Burke Lakefront Airport (BKL) sits snugly nestled along the south shore of Lake Erie and serves mostly business and traditional general aviation traffic, along with a handful of air carrier operations. Pilots like the place for its convenience to downtown Cleveland. Late one December evening in 2016, the pilot of a Cessna Citation CJ4 lost control of his airplane less than three minutes after takeoff from BKL. The Part 91-operated aircraft impacted the dark choppy waters of Lake Erie with no survivors amongst the six people aboard. Not surprisingly, a number of factors appear to have been at work in creating this accident.
Like an early comrade airport, Chicago’s now shuttered Meigs Field (CGX), Burke’s location requires a departure turn out over the lake that becomes riskier at night, and riskier still on a dark night conditions – no moon or starlight – where restricted visibilities make it nearly impossible for a pilot to differentiate between the horizon, the water and the night sky. With no usable horizon, a pilot’s depth perception also suffers. Once heading north from BKL, the nearest land that could possibly offer any lights and a potential horizon were nearly 50 miles away.
When professional flight crews brief a dark-night takeoff, the emphasis is always on the pilot flying being prepared for nearly instantaneous instrument flight, just as they would during takeoff into a low ceiling. If they don’t, spatial disorientation is almost certain to follow. Should that occur, the PIC quickly becomes nothing more than a passenger along for a brief ride to the inevitable. On the accident flight, the CJ4 never traveled further than two miles from BKL before impacting the water.
Such were the conditions the 45-year old businessman pilot faced just a few evenings before New Year’s Eve. Another contributor could well have been that he’d also been awake for nearly 17 hours having flown the CJ4 to Cleveland from Ohio State University Airport (OSU) earlier that night to attend a sporting event. The aircraft departed OSU about 1730 local for BKL following the pilot’s regular office workday.
The PIC
The 45-year old pilot of N614SB was relatively new to the CJ4, having logged less than 9 hours of PIC time since passing his type rating checkride in the aircraft three weeks before. The pilot previously owned a Citation Mustang in which he’d logged nearly 380 hours before purchasing the CJ4. He’d logged approximately 1,205 hours total since learning to fly with 47 of those hours in the CJ4 during training. He held a private pilot certificate with single-engine, multi-engine and instrument ratings. He completed a simulator-based CJ4 recurrent course with a single-pilot endorsement at FlightSafety 12 days before the accident. During interviews with FSI an FSI instructor, investigators learned the pilot had been trained to engage the autopilot right after takeoff. The NTSB also found no mechanical issues that might have caused the accident.
Cleveland weather the night of the accident was reported as marginal VFR with a broken cloud deck at 2,300 feet, visibility of 9 miles and winds nearly aligned with Runway 24 Right at BKL blowing at 22 knots, with gusts to 31 knots. The CJ4 pilot and his passengers returned to BKL at 2230 local and prepared for the short 110 nm IFR flight back to OSU. By 2255 local, the CJ4 was rolling down Runway 24 Right on takeoff having been cleared by ATC for a right turn heading 330 and a climb to 2,000 feet.
At 2256:33 local, approximately 90 seconds after takeoff, the cockpit voice recorder heard the automated voice announce “altitude” as the aircraft was approaching it’s 2,000 foot restriction. The airplane’s initial climb rate at that point however, exceeded 6,000 fpm and a second altitude warning was heard 14 seconds later as the aircraft passed through 2,000 feet. The CJ4’s 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 dive, airspeed and descent rate reached about 300 knots and 6,000 fpm, respectively. The enhanced ground proximity warning system provided both “bank angle” and “sink rate” alerts.
At 2257:25, two seconds after the bank angle warning, the tower controller instructed the pilot to contact departure. The pilot replied, but apparently in the confusion, did not hit the push-to-talk button because the transmission was only picked up inside the cockpit.
Beginning at 2257:43, approximately 2 ½ minutes after takeoff, the enhanced ground proximity warning system provided seven separate “pull up” warnings at 1.6-second intervals until the end of the CVR recording. During that same time, a sound similar to the overspeed warning began, that also continued until the end of the recording at 2257:58.
The NTSB’s Findings
It comes as no surprise that the NTSB decided controlled flight into terrain due to pilot spatial disorientation was the cause of this accident. Clearly, the pilot was behind the airplane almost before the wheels had retracted.
However, as with most accidents, the Board added a number of contributing factors like pilot fatigue and most interesting, mode confusion related to the status of the autopilot. While the flight guidance panel on his previous airplane, the Mustang and the CJ4 are similar, there are some significant differences meaning the pilot may not have had enough experience in the CJ4 to unlearn what he’d become used to in the Mustang.
The flight guidance panel (FGP) on the CJ4’s glareshield, allows the pilot to select manual or autopilot guidance for airplane control. The autopilot button is located on the upper row of button controls near the right side of the panel. Autopilot engagement is indicated in the flight control system display area along the upper portion of the primary flight display (PFD). There is no indication of the autopilot status on or near the autopilot button however.
It is possible that differences between the avionics panel layout on the CJ4 and his earlier Mustang contributed to mode confusion and his failure to actually engage the autopilot. A comparison of the CJ4 systems and those of the Mustang, revealed the autopilot engagement button on the Mustang is located in a slightly different location on the automatic flight control system panel. In the Mustang, autopilot engagement is indicated along the upper portion of the PFD similar to the accident airplane. In addition however, the Mustang offers an indicator light adjacent to the autopilot button on the AFCS panel that lights up when the autopilot is engaged.
The NTSB believed it likely that the pilot attempted to engage the autopilot after takeoff as he had been trained, but was not successful, implying the pilot failed to confirm autopilot engagement via an indication on the primary flight display (PFD), the CJ’s only indication of autopilot engagement. Perhaps he pressed a button in the location he expected to feel in the bumpy air that night, but it apparently did not engage the autopilot.
Inadequate flight instrument scanning during this time of elevated workload resulted in the pilot allowing the airplane to climb through the assigned altitude, develop an overly steep bank angle, continue through the assigned heading and to ultimately enter a rapid descent with no corrective action on his part. The NTSB said a belief that the autopilot was engaged may have contributed to his lack of attention.
Adding to the pilot’s confusion that night may have been that the primary flight display on the CJ4 was different from that of the Mustang. The CJ4’s PFD was an ego-centric (“inside out”) type display. This “inside out” perspective uses a fixed aircraft symbol and a moving horizon similar to what a pilot sees when looking outside the aircraft. The Mustang, however, uses an exo-centric (“outside in”) display. That “outside in” perspective involves a fixed horizon and a moving aircraft symbol.
Finally there’s the unfortunate human factors conclusion buried between the words of this accident report, that in addition to the flight guidance panel issues, there are aircraft performance issues that should have been addressed.
Anyone who has flown both a Citation Mustang and a CJ4 realize that the larger aircraft performs like more of a sports car than the Mustang, thanks in part to engines on the CJ4 that produce nearly twice as much thrust as the Mustang. And when a pilot is new to a much more powerful aircraft, along with the dark night conditions at BKL and the gusty winds and turbulence, plus his lack of PIC experience in the CJ4, the pilot should have realized that the faster airplane not properly controlled could have allowed bad things to happen just that much faster. This is not the first accident in which a relatively low-time PIC assumed punching on the autopilot would cure just about any problem that might occur.
Despite all these Monday-morning quarterbacking factors, would the pilot’s ego have allowed him to cancel the trip that night in front of his friends? There’s no evidence indicating the pilot considered that option.
