CHI07MA160

NTSB accident investigation · Cessna 550 · Milwaukee, WI · June 4, 2007

Accident · FatalClass 1 · MajorFinal report
Date
June 4, 2007, 16:00 local (21:00 UTC)
Place
Milwaukee, WI
Injuries
6 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N550BPCessna 550
Weather
Visual (VMC) · Day
Status
Completed · report November 17, 2009
Report
Board-adopted at Board Meeting
Investigation class
Class 1
Parties
Honeywell, Marlin Air, Inc., FAA, Cessna Aircraft, Pratt and Whitney
Safety recommendations
Yes
FAA report
20070604012579A
Case key
65921

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 National Transportation Safety Board determines that the probable cause of this accident was the pilots’ mismanagement of an abnormal flight control situation through improper actions, including failing to control airspeed and to prioritize control of the airplane, and lack of crew coordination. Contributing to the accident were Marlin Air’s operational safety deficiencies, including the inadequate checkrides administered by Marlin Air’s chief pilot/check airman, and the Federal Aviation Administration’s failure to detect and correct those deficiencies, which placed a pilot who inadequately emphasized safety in the position of company chief pilot and designated check airman and placed an ill-prepared pilot in the first officer’s seat.

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.

Airframe/component/system failure/malfunctionClimb
Autopilot/flight director,transmitter(autopilot) - disengagedFactor
Loss of control - in flightCruise
In flight collision with terrain/waterDescent - uncontrolled

Analysis

The Safety Board's full report is available at http://www.ntsb.gov/publictn/A_Acc1.htm. The Aircraft Accident Report number is NTSB/AAR-09/06.

On June 4, 2007, about 1600 central daylight time, a Cessna Citation 550, N550BP, impacted Lake Michigan shortly after departure from General Mitchell International Airport, Milwaukee, Wisconsin (MKE). The two pilots and four passengers were killed, and the airplane was destroyed. The airplane was being operated by Marlin Air under the provisions of 14 Code of Federal Regulations Part 135 and departed MKE about 1557 with an intended destination of Willow Run Airport, near Ypsilanti, Michigan. At the time of the accident flight, marginal visual meteorological conditions prevailed at the surface, and instrument meteorological conditions prevailed aloft; the flight operated on an instrument flight rules flight plan.

Factual narrative

The Safety Board's full report is available at http://www.ntsb.gov/publictn/A_Acc1.htm. The Aircraft Accident Report number is NTSB/AAR-09/06.

On June 4, 2007, about 1600 central daylight time, a Cessna Citation 550, N550BP, impacted Lake Michigan shortly after departure from General Mitchell International Airport, Milwaukee, Wisconsin (MKE). The two pilots and four passengers were killed, and the airplane was destroyed. The airplane was being operated by Marlin Air under the provisions of 14 Code of Federal Regulations Part 135 and departed MKE about 1557 with an intended destination of Willow Run Airport, near Ypsilanti, Michigan. At the time of the accident flight, marginal visual meteorological conditions prevailed at the surface, and instrument meteorological conditions prevailed aloft; the flight operated on an instrument flight rules flight plan.

Aircraft

Registration
N550BP
Reported as
Cessna 550
Category
Airplane
Serial number
550-0246
Airframe hours
4,402
Engines
Pratt & Whitney JT15D-4, 2,500 lbs thrust, turbo fanPratt & Whitney JT15D-4, 2,500 lbs thrust, turbo fan
Damage
Destroyed
Flight
Part 135
Operator
Marlin Air Inc
Registered owner
Toy Air Inc
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · March 1, 2007 · 90 hours before
Departed
MKE · Milwaukee, WI
Destination
YIP · Detroit, MI
Flight plan
IFR
Airport
MKE · General Mitchell International

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
59
Injuries
Fatal
Certificates
Flight instructor, Private, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
April 1, 2007
Seat
Left
Toxicology
Performed
Flight hours
14,000 total
Role
Co-pilot
Injuries
Fatal

Weather

Conditions
Visual (VMC) · Day
Wind
340° at 10 knots, gusting 19
Visibility
9 statute miles
Lowest ceiling
3,000 ft broken
Temperature
63 °F, dew point 59 °F
Altimeter
29.53 inHg
Observed at
MKE, 5 nm away

Docket · 22

The files NTSB released with the investigation on October 13, 2009, on NTSB’s docket system: statements, records, photos and specialists’ reports. 34.2 MB in all.

Meteorology 5 - Factual Report of Group ChairmanItem 1 · .PDF · 1.7 MBAirworthiness Factual Report of Group Chairman, Pages 1-63Item 2 · .PDF · 3.9 MBAirworthiness Factual Report of Group Chairman, Pages 64 - EndItem 3 · .PDF · 2.6 MBAddendum to Airworthiness Factual Report of Group ChairmanItem 4 · .PDF · 1.1 MBAirworthiness Circuit StudyItem 5 · .PDF · 1.3 MBMedical Records InformationItem 6 · .PDF · 15 KBCockpit Voice Recorder 12 - Sound Spectrum StudyItem 7 · .PDF · 24 KBCockpit Voice Recorder 12 - Factual Report of Group ChairmanItem 8 · .PDF · 124 KBOperational Factors/Human Performance 14 - Factual Report of Group ChairmanItem 9 · .PDF · 1.5 MBMaintenance Records 11 - Factual Report of Group ChairmanItem 10 · .PDF · 110 KBOperational Factors/Human Performance 14-Interview SummariesItem 11 · .PDF · 155 KBOperational Factors/Human Performance 14--Factual Report ADDENDUMItem 12 · .PDF · 57 KBAircraft Performance 13 - Recorded Radar and Performance Study, Addendum 1Item 13 · .PDF · 678 KBToxicological Report-Pilot in CommandItem 14 · .PDF · 70 KBToxicological Report-Second in CommandItem 15 · .PDF · 66 KBParty Submission - CessnaItem 16 · .PDF · 4.8 MBParty Submission - HoneywellItem 17 · .PDF · 35 KBParty Submission - Marlin AirItem 18 · .PDF · 582 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 19 · .PDF · 158 KBOperational Factors/Human Performance 14--Factual Report, Addendum 2Item 20 · .PDF · 17 KBLetter from Cessna dated 09-25-2009Item 21 · .PDF · 15.0 MBCessna letter of October 5, 2009Item 22 · .PDF · 211 KB

FAA reports on this event · 1

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