February 16, 2005
NTSB Number: AAR-07-02
NTIS Number: PB2007-910403
On February 16, 2005, about 0913 mountain standard time, a Cessna Citation 560, N500AT, operated by Martinair, Inc., for Circuit City Stores, Inc., crashed about 4 nautical miles east of Pueblo Memorial Airport, Pueblo, Colorado, while on an instrument landing system approach to runway 26R. The two pilots and six passengers on board were killed, and the airplane was destroyed by impact forces and postcrash fire. The flight was operating under the provisions of 14 Code of Federal Regulations Part 91 on an instrument flight rules flight plan. Instrument meteorological conditions prevailed at the time of the accident.
The National Transportation Safety Board determines that the probable cause of this accident was the flight crew's failure to effectively monitor and maintain airspeed and comply with procedures for deice boot activation on the approach, which caused an aerodynamic stall from which they did not recover. Contributing to the accident was the Federal Aviation Administration's failure to establish adequate certification requirements for flight into icing conditions, which led to the inadequate stall warning margin provided by the airplane's stall warning system.
The safety issues discussed in this report include inadequate training on operations in icing conditions, inadequate deice boot system operational guidance, the need for automatic deice boot systems, inadequate certification requirements for flight into icing conditions, and inadequate stall warning margins in icing conditions. Safety recommendations concerning these issues are addressed to the Federal Aviation Administration.
As a result of its investigation of the February 16, 2005, accident involving a Cessna Citation 560, the National Transportation Safety Board makes the following recommendations to the Federal Aviation Administration:
Require that operational training in the Cessna 560 airplane emphasize the airplane flight manual requirements that pilots increase the airspeed and operate the deice boots during approaches when ice is present on the wings. (A-07-12)
Require that all pilot training programs be modified to contain modules that teach and emphasize monitoring skills and workload management and include opportunities to practice and demonstrate proficiency in these areas. (A-07-13)
Require manufacturers and operators of pneumatic deice boot-equipped airplanes to revise the guidance contained in their manuals and training programs to emphasize that leading edge deice boots should be activated as soon as the airplane enters icing conditions. (A-07-14) (This safety recommendation supersedes Safety Recommendation A-98-91 and is classified "Open-Unacceptable Response.")
Require that all pneumatic deice boot-equipped airplanes certified to fly in known icing conditions have a mode incorporated in the deice boot system that will automatically continue to cycle the deice boots once the system has been activated. (A-07-15)
When the revised icing certification standards (recommended in Safety Recommendations A-96-54 and A-98-92) and criteria are complete, review the icing certification of pneumatic deice boot-equipped airplanes that are currently certificated for operation in icing conditions and perform additional testing and take action as required to ensure that these airplanes fulfill the requirements of the revised icing certification standards. (A-07-16) (This safety recommendation supersedes Safety Recommendation A-98-100 and is classified "Open-Unacceptable Response.")
Require modification of the Cessna 560 airplane's stall warning system to provide a stall warning margin that takes into account the size, type, and distribution of ice, including thin, rough ice on or aft of the protected surfaces. (A-07-17)
The Safety Board reiterates the following safety recommendations to the Federal Aviation Administration:
Revise the icing criteria published in 14 Code of Federal Regulations Parts 23 and 25, in light of both recent research into aircraft ice accretion under varying conditions of liquid water content, drop size distribution, and temperature, and recent developments in both the design and use of aircraft. Also, expand the Appendix C icing certification envelope to include freezing drizzle/freezing rain and mixed water/ice crystal conditions, as necessary. (A-96-54)
With the National Aeronautics and Space Administration and other interested avation organizations, conduct additional research to identify realistic ice accumulations, to include intercycle and residual ice accumulations and ice accumulations on unprotected surfaces aft of the deicing boots, and to determine the effects and criticality of such ice accumulations; further, the information developed through such research should be incorporated into aircraft certification requirements and pilot training programs at all levels. (A-98-92)
For more information about these recommendations, see sections 126.96.36.199 and 2.4.