# NTSB CHI07MA160: Cessna 550, N550BP, Milwaukee, WI, June 4, 2007

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Class 1 · Major · Final report
- Date: June 4, 2007, 16:00 local (21:00 UTC)
- Place: Milwaukee, WI
- Coordinates: 43.036666, -87.856391
- Nearby events: https://openairdocs.org/map.md?lat=43.0367&lon=-87.8564&mi=10
- Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping)
- Highest injury: Fatal
- Injuries: 6 fatal
- 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
- NTSB case key (mKey): 65921
- NTSB case page: https://www.ntsb.gov/investigations/Pages/CHI07MA160.aspx
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/65921/pdf
- Board report AAR0906 (PDF): https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR0906.pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=65921
- Page: https://openairdocs.org/ntsb/CHI07MA160

## 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

In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf).

- Airframe/component/system failure/malfunction, climb
  - autopilot/flight director,transmitter(autopilot) - disengaged (contributing factor)
- Loss of control - in flight, cruise
- In flight collision with terrain/water, descent - 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](https://openairdocs.org/deregistered/N550BP-2015-05-13), registration cancelled 2015-05-13, S/N 550-0246, built 1981 (OpenAirDocs)
- Reported make and model: Cessna 550
- Registry model: [Cessna 550](https://openairdocs.org/model/cessna-550) (registry code 2076604) (OpenAirDocs)
- Registry engine: [Pratt & Whitney Canada JT15D-4 series](https://openairdocs.org/engine/pratt-whitney-canada-jt15d-4-series) (registry code 52112, turbo-fan) (OpenAirDocs)
- Category: Airplane
- Serial number: 550-0246
- Airframe hours: 4402
- Engines: Pratt & Whitney JT15D-4 2500 lbs thrust turbo fan; Pratt & Whitney JT15D-4 2500 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

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 59; injuries: fatal; 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
- 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

## 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 20070604012579A](https://openairdocs.org/incident/20070604012579A), Jun 4, 2007: Cessna 550, Milwaukee, Destroyed, 6 fatal. (-23) On June 4, 2007, at approximately 1600 CDT, a Cessna CE-550 jet, N550BP, serial number 550-0246, registered to toy air inc., crashed into lake Michigan…

## Docket (22 files)

The files NTSB released with the investigation on October 13, 2009, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=65921. 34.2 MB in all.

- Meteorology 5 - Factual Report of Group Chairman (item 1, .PDF, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40284897&FileExtension=.PDF&FileName=Meteorology%205%20-%20Factual%20Report%20of%20Group%20Chairman-Master.PDF
- Airworthiness Factual Report of Group Chairman, Pages 1-63 (item 2, .PDF, 3.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40288352&FileExtension=.PDF&FileName=Airworthiness%20Factual%20Report%20of%20Group%20Chairman,%20Pages%201-63-Master.PDF
- Airworthiness Factual Report of Group Chairman, Pages 64 - End (item 3, .PDF, 2.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40288354&FileExtension=.PDF&FileName=Airworthiness%20Factual%20Report%20of%20Group%20Chairman,%20Pages%2064%20-%20End-Master.PDF
- Addendum to Airworthiness Factual Report of Group Chairman (item 4, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40290041&FileExtension=.PDF&FileName=Addendum%20to%20Airworthiness%20Factual%20Report%20of%20Group%20Chairman-Master.PDF
- Airworthiness Circuit Study (item 5, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40290042&FileExtension=.PDF&FileName=Airworthiness%20Circuit%20Study-Master.PDF
- Medical Records Information (item 6, .PDF, 15 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40290963&FileExtension=.PDF&FileName=Medical%20Records%20Information-Master.PDF
- Cockpit Voice Recorder 12 - Sound Spectrum Study (item 7, .PDF, 24 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40291106&FileExtension=.PDF&FileName=Cockpit%20Voice%20Recorder%2012%20-%20Sound%20Spectrum%20Study-Master.PDF
- Cockpit Voice Recorder 12 - Factual Report of Group Chairman (item 8, .PDF, 124 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40291107&FileExtension=.PDF&FileName=Cockpit%20Voice%20Recorder%2012%20-%20Factual%20Report%20of%20Group%20Chairman-Master.PDF
- Operational Factors/Human Performance 14 - Factual Report of Group Chairman (item 9, .PDF, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40291285&FileExtension=.PDF&FileName=Operational%20Factors%2FHuman%20Performance%2014%20-%20Factual%20Report%20of%20Group%20Chairman-Master.PDF
- Maintenance Records 11 - Factual Report of Group Chairman (item 10, .PDF, 110 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40292199&FileExtension=.PDF&FileName=Maintenance%20Records%2011%20-%20Factual%20Report%20of%20Group%20Chairman-Master.PDF
- Operational Factors/Human Performance 14-Interview Summaries (item 11, .PDF, 155 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40304500&FileExtension=.PDF&FileName=Operational%20Factors%2FHuman%20Performance%2014-Interview%20Summaries-Master.PDF
- Operational Factors/Human Performance 14--Factual Report ADDENDUM (item 12, .PDF, 57 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40306554&FileExtension=.PDF&FileName=Operational%20Factors%2FHuman%20Performance%2014--Factual%20Report%20ADDENDUM-Master.PDF
- Aircraft Performance 13 - Recorded Radar and Performance Study, Addendum 1 (item 13, .PDF, 678 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40306957&FileExtension=.PDF&FileName=Aircraft%20Performance%2013%20-%20Recorded%20Radar%20and%20Performance%20Study,%20Addendum%201-Master.PDF
- Toxicological Report-Pilot in Command (item 14, .PDF, 70 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40312225&FileExtension=.PDF&FileName=Toxicological%20Report-Pilot%20in%20Command-Redacted.PDF
- Toxicological Report-Second in Command (item 15, .PDF, 66 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40312227&FileExtension=.PDF&FileName=Toxicological%20Report-Second%20in%20Command-Redacted.PDF
- Party Submission - Cessna (item 16, .PDF, 4.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40313726&FileExtension=.PDF&FileName=Party%20Submission%20-%20Cessna-Redacted.PDF
- Party Submission - Honeywell (item 17, .PDF, 35 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40313727&FileExtension=.PDF&FileName=Party%20Submission%20-%20Honeywell-Master.PDF
- Party Submission - Marlin Air (item 18, .PDF, 582 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40313728&FileExtension=.PDF&FileName=Party%20Submission%20-%20Marlin%20Air-Master.PDF
- Release of Aircraft Wreckage, NTSB Form 6120.15 (item 19, .PDF, 158 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40316144&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF
- Operational Factors/Human Performance 14--Factual Report, Addendum 2 (item 20, .PDF, 17 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40319240&FileExtension=.PDF&FileName=Operational%20Factors%2FHuman%20Performance%2014--Factual%20Report,%20Addendum%202-Master.PDF
- Letter from Cessna dated 09-25-2009 (item 21, .PDF, 15.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40319430&FileExtension=.PDF&FileName=Letter%20from%20Cessna%20dated%2009-25-2009-Redacted.PDF
- Cessna letter of October 5, 2009 (item 22, .PDF, 211 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40319865&FileExtension=.PDF&FileName=Cessna%20letter%20of%20October%205,%202009-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.