Accident on 7/17/2001 12:00:00 AM in Oak Creek, WI
Tail Number: N1448Z
Aircraft Type: Cessna 310R
Serial Number: 310R1527
Visibility: 0.5 statute miles
Wind Velocity: 5 knots
Wind Gusts: knots
Sky Condition: BKN at 300 feet
Total Injuries: 1
Total Fatal Injuries: 1
NTSB No.: CHI01FA218
HISTORY OF FLIGHT
On July 17, 2001, about 2240 central daylight time, a Cessna 310R, N1448Z, operated by Heartland Aviation, was destroyed on impact with trees and terrain in Oak Creek, Wisconsin, while on approach to runway 1L at General Mitchell International Airport (MKE), Milwaukee, Wisconsin. A post-impact ground fire occurred. A commercial pilot operating under 14 CFR Part 135 piloted the non-scheduled domestic cargo flight. Instrument meteorological conditions prevailed at the time of the accident and the flight was on an instrument flight plan. The pilot was fatally injured. The flight originated from Central Wisconsin Airport (CWA), near Mosinee, Wisconsin, at 2149 and was on the instrument landing system (ILS) 1L approach to MKE at the time of the accident.
The Federal Aviation Administration (FAA) supplied a tape recording and transcript of the MKE Air Traffic Control Tower (ATCT) radio transmissions. The first communication time listed below was 0326:08 Zulu, which was 2226:08 central daylight time. The MKE Approach Control was abbreviated as A/C, MKE Local Control was abbreviated as LC, Airborne Express flight 147 was abbreviated as ABX147, and the accident flight, call sign Night Chase 101, was abbreviated as NTC101 in the transcript. An excerpt from the transcript stated the following:
Time Abbreviation Communication
0326:08 A/C night chase one o one ah fly heading of
one seven zero I'll have lower for you in
just a little bit
0326:14 NTC101 ok heading one seven zero for night chase
one o one
0327:03 A/C [controller's first name]
0327:04 LC yes
0327:05 A/C fifteen northwest night chase one o one
wants to come lower is that ok
0327:08 LC yea approved
0327:08 A/C thanks
0327:09 LC [controller's working initials]
0327:10 A/C night chase one o one descend and
maintain two thousand six hundred
0327:13 NTC101 ok down to two thousand six hundred
night chase one o one
0331:46 A/C night chase one o one fly heading one
0331:50 NTC101 ok one three zero night chase one o one
0333:47 A/C night chase one o one fly heading one
zero zero vector for the base
0333:50 NTC101 ok one zero zero night chase one o one
0334:31 A/C night chase one o one turn left heading
zero three zero intercept the localizer
0334:34 NTC101 ok left zero three zero intercept the
localizer for one o one
0334:42 A/C night chase one o one if you can keep
the speed up i show you three miles
from cappy you're cleared for the i l s
one left approach
0334:48 NTC101 ok night chase one o one cleared for
the i l s i'll keep the speed up if i can
0334:52 A/C thank you
0335:42 A/C night chase one o one tower one one
niner point one
0335:44 NTC101 ok over to tower nineteen one good night
0335:50 NTC101 milwaukee tower (unintelligible) with
you on the localizer for the i l s one left
0335:55 LC night chase one o one milwaukee runway
one left cleared to land wind is calm keep
your speed up as much as feasible please
0336:00 NTC101 okay one o one i'll ah keep to the gear and
cleared to land one left
0336:04 LC and where do you park
0336:11 LC night chase one o one where do you park tonight
0336:13 NTC101 ah one o one we'll be ah at signature
0336:17 LC all right thanks
0336:23 LC abex one forty seven taxi up to and
hold short of one left there'll be ah
three arrivals and we'll get you out
0336:29 ABX147 up to hold short of one left abex one
0339:32 LC night chase ah one o one exit at your
first left turn and let me know where
that'll be i don't see you
0339:45 LC night chase one o one milwaukee
0339:51 LC night chase one zero one milwaukee
0339:57 LC ah night chase one o one milwaukee
are you on
0340:13 ABX147 tower abex ah one forty seven
0340:16 LC yes sir
0340:17 ABX147 yea we didn't see that guy land
0340:21 LC all right thanks ah i didn't either so i'm
not sure where he is right now
0340:24 ABX147 now just out here to the right of the
runway I did see a big ah red flash that
lit up the whole sky I don't know if
there's a factor or something but I saw
some big flames come up over there
0340:40 LC all right thank you
The pilot held commercial pilot and flight instructor certificates with airplane multiengine land, airplane single engine land, and instrument airplane ratings. The pilot held a FAA first-class aviation medical certificate issued on September 13, 2000, with no restrictions. The operator reported that the pilot had 1,250 hours total time and that he had flown a total of 194 hours time in type in the last 90 days. The operator reported that the pilot flew 44.5 hours during instrument meteorological conditions and that he had flown 60 instrument approaches in the last 90 days.
The accident airplane, N1448Z, was a Cessna 310R, serial number 310R1527, twin-engine, low-wing airplane with retractable tricycle landing gear. The fuselage and empennage was of semimonocoque construction. The interior of the airplane was configured to carry cargo. Two, six-cylinder, fuel injected, Continental IO-550-A (2) engines powered the airplane. The engines were rated at 300 horsepower. The engine's propellers were McCauley three-bladed, constant speed, full feathering propellers. The airplanes last inspection was a progressive inspection completed on July 13, 2001. The airplane accumulated 11,220.7 hours of total time at that inspection.
At 2203, the MKE weather was: Wind 090 degrees at 5 knots; visibility 1/2 statute mile; present weather mist; sky condition broken 300 feet; temperature 21 degrees C; dew point 21 degrees C; altimeter 29.97 inches of mercury.
AIDS TO NAVIGATION
The pilot was cleared for an ILS approach to runway 1L. The straight in decision height for that approach is 904 feet mean sea level (200 feet above ground level) and the required RVR [runway visual range] for a 14 CFR Part 135 flight to commence an approach is 1800 (3/8 mile). The ILS runway 1L approach had an approach lighting system with sequenced flashing lights. A copy of that approach procedure and the approach lighting system legend are included with the docket information associated with this factual report.
Following the accident, the ILS 1L was not used for approaches until the FAA's Airways and Facilities branch examined the approach. No anomalies were detected during the flight check of that approach.
MKE had a field elevation of 723 feet. MKE had five runways. Runway 13/31 was concrete-surfaced, 5,868 feet long, and 150 feet wide. Runway 7R/25L was asphalt-surfaced, 8,012 feet long, and 150 feet wide. Runway 7L/25R was asphalt and concrete-surfaced, 4,800 feet long, and 100 feet wide. Runway 1R/19L was concrete-surfaced, 4,183 feet long, and 150 feet wide. Runway 1L/19R was asphalt and concrete-surfaced, 9,690 feet long, and 200 feet wide.
WRECKAGE AND IMPACT INFORMATION
An on-scene investigation was conducted. The airplane impacted a wooded area west of the approach lights to runway 1L. Tree branches and a tree, along a linear path from the edge of this wooded area to where the airplane's fuselage came to rest, were found broken off and laying on the ground. That linear path was about 500 feet long. The fuselage came to rest about 400 feet south of College Avenue and about 1,800 feet from the approach end of runway 1L's centerline at latitude 42 degrees 55.734' N and longitude 87 degrees 54.204' W. A post impact on ground fire occurred. The airplane's fuselage was found inverted, discolored, and deformed. Sections of the fuselage were found melted. The horizontal stabilizer and rudder were found detached from the fuselage. The landing gear was found in the down position. Wood fragments were found retained by the right tire's bead and rim. Both propellers were found detached from their engine flanges and the threaded bolt holes on the propeller hub assemblies were found oval shaped. The left engine produced a thumb compression on all cylinders except for the number six cylinder when the engine's crankshaft was rotated. That number six cylinder was found discolored and deformed. Valve train continuity was established to the number six cylinder. Both of the left engine's magnetos produced sparks when rotated by hand. The left engine's vacuum pump produced suction when rotated by hand. The right engine produced a thumb compression on all cylinders when the engine's crankshaft was rotated and one of its magnetos produced sparks. The right engine's vacuum pump was found with a broken base and coupler. That vacuum pump produced suction when the coupler was rotated by hand. Removed spark plugs exhibited a light gray color. Flight control cables were traced from the cockpit to the flight control surfaces and continuity was established. Engine control continuity was established. No pre-impact anomalies were found. See appended photographs.
MEDICAL AND PATHOLOGICAL INFORMATION
An autopsy was performed on the pilot by the Milwaukee County Medical Examiner's Office on July 18, 2001.
The FAA Civil Aeromedical Institute prepared a Final Forensic Toxicology Accident Report. The report was negative for all tests performed.
The parties to the investigation included the FAA, Cessna Aircraft Company, and Teledyne Continental Motors.
The aircraft wreckage was released to a representative of the MKE airport and retained items were released to a representative of the insurance company.
North of the wreckage site, across College Avenue, was a lighted aircraft ramp area.
An excerpt from Federal Aviation Regulation (FAR) 135.243, pilot in command qualifications, stated:
(c) Except as provided in paragraph (a) of this section, no certificate
holder may use a person, nor may any person serve, as pilot in
command of an aircraft under IFR unless that person -
(1) Holds at least a commercial pilot certificate with appropriate
category and class ratings and, if required, an appropriate type rating
or that aircraft; and
(2) Has had at least 1,200 hours of flight time as a pilot, including
500 hours of cross country flight time, 100 hours of night flight time,
and 75 hours of actual or simulated instrument time at least 50 hours
of which were in actual flight; ...
Subsequent to the accident, the operator instituted a high minimums requirement for their pilots-in-command of piston-powered aircraft in accordance with FAR 135.225 (d) requirements for turbine-powered pilots in command.
The airplane was destroyed on impact with trees and terrain during an ILS approach. A post-impact on ground fire occurred. The air traffic controllers asked the pilot to keep the speed up on the approach. The reported weather was: Visibility 1/2 statute mile; present weather mist; sky condition broken 300 feet; temperature 21 degrees C; dew point 21 degrees C; altimeter 29.97 inches of mercury. The airplane impacted a wooded area west of the approach lights to the intended runway. Tree branches and a tree, along a linear path from the edge of this wooded area to where the airplane's fuselage came to rest, were found broken off and laying on the ground. The linear path was about 500 feet long. The fuselage came to rest about 400 feet south of College Avenue and about 1,800 feet from the approach end of the intended runway's centerline. The airplane's fuselage was found inverted, discolored, and deformed. Sections of the fuselage were found melted. The landing gear was found in the down position. No pre-impact anomalies were found. North of the wreckage site, across College Avenue, was a lighted aircraft ramp area. FAR 135.243 requires a pilot operating under IFR to have at least 1,200 hours of flight time. The operator reported that the pilot had 1,250 hours total time and that he had flown a total of 194 hours time in type in the last 90 days. The operator reported that the pilot flew 44.5 hours during instrument meteorological conditions and that he had flown 60 instrument approaches in the last 90 days.
The pilot not maintaining clearance from objects during an ILS approach in low night IFR conditions and his descent below decision height. Factors were the dark night, mist, low ceiling, and the trees west of the approach.