Pilot Error in Med Flight Fatal Accident

The National Transportation Safety Board (NTSB) recently ruled that pilot mismanagement of an abnormal flight control situation caused the fatal crash of a medical transport near Milwaukee.

On June 4, 2007, a Cessna Citation 550 (N550BP) impacted Lake Michigan shortly after departure from General Mitchell International, Milwaukee, WI(MKE). The two pilots and four passengers onboard were killed. The airplane being operated by Marlin Air under the provisions of Part 135 was carrying a human organ for a transplant operation.  At the time of the accident, marginal visual meteorological conditions prevailed at the surface, and instrument meteorological conditions prevailed aloft; the flight operated on an instrument flight rules flight plan.

Due to lack of a flight data recorder, the Safety Board could not determine the exact nature of the initiating event of the accident.  However, the evidence indicated that the two most likely scenarios were a runaway trim or the inadvertent engagement of the autopilot, rather than the yaw damper, at takeoff.

The Board further noted that the event was controllable if the captain had not allowed the airspeed and resulting control forces to increase while he tried to troubleshoot the problem.   By allowing the airplane's airspeed to increase while engaging in poorly coordinated troubleshooting efforts, the pilots allowed an abnormal situation to escalate to an emergency.

The NTSB concluded that if the pilots had simply maintained a reduced airspeed while they responded to the situation, the aerodynamic forces on the airplane would not have increased significantly.  At reduced airspeeds, the pilots should have been able to maintain control of the airplane long enough to either successfully troubleshoot and resolve the problem or return safely to the airport.