CHI02FA093

NTSB accident investigation · Cessna 208B · Alma, WI · March 15, 2002

Accident · FatalField investigationFinal report
Date
March 15, 2002, 02:00 local (08:00 UTC)
Place
Alma, WI
Injuries
1 fatal
Damage
Substantial damage
Phase of flight
Other
Aircraft
N228PACessna 208B
Weather
Instrument (IMC) · Night/dark
Status
Completed · report December 30, 2003
Report
Approved by Office Director
Parties
Federal Aviation Administration - MSP FSDO, Priority Air Charter ( JILCO Industries, Inc. ), Cessna Aircraft Company
FAA report
20020315005629A
Case key
54355

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 pilot not removing the ice contamination from the airplane prior to departure and the pilot intentionally flying into known severe icing conditions, resulting in the aircraft not being able to maintain altitude/clearance from the terrain. Factors to the accident included the icing conditions and the trees encountered during the forced landing.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Miscellaneous/otherOther
Ice/frost removal from aircraft - not performedPilot in commandCause
Procedures/directives - not complied withPilot in command
In flight encounter with weatherCruise
Weather condition - icing conditionsFactor
Flight into known adverse weather - intentionalPilot in commandCause
Procedures/directives - not complied withPilot in command
In flight collision with terrain/waterDescent
Altitude/clearance - not possiblePilot in commandCause
Aircraft performance - deteriorated
Object - tree(s)Factor

Analysis

The pilot departed with the airplane contaminated with ice, into known severe icing conditions, and was unable to maintain altitude, subsequently impacting trees and terrain. Witnesses reported the accident airplane arrived at the departure airport contaminated with ice. Several witnesses stated they asked the pilot if he needed the airplane deiced prior to his next departure and the pilot stated he did not need any deice service. Several witnesses said they noticed the pilot chipping-off ice from the airplane prior to his departure. While en route the pilot reported the airplane had encountered icing conditions and he was unable to maintain altitude. Several thick pieces of ice were recovered around the accident site and one of the recovered ice pieces had a semicircular shaped edge that was consistent with a leading edge of an airfoil. No pre-impact anomalies were found with the leading edge de-ice boots that were installed on both wings, vertical and horizontal stabilizers, and wing struts. Federal Aviation Regulations state that all ice contimination shall be removed prior to flight. The Cessna 208B Pilot Operating Handbook indicates that continued flight into known icing conditions must be avoided.

Factual narrative

History of flight

On March 15, 2002, at 0200 central standard time, a Cessna 208B, N228PA, operated by Priority Air Charter, Kidron, Ohio, sustained substantial damage during impact with trees and terrain near Alma, Wisconsin. Instrument meteorological conditions prevailed at the time of the accident. The flight was being operated under the provisions of 14 CFR Part 135 as an on-demand cargo flight and was on an instrument flight rules (IFR) flight plan. The commercial pilot was fatally injured. The flight departed Minneapolis - St. Paul International Airport (MSP), Minneapolis, Minnesota, at 0105 and had the intended destination of Willow Run Airport, Detroit, Michigan.

Employees of a fixed base operator (FBO) located at MSP reported N228PA arrived at the FBO between 0000 and 0030. One FBO employee reported there was about 1/4 inch strip of ice on the leading edges of the wings and horizontal stabilizer. The employee stated a "clear coat" of ice covered the propeller and that 3/4 inch of mixed ice covered the area aft of the leading edge de-ice boots on both wings. The employee asked the pilot how the weather was coming into MSP and the pilot replied that it was "pretty bad up there." Another employee reported the airplane had ice on both wings, both wing struts, and the fuselage. The employee estimated the thickness of the ice accumulation to be 1/8 to 1/2 inch. Several FBO employees stated they asked the pilot if he needed the airplane deiced prior to his next departure and that the pilot stated to multiple FBO employees that he did not need any deice service. Several FBO employees said they noticed the pilot chipping-off ice from the airplane prior to his departure. The airplane was fueled with 180 gallons of Jet-A fuel prior to its departure and was loaded with four boxes that had a reported combined weight of 100 lbs. No additional services were provided. The airplane departed the FBO ramp about 0100.

According to information provided by the Federal Aviation Administration (FAA) Minneapolis Air Route Traffic Control Center (ARTCC), the pilot of N228PA established radio contact at 0126:21 (hhmm:ss) and reported that he was climbing to 5,000 feet above mean sea level (msl). The following is a summary of the voice communications between Minneapolis ARTCC and N228PA:

0126:38 The controller advised N228PA of a pilot report of light rime ice at 5,000 feet msl and that the reporting airplane descended to 4,000 feet msl.

0126:59 N228PA requested and was cleared to descend to 4,000 feet msl.

0132:40 N228PA queried the controller about when he would be clear of the icing conditions.

0132:49 The controller verified with the pilot that N228PA was in icing conditions.

0133:58 The controller advised N228PA that he did not know when N228PA would be out of icing conditions and advised N228PA that he would most likely be clear of the icing conditions at 11,000 feet msl heading eastbound. N228PA acknowledged.

0134:52 N228PA requested a turn to get clear of the icing conditions and that he was having a hard time maintaining altitude.

0135:40 The controller informed N228PA that an aircraft twenty miles in front of N228PA was reporting icing conditions at 4,000 feet msl. The controller asked N228PA if he wanted to turn back towards Minneapolis or continue eastbound.

0135:51 N228PA queried if a turn to the south would help.

0135:56 The controller informed N228PA that there were no aircraft to the south of N228PA and that the only precipitation he had on his scope was east of Minneapolis, Minnesota, extending up north of Eau Claire, Wisconsin, and towards Rhinelander, Wisconsin. The controller informed N228PA that the preceding aircraft was in icing conditions at 4,000 feet msl.

0136:12 N228PA replied that he was going to continue as previously cleared.

0136:19 The controller advised N228PA that he believed that there was no icing above 10,000 feet.

0138:15 The controller advised N228PA that the weather at Madison, Wisconsin, was broken clouds at 2,500 feet above ground level (agl), mist, and no reports of snow.

0138:28 N228PA asked to head towards Madison.

0141:15 The controller queried N228PA on how he was doing.

0141:18 N228PA responded, "ah we're holding our own here sir, we seem to be doing alright at this altitude".

0145:26 N228PA asked the controller, "... any suggestions here looks like we're gonna need to land somewhere we're starting to have a hard time holding altitude here."

0145:33 The controller informed N228PA that the Winona airport was about 22 miles at the one o'clock position.

0145:41 The controller advised N228PA that the weather at Winona was broken clouds at 500 feet agl, 1,100 feet agl overcast, 3 miles visibility, and altimeter setting was 29.56 inches-of-mercury.

0145:52 N228PA reported that he wanted to go to Winona.

0146:43 N228PA asked what type of instrument approaches were at Winona.

0146:46 The controller advised N228PA that there were the VOR 29, VOR A, and GPS 29 approaches at Winona.

0148:13 The controller queried N228PA on how he was doing.

0148:15 N228PA asked what the distance to Winona was.

0148:35 The controller advised N228PA that Winona was about 15 miles at the one o'clock position.

0148:39 N228PA advised he was going to Winona and asked what the airport identifier was for Winona.

0148:44 The controller advised N228PA that the Winona airport identifier was ONA, the frequency of the VOR, and gave him the inbound radial for the VOR A approach.

0149:53 The controller queried N228PA on how he was doing.

0150:16 The controller asked if N228PA had the Winona VOR tuned-in.

0150:20 N228PA replied that he had the Winona VOR tuned-in.

0150:21 The controller asked N228PA what radial he was tracking in-bound to the VOR.

0150:26 N228PA replied that he was tracking the 330 radial to the VOR.

0150:32 The controller asked N228PA if he had the approach plates and if he had any time to look at the them.

0150:35 N228PA reported, "I tell you what, I got my hands full right now."

0150:54 N228PA asked what the identifier was for the Winona Municipal Airport.

0150:56 The controller informed N228PA that the identifier was ONA and that the airport was the Winona Municipal Airport.

0151:04 N228PA asked what the identifier was for the Winona Municipal Airport.

0151:06 The controller informed N228PA that it was ONA.

0151:53 The controller advised N228PA that the minimum safe altitude for the area was 3,000 feet msl.

0152:00 N228PA replied that he was unable to maintain 3,000 feet msl.

0152:25 N228PA asked what the identifier was for the Winona Municipal Airport.

0152:28 The controller informed N228PA that the identifier was ONA.

Minneapolis ARTCC did not receive any additional communications from N228PA and radar contact was lost at 0155:00.

A full transcription of the voice communications between Minneapolis ARTCC and the N228PA is included with the docket material associated with this accident report.

Personnel information

According to Federal Aviation Administration (FAA) records, the pilot held a commercial pilot certificate with airplane single-engine land, airplane multiengine land, and instrument airplane ratings. FAA records show the pilot's last medical examination was completed on March 29, 2001, and the pilot was issued a second-class medical certificate with no restrictions or limitations.

According to Priority Air Charter, the pilot reported a total flight time of 3,800 hours when he was hired during January 2000, of which 3,775 hours were in single-engine airplanes and 25 hours were in multiengine airplanes. The pilot reported that he had 1,500 hours in the Cessna 208 at the time of hire. Priority Air Charter reported that the pilot had flown 816.7 hours since January 2000, all of which were in the Cessna 208. Priority Air Charter reported that the pilot had flown 47.

Aircraft

Registration
N228PA
Reported as
Cessna 208B
Category
Airplane
Serial number
208B0049
Airframe hours
1,031.5
Engine
Pratt & Whitney PT6A-114A, 675 horsepower, turbo prop
Damage
Substantial damage
Flight
Part 135
Operator
Priority Air Charter
Registered owner
JILCO Industries, Inc
Airworthiness certificate
Standard, Normal
Last inspection
Continuous airworthiness · March 1, 2002 · 39 hours before
Departed
MSP · Minneapolis, MN
Destination
YIP · Detroit, MI
Flight plan
IFR

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
40
Injuries
Fatal
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--no waivers/lim.
Last flight review
March 9, 2002
Seat
Left
Toxicology
Performed
Flight hours
4,617 total · 2,317 in this make and model

Weather

Conditions
Instrument (IMC) · Night/dark
Wind
310° at 6 knots
Visibility
2.5 statute miles
Lowest ceiling
600 ft broken
Temperature
30 °F, dew point 30 °F
Altimeter
29.56 inHg
Observed at
ONA, 17 nm away

Docket · 23

The files NTSB released with the investigation on October 30, 2003, on NTSB’s docket system: statements, records, photos and specialists’ reports. 62.3 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.