Wednesday, June 20, 2018

Cessna 525C Citation CJ4, N614SB, registered to Maverick Air LLC and operated by the pilot: Fatal accident occurred December 29, 2016 near Cleveland Burke Lakefront Airport (KBKL), Cleveland, Ohio

John Fleming, his wife, Suzanne; their 2 sons, 15-year-old John Robert Fleming, and 14-year-old Andrew Fleming, a neighbor Brian Casey; and Casey's teenage daughter, Megan Casey, were on the Cessna 525C Citation CJ4.


The National Transportation Safety Board traveled to the scene of this accident.

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; North Olmsted, Ohio
Textron Aviation; Wichita, Kansas
Williams International; Walled Lake, Michigan
Rockwell Collins; Cedar Rapids, Iowa

Aviation Accident Final Report - National Transportation Safety Board: https://app.ntsb.gov/pdf


Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms


http://registry.faa.gov/N614SB

Analysis 

The airplane entered a right turn shortly after takeoff and proceeded out over a large lake. Dark night visual conditions prevailed at the airport; however, the airplane entered instrument conditions shortly after takeoff. The airplane climb rate exceeded 6,000 fpm during the initial climb and it subsequently continued through the assigned altitude of 2,000 ft mean sea level. The flight director provided alerts before the airplane reached the assigned altitude and again after it had passed through it. The bank angle increased to about 62 degrees and the pitch attitude decreased to about 15 degrees nose down, as the airplane continued through the assigned heading. The bank angle ultimately decreased to about 25 degrees. During the subsequent descent, the airspeed and descent rate reached about 300 knots and 6,000 fpm, respectively. The enhanced ground proximity warning system (EGPWS) provided both "bank angle" and "sink rate" alerts to the pilot, followed by seven "pull up" warnings.

A postaccident examination of the recovered wreckage did not reveal any anomalies consistent with a preimpact failure or malfunction.

It is likely that the pilot attempted to engage the autopilot after takeoff as he had been trained. However, based on the flight profile, the autopilot was not engaged. This implied that the pilot failed to confirm autopilot engagement via an indication on the primary flight display (PFD). The PFD annunciation was the only indication of autopilot engagement. Inadequate flight instrument scanning during this time of elevated workload resulted in the pilot allowing the airplane to climb through the assigned altitude, to develop an overly steep bank angle, to continue through the assigned heading, and to ultimately enter a rapid descent without effective corrective action. A belief that the autopilot was engaged may have contributed to his lack of attention.

It is also possible that differences between the avionics panel layout on the accident airplane and the airplane he previously flew resulted in mode confusion and contributed to his failure to engage the autopilot. The lack of proximal feedback on the flight guidance panel might have contributed to his failure to notice that the autopilot was not engaged.

The pilot likely experienced some level of spatial disorientation due to the dark night lighting conditions, the lack of visual references over the lake, and the encounter with instrument meteorological conditions. It is possible that once the pilot became disoriented, the negative learning transfer due to the differences between the attitude indicator display on the accident airplane and the airplane previously flown by the pilot may have hindered his ability to properly apply corrective control inputs.

Available information indicated that the pilot had been awake for nearly 17 hours at the time of the accident. As a result, the pilot was likely fatigued which hindered his ability to manage the high workload environment, maintain an effective instrument scan, provide prompt and accurate control inputs, and to respond to multiple bank angle and descent rate warnings. 

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
Controlled flight into terrain due to pilot spatial disorientation. Contributing to the accident was pilot fatigue, mode confusion related to the status of the autopilot, and negative learning transfer due to flight guidance panel and attitude indicator differences from the pilot's previous flight experience. 

Findings

Personnel issues
Spatial disorientation - Pilot (Cause)
Alertness/Fatigue - Pilot (Factor)
Monitoring equip/instruments - Pilot (Factor)
Total experience w/ equipment - Pilot (Factor)

Factual Information

History of Flight

Initial climb
Altitude deviation
Course deviation
Other weather encounter
Collision avoidance alert
Loss of control in flight (Defining event)

Uncontrolled descent
Collision with terr/obj (non-CFIT)


Location: Cleveland, OH
Accident Number: CEN17FA072
Date & Time: 12/29/2016, 2257 EST
Registration: N614SB
Aircraft: CESSNA 525
Aircraft Damage: Destroyed
Defining Event: Controlled flight into terr/obj (CFIT)
Injuries: 6 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal 

On December 29, 2016, at 2257 eastern standard time, a Cessna 525C (Citation CJ4) airplane, N614SB, was destroyed during an in-flight collision with Lake Erie shortly after takeoff from runway 24R (6,604 feet by 150 feet, asphalt) at the Burke Lakefront Airport (BKL), Cleveland, Ohio. The pilot and five passengers were fatally injured. The airplane was registered to Maverick Air LLC and operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight. Night visual meteorological conditions prevailed for the flight, which was operated on an instrument flight rules (IFR) flight plan. The intended destination was the Ohio State University Airport (OSU), Columbus, Ohio.

The pilot and passengers departed OSU about 1730 and arrived at BKL about 1800. The pilot checked in at the fixed base operator (FBO) at 1812. The pilot and passengers attended a local sporting event before returning to the airport about 2230.

A review of the air traffic control (ATC) communications transcript, the cockpit voice recorder (CVR) transcript, automated dependent surveillance – broadcast (ADS-B) data, and full authority digital engine control (FADEC) unit data revealed the following:

At 2255, the pilot was cleared for takeoff. He was instructed to turn right to a heading of 330° and maintain 2,000 feet mean sea level (msl) after departure. The pilot acknowledged the clearance. At 2256:33, the engine power increased for takeoff, and 15 seconds later the airplane became airborne. At 2257:09, an automated voice annunciated "altitude." A second "altitude" annunciation followed 14 seconds later. At 2257:25, a sound similar to a decrease in engine power was recorded. Two seconds later, the enhanced ground proximity warning system (EGPWS) provided an excessive bank angle warning. At 2257:29, about 2 seconds after the bank angle warning, the tower controller instructed the pilot to contact departure control. The pilot replied, "to departure six one four sierra bravo;" however, that communication was not received by the tower controller suggesting that the pilot did not have the microphone push-to-talk button depressed.

At 2257:37, the controller again attempted to contact the pilot. Two seconds after the controller's transmission, the EGPWS provided a "sink rate" warning to the pilot. The pilot again responded, "six one four sierra bravo," but this was not received by the tower controller. Beginning at 2257:43, the EGPWS provided 7 "pull up" warnings at 1.6-second intervals until the end of the CVR recording. During that time, a sound similar to the overspeed warning began, which continued until the end of the recording. The CVR recording ended at 2257:58.

The tower controller's continued attempts to contact the pilot were unsuccessful, and he subsequently initiated search and rescue procedures.

A summary of the operational factors associated with the accident, including a detailed history of flight, is included in the docket associated with the investigation.

Pilot Information

Certificate: Private
Age: 45, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): Helicopter
Restraint Used: 5-point
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 3 Without Waivers/Limitations
Last FAA Medical Exam: 10/15/2015
Occupational Pilot: No
Last Flight Review or Equivalent: 12/08/2016
Flight Time: 1205 hours (Total, all aircraft), 56 hours (Total, this make and model), 919 hours (Pilot In Command, all aircraft), 56 hours (Last 90 days, all aircraft), 22 hours (Last 30 days, all aircraft), 0.5 hours (Last 24 hours, all aircraft)

The pilot's Cessna 525 single-pilot type rating was added December 8, 2016, after he successfully completed the prescribed Federal Aviation Administration (FAA) practical test (checkride). His initial Cessna 525 training was completed in the accident airplane. The pilot subsequently completed a simulator-based recurrent training course at FlightSafety International on December 17, 2016.

The pilot had accumulated a total of 56.5 hours in Cessna 525 airplanes. Of that time, 8.7 hours were as pilot-in-command which included the practical test. His most recent logged flight was on December 17 from Orlando International (MCO) to OSU. The pilot owned a Cessna 510 (Mustang) for about 2 years before purchasing the accident airplane. He had logged 372.9 hours total time in Cessna 510 airplanes. Interviews with the pilot's instructor confirmed that the pilot was trained to consistently use the autopilot after takeoff.

Available information indicated that the pilot had been awake for nearly 17 hours at the time of the accident. 

Aircraft and Owner/Operator Information

Aircraft Manufacturer: CESSNA
Registration: N614SB
Model/Series: 525
Aircraft Category: Airplane
Year of Manufacture: 2012
Amateur Built: No
Airworthiness Certificate: Commuter
Serial Number: 525C0072
Landing Gear Type: Retractable - Tricycle
Seats: 11
Date/Type of Last Inspection: 12/17/2016, AAIP
Certified Max Gross Wt.: 17110 lbs
Time Since Last Inspection: 1 Hours
Engines: 2 Turbo Fan
Airframe Total Time: 861.5 Hours at time of accident
Engine Manufacturer: Williams International
ELT: C126 installed, activated, did not aid in locating accident
Engine Model/Series: FJ44-4A
Registered Owner: Maverick Air LLC
Rated Power: 3621 lbs 
Operator: On file
Operating Certificate(s) Held: None

FAA records revealed that the airplane was issued a standard airworthiness certificate in January 2012 and was subsequently exported to Brazil. The airplane was imported to the United States and purchased by the owner in October 2016. An FAA standard airworthiness certificate was issued at that time.

According to the airplane maintenance records, the most recent inspection was completed on October 3, 2016, at 812.7 hours airframe total time. Compliance with all current airworthiness directives and mandatory service bulletins was confirmed at that time. Additional maintenance work was completed on October 14, 2016, at 814.1 hours total airframe time. The most recent maintenance work occurred on December 17, 2016, at 860.7 hours total airframe time. 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Night/Dark
Observation Facility, Elevation: BKL, 584 ft msl
Observation Time: 2300 EST
Distance from Accident Site: 2 Nautical Miles
Direction from Accident Site: 135°
Lowest Cloud Condition: Scattered / 1500 ft agl
Temperature/Dew Point: 1°C / -2°C
Lowest Ceiling: Broken / 2300 ft agl
Visibility: 9 Miles
Wind Speed/Gusts, Direction: 22 knots/ 31 knots, 260°
Visibility (RVR):
Altimeter Setting: 29.74 inches Hg
Visibility (RVV):
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Cleveland, OH (BKL)
Type of Flight Plan Filed: IFR
Destination: Columbus, OH (OSU)
Type of Clearance: IFR
Departure Time: 2256 EST
Type of Airspace: Class D 

The observations from BKL and Cleveland Hopkins International (CLE) indicated that marginal visual conditions prevailed at the time of the accident. Precipitation was reported in the one-minute observations at BKL until 2251, with no precipitation reported at the surface until 2342. While the surface temperature remained above freezing after the airplane landed at BKL and about the accident time, the dew point temperature remained below freezing the entire time with precipitation occurring on and off in the snow shower activity.

Airport Information

Airport: Burke Lakefront (BKL)
Runway Surface Type: Asphalt
Airport Elevation: 584 ft
Runway Surface Condition: Wet
Runway Used: 24R
IFR Approach: None
Runway Length/Width: 6604 ft / 150 ft
VFR Approach/Landing: None

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: 5 Fatal
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 6 Fatal
Latitude, Longitude: 41.554722, -81.703333

The accident site was located in Lake Erie about 2 miles northwest of BKL. The depth of the lake at that location was about 40 feet. Search and recovery efforts were hampered by weather and lake conditions. Airplane debris, including the cockpit voice recorder, was located beginning on January 5. The recovery operations were conducted over the following 2 weeks as lake conditions permitted.

A postaccident examination of the recovered wreckage did not reveal any anomalies consistent with a preimpact failure or malfunction. 

Medical And Pathological Information

An autopsy and toxicology testing were not performed due to the limited remains recovered. 

Additional Information

Flight Guidance Panel

The flight guidance panel (FGP), located on the glareshield, allows the pilot to select manual or autopilot guidance for airplane control. The autopilot button is located on the upper row of button controls near the right side of the panel. Autopilot engagement is indicated in the flight control system display area along the upper portion of the primary flight display (PFD). There is no indication of the autopilot status on or near the autopilot button on the flight guidance panel.

A comparison of the Cessna 525 systems and those of the airplane previously flown by the pilot, a Cessna 510, revealed that the autopilot engagement button on the Cessna 510 is located in a slightly different location on the Automatic Flight Control System (AFCS) panel. In the Cessna 510, autopilot engagement is indicated along the upper portion of the PFD similar to the accident airplane. In addition, an indicator light adjacent to the autopilot button on the AFCS panel is illuminated when the autopilot is engaged.

Primary Flight Display

The attitude indicator presented by the PFD on the Cessna 525 was an ego-centric ("inside out") type display. An "inside out" perspective involves a fixed aircraft symbol and moving horizon similar to what a pilot sees when looking outside of the aircraft. On the other hand, the Cessna 510 utilizes an exo-centric ("outside in") display. An "outside in" perspective involves a fixed horizon and a moving aircraft symbol.

Spatial Disorientation

The FAA Civil Aeromedical Institute's publication, "Introduction to Aviation Physiology," defines spatial disorientation as a loss of proper bearings or a state of mental confusion as to position, location, or movement relative to the position of the earth. Factors contributing to spatial disorientation include changes in acceleration, flight in IMC, frequent transfer between visual meteorological conditions (VMC) and IMC, and unperceived changes in aircraft attitude.


The FAA's Airplane Flying Handbook (FAA-H-8083-3A) describes some hazards associated with flying when the ground or horizon are obscured. The handbook states, in part: "The vestibular sense (motion sensing by the inner ear) in particular tends to confuse the pilot. Because of inertia, the sensory areas of the inner ear cannot detect slight changes in the attitude of the airplane, nor can they accurately sense attitude changes that occur at a uniform rate over a period of time. On the other hand, false sensations are often generated; leading the pilot to believe the attitude of the airplane has changed when in fact, it has not. These false sensations result in the pilot experiencing spatial disorientation."



Location: Cleveland, OH
Accident Number: CEN17FA072
Date & Time: 12/29/2016, 2257 EST
Registration: N614SB
Aircraft: CESSNA 525
Injuries: 6 Fatal
Flight Conducted Under:  Part 91: General Aviation - Personal 

On December 29, 2016, at 2257 eastern standard time, a Cessna model 525C (Citation CJ4) airplane, N614SB, was destroyed during an in-flight collision with Lake Erie shortly after takeoff from runway 24R (6,604 feet by 15o feet, asphalt) at the Burke Lakefront Airport (BKL), Cleveland, Ohio. The pilot and five passengers are missing and presumed fatal. The airplane was registered to Maverick Air LLC and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Night visual meteorological conditions prevailed for the flight, which was operated on an instrument flight rules (IFR) flight plan. The intended destination was the Ohio State University Airport (OSU), Columbus, Ohio.

The pilot and passengers initially departed OSU about 1730 and arrived at BKL about 1800. The pilot checked in at the fixed base operator (FBO) at 1812. The pilot and passengers reportedly attended a local sporting event before returning to the airport about 2230.

An initial review of Air Traffic Control (ATC) transmissions between the pilot and the Midwest ATC Federal Contract Tower at BKL revealed that the pilot requested the IFR clearance at 2247, followed by the taxi clearance at 2251. At 2256, the pilot informed the BKL tower controller that he was holding short of the runway and ready for takeoff. The controller subsequently cleared the pilot for takeoff and instructed him to turn right to a heading of 330 degrees and maintain 2,000 feet msl after departure. The pilot acknowledged the clearance. After takeoff, the controller instructed the pilot to contact departure control; however, no further communications were received from the pilot. After multiple attempts to contact the pilot were unsuccessful, the controller initiated search and rescue procedures.

Automated Dependent Surveillance – Broadcast (ADS-B) position data indicated that the takeoff began about 2256:47 (hhmm:ss). The data depicted the airplane entering a right turn shortly after crossing the runway departure threshold. The airplane became established on a magnetic course of 310 degrees at about 2257:28. During this time, the airplane reached an altitude of approximately 2,925 feet msl. About 5 seconds later, the airplane entered a descending right turn that continued until the final data point. The final data point was recorded at 2257:52 and was located 1.83 miles northwest of BKL. The associated altitude was 775 feet msl.

The resulting search and recovery effort was hampered by weather and lake conditions. Airplane debris, including the cockpit voice recorder, was ultimately located about 0.10 mile northeast of the final data point. The cockpit voice recorder was transferred to the NTSB Recorders Laboratory for readout. A detailed wreckage examination will be conducted once recovery operations have concluded.

The Cessna 525C Citation CJ4 airplane has a low-wing, T-tail airframe arrangement, with a retractable tricycle landing gear configuration. The cabin is pressurized and the airplane is capable of operating at a maximum pressure altitude of 45,000 feet. It is configured for up to 10 occupants including the pilot(s). The airplane is approved for single pilot operations provided the pilot-in-command holds a CE525S (single pilot) type rating, the airplane is configured for single pilot operations in accordance with the operating limitations, and the pilot occupies the left pilot seat.

Federal Aviation Administration (FAA) records indicated that the accident airplane was a 2012 model year Cessna 525C, serial number 525C-0072. It was powered by two Williams International FJ44-4A turbofan engines, serial numbers 211155 and 211156. The airplane was initially issued a commuter category standard airworthiness certificate in January 2012. It was subsequently exported to Brazil. The airframe and engines had accumulated about 10 hours total time when exported. The airplane was imported to the United States and purchased by the accident owner in October 2016. The airframe and engines had accumulated about 812 hours total time when the airplane was returned to the United States. Available records indicated that the most recent maintenance activity occurred on December 17, 2016. At that time the airplane had accumulated 860 hours total time.

FAA records revealed that the accident pilot held a private pilot certificate with airplane single and multi-engine land, rotorcraft helicopter, and instrument airplane category/class ratings. In addition, the pilot held CE-510S and CE-525S type ratings. He was issued a third class airman medical certificate without limitations on October 15, 2015. The pilot's CE-525S type rating was added December 8, 2016, after he successfully completed the prescribed FAA practical test (checkride). His initial Cessna 525 training was completed in the accident airplane. The pilot subsequently completed a simulator-based recurrent training course at FlightSafety International on December 17, 2016. 

Aircraft and Owner/Operator Information

Aircraft Manufacturer: CESSNA
Registration: N614SB
Model/Series: 525
Aircraft Category: Airplane
Amateur Built: No
Operator: On file
Operating Certificate(s) Held: None 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Night/Dark
Observation Facility, Elevation: BKL, 584 ft msl
Observation Time: 2300 EST
Distance from Accident Site: 2 Nautical Miles
Temperature/Dew Point: 1°C / -2°C
Lowest Cloud Condition: Scattered / 1500 ft agl
Wind Speed/Gusts, Direction: 22 knots/ 31 knots, 260°
Lowest Ceiling: Broken / 2300 ft agl
Visibility:  9 Miles
Altimeter Setting: 29.74 inches Hg
Type of Flight Plan Filed: IFR
Departure Point: Cleveland, OH (BKL)
Destination: Columbus, OH (OSU)

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: 5 Fatal
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 6 Fatal
Latitude, Longitude:  41.517778, -81.682778 (est)


CLEVELAND -- The National Transportation Safety Board on Wednesday released its official report following its investigation of the small plane crash that killed a Columbus family of four and their two neighbors in December 2016.

The Cessna 525 Citation plane departed Burke Lakefront Airport Dec. 29, 2016. Minutes later, the plane disappeared.

Crews spent weeks searching Lake Erie for wreckage. The plane's cockpit voice recorder was recovered Jan. 5 and hundreds of pieces of debris were found during the search. NTSB the plane's crash site was located about two miles northwest of Burke Lakefront Airport.

NTSB's report also says post crash examination of the recovered wreckage "did not reveal any anomalies consistent with a preimpact failure or malfunction."

TIMELINE | Plane disappears over Lake Erie

The report says the plane was cleared for takeoff at 10:55 p.m. and a decrease in engine power was recorded at 10:57 p.m. Two seconds later, the enhanced ground proximity warning system provided an excessive bank angle warning. Two seconds after that, the tower controller instructed the pilot to contact departure control. The pilot replied, "to departure six one four sierra bravo" but that communication was not received.

At 10:57 p.m., the enhanced ground proximity warning system provided seven "pull up" warnings until an overspeed warning began. The recording ended at 10:57:58 p.m.

View the full report here.

The plane was flown by John T. Fleming, the CEO of a Columbus beverage distributor. Fleming, his wife and their two sons were all killed in the crash. Their neighbors, Brian and Megan Casey, were also killed. The group was visiting Cleveland for a Cleveland Cavaliers game and was flying back to The Ohio State University in Columbus.

NTSB says Fleming purchased the plane in October 2016 and an inspection was conducted Oct. 3. Fleming had passed the required tests and logged 56 1/2 hours flying Cessna 525 models.

Fleming had been awake for 17 hours prior to the crash, NTSB says.

MORE | Pennsylvania coroner: Leg in Lake Erie from Cleveland plane crash

The remains of Fleming, his son Jack, and Brian Casey were found and identified by the Cuyahoga County Medical Examiner. Additional remains washed ashore in Erie, Pennsylvania in September 2017. Though authorities confirmed the remains belonged to one of the remaining unaccounted victims of the crash, they declined to publicly identify them.

Original article ➤ https://www.wkyc.com






The three minutes of events leading up to a small plane crash in Lake Erie that left the pilot and five passengers dead has been released by the National Transportation Safety Board. The report also said the pilot had been awake for nearly 17 hours before the time of the accident.

The personal flight was intended to go to the Ohio State University Airport (OSU), according to NTSB. The plane had flown from OSU to Burke at 5:30 p.m. on Dec. 29, 2016, and the pilot and passengers attended a sporting event before returning to the airport. John T. Fleming, the CEO of Columbus-based Superior Beverage Group, was piloting the plane. His wife, Suzanne, and their two sons, Jack and Andrew, and neighbors Megan and Brian Casey, were also aboard the aircraft. 

NTSB shared what can be heard in the communications between air traffic control and the pilot of the Cessna 525C aircraft in the few minutes between takeoff from the Burke Lakefront Airport and when the plane crashed in the lake.

RELATED: NTSB: Cockpit voice recorder was working when plane crashed into Lake Erie

According to the NTSB report, at 10:55 p.m., the pilot was cleared for takeoff and he acknowledged. A minute and a half later, the engine power increased for takeoff and 15 seconds later the plane became airborne.

RELATED: Videos of crashed Lake Erie Cessna 525 show plane take off, veer to the right

Then things went south.

A few seconds later, an automated voice said, "altitude," and 14 seconds later, "altitude" was heard again, according to the report. Then a sound similar to a decrease in engine power can be heard, followed by the enhanced ground proximity warning system (EGPWS), which provided a bank angle warning, NTSB said. 

Shortly after, the tower controller instructed the pilot to contact departure control. The pilot tried to communicate with the tower controller, but communication was not received, suggesting the pilot did not have the microphone push-to-talk button depressed, according to NTSB.

The report said after tower control tried to contact the pilot again, the EGPWS gave a "sink rate" warning. The pilot tried contact the tower again without success. Then the EGPWS gave seven "pull up" warnings 

A sound similar to the overspeed warning can be heard, which continues until the end of the recording, NTSB said.

The recording ends almost three minutes after the pilot was cleared for takeoff.

RELATED: Remains found along Lake Erie identified as plane crash victim

The tower controller continued to try and contact the pilot, but was unsuccessful, causing him to begin search and rescue procedures, according to NTSB.

According to the NTSB report, the pilot had accumulated a total of 56.5 hours in Cessna 525 airplanes. Of that time, 8.7 hours were as pilot-in-command, which included his practical test. He had 372.9 hours logged in a Cessna 510 airplane, which he owned for about two years before purchasing the plane in the accident. 

The report notes that the plane passed its most recent inspection without any issues. 

Original article ➤ https://www.news5cleveland.com



The City of Cleveland has released a video of a plane preparing to take off from Burke Lakefront Airport shortly before it crashed into Lake Erie.

The Cessna 525C Citation CJ4 disappeared from radar on December 29 about a minute after takeoff and about two miles offshore.

On board:  Boardman native and Superior Beverage CEO John Fleming, his wife, Suzanne; their 2 sons, 15 year old John Robert Fleming, and 14 year old Andrew Fleming, a neighbor and neighbor's college age daughter.  

All six lived in Columbus.  The Flemings, in Dublin.  

The plane was headed to Columbus after a CAVS game.

The FAA released audio between the air traffic control towers of Cleveland Hopkins Airport and Cleveland's Burke Lakefront Airport.

Before learning of the crash air traffic spoke about icing issues.

"They're starting to get moderate icing at 6000 at least down to 4500," said one of the towers.

Then they realize they haven't heard from the Cessna.

"(CLE) I've called them four times, five times and they haven't answered one time.  (Lakefront) I don't even see them.  (CLE) I didn't see them either. He was there and I haven't seen him since."

Four minutes later, still nothing.

"I don't see anything. I don't see him or have talked to him at all."

A minute later, they start to consider the worst case scenario.

"I don't know if we might have to start search and rescue because, like is said, all I saw was at 3000, 2800. Should we do that? I think we'll have to because like I said, I'm not talking to them, I see nothing. Where he is supposed to be going? He's supposed to be going south."

Then nine minutes after that...

"(CLE) Just wondering what phone calls you have made? (LAKE) I'm calling the Coast Guard now, see if we can have them fly over. (CLE) You're calling them now? (LAKE) Yeah. (CLE) How about the police department or anything like that? (LAKE) Naw, I haven't made that call yet I'm trying to get the Coast Guard first and then we'll do everything after that. (CLE) Sounds good."

Since that night after days of searching the waters of Lake Erie, hundreds of pieces of debris and the remains from three of those on board the plane have been recovered.

So far investigators have not found the cause of the crash.

Source:   http://www.wfmj.com


CLEVELAND, Ohio - The Federal Aviation Administration (FAA) released audio recordings Monday of air traffic controllers' conversations on the night that a plane carrying six people - including a family of four - crashed into Lake Erie.

The FAA released more than 16 hours of audio recordings to cleveland.com. On the recordings, air traffic controllers and other airport officials can be heard discussing the missing Cessna Citation 525 after it disappeared over Lake Erie on the night of Dec. 29, 2016.

One air traffic controller from Cleveland Hopkins International Airport and the other, who was stationed at Burke Lakefront, spoke to make sure that the plane had not just dropped off one radar system but in fact had disappeared. The two also decided to call in the necessary officials to initiate a search-and-rescue effort.

You can listen to the conversation between the two controllers in the video above.

In January, the National Transportation Safety Board (NTSB) released a preliminary report on the crash. The report gave a timeline for the plane's takeoff from Burke Lakefront Airport and the subsequent disappearance of the aircraft.

The plane, flown by Ohio beverage distribution company CEO John Fleming, was cleared for takeoff at 10:56 p.m., the NTSB report states. The air traffic controller instructed Fleming to head west but turn back eastbound and maintain an altitude of 2,000 feet.

However, the plane dropped off radar after it turned eastward and reached an altitude of 2,925. About five seconds after the plane's first data point was recorded, the plane quickly descended and disappeared from the radar about 10:57 p.m., the report says.

Fleming, of Columbus, was on the plane with his wife, their two sons and the family's neighbors. The passengers had flown to Cleveland to watch a Cavaliers basketball game. 

Searchers worked for weeks to locate debris and human remains from the plane. The city of Cleveland officially ended the search on Jan. 17.

Story and video: http://www.cleveland.com



Updated at 03:51PM, February 13, 2017

CLEVELAND--  Air traffic control recordings from the night a plane crashed on Lake Erie are providing further insight into what happened.

The Federal Aviation Administration released the recordings to FOX 8 News on Monday through a Freedom of Information Act request.

In the audio recorded from the Cleveland Air Route Traffic Control Center, you can hear controllers giving pilot John Fleming clearance to take off from Burke Lakefront Airport on Dec. 29. Moments later, the Cessna 525C Citation CJ4 disappeared.

"Yeah, have you ever gotten a hold of that Citation? Negative. OK, because all I saw when this happened was something come off, it looked like it flashed 3,000 triple Xs and turned northeast on about a mile northeast of the field at 1,300 and then disappeared on me."

The National Transportation Safety Board said the Cessna Citation suddenly lost altitude and crashed just one minute after takeoff.

Fleming, his wife, their two sons and their neighbors were all killed. Remains from three of the deceased, Fleming, 15-year-old Robert Fleming and 50-year-old Brian Casey, were recovered. The Fleming family was remembered during memorial services in Columbus and Canfield.

Plane debris, including the cockpit voice recorder, were later discovered. The NTSB said a committee in Washington is still analyzing the audio for the investigation into the cause of the crash.

Search and recovery efforts ended on Jan. 17. During the search, crews found the plane's engine, winds and a large portions of its fuselage.

Records show Fleming purchased the Cessna 525C Citation CJ4 in mid-October.

Story and video:  http://fox8.com




Updated:  February 13th 2017, 8:55 pm EST

CLEVELAND, OH (WOIO) -  The city of Cleveland released surveillance video capturing the final moments before a Cessna 525C Citation CJ4  disappeared over Lake Erie in December.

There were six passengers on the plane that were all presumed dead after Commissioner Khalid Bahhur announced last month that Jan. 17 would be the last day for the search and recovery effort. Crews did recover parts of the plane, the cockpit voice recorder and human remains from some of the bodies.

John, Sue, Jack, and Andrew Fleming and neighbors Brian and Megan Casey were on board. They were at a Cleveland Cavaliers game and were headed back to Columbus when the plane disappeared off of radar.

"The medical examiner's office has determined three of the six profiles through DNA testing," said Bahhur.

The U.S. Coast Guard and city officials said they notified family members first about their decision to end the search in January.

The plane disappeared over Lake Erie on Dec. 29.

Story and video: http://www.cleveland19.com



















Brian Casey and daughter Megan


The Fleming Family


    
John T. Fleming


Brian and Megan Casey

 John T. Fleming

The Fleming Family





















































Khalid Bahurr, commissioner for Burke Lakefront Airport































John Fleming, his wife, Suzanne; their 2 sons, 15-year-old John Robert Fleming, and 14-year-old Andrew Fleming, a neighbor Brian Casey; and Casey's teenage daughter, Megan Casey, were on the Cessna 525C Citation CJ4 plane.


The National Transportation Safety Board traveled to the scene of this accident.


Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; North Olmsted, Ohio
Textron Aviation; Wichita, Kansas
Williams International; Walled Lake, Michigan
Rockwell Collins; Cedar Rapids, Iowa

Aviation Accident Factual Report - National Transportation Safety Board: https://app.ntsb.gov/pdf


Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms


Location: Cleveland, OH

Accident Number: CEN17FA072
Date & Time: 12/29/2016, 2257 EST
Registration: N614SB
Aircraft: CESSNA 525
Aircraft Damage: Destroyed
Defining Event: Controlled flight into terr/obj (CFIT)
Injuries: 6 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal 

On December 29, 2016, at 2257 eastern standard time, a Cessna 525C (Citation CJ4) airplane, N614SB, was destroyed during an in-flight collision with Lake Erie shortly after takeoff from runway 24R (6,604 feet by 150 feet, asphalt) at the Burke Lakefront Airport (BKL), Cleveland, Ohio. The pilot and five passengers were fatally injured. The airplane was registered to Maverick Air LLC and operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight. Night visual meteorological conditions prevailed for the flight, which was operated on an instrument flight rules (IFR) flight plan. The intended destination was the Ohio State University Airport (OSU), Columbus, Ohio.


The pilot and passengers departed OSU about 1730 and arrived at BKL about 1800. The pilot checked in at the fixed base operator (FBO) at 1812. The pilot and passengers attended a local sporting event before returning to the airport about 2230.


A review of the air traffic control (ATC) communications transcript, the cockpit voice recorder (CVR) transcript, automated dependent surveillance – broadcast (ADS-B) data, and full authority digital engine control (FADEC) unit data revealed the following:


At 2255, the pilot was cleared for takeoff. He was instructed to turn right to a heading of 330° and maintain 2,000 feet mean sea level (msl) after departure. The pilot acknowledged the clearance. At 2256:33, the engine power increased for takeoff, and 15 seconds later the airplane became airborne. At 2257:09, an automated voice annunciated "altitude." A second "altitude" annunciation followed 14 seconds later. At 2257:25, a sound similar to a decrease in engine power was recorded. Two seconds later, the enhanced ground proximity warning system (EGPWS) provided an excessive bank angle warning. At 2257:29, about 2 seconds after the bank angle warning, the tower controller instructed the pilot to contact departure control. The pilot replied, "to departure six one four sierra bravo;" however, that communication was not received by the tower controller suggesting that the pilot did not have the microphone push-to-talk button depressed.


At 2257:37, the controller again attempted to contact the pilot. Two seconds after the controller's transmission, the EGPWS provided a "sink rate" warning to the pilot. The pilot again responded, "six one four sierra bravo," but this was not received by the tower controller. Beginning at 2257:43, the EGPWS provided 7 "pull up" warnings at 1.6-second intervals until the end of the CVR recording. During that time, a sound similar to the overspeed warning began, which continued until the end of the recording. The CVR recording ended at 2257:58.


The tower controller's continued attempts to contact the pilot were unsuccessful, and he subsequently initiated search and rescue procedures.


A summary of the operational factors associated with the accident, including a detailed history of flight, is included in the docket associated with the investigation.


Pilot Information


Certificate: Private

Age: 45, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): Helicopter
Restraint Used: 5-point
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 3 Without Waivers/Limitations
Last FAA Medical Exam: 10/15/2015
Occupational Pilot: No
Last Flight Review or Equivalent: 12/08/2016
Flight Time: 1205 hours (Total, all aircraft), 56 hours (Total, this make and model), 919 hours (Pilot In Command, all aircraft), 56 hours (Last 90 days, all aircraft), 22 hours (Last 30 days, all aircraft), 0.5 hours (Last 24 hours, all aircraft)

The pilot's Cessna 525 single-pilot type rating was added December 8, 2016, after he successfully completed the prescribed Federal Aviation Administration (FAA) practical test (checkride). His initial Cessna 525 training was completed in the accident airplane. The pilot subsequently completed a simulator-based recurrent training course at FlightSafety International on December 17, 2016.


The pilot had accumulated a total of 56.5 hours in Cessna 525 airplanes. Of that time, 8.7 hours were as pilot-in-command which included the practical test. His most recent logged flight was on December 17 from Orlando International (MCO) to OSU. The pilot owned a Cessna 510 (Mustang) for about 2 years before purchasing the accident airplane. He had logged 372.9 hours total time in Cessna 510 airplanes. Interviews with the pilot's instructor confirmed that the pilot was trained to consistently use the autopilot after takeoff.


Available information indicated that the pilot had been awake for nearly 17 hours at the time of the accident. 


Aircraft and Owner/Operator Information


Aircraft Manufacturer: CESSNA

Registration: N614SB
Model/Series: 525
Aircraft Category: Airplane
Year of Manufacture: 2012
Amateur Built: No
Airworthiness Certificate: Commuter
Serial Number: 525C0072
Landing Gear Type: Retractable - Tricycle
Seats: 11
Date/Type of Last Inspection: 12/17/2016, AAIP
Certified Max Gross Wt.: 17110 lbs
Time Since Last Inspection: 1 Hours
Engines: 2 Turbo Fan
Airframe Total Time: 861.5 Hours at time of accident
Engine Manufacturer: Williams International
ELT: C126 installed, activated, did not aid in locating accident
Engine Model/Series: FJ44-4A
Registered Owner: Maverick Air LLC
Rated Power: 3621 lbs 
Operator: On file
Operating Certificate(s) Held: None

FAA records revealed that the airplane was issued a standard airworthiness certificate in January 2012 and was subsequently exported to Brazil. The airplane was imported to the United States and purchased by the owner in October 2016. An FAA standard airworthiness certificate was issued at that time.


According to the airplane maintenance records, the most recent inspection was completed on October 3, 2016, at 812.7 hours airframe total time. Compliance with all current airworthiness directives and mandatory service bulletins was confirmed at that time. Additional maintenance work was completed on October 14, 2016, at 814.1 hours total airframe time. The most recent maintenance work occurred on December 17, 2016, at 860.7 hours total airframe time. 


Meteorological Information and Flight Plan


Conditions at Accident Site: Visual Conditions

Condition of Light: Night/Dark
Observation Facility, Elevation: BKL, 584 ft msl
Observation Time: 2300 EST
Distance from Accident Site: 2 Nautical Miles
Direction from Accident Site: 135°
Lowest Cloud Condition: Scattered / 1500 ft agl
Temperature/Dew Point: 1°C / -2°C
Lowest Ceiling: Broken / 2300 ft agl
Visibility: 9 Miles
Wind Speed/Gusts, Direction: 22 knots/ 31 knots, 260°
Visibility (RVR):
Altimeter Setting: 29.74 inches Hg
Visibility (RVV):
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Cleveland, OH (BKL)
Type of Flight Plan Filed: IFR
Destination: Columbus, OH (OSU)
Type of Clearance: IFR
Departure Time: 2256 EST
Type of Airspace: Class D 

The observations from BKL and Cleveland Hopkins International (CLE) indicated that marginal visual conditions prevailed at the time of the accident. Precipitation was reported in the one-minute observations at BKL until 2251, with no precipitation reported at the surface until 2342. While the surface temperature remained above freezing after the airplane landed at BKL and about the accident time, the dew point temperature remained below freezing the entire time with precipitation occurring on and off in the snow shower activity.


Airport Information


Airport: Burke Lakefront (BKL)

Runway Surface Type: Asphalt
Airport Elevation: 584 ft
Runway Surface Condition: Wet
Runway Used: 24R
IFR Approach: None
Runway Length/Width: 6604 ft / 150 ft
VFR Approach/Landing: None

Wreckage and Impact Information


Crew Injuries: 1 Fatal

Aircraft Damage: Destroyed
Passenger Injuries: 5 Fatal
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 6 Fatal
Latitude, Longitude: 41.554722, -81.703333

The accident site was located in Lake Erie about 2 miles northwest of BKL. The depth of the lake at that location was about 40 feet. Search and recovery efforts were hampered by weather and lake conditions. Airplane debris, including the cockpit voice recorder, was located beginning on January 5. The recovery operations were conducted over the following 2 weeks as lake conditions permitted.


A postaccident examination of the recovered wreckage did not reveal any anomalies consistent with a preimpact failure or malfunction. 


Medical And Pathological Information


An autopsy and toxicology testing were not performed due to the limited remains recovered. 


Additional Information


Flight Guidance Panel


The flight guidance panel (FGP), located on the glareshield, allows the pilot to select manual or autopilot guidance for airplane control. The autopilot button is located on the upper row of button controls near the right side of the panel. Autopilot engagement is indicated in the flight control system display area along the upper portion of the primary flight display (PFD). There is no indication of the autopilot status on or near the autopilot button on the flight guidance panel.


A comparison of the Cessna 525 systems and those of the airplane previously flown by the pilot, a Cessna 510, revealed that the autopilot engagement button on the Cessna 510 is located in a slightly different location on the Automatic Flight Control System (AFCS) panel. In the Cessna 510, autopilot engagement is indicated along the upper portion of the PFD similar to the accident airplane. In addition, an indicator light adjacent to the autopilot button on the AFCS panel is illuminated when the autopilot is engaged.


Primary Flight Display


The attitude indicator presented by the PFD on the Cessna 525 was an ego-centric ("inside out") type display. An "inside out" perspective involves a fixed aircraft symbol and moving horizon similar to what a pilot sees when looking outside of the aircraft. On the other hand, the Cessna 510 utilizes an exo-centric ("outside in") display. An "outside in" perspective involves a fixed horizon and a moving aircraft symbol.


Spatial Disorientation


The FAA Civil Aeromedical Institute's publication, "Introduction to Aviation Physiology," defines spatial disorientation as a loss of proper bearings or a state of mental confusion as to position, location, or movement relative to the position of the earth. Factors contributing to spatial disorientation include changes in acceleration, flight in IMC, frequent transfer between visual meteorological conditions (VMC) and IMC, and unperceived changes in aircraft attitude.



The FAA's Airplane Flying Handbook (FAA-H-8083-3A) describes some hazards associated with flying when the ground or horizon are obscured. The handbook states, in part: "The vestibular sense (motion sensing by the inner ear) in particular tends to confuse the pilot. Because of inertia, the sensory areas of the inner ear cannot detect slight changes in the attitude of the airplane, nor can they accurately sense attitude changes that occur at a uniform rate over a period of time. On the other hand, false sensations are often generated; leading the pilot to believe the attitude of the airplane has changed when in fact, it has not. These false sensations result in the pilot experiencing spatial disorientation."

Location: Cleveland, OH

Accident Number: CEN17FA072
Date & Time: 12/29/2016, 2257 EST
Registration: N614SB
Aircraft: CESSNA 525
Injuries: 6 Fatal
Flight Conducted Under:  Part 91: General Aviation - Personal 

On December 29, 2016, at 2257 eastern standard time, a Cessna model 525C (Citation CJ4) airplane, N614SB, was destroyed during an in-flight collision with Lake Erie shortly after takeoff from runway 24R (6,604 feet by 15o feet, asphalt) at the Burke Lakefront Airport (BKL), Cleveland, Ohio. The pilot and five passengers are missing and presumed fatal. The airplane was registered to Maverick Air LLC and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Night visual meteorological conditions prevailed for the flight, which was operated on an instrument flight rules (IFR) flight plan. The intended destination was the Ohio State University Airport (OSU), Columbus, Ohio.


The pilot and passengers initially departed OSU about 1730 and arrived at BKL about 1800. The pilot checked in at the fixed base operator (FBO) at 1812. The pilot and passengers reportedly attended a local sporting event before returning to the airport about 2230.


An initial review of Air Traffic Control (ATC) transmissions between the pilot and the Midwest ATC Federal Contract Tower at BKL revealed that the pilot requested the IFR clearance at 2247, followed by the taxi clearance at 2251. At 2256, the pilot informed the BKL tower controller that he was holding short of the runway and ready for takeoff. The controller subsequently cleared the pilot for takeoff and instructed him to turn right to a heading of 330 degrees and maintain 2,000 feet msl after departure. The pilot acknowledged the clearance. After takeoff, the controller instructed the pilot to contact departure control; however, no further communications were received from the pilot. After multiple attempts to contact the pilot were unsuccessful, the controller initiated search and rescue procedures.


Automated Dependent Surveillance – Broadcast (ADS-B) position data indicated that the takeoff began about 2256:47 (hhmm:ss). The data depicted the airplane entering a right turn shortly after crossing the runway departure threshold. The airplane became established on a magnetic course of 310 degrees at about 2257:28. During this time, the airplane reached an altitude of approximately 2,925 feet msl. About 5 seconds later, the airplane entered a descending right turn that continued until the final data point. The final data point was recorded at 2257:52 and was located 1.83 miles northwest of BKL. The associated altitude was 775 feet msl.


The resulting search and recovery effort was hampered by weather and lake conditions. Airplane debris, including the cockpit voice recorder, was ultimately located about 0.10 mile northeast of the final data point. The cockpit voice recorder was transferred to the NTSB Recorders Laboratory for readout. A detailed wreckage examination will be conducted once recovery operations have concluded.


The Cessna 525C Citation CJ4 airplane has a low-wing, T-tail airframe arrangement, with a retractable tricycle landing gear configuration. The cabin is pressurized and the airplane is capable of operating at a maximum pressure altitude of 45,000 feet. It is configured for up to 10 occupants including the pilot(s). The airplane is approved for single pilot operations provided the pilot-in-command holds a CE525S (single pilot) type rating, the airplane is configured for single pilot operations in accordance with the operating limitations, and the pilot occupies the left pilot seat.


Federal Aviation Administration (FAA) records indicated that the accident airplane was a 2012 model year Cessna 525C, serial number 525C-0072. It was powered by two Williams International FJ44-4A turbofan engines, serial numbers 211155 and 211156. The airplane was initially issued a commuter category standard airworthiness certificate in January 2012. It was subsequently exported to Brazil. The airframe and engines had accumulated about 10 hours total time when exported. The airplane was imported to the United States and purchased by the accident owner in October 2016. The airframe and engines had accumulated about 812 hours total time when the airplane was returned to the United States. Available records indicated that the most recent maintenance activity occurred on December 17, 2016. At that time the airplane had accumulated 860 hours total time.


FAA records revealed that the accident pilot held a private pilot certificate with airplane single and multi-engine land, rotorcraft helicopter, and instrument airplane category/class ratings. In addition, the pilot held CE-510S and CE-525S type ratings. He was issued a third class airman medical certificate without limitations on October 15, 2015. The pilot's CE-525S type rating was added December 8, 2016, after he successfully completed the prescribed FAA practical test (checkride). His initial Cessna 525 training was completed in the accident airplane. The pilot subsequently completed a simulator-based recurrent training course at FlightSafety International on December 17, 2016. 


Aircraft and Owner/Operator Information


Aircraft Manufacturer: CESSNA

Registration: N614SB
Model/Series: 525
Aircraft Category: Airplane
Amateur Built: No
Operator: On file
Operating Certificate(s) Held: None 

Meteorological Information and Flight Plan


Conditions at Accident Site: Visual Conditions

Condition of Light: Night/Dark
Observation Facility, Elevation: BKL, 584 ft msl
Observation Time: 2300 EST
Distance from Accident Site: 2 Nautical Miles
Temperature/Dew Point: 1°C / -2°C
Lowest Cloud Condition: Scattered / 1500 ft agl
Wind Speed/Gusts, Direction: 22 knots/ 31 knots, 260°
Lowest Ceiling: Broken / 2300 ft agl
Visibility:  9 Miles
Altimeter Setting: 29.74 inches Hg
Type of Flight Plan Filed: IFR
Departure Point: Cleveland, OH (BKL)
Destination: Columbus, OH (OSU)

Wreckage and Impact Information


Crew Injuries: 1 Fatal

Aircraft Damage: Destroyed
Passenger Injuries: 5 Fatal
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 6 Fatal
Latitude, Longitude:  41.517778, -81.682778 (est)








Location: Cleveland, OH
Accident Number: CEN17FA072
Date & Time: 12/29/2016, 2257 EST
Registration: N614SB
Aircraft: CESSNA 525
Injuries: 6 Fatal
Flight Conducted Under:  Part 91: General Aviation - Personal 

On December 29, 2016, at 2257 eastern standard time, a Cessna model 525C (Citation CJ4) airplane, N614SB, was destroyed during an in-flight collision with Lake Erie shortly after takeoff from runway 24R (6,604 feet by 15o feet, asphalt) at the Burke Lakefront Airport (BKL), Cleveland, Ohio. The pilot and five passengers are missing and presumed fatal. The airplane was registered to Maverick Air LLC and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Night visual meteorological conditions prevailed for the flight, which was operated on an instrument flight rules (IFR) flight plan. The intended destination was the Ohio State University Airport (OSU), Columbus, Ohio.

The pilot and passengers initially departed OSU about 1730 and arrived at BKL about 1800. The pilot checked in at the fixed base operator (FBO) at 1812. The pilot and passengers reportedly attended a local sporting event before returning to the airport about 2230.

An initial review of Air Traffic Control (ATC) transmissions between the pilot and the Midwest ATC Federal Contract Tower at BKL revealed that the pilot requested the IFR clearance at 2247, followed by the taxi clearance at 2251. At 2256, the pilot informed the BKL tower controller that he was holding short of the runway and ready for takeoff. The controller subsequently cleared the pilot for takeoff and instructed him to turn right to a heading of 330 degrees and maintain 2,000 feet msl after departure. The pilot acknowledged the clearance. After takeoff, the controller instructed the pilot to contact departure control; however, no further communications were received from the pilot. After multiple attempts to contact the pilot were unsuccessful, the controller initiated search and rescue procedures.

Automated Dependent Surveillance – Broadcast (ADS-B) position data indicated that the takeoff began about 2256:47 (hhmm:ss). The data depicted the airplane entering a right turn shortly after crossing the runway departure threshold. The airplane became established on a magnetic course of 310 degrees at about 2257:28. During this time, the airplane reached an altitude of approximately 2,925 feet msl. About 5 seconds later, the airplane entered a descending right turn that continued until the final data point. The final data point was recorded at 2257:52 and was located 1.83 miles northwest of BKL. The associated altitude was 775 feet msl.

The resulting search and recovery effort was hampered by weather and lake conditions. Airplane debris, including the cockpit voice recorder, was ultimately located about 0.10 mile northeast of the final data point. The cockpit voice recorder was transferred to the NTSB Recorders Laboratory for readout. A detailed wreckage examination will be conducted once recovery operations have concluded.

The Cessna 525C Citation CJ4 airplane has a low-wing, T-tail airframe arrangement, with a retractable tricycle landing gear configuration. The cabin is pressurized and the airplane is capable of operating at a maximum pressure altitude of 45,000 feet. It is configured for up to 10 occupants including the pilot(s). The airplane is approved for single pilot operations provided the pilot-in-command holds a CE525S (single pilot) type rating, the airplane is configured for single pilot operations in accordance with the operating limitations, and the pilot occupies the left pilot seat.

Federal Aviation Administration (FAA) records indicated that the accident airplane was a 2012 model year Cessna 525C, serial number 525C-0072. It was powered by two Williams International FJ44-4A turbofan engines, serial numbers 211155 and 211156. The airplane was initially issued a commuter category standard airworthiness certificate in January 2012. It was subsequently exported to Brazil. The airframe and engines had accumulated about 10 hours total time when exported. The airplane was imported to the United States and purchased by the accident owner in October 2016. The airframe and engines had accumulated about 812 hours total time when the airplane was returned to the United States. Available records indicated that the most recent maintenance activity occurred on December 17, 2016. At that time the airplane had accumulated 860 hours total time.

FAA records revealed that the accident pilot held a private pilot certificate with airplane single and multi-engine land, rotorcraft helicopter, and instrument airplane category/class ratings. In addition, the pilot held CE-510S and CE-525S type ratings. He was issued a third class airman medical certificate without limitations on October 15, 2015. The pilot's CE-525S type rating was added December 8, 2016, after he successfully completed the prescribed FAA practical test (checkride). His initial Cessna 525 training was completed in the accident airplane. The pilot subsequently completed a simulator-based recurrent training course at FlightSafety International on December 17, 2016. 

Aircraft and Owner/Operator Information

Aircraft Manufacturer: CESSNA
Registration: N614SB
Model/Series: 525
Aircraft Category: Airplane
Amateur Built: No
Operator: On file
Operating Certificate(s) Held: None 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Night/Dark
Observation Facility, Elevation: BKL, 584 ft msl
Observation Time: 2300 EST
Distance from Accident Site: 2 Nautical Miles
Temperature/Dew Point: 1°C / -2°C
Lowest Cloud Condition: Scattered / 1500 ft agl
Wind Speed/Gusts, Direction: 22 knots/ 31 knots, 260°
Lowest Ceiling: Broken / 2300 ft agl
Visibility:  9 Miles
Altimeter Setting: 29.74 inches Hg
Type of Flight Plan Filed: IFR
Departure Point: Cleveland, OH (BKL)
Destination: Columbus, OH (OSU)

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: 5 Fatal
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 6 Fatal
Latitude, Longitude:  41.517778, -81.682778 (est)

8 comments:


  1. My theory is closely aligned with the FAA's report. The pilot was not focused on the instruments as he should have been, dark/foggy/over water with no visible horizon. I believe he was focused on engaging the autopilot immediately after takeoff and was unable to get it engaged probably because he was still somewhat unfamiliar with the panel, obviously in a hurry and trying to communicate with ATC all at the same time. This coupled with fatigue and no preflight preparation was what killed him and his family.

    ReplyDelete
  2. ONE MINUTE TEN SECONDS FROM ROTATION INTO THE WATER .. rip

    ReplyDelete
  3. I wonder if the use of autopilot during the instrument check ride and type ratings should be banned. It sounds like the cockpit was dark and the pilot couldn't remember how to get the autopilot engaged because of the minor differences between this plane and his previous plane. With multiple warnings going off, he must have gotten panicky (or at least flustered) instead of calmly flying the airplane by hand until out of the critical phase of flight.

    ReplyDelete
  4. I have noted a couple of experienced pilots pressing the A/P disconnect button on the yoke when intending to PTT. The frustration of perhaps repeatedly disconnecting the A/P when intending to communicate may have been a contributor. Also touching the electric trim will disconnect the A/P.

    Any similar experiences?

    ReplyDelete
  5. “Autopilot engagement is indicated in the flight control system display area along the upper portion of the primary flight display (PFD). There is no indication of the autopilot status on or near the autopilot button on the flight guidance panel.”

    This is a common complaint and takes a while to get used to. There are no on/off lights in the flight guidance panel push buttons. CJ4 operators must refer to the flight director window (aka the “scoreboard”) on the top of the PFD for auto pilot engagement indication. In my opinion a poor design and one of the only things I don’t like about this aircraft.

    That being said, no excuse not to take control and hand fly to a safe attitude and altitude. To my knowledge the CJ4 has the best thrust to weight ratio of any production business jet. Not uncommon to see verticle speeds of 6000 fpm. Would be a hand full with an early level off, a turn, at night, single pilot, after a long day. I would recomend flying the first 100 hours in this aircraft with an experienced pilot in the righ seat.

    Glad to see the final report was published.

    RIP.

    6000+ hrs corporate pilot
    1500+ hrs CJ4


    ReplyDelete
  6. “things happen fast” in the CJ4 -Randy Lane, Aviation Dynamix

    Yowza!

    ReplyDelete
  7. Does anyone have the Web link to the Final Report?

    Thanks Much!

    ... and yes it sounds like definite Spacial Orientation!

    ReplyDelete
  8. Spatial Orientation.
    No Final Report.

    ReplyDelete