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Last updated: 17 November 2018
Status:Final
Date:Thursday 29 December 2016
Time:22:57
Type:Silhouette image of generic C525 model; specific model in this crash may look slightly different
Cessna 525C Citation CJ4
Operator:Superior Beverage Group
Registration: N614SB
C/n / msn: 525C-0072
First flight: 2012
Total airframe hrs:861
Engines: 2 Williams International FJ44-4A
Crew:Fatalities: 1 / Occupants: 1
Passengers:Fatalities: 5 / Occupants: 5
Total:Fatalities: 6 / Occupants: 6
Aircraft damage: Destroyed
Aircraft fate: Written off (damaged beyond repair)
Location:3 km (1.9 mls) N off Cleveland-Burke Lakefront Airport, OH (BKL) (   United States of America)
Phase: Initial climb (ICL)
Nature:Private
Departure airport:Cleveland-Burke Lakefront Airport, OH (BKL/KBKL), United States of America
Destination airport:Columbus-Ohio State University Airport, OH (OSU/KOSU), United States of America
Narrative:
A Cessna 525C Citation CJ4 corporate jet, registered to Maverick Air and operated on behalf of the Superior Beverage Group, impacted the waters of Lake Erie shortly after takeoff from Cleveland-Burke Lakefront Airport, Ohio, USA.
The pilot and passengers departed Columbus-Ohio State University Airport, Ohio, USA about 17:30 and arrived at Cleveland-Burke Lakefront Airport about 18:00. The pilot and passengers attended a local sporting event before returning to the airport about 22:30.
At 22:55 the pilot was cleared for takeoff from runway 24R and the controller instructed him to turn right to a heading of 330 degrees and maintain 2,000 feet msl after departure. The pilot acknowledged the clearance. At 22:56:33, the engine power increased for takeoff, and 15 seconds later the airplane became airborne.
The airplane entered a right turn shortly after takeoff and proceeded out over a large lake. Dark night visual conditions prevailed at the airport; however, the airplane entered instrument conditions shortly after takeoff. The airplane climb rate exceeded 6,000 fpm during the initial climb and it subsequently continued through the assigned altitude of 2,000 ft mean sea level.
The flight director provided alerts before the airplane reached the assigned altitude and again after it had passed through it. The bank angle increased to about 62 degrees and the pitch attitude decreased to about 15 degrees nose down, as the airplane continued through the assigned heading. The bank angle ultimately decreased to about 25 degrees. During the subsequent descent, the airspeed and descent rate reached about 300 knots and 6,000 fpm, respectively. The enhanced ground proximity warning system (EGPWS) provided both "bank angle" and "sink rate" alerts to the pilot, followed by seven "pull up" warnings.
The aircraft impacted the water at 22:57:58.
The Coast Guard reported it suspended the search for possible survivors on December 31. Divers retrieved the cockpit voice recorder and pieces of debris on January 6, 2017.

A postaccident examination of the recovered wreckage did not reveal any anomalies consistent with a preimpact failure or malfunction.
It is likely that the pilot attempted to engage the autopilot after takeoff as he had been trained. However, based on the flight profile, the autopilot was not engaged. This implied that the pilot failed to confirm autopilot engagement via an indication on the primary flight display (PFD).
The PFD annunciation was the only indication of autopilot engagement. Inadequate flight instrument scanning during this time of elevated workload resulted in the pilot allowing the airplane to climb through the assigned altitude, to develop an overly steep bank angle, to continue through the assigned heading, and to ultimately enter a rapid descent without effective corrective action. A belief that the autopilot was engaged may have contributed to his lack of attention.
It is also possible that differences between the avionics panel layout on the accident airplane and the airplane he previously flew resulted in mode confusion and contributed to his failure to engage the autopilot. The lack of proximal feedback on the flight guidance panel might have contributed to his failure to notice that the autopilot was not engaged.
The pilot likely experienced some level of spatial disorientation due to the dark night lighting conditions, the lack of visual references over the lake, and the encounter with instrument meteorological conditions. It is possible that once the pilot became disoriented, the negative learning transfer due to the differences between the attitude indicator display on the accident airplane and the airplane previously flown by the pilot may have hindered his ability to properly apply corrective control inputs.
Available information indicated that the pilot had been awake for nearly 17 hours at the time of the accident. As a result, the pilot was likely fatigued which hindered his ability to manage the high workload environment, maintain an effective instrument scan, provide prompt and accurate control inputs, and to respond to multiple bank angle and descent rate warnings.

Probable Cause:

PROBABLE CAUSE: "Controlled flight into terrain due to pilot spatial disorientation. Contributing to the accident was pilot fatigue, mode confusion related to the status of the autopilot, and negative learning transfer due to flight guidance panel and attitude indicator differences from the pilot's previous flight experience."

Accident investigation:
cover
Investigating agency: NTSB
Status: Investigation completed
Duration: 1 year and 7 months
Accident number: CEN17FA072
Download report: Final report

Classification:
Insufficient rest / fatigue
Loss of situational awareness
Loss of control

Sources:
» WKYC
» WEWS Twitter feed
» NTSB

METAR Weather report:
03:45 UTC / 22:45 local time:
KBKL 300345Z 26023G32KT 6SM -SN BR SCT012 BKN021 OVC026 01/M02 A2973 RMK AO2 PK WND 26035/0254 SNB0259 P0000 T00061017

03:53 UTC / 22:53 local time:
KBKL 300353Z 26025G31KT 8SM -SN BKN013 BKN022 OVC032 01/M02 A2974 RMK AO2 PK WND 26035/0254 SNB0259 SLP076 P0000 T00061017

04:00 UTC / 23:00 local time:
KBKL 300400Z 26022G31KT 9SM SCT015 BKN023 OVC039 01/M02 A2974 RMK AO2 PK WND 26027/0356 SNE0355 P0000 T00061017


Photos

photo of Cessna 525C Citation CJ4 N614SB
Left and right wing
photo of Cessna 525C Citation CJ4 N614SB
fuselage section
photo of Cessna 525C Citation CJ4 N614SB
Flight path with time and altitude for selected points
photo of Cessna 525C Citation CJ4 N614SB
Flight path with time and altitude for selected points
photo of Cessna 525C Citation CJ4 N614SB
Altitude and calculated air and groundspeeds versus time
photo of Cessna 525C Citation CJ4 N614SB
Longitudinal, lateral, and vertical load factors from a simulation and altitude
photo of Cessna 525C Citation CJ4 N614SB
Altitude and roll versus time with sightline and cloud layer noted
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Map
This map shows the airport of departure and the intended destination of the flight. The line between the airports does not display the exact flight path.
Distance from Cleveland-Burke Lakefront Airport, OH to Columbus-Ohio State University Airport, OH as the crow flies is 197 km (123 miles).
Accident location: Approximate; accuracy within a few kilometers.

This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.
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