Two pilots who heard about a Cessna Citation CJ4 (Model 525C) crashing into Lake Erie after takeoff from Burke Lakefront Airport (KBKL) in Cleveland, Ohio, on Dec. 29, 2106, wrote to the National Transportation Safety Board about their experiences taking off from KBKL at night. One told about flying his Cessna 182 on a night VFR takeoff in which he was expecting a left turn out. “I was assigned a right turn out over the lake. When I made that turn, it was instantaneous IFR conditions. There was a black hole! No horizon at all. No stars, no lights anywhere. If I had not transitioned to the gauges until completing my turn towards the southeast, I would have had severe spatial disorientation.”
The other pilot wrote about his night takeoff from KBKL: “While I was able to handle the situation without undue difficulties, I believe that turning away from the lights of Cleveland into the absolute darkness over Lake Erie may result in pilot disorientation at too low an altitude to recover.”
But for the pilot of the Cessna CJ4 jet, the situation was more complex than just flying into a black hole that happened to be blanketed by marginal weather.
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By all accounts, the pilot was intensely serious about his plane, his training and his single-pilot operation of the jet. Yet the plane hit the water while descending at the screaming rate of about 6,000 feet per minute in a 15 degrees nose low attitude with the right wing 25 degrees down. The pilot and all five passengers were killed; the plane shattered into numerous pieces. The NTSB on July 16 of this year adopted a probable cause: spatial disorientation of the pilot, pilot fatigue, confusion as to the status of the autopilot, and what it called “negative learning transfer,” indicating the pilot didn't fully appreciate the differences between the flight guidance panels and attitude indicators on the Cessna Citation 510 Mustang he previously owned and the CJ4.
The pilot was a prominent person in Ohio: John Fleming, president and chief executive officer of the Superior Beverage Group in Columbus. The company services more than 12,000 retailers in 37 counties in northeast and central Ohio with more than 500 wine, beer and non-alcoholic beverage brands. Fleming's wife was on the plane, as were their two teenage sons, one of whom was vision impaired and accompanied by a service dog, and a neighbor and his daughter. They had been to a Cleveland Cavaliers basketball game, and this was the return flight to the Ohio State University Airport (KOSU) in Columbus.
The pilot held a private certificate for single-engine and multi-engine land with a Cessna 525 single pilot type rating, a helicopter rating and an instrument airplane rating. He had logged 1,205 hours with 56 in type. His third-class FAA medical was current. He began flying in July of 2003 and received his private certificate on May 3, 2006.
The accident took place at about 10:57 p.m. The airplane was operating on an IFR flight plan. Marginal visual meteorological conditions existed at KBKL. The observation recorded four minutes before the accident showed wind from 260 degrees at 25 knots with gusts to 31 knots, visibility 8 miles in light snow, scattered clouds at 1,200 feet AGL, broken clouds at 2,200 feet, and an overcast layer at 3,200 feet. The temperature was 1 degree C, the dew point was minus 2 degrees C, and the altimeter was 29.74. Is it possible the airplane picked up some ice before or during takeoff that affected its performance? The NTSB didn't think so.
Investigators talked to the pilot's colleagues and reviewed phone and text message activity to approximate his sleep opportunities for the three nights before the accident. They figured he had gotten about eight hours sleep three nights before the accident, 9-1/2 hours two nights before it happened and 7-1/2 hours on the night before the day of the accident. They said he awoke at 6 a.m. on the day of the accident and had been awake for about 17 hours at the time the plane went down.
The flight into KBKL departed from KOSU at about 5:30 p.m. and landed at about 6:00. The Safety Board did not report on precisely what the pilot and his passengers did after leaving the airport, such as where they had dinner, whether alcoholic beverages were consumed by anyone and how much energy the pilot may have expended rooting for a team or whether the pilot engaged in any business at the basketball arena. They returned to the airport at about 10:30 p.m., having left the game before its completion.
While the pilot was getting the airplane started, the Cockpit Voice Recorder (CVR) picked up the pilot presumably asking about the basketball game. “We win?” he's heard saying, and the person sitting in the right front seat said, “They were up four with eight seconds left—eight and a half seconds when we walked out the door, so I think so.”
At 10:37:48, the pilot radioed the Burke clearance delivery controller asking for his IFR clearance. The controller issued the clearance, and the pilot read it back but said the assigned departure control frequency was 135.55. The controller advised, “Readback correct except it's, uh, departure control frequency one two five point three five, twenty five thirty five.” The pilot then read it back correctly as 125.35 and asked for the phonetic spelling to be repeated for the Waahu navigation fix, which is on a radial off of Cleveland's Dryer VOR. Could these communications have been a reflection of some pilot fatigue? The NTSB didn't specifically speculate.
At 10:50:48, the pilot radioed the ground controller and reported ready to taxi. The controller cleared him to Runway 24R via taxiways Golf and Hotel. While the airplane was taxiing out, the CVR picked up unintelligible background conversations along with the pilot apparently verbalizing parts of a checklist. “Two three trim. Let's see,” he said. “Hydraulic. Battery amps are less. Pitot heat's comin' on.”
As the airplane taxied out, the tower controller asked the Cleveland Hopkins Airport TRACON for approval to release the Citation. The tower controller was told to have the airplane fly a heading of 330 degrees. When the pilot radioed the tower controller to report ready for takeoff at 10:55:43, the controller replied, “Citation six one four sierra bravo, Lakefront tower, runway two four, turn right heading three three zero, maintain two thousand, cleared for takeoff.” The pilot radioed, “Right turn to three three zero, six one four sierra bravo.” Three seconds later, the CVR recorded the sounds of the engine power increasing. The pilot then said, “Clear,” followed by, “That's when it's nice to have more thrust than you need.” The CVR picked up more unintelligible background conversation and the investigators calculated the airplane was off the ground at 10:56:48. Just over a second later, the CVR picked up what sounded like the landing gear handle being moved. The airplane climbed at about 5 degrees nose up for about 8 seconds while accelerating to about 215 knots. The airplane entered a right turn. The attitude continued to rise to about 16 degrees nose up, and the rate of climb reached more than 6,000 feet per minute. At that rate, the airplane would be at its clearance limit of 2,000 feet in less than 20 seconds.
At 10:57:09, the CVR picked up an automated voice warning “altitude.” There was a second “altitude” warning 14 seconds later accompanied by what sounded like engine power decreasing. Two seconds after that, the airplane's enhanced ground proximity warning system (EGPWS) warned “bank angle, bank angle.” The NTSB's aircraft performance study indicated that the airplane's pitch attitude then was decreasing and continued to decrease for a dozen seconds. The tower controller then radioed, “Six one four sierra bravo contact departure. Safe flight.” The CVR picked up the pilot saying, “To departure, six one four sierra bravo,” but that did not go out on the radio. The pilot apparently had neglected to press the push-to-talk button, perhaps a sign of distraction or work overload.
ADS-B data showed that at about 10:57:28, the airplane was flying a magnetic course of 310 degrees and had reached an altitude of 2,925 feet. The tower controller at 10:57:31 transmitted, “Six one four sierra bravo, Lake...” The CVR picked up the EGPWS warning “Sink rate, sink rate.” ADS-B data at about 10:57:33 showed that the airplane was now beginning a descending right turn. By now, the pitch attitude was about 15 degrees nose down, the airplane was descending at a rate that would reach 6,000 feet per minute, and the right wing was down by about 62 degrees. Just before 10:57:40, the CVR recorded the pilot saying, “Six one four sierra bravo,” but again the pilot's voice did not go out over the radio. The airplane leveled somewhat, coming up to only 25 degrees right wing down.
At 10:57:41, the CVR recorded the sound of air noise increasing, followed by two “pull up, pull up” warnings. Then, the CVR picked up what sounded like an overspeed warning which lasted until the end of the recording. There also were five more “pull up” warnings recorded.
The final ADS-B data point recorded was when the airplane was about 205 feet above the water surface and 1.83 miles northwest of KBKL.
Because the pilot did not acknowledge the instruction to contact departure, the tower controller called Cleveland Departure on the interphone system. “That Citation four sierra bravo come on with you?” he asked. “No, I saw something come up, hit three (thousand feet), disappeared on me,” the approach controller replied. “Alright, let me try him again,” advised the tower controller. Over about four minutes, the two controllers discussed the possible whereabouts of the airplane and the tower controller made various attempts to raise the pilot on the radio. At 11:03:55, the tower controller raised the possibility that the pilot might be talking with Cleveland Center, and the Cleveland Departure controller suggested that they might have to “start search and rescue.”
Finally, at 11:08:48, the tower controller asked the departure controller, “Are you gonna initiate the, uh, search and rescue?” The departure controller's reply: “Huh?” The tower controller said, “Are you gonna initiate that?” The departure controller replied, “I'm, I'm try'n to, I hate to say, I'm, we’re so far behind because I'm, I'm trying to get to the calls, but I don't know who I need to call.” At 11:13:23, the Cleveland Departure controller called the tower controller to see what phone calls he had made to alert authorities to the apparently missing plane. “I'm calling the Coast Guard now, see if find, have 'em fly over,” he replied. “How 'bout the police department or anything like that,” the departure controller asked. “Nah, I haven't made that call yet. I, I'm try'n to get the Coast Guard first, and then we're going to do everything after that,” was the reply.
Weather conditions delayed Cleveland police and the Coast Guard from beginning search operations after they were notified.
It wasn't until January 5, 2017, that airplane debris was located. The recovery operations took two weeks. The water was about 40 feet deep. Recovered pieces of wreckage were laid out for examination, and the examination did not reveal anything consistent with preimpact failures or malfunctions. Remains of the victims were not fully recovered, so toxicology testing for drug and alcohol use by the pilot could not be performed.
The NTSB noted that there are differences in the controls for engaging the autopilot in the CJ4 and the Cessna 510. The autopilot engagement button is on the upper row of buttons near the right side of the CJ4's Flight Guidance Panel. Autopilot status is shown on the CJ4's Primary Flight Display (PFD). The autopilot engagement button on the 510 is in a slightly different location on the Automatic Flight Control System (AFCS). In addition to the 510's PFD indicating when the autopilot is engaged, an indicator light next to the button on the AFCS panel comes on when the autopilot is engaged.
There also are differences in the way the attitude is displayed on the PFDs on the CJ4 and 510. A pilot used to the 510's attitude indicator would have to remain aware that the CJ4's attitude indicator is different or it would be easy to make a mistake leading to an attitude upset.
An instructor who trained the pilot for his type rating in the CJ4 said he and the pilot flew a total of about 50 hours during some 30 flights. He also said that he understood the pilot had completed a recurrent training course about a week after getting the type rating. He described the pilot as a “very sharp guy,” and said he “came to the lessons prepared.” He said that during takeoff, the minimum height for autopilot use is 300 feet and that the autopilot is critical to flight safety. He said that “things happen fast” in the airplane. He said that twice during training the pilot had pressed the wrong button when attempting to activate the autopilot. The person who provided the practical test for the pilot's type rating said that the pilot “did very well” and had “no issues at all.” He said the pilot was “extremely professional.” However, what the NTSB determined in this accident shows that it's easy for pilots to fall behind a complicated airplane where things really do happen really fast. Come to think of it, that happens in not-so-complicated ones, too, just like many of us fly.
Peter Katz is editor and publisher of NTSB Reporter, an independent monthly update on aircraft accident investigations and other news concerning the National Transportation Safety Board. To subscribe, visit www.ntsbreporter.us or write to: NTSB Reporter, Subscription Dept., P.O. Box 831, White Plains, NY 10602-0831.