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On March 15, 2002, at 0200 central standard time, a Cessna 208B, N228PA, operated by Priority Air Charter, Kidron, Ohio, sustained substantial damage during impact with trees and terrain near Alma, Wisconsin. Instrument meteorological conditions prevailed at the time of the accident. The flight was being operated under the provisions of 14 CFR Part 135 as an on-demand cargo flight and was on an instrument flight rules (IFR) flight plan. The commercial pilot was fatally injured. The flight departed Minneapolis - St. Paul International Airport (MSP), Minneapolis, Minnesota, at 0105 and had the intended destination of Willow Run Airport, Detroit, Michigan.
Employees of a fixed base operator (FBO) located at MSP reported N228PA arrived at the FBO between 0000 and 0030. One FBO employee reported there was about 1/4 inch strip of ice on the leading edges of the wings and horizontal stabilizer. The employee stated a "clear coat" of ice covered the propeller and that 3/4 inch of mixed ice covered the area aft of the leading edge de-ice boots on both wings. The employee asked the pilot how the weather was coming into MSP and the pilot replied that it was "pretty bad up there." Another employee reported the airplane had ice on both wings, both wing struts, and the fuselage. The employee estimated the thickness of the ice accumulation to be 1/8 to 1/2 inch. Several FBO employees stated they asked the pilot if he needed the airplane deiced prior to his next departure and that the pilot stated to multiple FBO employees that he did not need any deice service. Several FBO employees said they noticed the pilot chipping-off ice from the airplane prior to his departure. The airplane was fueled with 180 gallons of Jet-A fuel prior to its departure and was loaded with four boxes that had a reported combined weight of 100 lbs. No additional services were provided. The airplane departed the FBO ramp about 0100.
According to information provided by the Federal Aviation Administration (FAA) Minneapolis Air Route Traffic Control Center (ARTCC), the pilot of N228PA established radio contact at 0126:21 (hhmm:ss) and reported that he was climbing to 5,000 feet above mean sea level (msl). The following is a summary of the voice communications between Minneapolis ARTCC and N228PA:
0126:38 The controller advised N228PA of a pilot report of light rime ice at 5,000 feet msl and that the reporting airplane descended to 4,000 feet msl.
0126:59 N228PA requested and was cleared to descend to 4,000 feet msl.
0132:40 N228PA queried the controller about when he would be clear of the icing conditions.
0132:49 The controller verified with the pilot that N228PA was in icing conditions.
0133:58 The controller advised N228PA that he did not know when N228PA would be out of icing conditions and advised N228PA that he would most likely be clear of the icing conditions at 11,000 feet msl heading eastbound. N228PA acknowledged.
0134:52 N228PA requested a turn to get clear of the icing conditions and that he was having a hard time maintaining altitude.
0135:40 The controller informed N228PA that an aircraft twenty miles in front of N228PA was reporting icing conditions at 4,000 feet msl. The controller asked N228PA if he wanted to turn back towards Minneapolis or continue eastbound.
0135:51 N228PA queried if a turn to the south would help.
0135:56 The controller informed N228PA that there were no aircraft to the south of N228PA and that the only precipitation he had on his scope was east of Minneapolis, Minnesota, extending up north of Eau Claire, Wisconsin, and towards Rhinelander, Wisconsin. The controller informed N228PA that the preceding aircraft was in icing conditions at 4,000 feet msl.
0136:12 N228PA replied that he was going to continue as previously cleared.
0136:19 The controller advised N228PA that he believed that there was no icing above 10,000 feet.
0138:15 The controller advised N228PA that the weather at Madison, Wisconsin, was broken clouds at 2,500 feet above ground level (agl), mist, and no reports of snow.
0138:28 N228PA asked to head towards Madison.
0141:15 The controller queried N228PA on how he was doing.
0141:18 N228PA responded, "ah we're holding our own here sir, we seem to be doing alright at this altitude".
0145:26 N228PA asked the controller, "... any suggestions here looks like we're gonna need to land somewhere we're starting to have a hard time holding altitude here."
0145:33 The controller informed N228PA that the Winona airport was about 22 miles at the one o'clock position.
0145:41 The controller advised N228PA that the weather at Winona was broken clouds at 500 feet agl, 1,100 feet agl overcast, 3 miles visibility, and altimeter setting was 29.56 inches-of-mercury.
0145:52 N228PA reported that he wanted to go to Winona.
0146:43 N228PA asked what type of instrument approaches were at Winona.
0146:46 The controller advised N228PA that there were the VOR 29, VOR A, and GPS 29 approaches at Winona.
0148:13 The controller queried N228PA on how he was doing.
0148:15 N228PA asked what the distance to Winona was.
0148:35 The controller advised N228PA that Winona was about 15 miles at the one o'clock position.
0148:39 N228PA advised he was going to Winona and asked what the airport identifier was for Winona.
0148:44 The controller advised N228PA that the Winona airport identifier was ONA, the frequency of the VOR, and gave him the inbound radial for the VOR A approach.
0149:53 The controller queried N228PA on how he was doing.
0150:16 The controller asked if N228PA had the Winona VOR tuned-in.
0150:20 N228PA replied that he had the Winona VOR tuned-in.
0150:21 The controller asked N228PA what radial he was tracking in-bound to the VOR.
0150:26 N228PA replied that he was tracking the 330 radial to the VOR.
0150:32 The controller asked N228PA if he had the approach plates and if he had any time to look at the them.
0150:35 N228PA reported, "I tell you what, I got my hands full right now."
0150:54 N228PA asked what the identifier was for the Winona Municipal Airport.
0150:56 The controller informed N228PA that the identifier was ONA and that the airport was the Winona Municipal Airport.
0151:04 N228PA asked what the identifier was for the Winona Municipal Airport.
0151:06 The controller informed N228PA that it was ONA.
0151:53 The controller advised N228PA that the minimum safe altitude for the area was 3,000 feet msl.
0152:00 N228PA replied that he was unable to maintain 3,000 feet msl.
0152:25 N228PA asked what the identifier was for the Winona Municipal Airport.
0152:28 The controller informed N228PA that the identifier was ONA.
Minneapolis ARTCC did not receive any additional communications from N228PA and radar contact was lost at 0155:00.
A full transcription of the voice communications between Minneapolis ARTCC and the N228PA is included with the docket material associated with this accident report.
According to Federal Aviation Administration (FAA) records, the pilot held a commercial pilot certificate with airplane single-engine land, airplane multiengine land, and instrument airplane ratings. FAA records show the pilot's last medical examination was completed on March 29, 2001, and the pilot was issued a second-class medical certificate with no restrictions or limitations.
According to Priority Air Charter, the pilot reported a total flight time of 3,800 hours when he was hired during January 2000, of which 3,775 hours were in single-engine airplanes and 25 hours were in multiengine airplanes. The pilot reported that he had 1,500 hours in the Cessna 208 at the time of hire. Priority Air Charter reported that the pilot had flown 816.7 hours since January 2000, all of which were in the Cessna 208. Priority Air Charter reported that the pilot had flown 47.4 hours during the last 90 days and 20.0 hours during the last 30 days.
The pilot's last FAA Airman Competency/Proficiency Check was completed on March 9, 2002, and he was approved for 14 CFR Part 135 pilot-in-command operations.
The pilot attended recurrent ground training for the Cessna 208 aircraft on December 27, 2001. Portions of the recurrent training included instruction in the following areas:
* "Procedures for recognizing and avoiding severe weather conditions"
* "Procedures for escaping from severe weather situations, in case of inadvertent encounters, including low-altitude windshear"
* "Procedures for operating in or near thunderstorms, turbulent air, icing, hail, and other potentially hazardous meteorological conditions"
* "Each normal and emergency procedure"
* "Ground deicing/anti-icing program"
The airplane was a Cessna 208B Caravan, serial number 208B0049. The Cessna 208B is a single engine, turbo-prop, high-wing airplane. The Cessna 208B is equipped with a fixed tricycle landing gear and is powered by a single turboshaft engine. The fuselage and empennage are of an all-metal semimonocoque design. The wings are externally braced and have two integral fuel tanks. The accident airplane was configured for flight into known icing conditions and to carry cargo. The airplane was equipped with two cockpit seats. The Cessna 208B has a certified maximum takeoff weight of 8,750 lbs and a maximum useful load of 4,745 lbs.
The airplane was issued a Standard Airworthiness Certificate on November 9, 2000, after being rebuilt from a previous accident that occurred during November 1997. The last inspection was performed on March 1, 2002, at 9,902.9 hours total time and 992.1 hours since being rebuilt. Prior to the accident flight the airplane had accumulated 1,031.5 hours since the airplane was rebuilt and had a total flight time of 9,942.4 hours. The airplane was being maintained by compliance with a Cessna Progressive Inspection Program for the Cessna 208B.
The engine was a 675 horsepower Pratt & Whitney PT6A-114A, serial number PC-E17455. The engine was last overhauled on October 2, 2000, at a total time of 3,103.2 hours. The engine was installed on the accident airplane on November 8, 2000. The last inspection of the engine was on March 1, 2002, at 4,095.2 hours total time and 992.1 hours since the last overhaul. Prior to the accident flight the engine had accumulated 1,031.5 hours since the last overhaul and had a total time of 5,126.7 hours.
The propeller was an electrically heated three-bladed McCauley 3GFR34C703-B/106GA-0, hub serial number 960492. The propeller was last overhauled on October 18, 2000, at a total time of 3,976.6 hours. The propeller was installed on the accident airplane on November 8, 2000. The last inspection of the propeller was on March 1, 2002, at 4,968.7 hours total time and 992.1 hours since last overhaul. Prior to the accident flight the propeller had accumulated 1,031.5 hours since the last overhaul and had a total time of 5,008.1 hours.
A weather observation station, located at the Winona Municipal Airport (ONA), about 17 nautical miles (nm) and 168 degrees from the accident site, reported the weather approximately three minutes prior to the accident as:
Observation Time: 0157 cst
Wind: 310 degrees magnetic at 6 knots
Visibility: 2 1/2 statute miles
Current Weather: Unknown precipitation
Sky Condition: Broken clouds at 600 feet above ground level (agl)
Overcast layer at 1,200 feet agl
Temperature: -01 degrees centigrade
Dew Point: -01 degrees centigrade
Pressure: 29.57 inches of mercury
The Chicago area forecast (FA), issued at 2045 cst on March 14, 2002, indicated that the southern 3/4 of Minnesota was forecast to have overcast ceilings varying between 1,000 and 1,500 feet agl, clouds layered to flight level 200, and visibilities of 3 to 5 statute miles with light snow, blowing snow and mist. The wind was forecast to be from the north at 15 knots with gusts to 30 knots. Isolated embedded thunderstorms with snow, and cloud tops at flight level 250 were forecast. The outlook for the area was marginal visual flight rules (VFR) conditions due to low ceilings and snow.
An AIRMET for instrument flight rules (IFR) conditions was issued at 2045 cst on March 14, 2002, and indicated occasional widespread areas of ceilings below 1,000 feet agl and/or visibilities below 3 statute miles with light snow, blowing snow, and mist. The IFR conditions were forecast to continue beyond 0300 cst.
An AIRMET for icing conditions and freezing level was issued at 2045 cst on March 14, 2002, and indicated occasional moderate rime, mixed, and clear icing conditions in clouds and in precipitation below 16,000 feet msl. The icing conditions were expected to continue beyond 0300 cst. The freezing level was from the surface to 2,000 feet.
A SIGMET for icing conditions was issued at 2133 cst on March 14, 2002, and indicated occasional severe mixed and clear icing conditions in clouds and in precipitation between 3,000 and 14,000 feet msl. The icing conditions were expected to continue beyond 0233 cst.
The amended Chicago area forecast (FA), issued at 2142 cst on March 14, 2002, indicated that the southern 3/4 of Minnesota was forecast to have overcast ceilings varying between 1,000 and 1,500 feet agl, clouds layered to flight level 250, and visibilities of 3 to 5 statute miles with light snow, blowing snow and mist. The wind was from the north at 15 knots with gusts to 30 knots. Isolated embedded thunderstorms with snow, and cloud tops at flight level 250 were forecast. The outlook for the area was marginal visual flight rules (VFR) conditions due to low ceilings and snow.
On March 15, 2002, at 0230 a SIGMET was issued for occasional severe mixed and clear icing conditions in clouds and in precipitation below 12,000 feet msl. The icing conditions were reported to be moving east northeastward and were expected to continue beyond 0630 cst.
The pilot contacted the Lansing Automated Flight Service Station (AFSS) at 2057:56 while en route to Minneapolis for a weather briefing. The briefing consisted of the current and forecast weather conditions along the route of flight, including a forecast for occasional severe icing. At the completion of the briefing the pilot supplied a pilot weather report (PIREP).
The pilot contacted the Green Bay AFSS at 2226:39 while en route to Minneapolis for an updated weather briefing. The briefing consisted of the current and forecast weather conditions at Minneapolis. At the completion of the briefing the pilot supplied a pilot weather report (PIREP).
Transcriptions of both weather briefings are appended to this factual report.
WRECKAGE AND IMPACT INFORMATION
The National Transportation Safety Board's on-scene investigation began on March 16, 2002.
A global positioning system (GPS) receiver reported the accident site position as 44 degrees 21 minutes 26.34 seconds north latitude, 91 degrees 47 minutes 09.00 seconds west longitude, at approximately 900 feet msl. The accident site was located on the side of a ravine approximately 17 nm north-northwest of the Winona Municipal Airport. All components of the aircraft were identified and accounted for at the accident site.
The leading edges of both wings had several semicircular crush zones that were perpendicular to the leading edges. The semicircular crush marks were the same diameter of trees near the location of the accident. Several pieces of ice were recovered around the accident site and were between 1-1/2 to 3 inches thick. One of the recovered ice pieces had a semicircular shaped edge that was consistent with a leading edge of an airfoil. No pre-impact anomalies were found with the leading edge de-ice boots that were installed on both wings, vertical and horizontal stabilizers, and wing struts.
MEDICAL AND PATHOLOGICAL INFORMATION
An autopsy was performed on the pilot at the Sacred Heart Hospital, Eau Claire, Wisconsin, on March 16, 2002.
A Forensic Toxicology Fatal Accident Report was prepared by the FAA Civil Aeromedical Institute, Oklahoma City, Oklahoma.
The toxicology results for the pilot were:
* No Carbon Monoxide detected in Blood
* No Cyanide detected in Blood
* No Ethanol detected in Vitreous
* 0.0108 (ug/ml, ug/g) Tetrahydrocannabinol Carboxylic Acid (Marihuana) detected in Blood
* 0.042 (ug/ml, ug/g) Tetrahydrocannabinol Carboxylic Acid (Marihuana) detected in Urine
* 0.2285 (ug/ml, ug/g) Tetrahydrocannabinol Carboxylic Acid (Marihuana) detected in Bile
Ameristar was the customer of Priority Air Charter. According to the Ameristar vice president of operations, she contacted Priority Air Charter to see if they would be able to deliver some cargo from MSP to Detroit, Michigan. She informed the Priority Air Charter dispatcher that there was icing conditions around MSP and that one of their operators had a Cessna 402 declare an emergency and land at Eau Claire, Wisconsin, due to the existing icing conditions. She asked if Priority Air Charter would be still able to make the trip and the Priority Air Charter dispatcher responded, "Yes, I spoke with my boss and we can do it." She reported that the Priority Air Charter dispatcher called at 2004 cst and stated that N228PA was enroute to MSP to pick up the cargo.
According to the pilot of a Cessna 310 that was flying approximately 20 miles in front of the accident airplane, he had departed slightly ahead of the accident airplane and was flying in the same direction. The pilot reported that he was cleared to 7,000 feet msl where he encountered moderate icing conditions. The pilot stated that Minneapolis ARTCC advised that a Hawker jet reported no icing between 4,000 and 5,000 feet msl. The pilot reported that he requested and was cleared to descend to 4,000 feet msl. The pilot stated that he started to accrue ice at 4,000 feet msl and the ice on the windshield was "Bridging" over the windshield deice plate. The pilot reported that he instructed Minneapolis ARTCC that he needed to land at La Crosse, Wisconsin. During a post-flight inspection of the airplane the pilot noticed that there was 3 inches of clear ice on the leading edges of the wings and the tip tanks were covered with about 1/2 inch of ice. The pilot stated there were 3 to 4 inch long "horns" protruding out at right angles from the tip tank surfaces.
Federal Aviation Regulation (FAR) 135.227, entitled "Icing Conditions: Operating Limitations", states in-part:
(A) No pilot may takeoff an aircraft that has frost, ice, or snow adhering to any rotor blade, propeller, windshield, wing, stabilizing or control surface, to a powerplant installation, or to an airspeed, altimeter, rate of climb, or flight attitude instrument system.
(B) No certificate holder may authorize an airplane to takeoff and no pilot may takeoff an airplane any time conditions are such that frost, ice, or snow may reasonably be expected to adhere to the airplane unless the pilot has completed all applicable training as required by § 135.341 and unless one of the following requirements is met:
(1) A pretakeoff contamination check, that has been established by the certificate holder and approved by the Administrator for the specific airplane type, has been completed within 5 minutes prior to beginning takeoff. A pretakeoff contamination check is a check to make sure the wings and control surfaces are free of frost, ice, or snow.
(2) The certificate holder has an approved alternative procedure and under that procedure the airplane is determined to be free of frost, ice, or snow.
(3) The certificate holder has an approved deicing/anti-icing program that complies with § 121.629(c) of this chapter and the takeoff complies with that program.
(C) Except for an airplane that has ice protection provisions that meet section 34 of Appendix A, or those for transport category airplane type certification, no pilot may fly -
(1) Under IFR into known or forecast light or moderate icing conditions; or
(2) Under VFR into known light or moderate icing conditions; unless the aircraft has functioning deicing or anti-icing equipment protecting each rotor blade, propeller, windshield, wing, stabilizing or control surface, and each airspeed, altimeter, rate of climb, or flight attitude instrument system.
(E) Except for an airplane that has ice protection provisions that meet section 34 of Appendix A, or those for transport category airplane type certification, no pilot may fly an aircraft into known or forecast severe icing conditions.
(F) If current weather reports and briefing information relied upon by the pilot in command indicate that the forecast icing condition that would otherwise prohibit the flight will not be encountered during the flight because of changed weather conditions since the forecast, the restrictions in paragraphs (c), (d), and (e) of this section based on forecast conditions do not apply.
According the Cessna 208B Pilot Operating Handbook (POH), the airplane was certified for flight into known icing conditions. The POH further states that flight into freezing rain, freezing drizzle, mixed conditions or conditions defined as severe must be avoided. The POH notes, "Whenever icing conditions are encountered, immediate action should be taken to leave these conditions before airplane performance is degraded to a point where a climb, which is normally the best action to take, may not be achievable due to the residual ice buildup."
The FAA Aeronautical Information Manual (AIM), defines severe icing as: an icing condition where the rate of accumulation is such that deicing/anti-icing equipment fails to reduce or control the hazard. Immediate flight diversion is necessary.
Parties to the investigation included the Federal Aviation Administration, Cessna Aircraft Company, and Priority Air Charter.
The wreckage was released to a representative of Priority Air Charter on March 16, 2002.