The National Transportation Safety Board traveled to the scene of this accident.
Additional Participating Entities:
Federal Aviation Administration / Office of Accident Investigation and Prevention AVP-100; Washington, District of Columbia
Federal Aviation Administration / Flight Standards District Office; Fargo, North Dakota
Textron Aviation; Wichita, Kansas
Honeywell Aerospace; Phoenix, Arizona
Bismarck Air Medical; Bismarck, North Dakota
Additional Participating Entities:
Federal Aviation Administration / Office of Accident Investigation and Prevention AVP-100; Washington, District of Columbia
Federal Aviation Administration / Flight Standards District Office; Fargo, North Dakota
Textron Aviation; Wichita, Kansas
Honeywell Aerospace; Phoenix, Arizona
Bismarck Air Medical; Bismarck, North Dakota
Investigation Docket - National Transportation Safety Board:
Location: Harmon, North Dakota
Accident Number: CEN19FA030
Date & Time: November 17, 2018, 22:40 Local
Registration: N441CX
Aircraft: Cessna 441
Aircraft Damage: Destroyed
Defining Event: Aircraft structural failure
Injuries: 3 Fatal
Flight Conducted Under: Part 91: General aviation - Positioning
Analysis
The pilot and two medical crewmembers were repositioning the airplane to pick up a patient for aeromedical transport. Dark night instrument meteorological conditions prevailed for the flight. Radar data showed the airplane climb to 14,000 ft mean sea level after departure and proceed direct toward the destination airport before beginning a right descending turn. The airplane subsequently broke up inflight and impacted terrain. No distress calls were received from the pilot before the accident. Although weather conditions were conducive for inflight icing, no evidence of structural icing was identified at the scene.
The debris field was 2,500 ft long and the disbursement of the wreckage confirmed that both wings, the horizontal stabilizer, both elevators, and both engines separated from the airplane before impacting the ground. Examination of the wreckage revealed that the initiating failure was the failure of the wing where it passed through the center of the airplane. The three wing spars exhibited S-bending deformation, indicative of positive overload producing compressive buckling and fracture. Further, impact signatures as black paint transfers and gouged aluminum, were consistent with the left outboard wing separating when it was struck by the right engine after the wing spars failed. There was no evidence of any pre-exiting conditions that would have degraded the strength of the airplane structure at the fracture locations. Flight control continuity was confirmed. An examination of the engines, propellers, and available systems showed no mechanical malfunctions or failure that could have contributed to the accident. The descending right turn was inconsistent with the intended flight track and ATC-provided clearance. However, there was insufficient information to determine how it was initiated and when the pilot became aware of the airplane's state in the dark night IMC conditions. Yet, the absence of a distress call or communication with ATC about the airplane's deviation suggests that the pilot was not initially aware of the change in state. The structural failure signatures on the airplane were indicative of the wings failing in positive overload, which was consistent with the pilot initiating a pullup maneuver that exceeded the airplane spars' structural integrity during an attempted recovery from the spiral dive.
Probable Cause and Findings
The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's failure to maintain control of the airplane in dark night conditions that resulted in an in-flight positive overload failure of the wings and the subsequent in-flight breakup of the airplane.
Findings
Aircraft Center wing box (on wing) - Capability exceeded
Personnel issues Aircraft control - Pilot
Aircraft Pitch control - Incorrect use/operation
Environmental issues Dark - Effect on operation
Factual Information
History of Flight
Enroute-cruise Abrupt maneuver
Maneuvering Aircraft structural failure (Defining event)
Uncontrolled descent Collision with terr/obj (non-CFIT)
On November 18, 2018, about 2240 central standard time, a Cessna 441, N441CX, was destroyed when it was involved in an accident near Harmon, North Dakota. The pilot, flight nurse, and paramedic were fatally injured. The airplane was being operated as a Title 14 Code of Federal Regulations Part 91 positioning flight.
At 2049, the pilot and medical crew were notified of a mission to fly from Bismarck Municipal Airport (BIS), Bismarck, North Dakota, to Sloulin Field International Airport (ISN), Williston, North Dakota, to pick up a patient for the emergency medical services flight and return to BIS. The pilot notified the fixed base operator to load 50 gallons of Jet fuel on board. At 2159, the pilot obtained an on-line weather document that contained weather forecasts, meteorological aerodrome reports (METARs), terminal forecasts (TAFs), and notices to airmen (NOTAMs) for BIS and ISN.
At 2227, the pilot filed an instrument flight rules (IFR) flight plan. He estimated a departure time of 2234 and a cruising altitude of 14,000 ft. Estimated time en route was 45 minutes at an airspeed of 281 knots. Fuel on board was 3 hours 30 minutes. No alternate airport was listed.
Radar data indicated the airplane took off at 2231 and climbed to 14,000 ft mean sea level on a direct course to ISN. About 2239:30, radar showed the airplane enter a right descending turn. Between 2239:30 and 2240:09, the airplane lost 7,800 ft of altitude. At 2240:09, the airplane was still in left descending turn at 6,200 ft. Radar contact was lost at 2240:18. At that time the airplane was showing as a primary target. The airplane impacted terrain just northwest of the final contact point. No distress calls were received.
Witnesses on the ground reported hearing high-pitch, high-speed engine sounds prior to impact.
Pilot Information
Certificate: Airline transport; Commercial; Flight instructor
Age: 48,Male
Airplane Rating(s): Single-engine land; Multi-engine land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: 3-point
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): Airplane multi-engine; Airplane single-engine; Instrument airplane
Toxicology Performed: Yes
Medical Certification: Class 1 With waivers/limitations
Last FAA Medical Exam: March 28, 2018
Occupational Pilot: Yes
Last Flight Review or Equivalent: October 22, 2018
Flight Time: 4685 hours (Total, all aircraft), 70 hours (Total, this make and model), 3963 hours (Pilot In Command, all aircraft), 36 hours (Last 90 days, all aircraft), 16 hours (Last 30 days, all aircraft)
Aircraft and Owner/Operator Information
Aircraft Make: Cessna
Registration: N441CX
Model/Series: 441 No Series
Aircraft Category: Airplane
Year of Manufacture: 1982
Amateur Built:
Airworthiness Certificate: Normal
Serial Number: 441-0305
Landing Gear Type: Retractable - Tricycle
Seats: 5
Date/Type of Last Inspection: 100 hour
Certified Max Gross Wt.: 10340 lbs
Time Since Last Inspection:
Engines: 2 Turbo prop
Airframe Total Time:
Engine Manufacturer: Garrett
ELT: C91 installed, not activated
Engine Model/Series: TPE331-10N-53
Registered Owner:
Rated Power: 715 Horsepower
Operator: On file
Operating Certificate(s) Held: On-demand air taxi (135)
Operator Does Business As:
Operator Designator Code: R6DA
Meteorological Information and Flight Plan
Conditions at Accident Site: Visual (VMC)
Condition of Light: Night
Observation Facility, Elevation: KBIS,1661 ft msl
Distance from Accident Site: 16 Nautical Miles
Observation Time: 22:52 Local
Direction from Accident Site:
Lowest Cloud Condition: Few / 900 ft AGL
Visibility 10 miles
Lowest Ceiling: Overcast / 2400 ft AGL
Visibility (RVR):
Wind Speed/Gusts: 9 knots /
Turbulence Type Forecast/Actual: /
Wind Direction: 50°
Turbulence Severity Forecast/Actual: /
Altimeter Setting: 30.01 inches Hg
Temperature/Dew Point: -4°C / -6°C
Precipitation and Obscuration:
Departure Point: Bismarck, ND (BIS)
Type of Flight Plan Filed: IFR
Destination: Williston, ND (ISN)
Type of Clearance: IFR
Departure Time: 02:23 Local
Type of Airspace: Class E
The National Weather Service Surface Analysis Chart showed a low-pressure system over Minnesota, with a cold front extending west-southwest into South Dakota, and northwest into North Dakota, Montana, and Canada. The accident site was located behind the cold front. The Area Forecast indicated widespread marginal VFR conditions with localized IFR conditions were expected behind the cold front that had moved across North Dakota and was moving south. The National Radar Mosaic Image depicted several areas of snow showers north and east of the Bismarck area. The Weather Depiction Chart depicted several areas of IFR conditions over North Dakota and Montana due to low ceilings and low visibility in snow, with marginal visual flight rules (VFR) conditions extending over most of North Dakota. An upper air sounding supported nimbostratus-type clouds with precipitation in the form of snow, and greater than 80% relative humidity between 7,000 to 15,500 ft, supporting light-to-moderate intensity rime-to mixed-type ice conditions. Icing probability exceeded 90% in the icing layer.
Weather Surveillance Radar Imagery depicted a large area of light snow extending northwest through northeast of BIS. No weather watches or warnings were in effect during the period.
AIRMET Sierra was in effect for IFR conditions and AIRMET Zulu was in effect for icing conditions.
Wreckage and Impact Information
Crew Injuries: 3 Fatal
Aircraft Damage: Destroyed
Passenger Injuries:
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 3 Fatal
Latitude, Longitude: 46.783889,-100.763885
The accident site was located about 20 miles northwest of BIS. The wreckage was scattered over snowcovered terrain in an area that was about 2,500 ft long and 750 ft wide and oriented in a north to south direction. The north end of the field contained the left and right engines. The fuselage fragments and left and right wings were located in the middle of the debris field. The southern end of the debris field consisted of lighter weight parts as the baggage doors, and left and right horizontal stabilizers. Smaller and lighter items as insulation and airplane interior furnishings, were found at the farthest point from the main wreckage to the south. The rudder counterweight and parts of the elevators were also found in this portion of the debris field. The empennage, except for the left and right elevator fragments, was found east of the cockpit. The left engine was located about 225 ft north of the empennage. The right engine was located about 225 to 300 ft north and east of the cockpit.
Further examination of the right wing showed it had separated at the fuselage and exhibited crush damage along the leading edge. The right aileron remained attached and showed buckling damage on the upper and lower surfaces. The right flap was intact and remained attached to wing by the push rods. The left wing was broken at the fuselage and had fractured into two main pieces at mid-span. At the fracture was aft and downward crushing and bending and multiple fractures. There was also black paint transfers and gouged aluminum in this area. The left wing engine mount and engine located in this area were broken and separated. The inboard section was relatively intact. The left aileron was separated and fractured into three pieces. All three pieces showed extensive bending and crushing. The center wing area where it passed through the fuselage broken and deformed. The forward spar lower cap was bent upward and broken. The main spar lower cap showed upward bending and fracturing as did the aft spar lower cap. Flight control continuity was confirmed from the cockpit to both ailerons, the elevator and rudder.
An examination of the left and right engines showed no mechanical malfunctions or failure that would have prevented normal operation of either engine.
No evidence of failure or malfunction of the propellers was found.
Medical and Pathological Information
Autopsies of the pilot and two medical crewmembers were performed by the North Dakota Department of Health's State Forensic Examiner, Bismarck, North Dakota. The cause of death was listed as "multiple injuries" for each of the occupants. Toxicology testing of samples recovered from the pilot found no ethanol in vitreous, but 58 (mg/dL, mg/hg) ethanol was detected in blood cavity. However, because ethanol was not found in vitreous, its presence was most-likely the result of post-mortem putrefaction. No drugs tested for were found in the samples, and the samples were unsuitable for testing for carbon monoxide.
Tests and Research
The enhanced ground proximity warning system (EGPWS), or Multi-Hazard Awareness Unit (KMH820), was removed and examined by the manufacturer. No data were able to be retrieved.
The pilot's cellular telephone was found damaged in the wreckage; a forensic download of the phone indicated that the phone had been powered on multiple times. In August, in a text conversation with the Director of Operations (DO) for the company, the pilot queried concerns with the portable backup attitude heading reference system (AHRS). In October, the DO asked the pilot, "Did you get the gyro
flag?" to which the pilot responded, "No." In November, the pilot informed the DO that his Heading Situation Indicator (HIS) had precessed 25 degrees on the flight from Minot to Denver and that the autopilot started jerking again!" The DO asked, "Did you go into free mode?" The pilot responded, "Had to." A photograph taken by the pilot about 1816:37 on that flight showed the airplane in flight at 25,000 feet with the autopilot engaged and in NAV and ALT modes.
A Stratus-3 ADS-B (automatic dependent surveillance–broadcast) receiver with AHRS capabilities was found in the wreckage, but the unit was not turned on.
Location: Harmon, ND
Accident Number: CEN19FA030
Date & Time: 11/18/2018, 1040 CST
Registration: N441CX
Aircraft: Cessna 441
Injuries: 3 Fatal
Flight Conducted Under: Part 91: General Aviation - Positioning - Air Medical (Medical Emergency)
On November 18, 2018, at 2240 central standard time, a Cessna 441, N441CX, was destroyed when it broke up in-flight and impacted an open field near Harmon, North Dakota. The airline transport certificated pilot, flight nurse, and paramedic were fatally injured. The airplane was registered to and operated by Bismarck Air Medical under the provisions of Title 14 Code of Federal Regulations Part 135. Visual meteorological conditions prevailed at the time of the accident, and an instrument flight rules (IFR) flight plan had been filed for the air medical cross-country flight. The flight originated from Bismarck Municipal Airport (BIS), Bismarck, North Dakota, at 2230, and was en route to Sloulin Field International Airport (ISN), Williston, North Dakota.
Preliminary information indicated the crew was en route to ISN to pick up a neonatal infant for transport back to BIS. Radar data indicated the airplane climbed on a direct course until reaching 14,000 feet above sea level. Ground speed was at 240 knots. The airplane then entered a steep right bank and radar contact was lost. No distress calls were received.
Wreckage was scattered for about 1 mile long and 600 feet wide on snow-covered terrain. The cockpit area, cabin area, empennage, both engines and propellers, and both wings were identified and recovered. Flight control continuity was established.
Aircraft and Owner/Operator Information
Aircraft Make: Cessna
Registration: N441CX
Model/Series: 441 No Series
Aircraft Category: Airplane
Amateur Built: No
Operator: Bismarck Air Medical LLC
Operating Certificate(s) Held: On-demand Air Taxi (135)
Operator Does Business As:
Operator Designator Code: R6DA
Meteorological Information and Flight Plan
Conditions at Accident Site: Visual Conditions
Condition of Light: Night
Observation Facility, Elevation: KBIS, 1661 ft msl
Observation Time: 2252 CST
Distance from Accident Site: 16 Nautical Miles
Temperature/Dew Point: -4°C / -6°C
Lowest Cloud Condition: Few / 900 ft agl
Wind Speed/Gusts, Direction: 9 knots / , 50°
Lowest Ceiling: Overcast / 2400 ft agl
Visibility: 10 Miles
Altimeter Setting: 30.04 inches Hg
Type of Flight Plan Filed: IFR
Departure Point: Bismarck, ND (BIS)
Destination: Williston, ND (ISN)
Wreckage and Impact Information
Crew Injuries: 3 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 3 Fatal
Latitude, Longitude:
Todd James Lasky, 48, passed away November 18, 2018, as the result of an air ambulance crash. A joint celebration honoring all who perished will be held at 10:00 am Monday, November 26, 2018 at the Bismarck Event Center 315 S 5th St, Bismarck.
Family will greet visitors from 2:00 pm – 5:00 pm on Sunday, November 25, 2018 at Eastgate Funeral Service, 2302 East Divide Avenue, Bismarck.
Todd was born March 31, 1970 and raised in Virginia, Minnesota with his parents Diane and James Lasky and “Sis” Tammy Lasky-Barboni. His passion for service and community started at a young age, joining the Police Academy after graduation from high school in 1988. An incident affecting his “trigger finger” forcing him to choose another career path, Todd finished his Bachelor of Science degree in Aeronautics from the University of North Dakota in two years. Todd experienced a diverse background from Flight Instructor at UND, Chief Pilot for several private companies, corporate pilot for a major airline and then ending up in Bismarck as a pilot for Bismarck Air Ambulance.
Todd loved to fly and was an excellent and meticulous pilot. Passengers, patients, families and colleagues could count on him to sign, seal and deliver. He was dependable, honest, intelligent, patient, humble, quick witted and had a huge heart. He would always “do the right thing” and was quick to offer assistance to alleviate any un do stress and worry to another and take it on himself. A natural born “giver” he emulated that characteristic in his personal life, as well.
Todd’s talents and natural God-given gifts were a huge part of his life. His passion for motorcycles, snow cats, water craft, ATV’s….you name it, he could RIDE IT (and) FIX IT!!! His “need for speed” was apparent to all that knew him.
One of his fondest memories and experiences was the snowmobile he built with his father. This would become the fastest world record for speed in the NSSR 600cc class.
He lit up with pride and teared up with love in his eyes when he would talk about his dad and all of the time they spent together. Family was of the utmost importance to him and was also very close to his mama and big Sis. A day or two didn’t go by without a phone call or a text to check on how they were doing. Nephews and relatives alike were all impacted by his charm and giving spirit.
Todd was the proud owner of his “hobby job” and business, Year-Round Recreation. If he wasn’t flying or on an adventure with a motorized vehicle, he could be found inside his shop diagnosing the next piece of equipment or building a motorcycle from scratch!
Talent, drive, work ethic, and a Jack of All Trades, Todd was blessed to have had the opportunity to express his passions on a daily basis and share his excitement with everyone whom he came into contact with. The next “snowfall” when he could get his rig out into the white stuff was all he could talk about since the leaves were changing colors! His excitement was contagious and he could usually talk someone into getting just as excited as he was about it! Many of his friends and acquaintances from the shop claimed to have become a little more serious about riding after working with him on something he had fixed for them. He was charismatic and fun, a story teller and a prankster. His smart wit and humor was appreciated by everyone that came into contact with him.
A man of deep faith, inventor, teacher, business owner, father, friend, brother, significant other…Todd will forever hold sacred places in our hearts. From the twinkle in his puppy dog eyes, his out of this world amazing smile, his HUGE tight hugs and his gentle patient spirit, we will FOREVER miss and honor him.
Blessed to have shared his life was his mother, Diane Lasky and the late James Lasky; his sister, Tammy Lasky-Barboni, her husband Peter and nephews, Michael and Nicholas; his son Austin Lasky; his true love, Bonny Wesolowski-Senger and her family Jami (James) Summers, Jorden and Jace Senger and his fur babies, Lucy and Louie.
Fly high Todd….you are our hero!
Tailwinds to eternity…until we meet again, God bless your beautiful heart and soul. We love you always and forever.
https://www.eastgatefuneral.com
Chris Iverson, 47, Bismarck, died November 19, 2018 in Bismarck, ND.A memorial service will be held at 10:00 am on Monday, November 26, 2018 at Bismarck Event Center, 315 S 5th Street, Bismarck.
Family will greet visitors from 4:00 pm – 7:00 pm Sunday, November 25, at Parkway Funeral Service, 2330 Tyler Parkway, Bismarck, with a prayer service at 7:00 pm.
Once in a lifetime you meet someone who changes your whole world, for me that was my husband. Chris Alan Iverson was born May 7, 1971, in Tacoma, Washington to Donna Jean (Kjos) and Clayton Jacob Iverson, the 4th of 5 children. He was raised in Tacoma and attended Franklin Pierce High School, where he excelled in FFA and football. He spent his free time with friends camping, hunting,s and fishing in the Puget sound. His love of the outdoors stayed with him throughout his life.
Not long out of school Chris met his first love, his daughter Breyana Lynn, on September 29, 1992. He began working for Takasaki Construction on Fort Lewis Air Fort Base and continued there for almost 10 years. During this time, he met and married his lifetime love, Jennifer Darlene McKenzie. They were married September 13, 1997, in Tacoma, Washington. They resided in Tenino, Washington for 2 years where they welcomed their daughter, Emma Louise, on March 27, 1998 and mourned the loss of their son Christian Jacob on October 8, 1999. In 2000, they moved to The Tri-Cities and Chris began work at Boise Cascade Paper Mill. On November 15, 2002 they completed their family by welcoming their son, Seth Elias Iverson. In the search to find better hunting grounds and a good place to raise a family, the Iverson family moved to Cathay, North Dakota in 2003. Chris began work at Canadian Pacific Railroad as a conductor and joined the Cathay Volunteer Fire Department. Eventually, the family moved from the farmstead into Fessenden. Chris continued as a CP conductor for over 10 years and volunteered for 11 years as a fireman on the Cathay and Fessenden Fire Departments. In 2008, Chris and Jenny were introduced to the world of EMS. Chris quickly realized that this was the perfect job for him. It allowed him to take care of people, give to the community, and have work that pushed him both physically and intellectually. He excelled in EMS as a provider, an instructor, and a mentor. Everyone who worked with him and received care from him experienced his compassion and knowledgeable care.
Chris was taken too soon from this life. He is sadly survived in this world by his wife of 21 years, Jenny, his daughters, Breyana, Portland, OR and Emma, his son, Seth, his mother, Donna, Tacoma, WA; his sisters Melodee (Martin) Gaertner, Georgia; Mary Jamison (John) Olalla, WA , his brothers Jay Iverson and Curtis Iverson, Tacoma, WA, and a multitude of friends.
Chris was preceded in death by his father, Clayton Iverson.
http://www.parkwayfuneral.com
Bonnie was born May 25, 1955, in Richardton, ND. She grew up on a rural farm by Killdeer. The oldest of 15 brother and sisters, she quickly became a second mom to her brothers and sisters, showing love and dedication for her family and her work.
Bonnie met and eventually married the love of her life, Perry, August of 1979. They resided in Killdeer until they moved to Bismarck so she could pursue a career in Nursing at the University of Mary.
In 1992, she became a registered nurse and worked at St. Alexius in the Neonatal Intensive Care Unit (NICU) where she excelled in serving the babies who needed a higher level of care. She joined the NICU transport team, began instructing S.T.A.B.L.E. class onsite and via telemedicine to local and rural nurses. She also was an active member of the Nursing Communications Ambassadors, serving on the shared governance committee.
Bonnie’s dedication at work was only elapsed by her love and devotion to her family. She enjoyed spending weekends and vacations visiting and playing with her eight grandchildren to cherishing every moment of life. Bonnie loved to do crafts and share recipes with all her friends and family. Her strength and determination were infectious, and she volunteered throughout the Bismarck area in numerous capacities.
The family asks that in lieu of flowers or gifts that donations be made for the future purchase of Neonatal Transport Isolette. Bonnie’s passion and goal to equip nurses with the best equipment to increase the survival rate of neonates. Donations should be made out to the CHI foundation; mailed to C/O Perry Cook, 7009 Golden Crest Rd, Bismarck, ND 58503.
https://bismarckfuneralhome.com
Chris Iverson, paramedic, age 47 of Mandan
Bonnie Cook, NICU nurse, age 63 of Bismarck
Todd Lasky, pilot, age 48 of Bismarck
Pilot Todd Lasky
