Individually Owned: 151,845
Corporate Owned: 143,699
Lakeland /Noble F. Lee Airport
Aircraft Accident/Incident Report
Woodruff, Wisconsin 54568
Thursday, September 11, 2008 19:15 CDT
NTSB Narrative Summary Released at Completion of Accident
The pilot was attempting a non-precision instrument approach at dusk in instrument meteorological conditions (IMC) that were below the required approach minimums without an alternate airport. Near the missed approach point, the airplane entered a climb and the airspeed decreased. The airplane gave a stall warning and it subsequently crashed. Recorded flight data revealed that pilot was utilizing the autopilot intermittently and then about two minutes before the accident he turned it off, indicating that he was either not proficient in flying in IMC in the accident airplane make and model and/or utilizing its autopilot. This was further supported by the pilot previously failing his initial airman examination flight and his lack of experience in non precision approaches in such conditions. Furthermore, the postaccident investigation determined that the Part 135 certificate holder had used an unapproved airplane training program paid for by the airplane owner and had falsified air carrier records in order to meet air carrier flight training requirements.
The assignment of the flight shows a loss of operational control due to the attempted approach in below approach minimums; the lack of an alternate airport; the assignment of a pilot that lacked proficiency and/or experience in the weather conditions that were encountered during the flight; and pilot’s lack of explicit authorization for use of an autopilot in lieu of a second-in-command, which was due to the Federal Aviation Administration (FAA) Principal Operation Inspector's (POI) failure to complete the appropriate form. Additionally, the airplane’s registered owner had placed their airplanes on a previous Part 135 certificate but that certificate holder removed those airplanes from the certificate after the owner improperly exercised operational control instead of the certificate holder. The airplanes were then placed on the current certificate holder’s certificate during which time there are indications that the airplane owner was exercising operation control. At least one inspector from the FAA’s Flight Standard District Office (FSDO) was aware of the history of improper exercise of operational control of flights by the airplane owner (not the certificate holder) and no action was taken to stop this practice. Additionally, the FAA FSDO surveillance records revealed that the certificate holder was rated as satisfactory with no comments noted, although throughout the investigation numerous discrepancies were found that within the company that did not comply with Part 135 operations.
A postaccident examination revealed no mechanical anomalies that would have precluded normal airplane operation.
NTSB Probable Cause Narrative
The pilot’s failure to maintain airspeed during a missed approach leading to the inadvertent stall. Contributing to the accident were the pilot’s lack of experience in the type of operation conducted, the certificate holder’s loss of operational control, and the lack of adequate oversight of the operation by the Federal Aviation Administration.
Event Information
| Type of Event | Accident |
| Event Date | 9/11/2008 |
| Event Day of the Week | Thursday |
| Time of Event | 1915 |
| Event Time Zone | Central Daylight Time |
| Event City | Woodruff |
| Event State | WISCONSIN |
| Event Country | -- |
| Zipcode of the event site | 54568 |
| Event Date Year | 2008 |
| Event Date Month | 9 |
| MidAir Collision Indicator | No |
| On Ground Collision occurred ? | No |
| Event Location Latitude | -- |
| Event Location Longitude | -- |
| Event Location Airport | Lakeland Airport/Noble F. Lee |
| Event Location Nearest Airport ID | ARV |
| Indicates whether the acc/inc occurred off or on an airport | Off Airport/Airstrip |
| Distance from airport in statute miles | 0 |
| Degrees magnetic from airport | -- |
| Airport Elevation | 1629 |
| Weather Briefing Completeness | -- |
| Investigator's weather source | Weather Observation Facility |
| Time of the weather observation | 1915 Central Daylight Time |
| Direction of event from weather observation facility (degrees) | 19 |
| Weather Observation Facility ID | ARV |
| Elevation of weather observation facility | 1629 |
| Distance of event from weather observation facility (units?) | 1 |
| Time Zone of the weather observation | CDT |
| Lighting Conditions | Dusk |
| Lowest Ceiling Height | 200 |
| Lowest Non-Ceiling Height | -- |
| Sky/Lowest/Cloud Conditions | Clear |
| Sky Condition for Lowest Ceiling | Overcast |
| Visibility Runway Visual Range (Feet) | -- |
| Visibility Runway Visual Value (Statute Miles) | -- |
| Visibility (Statute Miles) | 3 |
| Air Temperature at event time (in degrees celsius) | 18 |
| Dew Point at event time (in degress fahrenheit) | 16 |
| Wind Direction (degrees magnetic) | 200 |
| Variable Wind Indicator | Wind direction could be determined |
| Wind Speed (knots) | 5 |
| Wind Velocity Indicator | -- |
| Wind Gust Indicator | Not Gusting |
| Wind Gust (knots) | -- |
| Altimeter Setting at event time (in. Hg) | 29.88 |
| Density Altitude (feet) | -- |
| Intensity of Precipitation | -- |
| METAR weather report | -- |
| Event Highest Injury | Fatal |
| On Ground, Fatal Injuries | -- |
| On Ground, Minor Injuries | -- |
| On Ground, Serious Injuries | -- |
| Injury Total Fatal | 3 |
| Injury Total Minor | -- |
| Injury Total None | -- |
| Injury Total Serious | -- |
| Injury Total All | 3 |
| Investigating Agency | NTSB |
| NTSB Docket Number (internal use) | 27952 |
| NTSB Notification Source | FAA |
| NTSB Notification Date | Sep 11 2008 12:00AM |
| NTSB Notification Time | -- |
| Fiche Number and/or location -used to find docket information | -- |
| Date of most recent change to record | Apr 21 2011 3:22PM |
| User who most recently changed record | kelz |
| Basic weather conditions | Instrument Meteorological Cond |
| FAA District Office | MKE FSDO |
Aircraft Involved |
|
|---|---|
Aircraft #1 |
|
| Aircraft Registration Number | N193BS |
| NTSB Number | CHI08FA282 |
| Missing Aircraft Indicator | -- |
| Federal Aviation Reg. Part | Part 135: Air Taxi & Commuter |
| Type of Flight Plan filed | IFR |
| Flight plan Was Activated? | Yes |
| Damage | Substantial |
| Aircraft Fire | None |
| Aircraft Explosion | None |
| Aircraft Manufacturer's Full Name | Cirrus Design Corporation |
| Aircraft Model | SR22 |
| Aircraft Series Identifier | -- |
| Aircraft Serial Number | 22-2761 |
| Certified Max Gross Weight | 3400 |
| Aircraft Category | Airplane |
| Aircraft Registration Class | -- |
| Aircraft is a homebuilt? | No |
| Flight Crew Seats | -- |
| Cabin Crew Seats | -- |
| Passenger Seats | -- |
| Total number of seats on the aircraft | 4 |
| Number of Engines | 1 |
| Fixed gear or retractable gear | Fixed |
| Aircraft, Type of Last Inspection | 100 Hour |
| Date of Last Inspection | Aug 6 2008 12:00AM |
| Airframe hours since last inspection | -- |
| Airframe Hours | 297.4 |
| ELT Installed | Yes |
| ELT Activated | Unknown |
| ELT Aided Location of Event Site | No |
| ELT Type | -- |
| Aircraft Owner Name | Bluesky Taxi Inc |
| Aircraft Owner Street Address | 360 Belle Foret Dr |
| Aircraft Owner City | Lake Bluff |
| Aircraft Owner State | IL |
| Aircraft Owner Country | USA |
| Aircraft Owner Zipcode | 60044 |
| Operator is an individual? | No |
| Operator Name | -- |
| Operator Same as Owner? | No |
| Operator Is Doing Business As | -- |
| Operator Address Same as Owner? | No |
| Operator Street Address | -- |
| Operator City | -- |
| Operator State | -- |
| Operator Country | USA |
| Operator Zip code | -- |
| Operator Code | -- |
| Owner has at least one certificate | Yes - certificate holder |
| Other Operator of large aircraft? | No |
| Certified for Part 133 or 137 Operation | -- |
| Operator Certificate Number | -- |
| Indicates whether an air carrier operation was scheduled or not | Non-scheduled |
| Indicates Domestic or International Flight | Domestic |
| Operator carrying Pax/Cargo/Mail | Passenger Only |
| Type of Flying (Per_Bus / Primary) | -- |
| Second Pilot on Board | No |
| Departure Point Same as Event | No |
| Departure Airport Code | MKE |
| Departure City | MILWAUKEE |
| Departure State | WI |
| Departure Country | USA |
| Departure Time | 1745 |
| Departure Time Zone | CDT |
| Destination Same as Local Flt | -- |
| Destination Airport Code | ARV |
| Destination City | MINOCQUA/WOODRU |
| Destination State | WI |
| Destination Country | USA |
| Specific Phase of Flight | Approach |
| Report sent to ICAO? | -- |
| Evacuation occurred | -- |
| Date of most recent change to record | Mar 23 2010 12:02PM |
| User who most recently changed record | galm |
| Since inspection or accident | Last Inspection |
| Event Location Runway Number and Location | 36 |
| Runway Length | 5150 |
| Runway Width | 100 |
| Sight Seeing flight | No |
| Air Medical Flight | No |
| Medical Flight | -- |