# NTSB GAA15CA005: Cessna 208B, N12155, Muskegon, MI, March 10, 2015

- Type: NTSB accident investigation
- Classification: Accident · No injuries · Data collection · Final report
- Date: March 10, 2015, 07:40 local (11:40 UTC)
- Place: Muskegon, MI
- Coordinates: 43.1725, -86.228332 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=43.1725&lon=-86.2283&mi=10
- Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping)
- Defining event: [Approach-IFR final approach: Abrupt maneuver](https://openairdocs.org/ntsb-events/270)
- Highest injury: No injuries
- Injuries: 1 uninjured
- Status: Completed, report September 11, 2015
- Report: Approved by Office Director
- NTSB office: General Aviation Accidents
- Parties: Federal Aviation Administration
- NTSB case key (mKey): 90855
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA15CA005
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/90855/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=90855
- Page: https://openairdocs.org/ntsb/GAA15CA005

## Probable cause

The pilot's improper decision to continue the landing when the airplane was not in a safe position to land, resulting in the collision with ground-based approach lighting.

## Findings

NTSB's coded findings; those marked are part of the probable cause.

- [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Cessna 208B, 18 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=2073701), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md)
- [Performance/control parameters: heading/course](https://openairdocs.org/ntsb-findings/01062047): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cessna 208B, 2 cases](https://openairdocs.org/ntsb-findings/01062047/cases.md?model=2073701), [All aircraft, 82 cases](https://openairdocs.org/ntsb-findings/01062047/cases.md)
- [Object/animal/substance: runway/taxi/approach light](https://openairdocs.org/ntsb-findings/03022012): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Cessna 208B, 2 cases](https://openairdocs.org/ntsb-findings/03022012/cases.md?model=2073701), [All aircraft, 106 cases](https://openairdocs.org/ntsb-findings/03022012/cases.md)
- [Use of equip/info: use of available resources](https://openairdocs.org/ntsb-findings/02063035): Personnel issues › Task performance · Pilot; cases with it: [Cessna 208B, 1 case](https://openairdocs.org/ntsb-findings/02063035/cases.md?model=2073701), [All aircraft, 41 cases](https://openairdocs.org/ntsb-findings/02063035/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Approach-IFR final approach: Altitude deviation](https://openairdocs.org/ntsb-events/282); cases with it: [Cessna 208B, 2 cases](https://openairdocs.org/ntsb-events/282/sequence.md?model=2073701), [All aircraft, 104 cases](https://openairdocs.org/ntsb-events/282/sequence.md)
- [Approach-IFR final approach: Attempted remediation/recovery](https://openairdocs.org/ntsb-events/060); cases with it: [Cessna 208B, 3 cases](https://openairdocs.org/ntsb-events/060/sequence.md?model=2073701), [All aircraft, 1,422 cases](https://openairdocs.org/ntsb-events/060/sequence.md)
- [Approach-IFR final approach: Abrupt maneuver](https://openairdocs.org/ntsb-events/270) (defining event); cases with it: [Cessna 208B, 6 cases](https://openairdocs.org/ntsb-events/270/sequence.md?model=2073701), [All aircraft, 346 cases](https://openairdocs.org/ntsb-events/270/sequence.md)
- [Approach-IFR final approach: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cessna 208B, 20 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2073701), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md)
- [Landing-flare/touchdown: Hard landing](https://openairdocs.org/ntsb-events/092); cases with it: [Cessna 208B, 7 cases](https://openairdocs.org/ntsb-events/092/sequence.md?model=2073701), [All aircraft, 2,102 cases](https://openairdocs.org/ntsb-events/092/sequence.md)

## Analysis

The pilot reported that he flew an autopilot coupled approach to minimums in instrument meteorological conditions (IMC). The pilot exited IMC at the decision height, disconnected the autopilot, and the approach lights became visible. The pilot determined he was right of the runway and as he maneuvered to realign the airplane with the runway, he struck elements of the approach light system. A postaccident examination revealed the airplane sustained substantial damage to the horizontal stabilizer. Effective at the time of this accident was a permanent Notice to Airmen (NOTAM) associated with the ILS runway 24 approach prohibiting a coupled autopilot approach from 1150 feet mean seal level to the surface. During a post-accident interview the pilot stated he was unaware of this NOTAM. The NOTAM had been in effect since February 21st, 2014 and the approach chart used did not note this approach restriction. Weather at the time of the accident was reported as winds from 250 degrees at 5 knots, ½ statute mile visibility, 200 feet overcast, temperature 32 degrees Fahrenheit, dew point 32 degrees Fahrenheit, and altimeter 30.04 inches of mercury. The pilot reported no preimpact mechanical failures or malfunctions with the airframe or engine that would have precluded normal operation.

## Factual narrative

The pilot reported that he flew an autopilot coupled approach to minimums in instrument meteorological conditions (IMC). The pilot exited IMC at the decision height, disconnected the autopilot, and the approach lights became visible. The pilot determined he was right of the runway and as he maneuvered to realign the airplane with the runway, he struck elements of the approach light system. A postaccident examination revealed the airplane sustained substantial damage to the horizontal stabilizer. Effective at the time of this accident was a permanent Notice to Airmen (NOTAM) associated with the ILS runway 24 approach prohibiting a coupled autopilot approach from 1150 feet mean seal level to the surface. During a post-accident interview the pilot stated he was unaware of this NOTAM. The NOTAM had been in effect since February 21st, 2014 and the approach chart used did not note this approach restriction. Weather at the time of the accident was reported as winds from 250 degrees at 5 knots, ½ statute mile visibility, 200 feet overcast, temperature 32 degrees Fahrenheit, dew point 32 degrees Fahrenheit, and altimeter 30.04 inches of mercury. The pilot reported no preimpact mechanical failures or malfunctions with the airframe or engine that would have precluded normal operation.

## Aircraft

- Registration: [N12155](https://openairdocs.org/aircraft/N12155), registered now, S/N 208B0562, built 1996 (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: 208B0562
- Year built: 1996
- Airframe hours: 11243
- Engines: Pratt and Whitney PT6A-114A 675 horsepower turbo prop
- Damage: Substantial damage
- Flight: Part 135
- Operator: Martinaire Aviation, L.L.C., doing business as Martinaire
- Registered owner: Aero Leasing INC
- Airworthiness certificate: Standard, Normal
- Last inspection: AAIP, March 3, 2015
- Departed: KLAN, Lansing, MI
- Destination: KMKG, Muskegon, MI
- Flight plan: IFR
- Airport: KMKG, Muskegon County Airport, runway 24, 6,501 × 150 ft, asphalt
- Equipment: Auto-pilot, Stall warning system

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 71; injuries: none; flight instructor, commercial; airplane ratings: single-engine sea, single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review November 7, 2014; seat: left; restraint: 3-point; flight hours: 8,316 total, 5,350 in this make and model, 8,020 as pilot in command, 19 in the last 90 days, 4 in the last 30 days, 2 in the last 24 hours

## Weather

- Conditions: Instrument (IMC), Night/dark
- Wind: 210° at 5 knots
- Visibility: 0.5 statute miles
- Lowest ceiling: 200 ft
- Temperature: 34 °F, dew point 34 °F
- Altimeter: 30.04 inHg
- Observed at: KMKG

## 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 20150310002149A](https://openairdocs.org/incident/20150310002149A), Mar 10, 2015: Cessna 208B, Muskegon, MI, Substantial damage. On March 10, 2015 at 07:41 eastern daylight time (EDT), a Cessna 208-B aircraft, N12153, registered to aero leasing inc. and operated by a commercial pilot for…

## Docket (5 files)

The files NTSB released with the investigation on May 26, 2015, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=90855. 1.8 MB in all.

- Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40426822&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF
- KMKG Weather Report (item 2, .PDF, 180 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40426823&FileExtension=.PDF&FileName=KMKG%20Weather%20Report-Redacted.PDF
- Kmkg ILS 24 NOTAM (item 3, .PDF, 54 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40426824&FileExtension=.PDF&FileName=KMKG%20ILS%2024%20NOTAM-Master.PDF
- Photo 1 - Horizontal Stabilizer Damage (item 4, .PDF, 102 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40426825&FileExtension=.PDF&FileName=Photo%201%20-%20Horizontal%20Stabilizer%20Damage-Master.PDF
- Photo 2 - Horizontal Stabilizer Damage (item 5, .PDF, 146 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40426826&FileExtension=.PDF&FileName=Photo%202%20-%20Horizontal%20Stabilizer%20Damage-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.

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