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.

Contributing to the accident were Marlin Air, which conducted inadequate check rides, and the Federal Aviation Administration's (FAA) failure to detect and correct those deficiencies, which placed an ill-prepared pilot in the first officer's seat, the NTSB stated.

Results from the Board's investigation indicated that the captain did not adhere to procedures or comply with regulations, and that he routinely abbreviated checklists.

The NTSB concluded that the pilots' lack of discipline, lack of in-depth systems knowledge, and failure to adhere to procedures contributed to their inability to cope with anomalies experienced during the accident flight.

The Safety Board issued numerous recommendations to the FAA and the American Hospital Association regarding airplane and system deficiencies, FAA oversight, and the safety ramifications of an operator's financial health.

They included to the FAA:

• Require all Part 91K and Part 135 operators to incorporate upset recovery training (similar to that described in the airplane upset recovery training aid used by many Part 121 operators) and related checklists and procedures into their training programs.
• Require Cessna to redesign and retrofit the yaw damper and autopilot switches on the autopilot control panel in Citation series airplanes to make them easily distinguishable and to guard against unintentional pilot activation.
• Conduct a detailed review of the oversight provided to Marlin Air to determine why the oversight system failed to detect (before and after the accident) and correct Marlin Air's operational deficiencies, particularly in the areas of pilot hiring, training, and adherence to procedures.