# NTSB CHI05FA077: Bombardier CL-600-2B19, N8932C, Milwaukee, WI, March 12, 2005 - Type: NTSB accident investigation - Classification: Accident · No injuries · Field investigation · Final report - Date: March 11, 2005, 23:02 local (Mar 12, 2005, 05:02 UTC) - Place: Milwaukee, WI - Coordinates: 42.931667, -87.898056 - Nearby events: https://openairdocs.org/map.md?lat=42.9317&lon=-87.8981&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 12 uninjured - Status: Completed, report January 31, 2007 - Report: Approved by Office Director - Parties: Bombardier Aerospace, Pinnacle Airlines, Inc., ALPA, FAA-FSDO - NTSB case key (mKey): 61142 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CHI05FA077 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/61142/pdf - Page: https://openairdocs.org/ntsb/CHI05FA077 ## Probable cause the captain's failure to adequately compensate for the crosswind conditions, and his failure to maintain directional control during landing. Contributing factors include the captain's failure to land at the nearest suitable airport after an in-flight mechanical problem, the airport operation's failure to conduct runway friction tests and to issue NOTAMS in accordance with existing regulations, the crosswind, the snow-covered runway, the runway sign, and night conditions. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Airframe/component/system failure/malfunction, climb - to cruise - hydraulic system - failure - flt control syst,wing spoiler system - failure,partial - not performed, pilot in command (contributing factor) - Loss of control - on ground/water, landing - flare/touchdown - compensation for wind conditions - inadequate, pilot in command (cause) - directional control - not maintained, pilot in command (cause) - airport operations - inadequate, airport personnel (contributing factor) - airport snow removal - inadequate, airport personnel (contributing factor) - weather condition - crosswind (contributing factor) - light condition - night (contributing factor) - airport facilities,runway/landing area condition - snow covered (contributing factor) - On ground/water collision with object, landing - roll - object - airport sign/marker (contributing factor) - terrain condition - rough/uneven - terrain condition - snowbank ## Analysis The Part 121 scheduled domestic passenger flight received substantial damage when it veered off the left side of runway 1L during landing. The flight had departed LaGuardia International Airport en route to Milwaukee International Airport (MKE). During climbout through Flight Level 20 (20,000 feet), the No. 1 Hydraulic Low Pressure caution light illuminated. The flight crew ran the Quick Reference Handbook (QRH) checklist for the caution message. The procedures outlined in the QRH instructed the flight crew to: "Land at the nearest suitable airport." The captain informed the airline's maintenance control about the caution message, but he did not inform flight dispatch about the caution message or the need to land at the nearest suitable airport. The flight continued to its destination airport. The flight was cleared to land on runway 1L. The winds were 290 degrees at 10 knots. The captain reported that the landing was normal until the airplane started to veer off the left side of the runway. The post accident inspection of the airplane revealed no preexisting anomalies, other than the loss of the No. 1 Hydraulic system which resulted in the loss of ground spoilers. The NTSB Aircraft Performance Study indicated that the airplane approached runway 1L crossing the threshold at about 2302:16 at a recorded radio altitude of about 50 feet above ground level, with an indicated airspeed of 139 knots (about 136 knots ground speed) and a pitch angle of about 4 degrees nose down. The airplane began to drift right of centerline by about 20 feet, and touchdown occurred at a calculated distance of 2,400 feet beyond the runway threshold in a crab angle of about 5 degrees nose left relative to the ground track, and at a roll angle of about 1 degree left bank angle. The lateral load at touchdown was recorded at -0.2 G's. After touchdown, the airplane's ground track continued to drift right of centerline about 25 feet while the airplane nose remained to the left of the ground track. The airplane's ground track then began to turn left and departed off the side of the runway (veered off the runway) at about 2302:37 and approximately 4,200 feet beyond the threshold. The longitudinal acceleration from point of touchdown to when it veered off the runway was recorded between -0.12 and -0.15 G's. An investigation of airport operations revealed that airport operations did not inspect Runway 1L/19R after a pilot report (PIREP) of NIL braking action by a Beech Jet at 2018. Airport operations did not conduct or provide friction measurement reports and (Notices to Airmen) NOTAMS for Runway 1L/19R between March 10 at 1925 and the time of the accident on March 11 at 2302, when airport conditions were changing with significant snowfall accumulations. The airport did not conduct a runway inspection or friction report of Runway 1L/19R after the airplane veered off the runway. ## Factual narrative HISTORY OF FLIGHT On March 11, 2005, at 2302 central standard time, a Bombardier CL-600-2B19, N8932C, operated by Pinnacle Airlines as "Flagship 2823," received substantial damage when it veered off the left side of runway 1L (9,690 feet by 200 feet, asphalt-concrete, grooved) during landing at the Milwaukee/General Mitchell International Airport (MKE), Milwaukee, Wisconsin. The captain, first officer (FO), flight attendant, and nine passengers received no injuries. The 14 Code of Federal Regulations Part 121 scheduled domestic passenger flight departed LaGuardia International Airport (LGA), New York, New York, at 2137 eastern standard time. Night instrument meteorological conditions prevailed at the time of the accident. The flight was on an IFR flight plan. The captain reported that the taxi and takeoff portions of the flight were normal. During climbout through Flight Level 20 (20,000 feet), the #1 Hydraulic Low Pressure caution light illuminated. The captain asked the FO to run the Quick Reference Handbook (QRH) checklist for the caution message. Once the checklist was accomplished, the captain sent Pinnacle's Maintenance Operations Center (MOC) an Aircraft Communications And Reporting System (ACARS) message informing the MOC of the caution message. Numerous ACARS messages were sent between the flight crew and the MOC. The QRH indicated that the outboard ground spoilers were not available due to the loss of the #1 hydraulic system, and that a 1.13 landing distance penalty would need to be applied to the landing runway. The captain reported that he decided to continue the flight to MKE after considering MKE's weather and runway length. MKE Approach Control delayed the flight for about 10 minutes to allow for snow removal operations that were being conducted at the intersection of runway 1L and 25L. The flight crew had obtained Automated Terminal Information System (ATIS) Oscar prior to flying the approach to MKE. The last braking action reported to ATC was from a flight that landed at about 1026, which reported the braking action as FAIR. ATC did not inform the flight crew what the braking action was on runway 1L, and the flight crew did not request the braking action report for the runway. The flight was cleared for the approach after intercepting the localizer for the ILS 1L approach. The flight was cleared to land on runway 1L. The reported winds were 290 degrees at 10 knots. The pilot reported that the landing approach was flown at Vref +5 and that he planned to touchdown firm due to the runway condition and the loss of the outboard ground spoilers. He reported that the landing was normal until the airplane started to veer off the left side of the runway. The airplane departed the left side of the runway about 4,600 feet from the approach end of runway 1L. The airplane veered across the grass infield before crossing runway 07R/25L. The airplane traveled through the intersection of taxiways A, E, and T before crossing another snow-covered grass in-field where the aircraft went through a snow bank and onto taxiway B. The airplane stopped near the intersection of taxiway B and M in front of concourse D. The captain reported that nothing appeared to be wrong with the airplane so the decision was made to taxi to gate E64. The captain reported to ATC that the braking action was "very poor." Then when queried by ATC, the captain reported the braking action was, "Extremely poor. NIL." The flight crew received progressive taxi instructions and taxied to the gate where the passengers were deplaned via the airstairs instead of the jet bridge. An examination of the airplane revealed that the forward pressure bulkhead at Fuselage Station 202.75 was compromised. The flaps, the main landing gear doors, the nose landing gear, and various skin panels also were damaged during the accident. PERSONNEL INFORMATION The captain was hired by Pinnacle Airlines in July 2002 as a Bombardier CL-600-2B19 copilot and was upgraded to Pilot-in-Command (PIC) in July 2004. He held an airline transport certificate with multiengine land airplane and an airplane instrument rating. He held a first class medical certificate with no limitations. He had about 4,900 hours of total flight time, including about 3,008 hours in multiengine airplanes. He had about 1,763 hours in the Bombardier CL-600-2B19 and had flown about 265 hours in the last 90 days and 85 hours in the last 30 days. The First Officer (FO) was hired by Pinnacle Airlines in July 2004 as a Bombardier CL-600-2B19 copilot. He held a commercial certificate with single-engine land, multiengine land, and instrument airplane ratings. He held a first class medical certificate. He had about 1,100 hours of total flight time, including about 750 hours in multiengine airplanes. He had about 450 hours in the Bombardier CL-600-2B19 and had flown about 193 hours in the last 90 days and 73 hours in the last 30 days. AIRCRAFT INFORMATION The airplane was a twin-engine Bombardier CL-600-2B19, serial number 7932, with a maximum takeoff weight of 53,000 pounds. The engines were General Electric CF-34-3B1 engines that delivered 8,900 pounds of thrust each. The airplane was on a Continuous Airworthiness maintenance program. The last service check was conducted on March 11, 2005. The procedures outlined in the QRH for a #1 Hydraulic Low Pressure caution light states that if the #1 hydraulic quantity readout is less that 5 percent, or if pressure is less than 1,800 psi, or if the hydraulic pressure is rapidly decreasing, the following procedures apply: 1. Hydraulic Pump 1B ON 2. Hydraulic Pressure and Fluid Quantity MONITOR If Hydraulic Pressure and Fluid Quantity Not Normal: 3. Hydraulic Pump Switch 1B SELECT TO OFF 4. Inoperative System REVIEW * Left and right outboard ground spoilers inoperative. 5. Land at the nearest suitable airport. 6. ANTI SKID Switch LEAVE ARMED 7. FLAPS Selector SET TO 45 DEGREES FOR LANDING 8. Actual Landing Distance INCREASE Increase as applicable by the following factors: a. Without thrust reversers 1.15 percent b. With thrust reversers: 1.13 percent METEOROLOGICAL INFORMATION At 2252, the surface weather observation at MKE was: Winds 270 at 8; visibility 1 1/4; light snow; 900 scattered; ceiling 1,800 broken; 9,000 overcast; temperature -1; dew point -3; altimeter 29.25 At 2259, the special surface weather observation at MKE was: Winds 290 at 10, gusts 16; visibility 3/4; light snow; ceiling 500 broken; 2,000 broken; 4,700 overcast; temperature -1; dew point -2; altimeter 29.25 At 2309, the special surface weather observation at MKE was: Winds 290 at 12, gusts 17; visibility 2 1/2; runway 1L RVR 2,800 variable 6,000; light snow; few clouds at 400; ceiling 1,000 broken; 7,000 overcast; temperature -1; dew point -2; altimeter 29.25 ATIS Information Oscar provided the following information: Milwaukee-Mitchell Airport Information Oscar 0352 (2152) Zulu: Winds 260 at 5; visibility 10; 2,400 scattered; ceiling one zero thousand broken; temperature -1; dew point -4; altimeter 29.27; ILS runway 1L approach in use; landing runway 1L; departing runway 1L; transponders required shall be on while operating on runways and taxiways; braking action advisories in effect; all taxiing and departing aircraft remain on ground control frequency until advised; pre-departure clearance available; all other departures contact clearance delivery on 120.8 Advise on initial contact you have information Oscar. ATIS Information Quebec was current at the time of the accident. It provided the following information: Milwaukee-Mitchell Airport Information Quebec 0459 (2259) Zulu Special: Winds 290 at 10, gusts 16; visibility 3/4; light snow; ceiling 500 broken; 2,000 broken; 4,700 overcast; temperature -1; dew point -2; altimeter 29.25; IL ## Aircraft - Registration: [N8932C](https://openairdocs.org/deregistered/N8932C-2025-10-01), registration cancelled 2025-10-01, S/N 7932, built 2004 (OpenAirDocs) - Reported make and model: Bombardier CL-600-2B19 - Registry model: [Bombardier CL-600-2B19](https://openairdocs.org/model/bombardier-cl-600-2b19) (registry code 1390008) (OpenAirDocs) - Registry engine: [GE CF34-3B1](https://openairdocs.org/engine/ge-cf34-3b1) (registry code 30070, turbo-fan) (OpenAirDocs) - Category: Airplane - Serial number: 7932 - Engines: General Electric CF-34-3B1 8900 lbs thrust turbo fan - Damage: Substantial damage - Flight: Part 121 - Operator: Pinnacle Airlines - Registered owner: Wells Fargo Bank Northwest NA Trustee - Airworthiness certificate: Standard, Transport - Last inspection: Continuous airworthiness, March 11, 2005 - Departed: LGA, New York, NY - Destination: MKE, Milwaukee, WI - Flight plan: IFR - Airport: MKE, Milwukee/General Mitchell, runway 1L, 9,690 × 200 ft, concrete ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 45; injuries: none; commercial, airline transport; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1; last flight review July 11, 2004; seat: left; flight hours: 4,900 total, 1,763 in this make and model, 3,525 as pilot in command, 265 in the last 90 days, 85 in the last 30 days, 5 in the last 24 hours - Co-pilot; age 26; injuries: none; commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1; last flight review September 22, 2004; seat: right; flight hours: 1,100 total, 450 in this make and model, 370 as pilot in command, 190 in the last 90 days, 73 in the last 30 days, 5 in the last 24 hours ## Weather - Conditions: Instrument (IMC), Night - Wind: 290° at 11 knots - Visibility: 1.5 statute miles - Lowest ceiling: 500 ft broken - Temperature: 30 °F, dew point 28 °F - Altimeter: 29.25 inHg - Observed at: MKE ## 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 20050311024829A](https://openairdocs.org/incident/20050311024829A), Mar 11, 2005: Cndair CL6002B19, Milwaukee, WI, Substantial damage. (-23) On March 11, 2005, at 2302 central daylight time, a Bombardier CL-600-2B, N8932C, operated by pinnacle aviation as "flagship 2823" received substantial… 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.