 repositioning flight for a subsequent Part 135 flight. According to the pilot in command who was flying the accident airplane, the airplane departed the Willow Run Airport (YIP), near Detroit, Michigan, and the crew was conducting an instrument landing system (ILS) approach to runway 33 at the Coleman A. Young Municipal Airport (DET), near Detroit, Michigan. The airplane broke out of the clouds about 1,500 ft above ground level (AGL), and the airplane had picked up rime icing during the flight. The air traffic controller at YIP advised them of the icing conditions present and the pilot turned on the airplane’s TKS [Tecalemit-Kilfrost-Sheepbridge Stokes] weeping wing deicing system. The airplane did not have any airspeed oscillations during the approach, and the crew maintained 140 knots on approach. The flight's calculated Vref speed was 128 knots. The pilot reported that the right wing "dropped" and a stall occurred. He said that there was no shaker activation during the flight. Federal Aviation Administration (FAA) inspectors examined and documented the airplane that came to rest on the infield grass near the control tower. The airplane had ice on the leading edge of the left wing and ice was observed on the ground under the left wing. An outboard section of the right wing was bent upward. Each engine’s Digital Electronic Engine Controller (DEEC) unit were shipped to their manufacturer for an examination under NTSB supervision. The download of the incident recorded data and fault history data from both N1 DEECs was completed successfully. Review of thedata revealed that both engines were rotating, operating, and responding to power lever inputs throughout the approach and accident sequence. The flying pilot’s accident report, in part, stated, “Although flight crew selected the correct Vref speed for the aircraft weight, they failed to add 10 kts for the ‘operation in icing conditions’ statement, per the aircraft checklist. Vref should have been calculated at 138 KIAS with a minimum approach speed of 148 KIAS.” The non-flying pilot stated the airplane had come to a full stop in the grass. At that point his arm touched the control column, and he could feel that the stick shaker was activated/shaking. He thought the control column was all the way back. About 0807, another BAE 125 800A airplane had landed at DET. The pilot of that airplane stated that he was in his own airplane on the ramp waiting for passengers and witnessed the accident airplane exiting runway 33 traveling through the grass and across the taxiway coming to rest in the grass past the taxiway. Before entering the clouds, the witness reported the TKS ice protection system, engine heat, and engine ignitions were turned on. The witness, in part, stated the ice detected light illuminated during the approach and after landing there was some minor ice on the wing leading edge. The small temperature probe had an umbrella shaped ice formation. The outboard ends of the horizontal stabilizer had ice formation on about the outer 9 inches of both horizontals." A review of 29 pilot reports during the 7 hours surrounding the period indicated 23 reports of icing between 1,600 ft and 4,000 ft. Most of the reports indicated light rime type icing being encountered with moderate rime to mixed icing encounters the second highest number of reports. There was a strong aircraft type bias in the reports with the majority of the light icing intensity reports being made by air carrier aircraft, and all the moderate icing from turboprop, business to smaller regional jet aircraft. The reports of no icing were also most common with departing jet aircraft rapidly climbing though the clouds, versus aircraft on a gradual descent. The reports of moderate icing were noted between 0500 and 0945 or immediately surrounding the time of the accident, with the light intensity icing reports dominating after 0945. No urgent or severe icing PIREPs were reported during the period. Cloud bases were reported near 1,600 ft with cloud tops ranging from 3,800 to 4,000 ft.

Aircraft

Registration
N469RJ
Reported as
BAE BAE125 (800A)
Category
Airplane
Serial number
258067
Built
1986
Airframe hours
19,714
Engines
Honeywell TFE731-5R-1H, 4,300 lbs thrust, turbo fanHoneywell TFE731-5R-1H, 4,300 lbs thrust, turbo fan
Damage
Substantial damage
Flight
Part 135
Operator
Business Jet Managers Inc
Registered owner
Business Jet Managers Inc
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · October 16, 2019
Departed
YIP · Detroit, MI
Destination
DET · Detroit, MI
Flight plan
IFR
Airport
DET · Coleman A Young Muni, runway 33, 5,090 × 100 ft, asphalt
Equipment
Onboard weather, Electronic primary flight display, Electronic multifunction display, Auto-pilot, Stall warning system

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
60
Injuries
None
Certificate
Airline transport
Airplane ratings
Single-engine land, Multi-engine land, Single-engine sea
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
August 29, 2019
Seat
Left
Restraint
5-point
Flight hours
18,500 total · 7,000 in this make and model · 16,500 as pilot in command · 150 in the last 90 days · 50 in the last 30 days · 0 in the last 24 hours
Role
Co-pilot
Age
65
Injuries
None
Certificate
Airline transport
Airplane ratings
Multi-engine land, Single-engine sea, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
August 29, 2019
Seat
Right
Restraint
5-point
Flight hours
15,895 total · 2,136 in this make and model · 13,606 as pilot in command · 169 in the last 90 days · 59 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
280° at 8 knots
Visibility
10 statute miles
Lowest ceiling
1,000 ft overcast
Temperature
28 °F, dew point 27 °F
Altimeter
29.86 inHg
Observed at
KDET

Docket · 22

The files NTSB released with the investigation on March 15, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 55.4 MB in all.

Pilot/operator aircraft accident report, NTSB form 6120.1 including icing sketch and crew statementItem 1 · PDF · 11 pages · 6.9 MBMemorandum for record a�� communication summary j tomassoni -- pilot of N122LJItem 2 · PDF · 1 page · 142 KBVideo file - det airport supplied videoItem 3 · MP4 · 8.3 MBWeather studyItem 4 · PDF · 33 pages · 3.4 MBRadar performance studyItem 5 · PDF · 15 pages · 2.9 MBPowerplants - engine deec examination summaryItem 6 · PDF · 5 pages · 2 photos · 1.8 MBMemorandum for record a�� communication summary -- Textron characterization of wing icingItem 7 · PDF · 1 page · 134 KBPhotos - supplied photosItem 8 · PDF · 8 pages · 8 photos · 7.1 MBMiscellaneous information - airport diagramItem 9 · PDF · 1 page · 107 KBMiscellaneous information - ILS runway 33 approach plateItem 10 · PDF · 1 page · 235 KBAir traffic control - tower communicationsItem 11 · WAV · 10.7 MBAir traffic control - radar data N469RJItem 12 · XLSX · 35 KBAir traffic control - radar data N122LJItem 13 · XLSX · 95 KBMemorandum for record a�� communication summary - w niesing L3 TAWS examItem 14 · PDF · 4 pages · 3 photos · 1.8 MBMiscellaneous information - tks excerptItem 15 · PDF · 6 pages · 2.3 MBMiscellaneous information - stall warning excerptItem 16 · PDF · 2 pages · 1.1 MBMiscellaneous information - ice and rain protection excerptItem 17 · PDF · 4 pages · 1.6 MBMiscellaneous information - icing conditions -- add airspeed to refItem 18 · PDF · 1 page · 269 KBStatement of party representatives to NTSB investigationItem 19 · PDF · 3 pages · 6.2 MBRelease of aircraft wreckage, NTSB form 6120.15Item 20 · PDF · 1 page · 94 KBEvidence control form - deecsItem 21 · PDF · 1 page · 132 KBCockpit voice recorder - specialista��s factual reportItem 22 · PDF · 6 pages · 190 KB

FAA reports on this event · 1

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