NTSB Factual Report

HISTORY OF FLIGHT

On February 20, 1997, at approximately 0650 central standard time (cst), a Cessna T210N, N7134J, registered to Prompt Air, Inc., of Chicago, Illinois, piloted by a commercial pilot, became missing shortly after takeoff from General Mitchell International Airport, Milwaukee, Wisconsin. The pilot-in-command and the co-pilot both sustained fatal injuries. The accident is presumed to have occurred at approximately 0650 cst on February 20, 1997. The 14 CFR Part 135 flight was operating in visual meteorological conditions. An IFR flight plan was on file. The flight departed Milwaukee, Wisconsin, at 0639 cst, as an on-demand cargo flight with the intended destination of Louisville, Kentucky.

The Civil Air Patrol, a United States Air Force Auxiliary, conducted an air and ground search for the missing airplane with negative results. The search included the southern section of Lake Michigan. The U.S. Coast Guard conducted a search of the southern section of Lake Michigan with negative results. The airplane was never found and is believed to be missing in Lake Michigan.

The Federal Aviation Administration's (FAA) radar data from the Milwaukee and Chicago facilities having responsibility for the area between the airplane's departure point and its last presumed contact indicated a radar target departing General Mitchell International Airport, Milwaukee, Wisconsin, on February 20, 1997, at 0639 cst. The assigned beacon codes for N7134J were 4523 and, subsequently, 1200 after canceling their IFR flight plan shortly after takeoff. There was no communication between the airplane and ATC after the flight cancelled IFR. Radar indicates the airplane was cruising at 3000 feet mean sea level (MSL), at approximately 143 knots ground speed. The flight path at time 0649.24 cst reveals an approximate 90-degree right turn toward the west with a descent from 3,100 feet MSL to 1,900 feet MSL within 14 seconds. Radar contact was lost at Latitude 42 degrees, 17 minutes, 20 seconds north and longitude 87 degrees, 45 minutes, 48 seconds west. See attached recorded radar from Milwaukee and O'Hare towers.

PERSONNEL INFORMATION

The pilot-in-command was born March 7, 1968. He held a commercial certificate for single/multi engine land and instrument rating. He held a first class medical issued on February 27, 1996. He had accumulated a total of 1,840 hours of flight time, 350 of which were in a Cessna 210 airplane.

AIRCRAFT INFORMATION

The airplane was a Cessna T210N, serial number 21063997, N7134J. The airplane had accumulated 3,473 hours time in service at the time of the accident. The engine had 800 hours total since its last overhaul. The most recent inspection was conducted on February 5, 1997, 50 hours prior to the accident.

METEOROLOGICAL INFORMATION

Weather reported at Waukegan (KUGN), at 0645 cst on February 20, 1997 with the following surface weather observation: 25,000 feet overcast, visibility 3 miles, mist, winds 170 degrees at 5 knots, temperature -1 degrees C, dew point -2 degrees C, altimeter setting 30.10 inches of Hg. There were AIRMETs for icing and turbulence that were in effect for a large area that included KUGN. The turbulence AIRMET called for occasional moderate, isolated severe turbulence below 8,000 feet. A review of the satellite and surface data (approximately 0700 cst) reveals high clouds in the KUGN area, mist and fog along Western Lake Michigan. The official sunrise for February 20, 1997, was at 0730 cst.

WRECKAGE AND IMPACT INFORMATION

To date, the entire wreckage has not been located.

MEDICAL AND PATHOLOGICAL INFORMATION

On July 31, 1997, boaters on the shore of Lake Michigan discovered the body of the pilot-in-command next to a public boat ramp in the town of Highland Park, Illinois. Dr. E. Choi, MD, performed an autopsy at the Lake County Coroner's Office, Waukegan, Illinois.

On August 2, 1997, a boater near the last known radar position in Lake Michigan discovered the body of the co-pilot. Dr. E. Choi, MD, performed an autopsy at the Lake County Coroner's Office, Waukegan, Illinois.

Both individuals suffered massive injuries to the head, trunk, and extremities; these injuries indicate a high-energy impact. No pre-existent anomalies were noted during these examinations which would have contributed to the accident or to the pilot's or co-pilot's death.

The pilot's toxicological analysis was performed by the FAA's Civil Medical Institute in Oklahoma City, Oklahoma. The toxicological examination of specimens from the pilot and co-pilot were negative for the drugs screened and ethanol.

TESTS AND RESEARCH

On March 27, 1998, a FAA approved computerized flight simulator was used to fly the known radar data points. The Beechcraft Bonanza Model A36 was selected in lieu of the Cessna 210, which was unavailable in that simulator database. The A36 was chosen because it was the closest match to the flight limits of the Cessna 210. The IIC flew the flight profile with the president of Prompt Air and a NTSB intern present. A flight profile that matched the known radar data points was a loose aileron roll to the left. In the last 15 seconds of recorded radar data, the rate of descent ranged anywhere from 2,400 feet per minute to in excess of 8,000 feet per minute. See enclosed performance data graphs.

In interviews with past Prompt Air employees, former pilots stated that the chief pilot said he had performed aileron rolls in Cessna 210 airplanes several times in the past. In a phone interview, one former company line pilot told a Safety Board employee that he witnessed the chief pilot perform two rolls in a Prompt Air Cessna 210. He said that he and the chief pilot were returning from a training flight when the chief pilot took over the manipulation of the flight controls. According to the pilot, the chief pilot then spoke about the maneuverability of the airplane, then said, "Let me show you what this plane can do." The chief pilot then performed an aileron roll to the right. The pilot stated that he then asked the chief pilot to do it again. The chief pilot performed another aileron roll to the right. The pilot said that the flight was returning from a training mission designed to prepare him for a check ride. They had been executing practice instrument approaches earlier in the flight. He said that the airplane's altitude was "at least 2000 feet above the ground." In the interview, the pilot stated that he felt tempted to perform this maneuver during later flights while flying alone, but did not.

Another company pilot stated that during a training flight, he was asked if he would like to roll the airplane. He declined. He stated that he did not feel comfortable performing a roll, indicating that the airplane's altitude at the time was 2000 feet above the ground. He stated that the flight was returning to Chicago-Midway Airport from an airport where he had been practicing instrument approaches.

A third former Prompt Air pilot told a Safety Board representative that while en route to Chicago-Midway Airport, the chief pilot performed a roll in the Cessna 210. He stated that the chief pilot proceeded to "train" him how to perform the maneuver. Shortly thereafter during the same flight, he performed the maneuver himself. The pilot stated that that was the first time he had experienced a roll in an airplane that he was onboard.

A review of the National Transportation Safety Board's database shows that Prompt Air has had nine accidents and one incident in the last 10 years, four of which were fatal accidents. Following a series of fatal accidents investigated by the North Central Regional office of the NTSB involving Prompt Air in 1988, a special FAA investigation of Prompt Air found sufficient discrepancies to revoke their operating certificate. Prompt Air was re-issued an operating certificate in September 1994. Since the second certification, Prompt Air has had six accidents. See attached records of FAA Letters of Investigation (LOIs). See attached records of sworn testimony taken by NTSB Investigators of Prompt Air and FAA employees.

ADDITIONAL DATA

The only party to the investigation was the Federal Aviation Administration.

NTSB Probable Cause

Undetermined.