Friday, January 22, 2016

Blaming Pilots: No More Easy Answers • National Transportation Safety Board



By Tim Maher and Brian Casey
Maher and Casey are lawyers with the firm of Barnes & Thornburg.  


When adding general aviation safety to its list of top priorities for 2011 the National Transportation Safety Board (NTSB) noted that accidents involving general aviation, or private planes, “are almost always a repeat of the circumstances of previous accidents.”


In the five decades since Congress created the NTSB to investigate accidents and make recommendations to prevent their recurrence, general aviation accidents have resulted in the deaths of more than 50,000 Americans — nine times more than airline crashes.


Despite this toll, NTSB’s last chairperson said that general aviation deaths are not numerous enough to warrant NTSB’s attention.


NTSB currently contends that it is not answerable in any court for its failure to investigate and make safety recommendations to prevent the same accident from happening time and again.


As reported in these pages, the system governing general aviation safety is broken.


It lacks oversight, accountability and resources, resulting in thousands of unnecessary deaths and subjecting private pilots, their passengers – and everyone in their flight paths to undue risk.


General aviation should be as safe as commercial airline travel.


It could be if the agency charged with investigating, assessing and reporting on general aviation crashes, the NTSB, applied the same diligence and resources to general aviation accident investigations as it does to commercial aviation accidents.


Instead, in 86 percent of private plane crashes, the NTSB attributes the accident to pilot error. End of investigation.


Researchers note that blaming the pilot relieves the NTSB as well as the FAA, aircraft and engine manufacturers and airport operators from the time and expense of a thorough accident investigation that could reveal the need for systemic reform or the actual cause of the accident. Worse yet, NTSB claims its findings are not subject to review by any other authorities or by the courts.


This could all change if the U.S. Supreme Court agrees to hear a case we filed on behalf of an Indiana man named Yatish Joshi. Joshi’s daughter, Georgina, died in 2006 when the plane she was piloting crashed outside Bloomington, Indiana. As it almost always does, the NTSB determined that the accident, which also killed the four passengers aboard, was Georgina’s fault.


It’s an easy answer. Blaming pilots, who often aren’t alive to defend themselves, absolves everyone else – air-traffic controllers, regulators, plane and parts manufacturers – and allows the system to carry on without identifying or solving the underlying problems.


Critical deficiencies are thus perpetuated – and accidents continue to happen for the same reasons.


Pilots are people, and can make mistakes. But air traffic controllers are people, airplane designers and manufacturers are people and airplane maintenance workers are people, too.  Yet pilots are disproportionately blamed for airplane accidents.  Making matters worse, if not subject to review, the NTSB’s determinations serve as the final word on the subject – even if they’re wrong. And the truth is never known.


Unsatisfied with the NTSB’s findings about his daughter’s plane crash, Joshi conducted an independent investigation, hiring experts who pored over flight records, examined conditions and interviewed witnesses. They even recreated the flight. The experts found disturbing holes in the NTSB’s report. The agency’s investigators didn’t learn, for example, that the FAA had only one air traffic controller on duty the night of the crash even though FAA regulations required two, or that the controller had received only 10 minutes of final approach control training, or that the radar and weather reporting equipment used by the controller were not appropriate for the services being provided to Georgina. Further, the NTSB never discovered reports of another plane in the area. That plane, which was heard and seen by witnesses immediately prior to the accident, may have flown into Georgina’s path, forcing her to take evasive action – the likely cause of her crash. The NTSB also failed to discover the aircraft damage report prepared by its own investigator.  This report directly contradicts the NTSB’s Probable Cause finding in Georgina’s accident.  Yet, the NTSB continues to say its investigation and findings are complete, accurate and not subject to review.


This isn’t an isolated incident. Similar horrors happen routinely in a system that fails to hold anyone but pilots accountable, leaving safety mechanisms unregulated and often badly outdated. Deployment of the NEXT Gen air traffic control system is more than ten years behind schedule.  That system, which should have been in place by the time of Georgina’s accident, is able to track planes all the way down to the ground, unlike the current radar based system.  When Georgina crashed, the radar covering the Bloomington area could not see planes flying below 1,000 feet; the NEXT Gen technology would have answered many questions about Georgina’s accident, and might have prevented the crash. As a sad testament to the truth of NTSB’s statement that these accidents continue to happen for the same reasons, on April 7, 2015, a near-identical crash occurred in Bloomington, Illinois, killing 7 people.


The NTSB knows it has problems — 15 years ago it commissioned a report by the RAND Corporation that found NTSB lacked the funding, training and investigative prowess it needed to do its job effectively. And yet the agency, operating largely without oversight, has failed to address those shortcomings.


It’s time for the NTSB to be subject to the checks and balances that are faced by other government agencies – that are fundamental to American democracy. That’s why Joshi has taken his case all the way to the Supreme Court. If he’s heard there, it could go a long way toward making the NTSB more effective – and making the skies safer for us all.


Original article can be found here:  http://thehill.com


USA TODAY investigation: Lies and coverups mask roots of small-aircraft crashes 





NTSB Identification: CHI06FA117
The docket is stored in the Docket Management System (DMS). Please contact Records Management Division
Accident occurred Thursday, April 20, 2006 in Bloomington, IN
Probable Cause Approval Date: 06/27/2007
Aircraft: Cessna U206G, registration: N120HS
Injuries: 5 Fatal.

NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

The airplane crashed into trees about 1/2-mile from the approach end of runway 35 while the aircraft was conducting a precision instrument approach in night instrument weather. The flight's plotted radar data was consistent with an airplane that was being vectored for an instrument landing system (ILS) approach. The radar track depicted the aircraft flying above glide path and to the right of course until radar contact was lost at 2,000 feet at 2338:34 about two and a half miles from the approach end of the runway. About 2345, the Sheriff responded to telephone calls of a possible airplane crash. A witness described the airplane sounds as an engine acceleration, followed by a thud, and then no more engine sounds were heard. The airport's weather about the time of the accident was: Wind 230 degrees at 5 knots; visibility 1 statute mile; present weather mist; sky condition overcast 100 feet. The published decision height for the approach was 200 feet agl and one-half mile visibility. A post accident inspection of the ILS determined the ILS was operating normally. The tower did not record after hour radio transmissions. An on-scene examination of the aircraft wreckage did not reveal any pre-impact anomalies. A review of data from an engine monitor showed a reduction in fuel flow consistent with a descent followed by an increase in fuel flow consistent with a full power setting.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The pilot's continued descent below decision height and not maintaining adequate altitude/clearance from the trees while on approach. Factors were the the night lighting conditions, and the mist.

HISTORY OF FLIGHT

On April 20, 2006, about 2345 eastern daylight time, a Cessna U206G, N120HS, piloted by an instrument rated private pilot, was destroyed on impact with trees and terrain while on approach to runway 35 at the Monroe County Airport (BMG), near Bloomington, Indiana. The personal flight was operating under the provisions of 14 Code of Federal Regulations Part 91. Night instrument meteorological conditions prevailed at the time of the accident. An instrument flight rules (IFR) flight plan was on file and was activated. The pilot and four passengers sustained fatal injuries. The flight originated from the Purdue University Airport (LAF), near Lafayette, Indiana, about 2245.

The person representing N120HS contacted the Terre Haute, Indiana, federal contract facility automated flight service station (AFSS) to get a weather briefing about 2213. The AFSS briefer at position "PF-3" gave the following brief, in part, to the pilot:

2213:25 PF-3 terre haute flight service

2213:27 N120HS hi i'd like to get a weather briefing

2213:29 PF-3 yes ma'am

2213:30 N120HS um lafayette lima alpha foxtrot and bloomington bravo mike golf and any interesting weather that might be between them

2213:39 PF-3 okay uh what's the aircraft call sign you're using

2213:42 N120HS november one two zero hotel sierra

2213:45 PF-3 and what time are you leaving lafayette

2213:47 N120HS we will probably be leaving in about twenty minutes to half an hour

2213:58 PF-3 okay and is this a v f r flight or i f r

2214:02 N120HS for v f r

2214:03 PF-3 v f r only

2214:05 N120HS *(ho ho) wait i'm sorry go ahead

2214:08 PF-3 is that v f r only

2214:10 N120HS yes yes sir well depending on what the 
weather's like

2214:13 PF-3 okay well we do have an airmet for i f r for the southern portion of indiana now

0214:18 N120HS okay

0214:19 PF-3 and they're saying that that may continue the rest of the evening into early tomorrow morning and

2214:23 N120HS okay

2214:23 PF-3 looking at the bloomington weather they do have i f r ceilings eight hundred broken right now with visibility eight miles

2214:30 N120HS *(okay)

2214:30 PF-3 so i wouldn't recommend v f r 

2214:32 N120HS okay well

2214:33 PF-3 uh

2214:33 N120HS definitely not i'm sorry i got i looked at the *(tafs they) didn't predict that okay can i file an i f r flight plan with you

2214:39 PF-3 sure would you like me to continue with the rest of the weather and and all that

2214:42 N120HS yeah that would that would be great

2214:44 PF-3 okay uh that's the only airmet uh going down that way for you uh looks like a low pressure system we've got uh one in western kentucky tennessee another one's up around the chicago area *(it's a) 
stationary front running from that one across northern indiana and ohio and then uh high pressure over to our east precip uh nothing really along that route there is some in southeastern indiana but it shouldn't affect your flight at all

2215:08 N120HS *(okay)

2215:08 PF-3 at lafayette uh the winds are two eighty at four ten miles skies clear below twelve thousand sixteen and seven and two nine nine one that's an automated report en route looking at a few clouds at thirteen 
thousand with niner miles and then again in the bloomington area winds two forty at three eight miles ceiling eight hundred broken seventeen and sixteen and two nine nine four that's also an automated report at bloomington and i don't see any uh pilot reports right now along that route for you the forecast lafayette was saying the rest of the evening a few clouds at six thousand winds three ten at five en route uh calling for *(uh) it looks like three thousand scattered six to ten thousand broken to overcast they were saying occasional showers in central indiana til zero three hundred though there's nothing really showing except for a little northeast of indy and then uh for the bloomington area uh six hundred broken five thousand overcast visibility better than six winds one sixty at four now they were saying within an hour you might see six hundred scattered five in mist around bloomington four hun four thousand broken and winds one fifty at four but the airmet was calling for i f r to continue the rest of the night into early tomorrow

2216:26 N120HS boy am i glad i called you wow

2216:27 PF-3 and

2216:28 N120HS okay

2216:28 PF-3 and then winds aloft uh would you like three and six for those

2216:32 N120HS um just three please

2216:33 PF-3 three thousand you're looking at light and variable winds at three thousand

2216:37 N120HS okay great

2216:38 PF-3 and notams uh lafayette r c o one two two three five is out of service

2216:44 PF-3 and uh it says the class d surface area and uh tower only available through zero one hundred daily down at Bloomington uh showing tower and class d surface area available through zero one thirty daily and 
three five pilot controlled lighting is out of service at bloomington indiana and otherwise en route i don't see anything else en route for you notam d wise as far as t f rs no unpublished t f rs along that route at this time

2217:15 N120HS *(great)

2217:15 PF-3 *(we'd) appreciate uh pilot reports flight watch is shut down for the evening but any any flight service frequencies along the route for you would you like to go ahead and file then

2217:24 N120HS yes sir

2217:25 PF-3 okay i'm ready to copy

2217:26 N120HS (unintelligible) november one two zero hotel sierra it's a cessna two oh six slash alpha airspeed a hundred and a hundred and thirty knots flying at three thousand feet departing lafayette lima alpha foxtrot lafayette direct bloomington indiana bravo mike golf five on board three hours of fuel the aircraft is based in south bend pilots name ... and aircraft is red white and blue 

2218:12 PF-3 (unintelligible) uh what's your time en route from lafayette to bloomington

2218:15 N120HS time on route forty minutes

2218:19 PF-3 and you say you're leaving in just a few minutes i put that out for zero two thirty that's on the half hour

2218:23 N120HS *(perfect)

The transcript of the weather briefing showed that the pilot did not give an alternate airport to the briefer when the flight plan was filed. The briefer did not ask for an alternate airport and was not required to ask for one.

About 2319, the pilot checked on with the Air Route Traffic Control Center controller working the Shelbyville, Indiana, sector (SHB R). The transcript of their transmissions, in part, stated:

2319:57 N120HS indy center november one two zero hotel sierra is with you at five thousand

2320:01 SHB R november one two zero hotel sierra indianapolis center roger how do you hear center

2320:04 N120HS ah loud and clear

2320:05 SHB R okay and ah what type of approach are you going to shoot into bloomington this morning or this evening

2320:11 N120HS we'd like to go for a runway three five six ah i l s

2320:14 SHB R i l s three five okay you can expect that ah one two zero hotel sierra do you have the ah asos weather

2320:19 N120HS yes sir

2320:20 SHB R all right

2323:11 SHB R cessna one two zero hotel sierra you're one two miles north of bloomington cross bloomington at or above two thousand six hundred cleared for the i l s runway three five approach report procedure turn inbound

2323:23 N120HS oh any way we can have vectors to the---ah final course

2323:26 SHB R not a problem at all ma'am what's your heading

2323:30 N120HS one seven zero

2323:32 SHB R okay turn ah right heading of ah one nine zero it'll be a vector for a left down wind entry for i l s three five straight in

2323:39 N120HS one niner zero for a---right down wind entry ah for three five zero hotel sierra

2323:43 SHB R yes ma'am and maintain five thousand

2323:46 N120HS maintain five thousand

2328:35 SHB R cessna one two zero hotel turn left heading one eight zero

2328:39 N120HS left heading one eight zero

2333:03 SHB R cessna one two zero hotel sierra descend at pilot's discretion maintain four thousand

2333:08 N120HS descend and maintain four thousand for zero hotel sierra

2333:13 SHB R i am going to take you about two miles outside of claye if that's okay with you ma'am

2333: 18 N120HS that's great

2333:50 SHB R cessna one two zero hotel sierra turn left heading zero eight zero

2333:53 N120HS left heading zero eight zero

2334:36 SHB R cessna one two zero hotel sierra three and a half miles south of claye turn left heading zero two zero maintain two thousand six hundred until established on the localizer you're cleared straight in i l s runway three five approach

2334:48 N120HS turn left heading zero two zero---cleared for the approach maintain twenty six hundred til ah established zero hotel sierra

2336:15 SHB R cessna one two zero hotel sierra see you joining up on the localizer now radar service is terminated change to advisory tower frequency of one two eight point zero two is approved---and i'll need you to 
cancel---with ah terre haute tower on that frequency one two eight point zero two they monitor that frequency and they'll relay for ya

2336:35 N120HS radar service terminated and cancel with terre haute on one two eight point zero two thanks (unintelligible) zero hotel sierra

2336:40 SHB R and you can change to that frequency now you have a good night

2336:43 N120HS thanks

A Continuous Data Recording (CDR) airplane radar track data file was obtained from the Federal Aviation Administration (FAA) in reference to the accident flight. The airplane's radar returns along with their respective altitudes and times were plotted. The plotted data was consistent with an airplane that was being vectored for an instrument landing system (ILS) approach to runway (rwy) 35. The plot showed the airplane at about 5,000 feet on a downwind. At 2334:30, the return showed the airplane was about 4,500 feet on base about ten miles from the approach end of runway 35. The airplane's return at 2337 was right of and approaching the outer marker CLAYE at an altitude of 3,300 feet. About 2337, the pilot made an advisory radio call on the Hulman Approach control frequency for BMG (128.025) that the flight was six miles south of BMG and inbound for runway 35. The last plotted return showed the airplane at 2,000 feet at 2338:34 about two and a half miles from the approach end of runway 35. About 2343, the controller from the Terre Haute International Airport-Hulman Field air traffic control tower, near Terre Haute, Indiana, who was working the approach frequency, advised the flight that the BMG common traffic advisory frequency (CTAF) was 120.77 and the flight responded with "Thank you sir." No further communication was recorded with the accident flight. That plotted chart is appended to the docket material associated with this case.

About 2345, the Monroe County Sheriff responded to telephone calls of a possible airplane crash. About 0400, the wreckage was located in a wooded area about one-half mile from the approach end of runway 35. 

Witnesses in the area stated that they were awakened by a low flying aircraft. A witness said that the airplane noise was like a roar. Another described it as an engine acceleration. A thud was heard and no more engine sounds were heard.

PERSONNEL INFORMATION

The pilot held a private pilot certificate with single-engine land, multiengine land, and instrument airplane ratings. The airplane operator reported that the pilot had completed a flight review or equivalent on July 3, 2005. It was further reported that the pilot had accumulated 379.1 hours of total flight time, 24.5 hours of actual instrument time, 51.1 hours of simulated instrument time, 30.4 hours of total flight time in the previous 90 days, 18.0 hours of total flight time in the previous 30 days, and 1.8 hours of total flight time in the previous 24 hours. 

She held a FAA third-class medical certificate issued on August 19, 2003, with a limitation for corrective lenses. 

AIRCRAFT INFORMATION

N120HS, a Cessna U206G, Stationair 6, serial number U20604728, was a six-place, single engine, high-wing, all-metal airplane of semimonocoque construction. The wings were externally braced and each wing contained a standard integral 46-gallon fuel tank. The airplane was powered by a six-cylinder, horizontally opposed, air cooled, fuel injected, marked as a Continental IO-520-F (17) engine, with serial number 812264-R. The engine was rated at 300 horsepower for five minutes and 285 horsepower continuously. Maintenance records showed that the airplane's propeller was a three-bladed McCauley D3A34C404B model, hub serial number 785309. The airplane was issued a standard airworthiness certificate and was certified for normal category operations.

Maintenance records show that the last annual inspection was performed on June 7, 2005, and that the airplane had accumulated 2,125.7 hours at the time of that inspection. An entry in the records showed that the static system was inspected in accordance with Part 91.411 and 91.413 requirements on May 19, 2005.

The airplane was equipped with a J.P. Instruments Engine Data Management (EDM) 700 system. According to manufacturer's data, the EDM will monitor up to twenty-four critical parameters in your engine, four times a second, with a linearized thermocouple accuracy of better than 0.1 percent or 2 degrees F, has a user selectable index rate, fast response probes, non-volatile long term memory, records and stores data up to 30 hours, and has post-flight data retrieval capabilities.

METEOROLOGICAL INFORMATION

At 2340, the recorded weather at BMG was: Wind 230 degrees at 5 knots; visibility 1 statute mile; present weather mist; sky condition overcast 100 feet; temperature 17 degrees C; dew point 16 degrees C; altimeter 29.94 inches of mercury.

AIDS TO NAVIGATION

There were eight non-precision instrument approaches and one precision approach available at the airport.

The published inbound course for BMG's ILS RWY 35 approach was 354 degrees magnetic, with the published decision height (DH) of 1,045 feet msl. The crossing altitude for the final approach fix (CLAYE) was 2,533 feet msl. The distance between CLAYE and the missed approach point was 5.1 nautical miles (nm). The airport elevation was 846 feet msl. 

The published weather minimums for the ILS RWY 35 approach were a 200-foot ceiling and one-half mile visibility for category A, B, C, and D aircraft. 

On April 21, 2006 the FAA conducted a post aircraft accident technical inspection and found the ILS system was operating normally.

AIRPORT INFORMATION

BMG had two asphalt-surfaced runways, 17/35 and 6/24. Runway 17/35 was 6,500 feet long and 150 feet wide. Runway 35 was equipped with a medium intensity approach lighting system with runway alignment indicator lights (MALSR) and high intensity runway lights (HIRL). Runways 6,17, and 24 were equipped with visual approach slope indicators (VASI) located on the left side of their respective runways.

The airport was serviced by an Air Traffic Control tower. The tower was attended from 0630 - 2130 local. After hour local traffic communications were accomplished via the published airport CTAF 120.775 megahertz (MHz). The tower did not record the CTAF transmissions made after hours. Indianapolis Approach provided approach/departure control services for the airport.

The pilot controlled lighting function of the approach lights was not operative. The approach lights were turned on before the tower was closed.

WRECKAGE AND IMPACT INFORMATION

The airplane came to rest inverted on an approximate 180 degree magnetic heading. Broken and linearly separated tree branches were observed. A tree on a 230 degree magnetic heading from the wreckage and about 6 feet from the wreckage contained embedded aluminum colored metal consistent with the nose wheel rim. The engine was found about three feet below the surface. The propeller hub remained attached to the engine crankshaft propeller flange. The propeller blades separated from their hub. One blade exhibited forward bending and leading edge deformation. All of the blades exhibited chordwise abrasion. The wings were detached from the fuselage. The outboard section of the left wing had separated from the inboard section. The rudder was detached from the empennage and its control cables remained attached.

An on-scene examination of the wreckage was conducted. Flight control cables were traced. All breaks in cables were consistent with overload. Flight control continuity was established from the cabin area to all flight control surfaces. The engine's control cables were traced from the cabin to the engine and engine control continuity was established. A blue liquid consistent with 100 low lead aviation gasoline was observed in the left tank.

The wreckage was relocated for a detailed examination and wreckage layout. The right engine driven vacuum pump was separated from the accessory case. The pump's drive coupler was not recovered. The right vacuum pump was rotated by hand and an inspection revealed that its rotor and vanes were intact. The left pump was attached to the accessory case. The pump was crushed and an inspection revealed its rotor was fragmented. The sparkplugs were removed and no anomalies were detected. The engine was rotated by hand and a thumb compression was observed at all cylinders. The right magneto was crushed, deformed, and did not produce any spark when rotated by hand. The left magneto produced spark at all leads when rotated by hand. The engine driven fuel pump's coupler was intact. A blue liquid consistent with 100 low lead aviation gasoline was found in the fuel line from the engine driven fuel pump to the manifold valve. The attitude indicator and horizontal situation indicator rotors exhibited rotational scoring. The rotor housings exhibited witness marks consistent with contact with their rotors. The altimeter's Kollsman window indicated 29.91. The airplane's engine monitor was crushed. The on-scene investigation did not reveal any pre-impact anomalies.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was performed on the pilot by the Monroe County Coroner's Office on April 22, 2006.

The FAA Civil Aeromedical Institute prepared a Final Forensic Toxicology Accident Report. The report was negative for the tests performed.

TESTS AND RESEARCH

The engine monitor was examined at its manufacturer. The unit and its circuit board were crushed. The data memory chip was removed from its circuit board and installed on a serviceable circuit board. The accident flight's data was downloaded. The downloaded data was graphed. The end of the graph showed a reduction in fuel flow consistent with a descent followed by an increase in fuel flow consistent with a full power setting and the data stopped at that point. The graph of the engine monitor's data is appended to the docket material associated with this investigation.

ADDITIONAL DATA/INFORMATION

Federal Aviation Regulation Part 91.169 IFR flight plan: information required, in part, stated:

(a) Information required. Unless otherwise authorized by ATC, each person filing an IFR flight plan shall include in it the following information:

(1) Information required under Sec. 91.153(a).
(2) An alternate airport, except as provided in paragraph (b) of this section.
(b) Exceptions to applicability of paragraph (a)(2) of this section. 
Paragraph (a)(2) of this section does not apply if part 97 of this chapter prescribes a standard instrument approach procedure for the first airport of intended landing and, for at least 1 hour before and 1 hour after the estimated time of arrival, the weather reports or forecasts, or any combination of them indicate--
(1) The ceiling will be at least 2,000 feet above the airport elevation; and
(2) The visibility will be at least 3 statute miles.
(c) IFR alternate airport weather minimums. Unless otherwise 
authorized by the Administrator, no person may include an alternate airport in an IFR flight plan unless current weather forecasts indicate that, at the estimated time of arrival at the alternate airport, the ceiling 
and visibility at that airport will be at or above the following alternate airport weather minimums:
(1) If an instrument approach procedure has been published in part 97 of this chapter for that airport, the alternate airport minimums specified in that procedure or, if none are so specified, the following minimums:
(i) Precision approach procedure: Ceiling 600 feet and visibility 2 statute miles.
(ii) Nonprecision approach procedure: Ceiling 800 feet and visibility 2 statute miles.
(2) If no instrument approach procedure has been published in part 97 of this chapter for that airport, the ceiling and visibility minimums are those allowing descent from the MEA, approach, and landing under basic VFR.

The operator's safety recommendation, in part stated:

Even if a tower is closed, as it was in this case, there should be an automatic recording of all pilot transmissions on the common frequency. Such a recording would make available vital information in the case of a fatal accident [for example] did the pilot make a distress call? Does the pilot's voice indicate that they are under duress? Was it the pilot's intention to do a missed approach? Was there anything that may have interfered with the pilot's conduct of the flight? Did the pilot make any announcement indicating what problem they were facing? Was there any other aircraft in the immediate vicinity? The parties to the investigation included the FAA, Cessna Aircraft Company, and Teledyne Continental Motors.  The aircraft wreckage was released to a representative of the insurance company.














MAKE IT HAPPEN AVIATION LLC: http://registry.faa.gov/N789UP

NTSB Identification: CEN15FA190
14 CFR Part 91: General Aviation
Accident occurred Tuesday, April 07, 2015 in Bloomington, IL
Aircraft: CESSNA 414A, registration: N789UP
Injuries: 7 Fatal.

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

On April 7, 2015, about 0006 central daylight time (all referenced times will reflect central daylight time), a Cessna model 414A twin-engine airplane, N789UP, was substantially damaged when it collided with terrain following a loss of control during an instrument approach to Central Illinois Regional Airport (BMI), Bloomington, Illinois. The airline transport pilot and six passengers were fatally injured. The airplane was owned by and registered to Make It Happen Aviation, LLC, and was operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 while on an instrument flight rules (IFR) flight plan. Night instrument meteorological conditions prevailed for the cross-country flight that departed Indianapolis International Airport (IND), Indianapolis, Indiana, at 2307 central daylight time.

According to preliminary Federal Aviation Administration (FAA) Air Traffic Control (ATC) data, after departure the flight proceeded direct to BMI and climbed to a final cruise altitude of 8,000 feet mean sea level (msl). According to radar data, at 2344:38 (hhmm:ss), about 42 nautical miles (nm) south-southeast of BMI, the flight began a cruise descent to 4,000 feet msl. At 2352:06, the pilot established contact with Peoria Terminal Radar Approach Control, reported being level at 4,000 feet mean sea level (msl), and requested the Instrument Landing System (ILS) Runway 20 instrument approach into BMI. According to radar data, the flight was located about 21 nm south-southeast of BMI and was established on a direct course to BMI at 4,000 feet msl. The approach controller told the pilot to expect radar vectors for the ILS Runway 20 approach. At 2354:18, the approach controller told the pilot to make a right turn to a 330 degree heading. The pilot acknowledged the heading change. At 2359:16, the approach controller cleared the flight to descend to maintain 2,500 feet msl. At 2359:20, the pilot acknowledged the descent clearance.

At 0000:01, the approach controller told the pilot to turn left to a 290 heading. The pilot acknowledged the heading change. At 0000:39, the approach controller told the pilot that the flight was 5 nm from EGROW intersection, cleared the flight for the ILS Runway 20 instrument approach, issued a heading change to 230 degrees to intercept the final approach course, and told the pilot to maintain 2,500 feet until established on the inbound course. The pilot correctly read-back the instrument approach clearance, the heading to intercept the localizer, and the altitude restriction.

According to radar data, at 0001:26, the flight crossed through the final approach course while on the assigned 230 degree heading before it turned to a southerly heading. The plotted radar data showed the flight made course corrections on both sides of the localizer centerline as it proceeded inbound toward EGROW. At 0001:47, the approach controller told the pilot to cancel his IFR flight plan on the approach control radio frequency, that radar services were terminated, and authorized a change to the common traffic advisory frequency (CTAF). According to radar data, the flight was 3.4 nm outside of EGROW, established inbound on the localizer, at 2,400 feet msl. At 0002:00, the pilot transmitted over the unmonitored CTAF, "twin Cessna seven eight nine uniform pop is coming up on EGROW, ILS Runway 20, full stop." No additional transmissions from the pilot were recorded on the CTAF or by Peoria Approach Control.

According to radar data, at 0003:12, the flight crossed over the locator outer marker (EGROW) at 2,100 feet msl. The flight continued to descend while tracking the localizer toward the runway. At 0003:46, the airplane descended below available radar coverage at 1,500 feet msl. The flight was about 3.5 nm from the end of the runway when it descended below radar coverage. Subsequently, at 0004:34, radar coverage was reestablished with the flight about 1.7 nm north of the runway threshold at 1,400 feet msl. The plotted radar data showed that, between 0004:34 and 0005:08, the flight climbed from 1,400 feet msl to 2,000 feet msl while maintaining a southerly course. At 0005:08, the flight began a descending left turn to an easterly course. The airplane continued to descend on the easterly course until reaching 1,500 feet msl at 0005:27. The airplane then began a climb while maintaining an easterly course. At 0005:42, the airplane had flown 0.75 nm east of the localizer centerline and had climbed to 2,000 feet. At 0005:47, the flight descended below available radar coverage at 1,800 feet msl. Subsequently, at 0006:11, radar coverage was reestablished at 1,600 feet msl about 0.7 nm southeast of the previous radar return. The next two radar returns, recorded at 0006:16 and 0006:20, were at 1,900 feet msl and were consistent with the airplane continuing on an easterly course. The final radar return was recorded at 0006:25 at 1,600 feet msl about 2 nm east-northeast of the runway 20 threshold.

At 0005, the BMI automated surface observing system reported: wind 060 degrees at 6 knots, an overcast ceiling at 200 feet above ground level (agl), 1/2 mile surface visibility with light rain and fog, temperature 13 degrees Celsius, dew point 13 degrees Celsius, and an altimeter setting of 29.98 inches of mercury.

Federal Aviation Administration Flight Standards District Office: FAA Springfield FSDO-19








McLean County Sheriff Jon Sandage joined by Coroner Kathleen Davis as he reads a statement to reporters.


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