# NTSB CHI02FA093: Cessna 208B, N228PA, Alma, WI, March 15, 2002 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: March 15, 2002, 02:00 local (08:00 UTC) - Place: Alma, WI - Coordinates: 44.357223, -91.785835 - Nearby events: https://openairdocs.org/map.md?lat=44.3572&lon=-91.7858&mi=10 - Phase of flight: [Other](https://openairdocs.org/ntsb-phases/800) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - 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 - NTSB case key (mKey): 54355 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CHI02FA093 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/54355/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=54355 - Page: https://openairdocs.org/ntsb/CHI02FA093 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Miscellaneous/other, other - ice/frost removal from aircraft - not performed, pilot in command (cause) - procedures/directives - not complied with, pilot in command - In flight encounter with weather, cruise - weather condition - icing conditions (contributing factor) - flight into known adverse weather - intentional, pilot in command (cause) - procedures/directives - not complied with, pilot in command - In flight collision with terrain/water, descent - altitude/clearance - not possible, pilot in command (cause) - aircraft performance - deteriorated - object - tree(s) (contributing 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](https://openairdocs.org/deregistered/N228PA-2004-10-27), registration cancelled 2004-10-27, S/N 208B0049, built 1987 (OpenAirDocs) - Reported make and model: Cessna 208B - Registry model: [Cessna 208B](https://openairdocs.org/model/cessna-208b) (registry code 2073701) (OpenAirDocs) - Registry engine: [Pratt & Whitney PT6A series](https://openairdocs.org/engine/pratt-whitney-pt6a-series) (registry code 52032, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: 208B0049 - Airframe hours: 1031.5 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 40; injuries: fatal; 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 ## 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 20020315005629A](https://openairdocs.org/incident/20020315005629A), Mar 15, 2002: Cessna 208B, No damage. (-23) Witness stated that ice was present on aircraft prior to departure from msp. Witness also stated that the pilot declined deice service at msp. Aircraft… ## Docket (23 files) The files NTSB released with the investigation on October 30, 2003, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=54355. 62.3 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399316&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Witness Statements and Record of Interview (item 2, .PDF, 435 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399345&FileExtension=.PDF&FileName=Witness%20Statements%20and%20Record%20of%20Interview-Redacted.PDF - Weather Forecast (item 3, .PDF, 270 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40199449&FileExtension=.PDF&FileName=Weather%20Forecast-Master.PDF - ATC Report of Accident (item 4, .PDF, 214 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399318&FileExtension=.PDF&FileName=ATC%20Report%20of%20Accident-Redacted.PDF - ATC Transcripts (item 5, .PDF, 247 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399319&FileExtension=.PDF&FileName=ATC%20Transcripts-Redacted.PDF - ATC Personnel Statements (item 6, .PDF, 119 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399320&FileExtension=.PDF&FileName=ATC%20Personnel%20Statements-Redacted.PDF - FAA - FSS En-Route Briefing (item 7, .PDF, 180 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399322&FileExtension=.PDF&FileName=FAA%20-%20FSS%20En-Route%20Briefing-Redacted.PDF - NWS Radar Reflectivity Plots (item 8, .PDF, 34.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40199461&FileExtension=.PDF&FileName=NWS%20Radar%20Reflectivity%20Plots-Master.PDF - Aircraft Radar Track Data Plots (item 9, .PDF, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40199464&FileExtension=.PDF&FileName=Aircraft%20Radar%20Track%20Data%20Plots-Master.PDF - NWS Radar Reflectivity Plot With FAA Radar Track Returns (item 10, .PDF, 17.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40199522&FileExtension=.PDF&FileName=NWS%20Radar%20Reflectivity%20Plot%20With%20FAA%20Radar%20Track%20Returns-Master.PDF - Pilot Records (item 11, .PDF, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399323&FileExtension=.PDF&FileName=Pilot%20Records-Redacted.PDF - Pilot's Operating Handbook Supplement-Known Icing Equipment (item 12, .PDF, 749 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399324&FileExtension=.PDF&FileName=Pilot%27s%20Operating%20Handbook%20Supplement-Known%20Icing%20Equipment-Redacted.PDF - FAR 135.227 Icing Conditions: Operating Limitations (item 13, .PDF, 69 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40199471&FileExtension=.PDF&FileName=FAR%20135.227%20Icing%20Conditions%3A%20Operating%20Limitations-Master.PDF - Toxicological Report (item 14, .PDF, 57 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399327&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 15, .PDF, 326 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399330&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 16, .PDF, 70 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399331&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Photo 1. Main Wreckage Overview (item 17, .PDF, 228 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40199475&FileExtension=.PDF&FileName=Photo%201.%20%20Main%20Wreckage%20Overview-Master.PDF - Photo 2. Main Wreckage overview (item 18, .PDF, 232 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40199476&FileExtension=.PDF&FileName=Photo%202.%20%20Main%20Wreckage%20overview-Master.PDF - Photo 3. Main Wreckage Overview (item 19, .PDF, 228 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40199477&FileExtension=.PDF&FileName=Photo%203.%20%20Main%20Wreckage%20Overview-Master.PDF - Photo 4. Main Wreckage Overview (item 20, .PDF, 217 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40199478&FileExtension=.PDF&FileName=Photo%204.%20%20Main%20Wreckage%20Overview-Master.PDF - Photo 5. Structural Ice (item 21, .PDF, 218 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40199479&FileExtension=.PDF&FileName=Photo%205.%20%20Structural%20Ice-Master.PDF - Photo 6. Structural Ice (item 22, .PDF, 216 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40199480&FileExtension=.PDF&FileName=Photo%206.%20%20Structural%20Ice-Master.PDF - Photo 7. Structural Ice (item 23, .PDF, 232 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40199481&FileExtension=.PDF&FileName=Photo%207.%20%20Structural%20Ice-Master.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.