N636SE

Substantial
Fatal

Cessna 560S/N: 560-0636

Accident Details

Date
Wednesday, July 19, 2006
NTSB Number
CHI06FA193
Location
Cresco, IA
Event ID
20060725X01011
Coordinates
43.366111, -92.131111
Aircraft Damage
Substantial
Highest Injury
Fatal
Fatalities
2
Serious Injuries
2
Minor Injuries
0
Uninjured
0
Total Aboard
4

Probable Cause and Findings

The flight crew's inadequate aeronautical decision-making and poor crew resource management (CRM), including the inadequate use of the on-board sources (such as the flight management system and navigation charts), to get critical information about Ellen Church Field Airport, including runway direction and length. Contributing factors to the accident were the flight crew's failure to consider and understand indications that the runway length was insufficient and inadequate CRM training for pilots at Part 135 on-demand operators.

Aircraft Information

Registration
N636SE
Make
CESSNA
Serial Number
560-0636
Engine Type
Turbo-jet
Year Built
2003
Model / ICAO
560C560
Aircraft Type
Fixed Wing Multi Engine
No. of Engines
2

Registered Owner (Historical)

Name
SALE REPORTED
Address
404 BNA DR BLDG 200 STE 305
Status
Deregistered
City
NASHVILLE
State / Zip Code
TN 37217
Country
United States

Analysis

HISTORY OF FLIGHT

On July 19, 2006, at 1104 central daylight time, a Cessna 560, N636SE, received substantial damage on impact with terrain during an aborted landing on runway 33 (2,949 feet by 50 feet, concrete) at Ellen Church Field Airport (CJJ), Cresco, Iowa. The airplane was located in a cornfield about 1,751 feet north of the departure end of runway 33. Visual meteorological conditions prevailed at the time of the accident. The 14 CFR Part 91 flight was operating on an instrument flight rules (IFR) flight plan. Flight crew services were provided by Jackson Air Charter, Inc (JAC). The left seat pilot and right seat pilot received fatal injuries, and the two passengers received serious injuries. The flight last departed from University-Oxford Airport (UOX), Oxford, Mississippi, at 0920, and was en route to Rochester International Airport (RST), Rochester, Minnesota, when it diverted to CJJ.

The JAC Trip Sheet Information lists the following itinerary for four passengers, including the passengers aboard the accident flight.

---------------------------------------

Depart from Jackson at 0600; Arrive Gulfport-Biloxi at 0639

Depart from Gulfport-Biloxi at 0700; Arrive at Destin-Ft. Walton, Fla. at 0739

Depart Destin-Ft. Walton at 0745; Arrive at Meridian, Miss. at 0830

Depart from Key Field, Miss. at 0845; Arrive at Oxford, Miss., at 0924

Depart from Oxford, Miss. at 1000; Arrive at Rochester, Minn. At 1151

Depart from Rochester, Minn. at 1300; Arrive at Oxford, Miss. at 1445

Depart from Oxford, Miss. at 1730; Arrive at Meridian, Miss. at 1809

Depart from Meridian, Miss. at 1830; Arrive at Destin-Ft. Walton, Fla. at 1915

Depart from Destin-Ft. Walton, Fla. at 1930; Arrive at Jackson at 2027

------------------------------

One of the four passengers is designated as the "primary passenger" on the Trip Information Sheet, which also lists the primary passenger's corporation as the customer. According to JAC and the primary passenger, the flights on the day of the accident were 14 CFR Part 91 flights. The Trip Sheet Information also provides a quote and list of charges.

The left front second row seat (#5) passenger stated that he had not flown in N363SE prior to the accident but has flown on similar airplanes with 8-12 seats but did not recall whether they were in Cessna 560 airplanes.

The right front seat (#4) passenger called the left front seat passenger and asked him to accompany him to Mayo Clinic to undergo medical tests. They both boarded the airplane at Gulfport, Mississippi, and flew to Destin, Florida, where the primary passenger boarded the airplane. They then flew to Meridian, Mississippi, where they dropped off the primary passenger. They then flew to Oxford, Mississippi, where the dropped off the primary passenger's wife.

The primary passenger stated that he boarded the airplane with his wife at Destin-Ft. Walton Beach, Destin, Florida, where he met his friend who was the #4 passenger and the other passenger who was the #5 passenger. They departed a few minutes after 0715 en route to Key Field Airport, Meridian, Mississippi, where the primary passenger deplaned and his wife continued onto University-Oxford, Oxford, Mississippi, where she then deplaned. The primary passenger stated that his wife overheard the pilots saying that they were going to top off the fuel and the remaining passengers could get some coffee or something to eat.

The #5 passenger stated that he had lunch with the right seat pilot (viewed looking forward from within the airplane). The right seat pilot was a "great guy" and was alert. During lunch, the right seat pilot ate a biscuit and drank a nonalcoholic beverage, but the left front seat passenger could not recall if it was coffee. The right seat pilot was a "young good looking healthy guy." The left seat pilot remained with the airplane. He stated that it was a "beautiful day" on the coast.

The #5 passenger stated that the crew obtained fuel for the airplane in University-Oxford, Oxford, Mississippi (a credit card receipt for 527 gallons of Jet A time stamp with a time stamp of 0846 at University-Oxford, Oxford, Mississippi, was found at the accident site). He stated that the cockpit door was left open during the flight and they did not talk to the flight crew because the noise level was "loud," and they were "far" from the flight crew.

According to Flight Service Station information, an IFR flight plan for N636SE was filed for a flight from UOX to RST at flight level (FL) 380 with no alternate airport.

The #5 passenger stated they were flying north toward Rochester, Minnesota, when they made a "hard u-turn" and started "dropping down" to Cresco, Iowa. He stated that it was a "pretty aggressive drop," and the descent was "more aggressive" than a "commercial airliner." He said he had "no fears what so ever." The descent was so steep that he could see the runway through the pilot windshield at an altitude of 5,000 feet. The airplane then felt as if it got "jarred" and a couple of overhead panels opened. The flight crew recovered and lined themselves up for landing. He stated alarms were "going on," and he heard a "beeping" and "pull-up pull-up." He stated that it looked like the flight crew was going to make a "picture perfect" landing.

The cockpit voice recorder (CVR) was read out by the National Transportation Safety Board's Recorders Laboratory. The CVR begins as the airplane is on final approach to University-Oxford airport in Oxford, Mississippi. The crew states the items in the landing checklist and the sound of touchdown, followed by in an increased background noise (similar to thrust reverser) is recorded. The CVR stops recording followed immediately by the sound of a CVR power-up tone. It is unknown how much local time actually elapsed between the shut down and power up of the CVR. However, eight minutes and thirty-two seconds elapsed from the beginning of the recording to the shut down/power-up of the CVR.

The second part of the recording began at the power-up tone on the CVR at 09:09:20 (approximately 8 minutes, 32 seconds after the start of the recording). About 09:11:54, the crew discusses the weather between Oxford, Mississippi, and Rochester, Minnesota. The crew states items in the before taxi and the before takeoff checklists and about 09:17:52, the right seat pilot states within the crew briefing that he will be flying the airplane. About 09:18:36, the sound of increased engine RPM is recorded. The airplane is issued an IFR clearance, as filed, from Memphis Center about 09:21:58. The airplane is subsequently issued clearance to climb to FL 380 and about 09:47:31, the airplane is transferred to Kansas City Center, where they are given clearance to climb to FL 400. About 10:20:00, the airplane is transferred to Chicago Center and about 11 minutes later reports light chop. About 10:32:19, the airplane is transferred to another Chicago Center controller.

At 10:33:14, the crew requests a lower altitude, which the center controller approves to FL 350. About 10:42:33, the airplane is transferred to Minneapolis Center. About 10:43:13, the left seat pilot relays to Minneapolis Center that they are deviating from weather (but direct to Rochester), and additionally are not able to pick up automatic terminal information service (ATIS) at Rochester. The controller then relays the weather information to the airplane. About 10:45:54, the left seat pilot radios Center stating, "we're just gonna' keep kinda' heading this direction stay on the west side of the weather 'til we get north of Rochester and then turn around and take a look at it." The controller asks for clarification that he means "on the east side of the weather" and the left seat pilot replies, "affirmative." After, the airplane is transferred to another Minneapolis Center controller, the controller states at 10:51:57, "it's heck of a bow hook we got going on there… but ah you'd have to go about a hundred miles or more north to get around the very northern edge of it. Ah if you go around the south side um it's about eighty miles to get around the south side." The crew discusses it and decides to "pick [their] way through it."

About 10:54:54, the airplane is continuing its descent and is transferred to Rochester Approach. Approximately 8 seconds later, a partial ATIS recording for Rochester is recorded on the crew channels. At 10:55:26, the left seat pilot checks in with the Rochester Approach descending from 14,700 feet to 10,000 feet with ATIS information Victor. At 10:55:42, Rochester Approach states, "Citation six three six Sierra Echo Rochester approach and expect vectors for the ah loca- well wind three four zero at six gusts two four that would favor the I-L-S to three one but right now the area of weather that we've got is all along that final and we're showing weather echoes along that final approach course. say your intentions" The left seat pilot replies that they will continue for another 20 miles on their present heading of 240 degrees and "take a look at it on the radar."

10:56:25, the right seat pilot states, "probably what I'm going to do is go here to this hole then work my way up around that way."

10:56:27, the left seat pilot states, "yep yeah."

10:56:32, Rochester Approach clears the clears the airplane to descend and maintain 9,000 feet which the left seat pilot acknowledges.

10:57:00, the left seat pilot states, "so we're just going through the localizer right right now… about you have to go up and come back."

10:57:22, the left seat pilot states "yeah that's the only hole this is what he was talking about for the final yeah."

10:57:28, ATIS, "…Rochester Tower information Victor one five three eight Zulu special observation wind three two zero at two niner gusts three niner visibility one half thunderstorm heavy rain **."

10:57:43, the right seat pilot states, " (teah) couldn't get there at a worse time."

10:58:01, the left seat pilot states, "I'm wondering if that hole's (blink...

Data Source

Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# CHI06FA193