Cirrus Design Corporation SR22

Full Narrative

HISTORY OF FLIGHT

On September 11, 2008, approximately 1915 central daylight time, a Cirrus Design Corporation SR22, N193BS, sustained substantial damage when it impacted terrain during a nonprecision instrument approach to runway 36 at the Lakeland Airport/Noble F. Lee Memorial Field (ARV), Minocqua-Woodruff, Wisconsin. Instrument meteorological conditions prevailed at the time of the accident. The Title 14 Code of Federal Regulations (CFR) Part 135 on-demand passenger flight was operating on an instrument flight rules (IFR) flight plan. The pilot and two revenue passengers received fatal injuries. The flight departed from General Mitchell International Airport (MKE), Milwaukee, Wisconsin, at 1745, and was en route to ARV. According to available documentation, the airplane was registered to Bluesky Taxi Inc. (BST), Lincolnshire, Illinois, and was listed on Midwest Air Transport, Inc's (MAT) Part 135 operating certificate.

Earlier on the day of the accident, the pilot had flown his airplane to Lafayette, Indiana, and arrived about 1045 eastern daylight time to meet a friend. The friend stated that the pilot was in “fine” condition, in a “great mood,” and “relaxed.” The pilot told his friend that the Bluesky Taxi (BST) operating certificate was owned by a private individual, but that individual did not operate the flights. The pilot also told him that the owners of BST were the operators and that they assigned the flights. The pilot also told his friend that there was no dispatcher and that the pilots dispatch themselves and would try to fly under visual flight rules (VFR) as much as possible to minimize the cost to the customers as much as possible. The pilot further told him that he would get a call from the chief pilot of BST if he flew IFR and did not absolutely have to. The pilot then departed from Lafayette in the afternoon to return to his home in Illinois.

The president of MAT stated that the accident flight was originally scheduled with a pilot who could only fly under VFR; however, IMC conditions prevailed to the north along the intended route of flight, so the MAT president called the accident pilot via telephone and asked if he was available. The pilot said he was available and was provided flight itinerary information. The pilot was dispatched from DuPage Airport (DPA), West Chicago, Illinois, in N193BS because the airplane was closer to the accident pilot’s home. The president stated that he believed that he talked to the originally scheduled pilot and the accident pilot before 1500, a couple of hours before the scheduled pick-up at 1700. The pilot left his house about 1600 to pick up the airplane at DPA.

At 1627:58, a caller representing himself as the pilot of N193BS called Kankakee automated flight service station (AFSS) and filed two IFR flight plans from MKE to ARV and ARV to DPA. The caller filed the first flight plan for N193BS and specified the airplane equipment capability as “slash golf” (Global Navigation Satellite System (GNSS), including GPS or WAAS, with en route and terminal capability). The proposed departure time from MKE was 1700, at an altitude of 8,000 feet, destination ARV, time en route of 1 hour 15 minutes, and 3 hours 30 minutes of fuel on board. The caller filed a return flight plan with a proposed departure time from ARV to DPA at an altitude of 8,000 feet, with a proposed arrival time of 2330. The FSS specialist asked the caller if he had the latest information on weather conditions, to which the caller responded by saying, “yes I do since (unintelligible).” The specialist then provided the caller with convective Significant Meteorological Information (SIGMET) for thunderstorms and an Airmen's Meteorological Information (AIRMET) for IFR.

At 1631:16, the call to Kankakee AFSS was concluded.

A credit card receipt from Signature Flight Support at MKE shows a charge for 30 gallons of 100 low lead fuel for N193BS and the customer listed is “Bluesky Taxi LLC.”

The following is a chronological summary of voice communications of the airplane and airplane flight data extruded from the airplane flight instruments.

At 1742:13, N193BS requested and was issued an IFR clearance to ARV by MKE Air Traffic Control (ATC). The clearance to ARV was via the Brew Three departure direct to Oshkosh, and to maintain 5,000 feet.

At 1743:36, N193BS requested and received a taxi clearance from Signature Flight to runway 19R by MKE ground control.

At 1745:00, N193BS was issued a takeoff clearance by MKE local control.

At 1831:50, Minneapolis Air Route Traffic Control Center (ARTCC), Sector 4 Radar Controller (ZMP04) transmitted, “tango November one niner three bravo sierra advise when you have the current arbor vitae weather---and the arbor vitae altimeter’s two nine eight niner.”

At 1831:57, N193BS transmitted, “yea we’ve got the weather.”

At 1831:59, ZMP04 transmitted, “and (your) tango november one niner three bravo sierra a couple notams at arbor vitae n d b is out of service runway three six i l s d m e is out of service.” [A Notice to Airmen (NOTAM) was issued on September 3, 2008, stating that the ARV nondirectional radio beacon (NDB) was out of service. A second NOTAM was issued on September 8, 2008, stating that the ARV runway 36 instrument landing system (ILS) distance measuring equipment (DME) was out of service.]

At 1832:10, N193BS transmitted, “ah the i l s completely out or is it just the d m e.”

At 1832:16, ZMP04 transmitted, “tango november one niner three bravo sierra say again.”

At 1832:19, N193BS transmitted, “is the i l s completely out or is it just the d m e.”

At 1832:22, ZMP04 transmitted, “and i am just showing three six i l s d m e is out of service.”

At 1832:27, N193BS transmitted, “o k well ah that may be a problem for us to get in then i’ve got to figure something out and get back to you.”

At 1834, ZMP04 instructed N193BS to contact Minneapolis ARTCC with a frequency change. N193BS then initiated contact with the Minneapolis ARTCC, Sector 03 Radar Controller (ZMP03) and reported an altitude of 8,000 feet.

At 1835:55, N193BS transmitted, and Minneapolis three bravo sierra so for planning purposes uh (unintelligible) we are going to get radar vectors to the localizer three six.”

At 1836:01, ZMP03 transmitted, “november three bravo sierra affirmative.”

At 1904:49, ZMP03 transmitted, “a november three bravo sierra’s four south of dougy maintain three thousand five hundred til on a published portion of the approach cleared for the localizer three six approach arbor vitae.”

At 1905:07, N193BS transmitted, “ah i got all that ah three thousand five hundred till on a published segment (unintelligible) cleared three six approach.”

At 1905:13, ZMP03 transmitted, “November three bravo sierra roger and are you going to be able to shoot the approach from a couple south of the marker there.”

At 1905:19, N193BS transmitted, “i’m sorry what.”

At 1905:20, ZMP03 transmitted, “are you going to be able to make the approach from fifty two hundred from a couple south of the marker.”

At 1905:29, the autopilot (AP) was selected OFF at a pressure altitude of 5,033 feet and a heading of 359 degrees magnetic.

At 1906, N193BS transmitted, “yea i’m going to need to go back around three bravo sierra if i can just do one oval i should be o k.” ZMP03 approved a left 360 degree turn.

At 1906:07, the active waypoint transitioned from DOUGY to runway 36 at a pressure altitude of 4,509 feet and a heading of 354 degrees. The airplane started a descending left hand 360 degree turn without the AP selected ON.

At 19:07:04, 190 degrees into the turn the AP was selected ON and the turn continued using the heading bug selection. The autopilot altitude reference selected was initially set at 3,500 feet and adjusted to 3,200 feet during the descent.

At 1907:30, ZMP03 transmitted, “november three bravo sierra let me know when uh you’re reestablished inbound on the loc.”

At 1907:34, N193BS transmitted, “yea we are starting to turn back now.”

At 1910:05, ZMP03 transmitted, “o k show you right over the marker now you can change to advisory cancellation or down time um ah with me or forward it through flight
service.”

At 1910:11, N193BS transmitted, “wilco three bravo sierra.” There were no further recorded transmissions from N193BS.

At 1910:11, the final recorded altitude and heading bug settings were 1,900 feet and 0 (360) degrees.

At 1910:24, the AP was selected OFF. The AP remained OFF for the remainder of the recording. The final descent into ARV began just after the AP OFF selection.

At 1910:42, the flap setting changed from 0 percent to 50 percent.

At 1912:06, the engine RPM was at 1,670 rpm.

At 1912:07, the Horizontal Deviation Indication started to indicate a fly right command and the altitude rate, indicating a descent, began a transition to a climb.

At 1912:12, the engine RPM increased to 2,590 rpm.

At 1912:14, a maximum pitch of 45.5 degrees was recorded. The indicated airspeed was 73.2 knots and a roll attitude of 15 degree left wing down.

Prior to a stall warning discrete, the Recoverable Data Module (RDM) recorded an increase in engine manifold pressure, fuel flow, and engine speed.

At 1912:16, the stall warning discrete was set on the RDM. The indicated airspeed was 60 knots, ground speed 61 knots, pitch attitude 39 degrees, and a roll attitude of 32 degrees left wing down.

At 1912:24, the recorded data ends.

WITNESSES

The pilot of a Piper PA-32R-301, which preceded N193BS on the approach, stated that he held a private pilot certificate with an instrument rating and accumulated 5,018 hours of flight time of which 1,017 hours was instrument flight time. The pilot was en route from Dubuque, Iowa, to ARV. The ARV automated weather observing system (AWOS) was reporting ceiling height of 400 feet and a visibility of 3 miles the entire time he was en route. He stated that the cloud tops were about 5,000 feet, but he did not recall the sky condition above the tops. He heard Minneapolis Air Traffic Control Center (ATCC) transmit to N193BS that N193BS was number two for the approach and that his Piper was lower or faster. The Piper pilot said that N193BS was at 7,000 feet and his Piper was at 5,000 feet. ATCC then gave N193BS a vector, cleared the Piper for the approach, and asked the Piper to close his flight plan through N193BS because it would take too long through flight service due to the Piper's low altitude.

The Piper pilot stated that he flew the localizer 36 approach at an approach speed of 90 knots due to a tailwind from 180 degrees at 9-10 knots. The Piper pilot monitored the ARV AWOS until reaching the outer marker and then descended to the minimum descent altitude. The Piper pilot then turned the runway lights on high at an altitude of about 400 feet above ground level. The Piper pilot said that he was on the final approach segment about 20 minutes before sunset, it was “getting dark,” and the visibility was a “little hazy.” He saw the approach lights “clear as a bell” off his left wing so he descended a “little.” He had “good” visibility and could see the runway. The Piper touched down a “few minutes” after 1900.

He transmitted to N193BS to close the flight plan for his Piper. N193BS then called back and said ATCC had his cancellation. The Piper pilot then transmitted that he was clear of the active runway and the ceilings were “pretty” low. There was no response from N193BS to that transmission and a few seconds later the Piper pilot heard N193BS respond to ATCC by transmitting “cleared for the approach.” The N193BS pilot sounded “fine, alert, calm,” and “matter of fact.”

About 3-5 minutes after touchdown and while taxiing to his hangar, the Piper pilot checked the ARV AWOS, which reported ceiling and visibility 200 feet and 2 miles. He taxied to his hangar, got out of the airplane, and was standing outside about 100 yards east of runway 36, talking on his cell phone when he heard the engine of N193BS. The Piper pilot could not see the runway lights from his position, but heard engine noise in the distance, which he said was “normal” and “constant.” He stated that the engine noise was “throttled back” when it changed to “full power.” The intensity of the noise increased by twofold to what he assumed was full throttle for about 4-5 seconds. He then heard a “thud” and the cessation of engine noise. He judged the position of the airplane when he heard it based upon engine noise as being south and west of the runway 36 and never heard the airplane overhead or pass over the runway. He didn’t think that N193BS performed more than one approach attempt.

The Piper pilot said that he met a couple in a car at the airport who were waiting for a passenger from Milwaukee, who was “running late.” They had also heard the “thud.” The Piper pilot called Flight Service and asked if they lost somebody. He took the people to the accident site.

The Piper pilot stated that he did not have any concerns regarding his approach or the airport.

PERSONNEL INFORMATION

Accident Pilot Background

According to airman records, the pilot held a commercial pilot certificate with single-engine land and instrument airplane ratings. As of September 8, 2008, he accumulated a total flight time of 2,212.5 hours, 233.7 hours of night flight, 140.7 hours of actual instrument time, and 118.9 hours of simulated instrument time. He was last issued a second class airman medical certificate on March 10, 2008, with no limitations. On March 22, 1975, he was issued a private pilot certificate with an airplane single-engine land rating at a total instruction time of 64.7 hours and a total pilot-in-command time of 48.2 hours. On December 2, 1990, he was issued an instrument airplane rating at a total flight time of 401 hours. On October 18, 1995, he was issued an airplane single-engine sea rating at a total flight time of 776 hours. On April 9, 2007, he was issued a commercial pilot certificate at a total flight time of 1,847 hours. The pilot had no previous record of accidents, incidents, or enforcement actions.

Employment and Training

The accident pilot’s representative stated that the accident pilot was enthused to fly and that he flew about 100 hours in August, which equaled his total flight time in the previous year. He pursued employment flying BST flights because he “loved” to fly and it gave him different “opportunities” to fly. The representative had never heard of MAT since the accident pilot always used the name of BST when he referred to his flying. His other flying, which was concurrent with BST flights, was WBBM Shadow Traffic out of Illinois Aviation Academy on Mondays and Fridays. He also flew Angel Flights.

According to MAT’s Training Program and Employment Data records, the accident pilot did not have a date next to his “Preemployment pilot safety background information verification.” A background check in accordance with the Pilot Records Improvement Act (PRIA) was not performed by MAT. The MAT president stated that he was unaware of the “official notification” that had to be made to the FAA until the National Transportation Safety Board (NTSB) Investigator-In-Charge (IIC) told him about the Act. The MAT president said that the only checks he performed were premployment and that nobody made him aware that it was a statutory requirement and that it was not a Federal Aviation Regulation requirement. FAA Order 8000.88, PRIA Guidance for FAA Inspectors, effective March 14, 2006, states that an air carrier cannot place a pilot into service until after it obtains and reviews the last 5 years of the pilot’s records specified in the Act. Furthermore, the primary responsibilities of the FAA’s principal operations inspector (POI) includes, in part:

a. Be knowledgeable concerning PRIA.
b. Promote the assigned air carrier’s awareness of and compliance with PRIA.
c. Conduct regularly scheduled reviews of the assigned air carrier’s PRIA records.
d. Be prepared to conduct an investigation upon receipt of a report indicating that the air carrier is not complying with the PRIA law.

The accident pilot had no flight time in Cirrus SR22 airplanes prior to beginning his Cirrus SR22 training. From June 23 to July 14, 2008, the accident pilot and two other pilots attended a “Blue Sky Taxi, Inc. Cirrus Transition Training” provided by Illinois Aviation Academy. The training program was conducted under Part 91 and was not an approved training program under Part 135. The training program was paid for by BST and taught by an Illinois Aviation Academy flight instructor who held a Cirrus Standardized Instructor Program (CSIP) designation. A copy of the training program was provided by the Illinois Aviation Academy president and included one lesson record relating to the accident pilot, which was dated June 24, 2008, and showed that he received 2.4 hours of flight time during that one lesson.

The MAT president stated that he is the only company instructor who provides Part 135 training to MAT pilots. MAT’s Part 135, Chapter 6, Training Program, Flight Training Record, dated July 16, 2008, and signed by the MAT president, states that the accident pilot received a total of 15 hours of training and listed the president as the instructor for each date of instruction. The dates and corresponding hours of instruction were:

June 24, 2008, 2.4 hours
June 26, 2008, 2.1 hours
June 29, 2008, 3.7 hours
July 4, 2008, 3.1 hours
July 11, 2008, 2.7 hours
July 13, 2008, 3.1 hours
July 14, 2008, 2.2 hours
July 15, 2008, 3.0 hours

MAT’s Part 135 training modules included: Takeoffs, En Route, Approaches, Landings, and Emergency Procedures. The accident pilot’s Flight Training Record shows that stalls were performed on June 26, 2008, July 4, 2008, July 13, 2008, and July 15, 2008. The Approaches listed within the training module were: Precision, Nonprecision, Circling, Missed, and Nonprecision. Approaches were performed on June 24, 2008, June 29, 2008, and June July 11, 2008. Missed approach training was preformed on June 24, 2008, June 29, 2008, July 11, 2008, and July 14, 2008. The results of all training were checked “satisfactory.”

A comparative review of the accident pilot’s logbook for those dates of training listed on MAT’s Part 135 Flight Training Record showed the following.

A June 24, 2008, logbook entry lists a flight 2.4 hours in duration in N192BS from DPA to Whiteside County Airport-Jos H Bittorf Field (SQI), Sterling/Rockfalls, Illinois. The recorded remarks are: “holds, DME arcs, steep turns, slow flight, power on stalls, traffic pattern.” One landing was recorded and the flight duration was 2.4 hours. No instrument approaches were entered into the entry; however, the Flight Training Record shows that precision and nonprecison approaches were performed. The entry for this flight contains the signature of the Illinois Aviation Academy flight instructor and not MAT’s president.

On June 26, 2008, a logbook entry lists a flight 2.1 hours in duration in N193BS from DPA to PWK to DPA. The recorded remarks are: “holds at PLL – ILS 7 (2) at RFD one hand flew - ILS 1 at RFD.” Three instrument approaches and one landing were recorded. The Flight Training Record shows that no precision and nonprecision approaches were performed. The entry for this flight as well as the previous flight in the pilot’s logbook contains the name/signature of the Illinois Aviation Academy flight instructor and not the MAT’s president.

On July 4, 2008, there are no entries of training flights or flights in a Cirrus SR22 in the accident pilot’s logbook.

On July 11, 2008, there are three flights in Cirrus SR22 airplanes that total 2.7 hours; however these flights are not recorded as training flights. The first flight was to Burlington Municipal Airport (BUU), Burlington, Wisconsin, for a “100-hour annual”. The second flight was to Indianapolis Metropolitan Airport, Indianapolis, Indiana, “to pick up …GPS.” The third flight was a repositioning flight, “dropped off … at PWK then reposition to DPA.” The flight was from Waukegan Regional Airport Chicago/Waukegan, Illinois, to PWK to DPA. None of these entries contain the MAT president’s name/signature.

On July 13, 2008, there are two flights that total 2.2 hours in duration in Cirrus SR22 airplanes. The first flight was a local flight that from DPA for “Part 135 prep – steep turns stalls ILS 33, GPS 27 at ARR.” The flight was 2.0 hours in duration and is the only entry in the accident pilot’s logbook that contains the MAT president’s name. The second flight was 1.1 hours in duration with remarks, “returned from Blue Taxi charter did 20R GPS at DPA…”

On July 14, 2008, there is one local flight 2.2 hours in duration in N192BS from DPA for “Approaches, Missed Appr. Procedures." The entry for this flight contains the Illinois Aviation Academy flight instructor’s name/signature and not the MAT’s president’s name/signature.

On July 15, 2008, there are three flights that total 3.0 hours in duration in N193BS. The first flight is 0.5 hours in duration from PWK to BUU and states “flew with … to reposition the A/C.” The second flight is 1.5 hours in duration from DPA to LCL and states “flew mock checkride – ILS 9 at ARR, ILS 33 and DPA 10 VOR – air work.” The entry has the name of another MAT pilot listed as “safety pilot.” The third flight is 1.0 hours in duration from DPA-PWK-DPA and states “returned … to PWK then back to DPA ILS 16. The entry has the name of another MAT pilot listed as “safety pilot.” The pilot’s Flight Training Record does not annotate that precision and nonprecison approaches were performed on this day nor do any of the logbook entries contain the MAT president’s name/signature on this date.

Part 135.273 Duty Period Limitations and Rest Time Requirements, states, in part, “Duty period means the period of elapsed time between reporting for an assignment involving flight time and release from that assignment by the certificate holder”. A review the MAT president’s duty time records shows that from June 24, 2008 to July 15, 2008, there were only four entries during the period. The four entries were on July 3, July 10, July 13, and July 14, 2008.

A comparative review of a second MAT’s pilot’s logbook and his Part 135 Flight Training Record, shows instructional flights by the Illinois Aviation Academy flight instructor on the same dates with the same flight duration as those entered into the pilot’s Part 135 Flight Training Record by the MAT president.

The Illinois Aviation Academy instructor stated that the MAT president would meet with the accident pilot on Saturday mornings or Sunday afternoons for three hours providing the accident pilot training in order to prepare him for a Part 135 check ride. The MAT president performed the accident pilot’s Part 135 training concurrently with the Illinois Aviation Academy flight instructor’s training that she was providing to the accident pilot. The MAT president did “a lot” of the Part 135 training at Illinois Aviation Academy, but the instructor did not know what occurred during that training. The instructor stated that the accident pilot told her that he was not going take his initial airman competency/proficiency Part 135 check ride, but the instructor later learned that he took the check ride.

On July 17, 2008, the accident pilot received an initial airman competency/proficiency check under Part 135.293, 135.297, and 135.299 using N193BS that was 1.0 hour in duration. The check was administered by a DuPage FSDO principal operations inspector (POI) assigned to MAT. The accident pilot satisfactorily completed 7 of the 32 elements of the check and failed the instrument procedures portion relating to VOR approaches. The accident pilot’s logbook entry shows that the local flight departed from DPA and that the he “failed VOR 33 approach.”

The Illinois Aviation Academy’s flight instructor stated the accident pilot was “pushed” into a Part 135 checkride before completing Cirrus SR22 training because there was “pressure” for a trip on a Friday and that they needed him for that trip. He was not prepared for the checkride and failed because he “continuously forgot” to turn in the course deviation indicator (CDI) needle for the approach course. The global positioning system and localizer approaches are “automatic,” so the course deviation indicator (CDI) for the approach course loads into the primary flight display (PFD). The VOR CDI is displayed at its last setting on the PFD. The Illinois Aviation Academy instructor then flew with the accident pilot after the check ride for another 2-3 hours providing training in the area(s) that he failed.

Part 135.297 Pilot-in-Command: Instrument Proficiency Check Requirements, states in part, “(a) No certificate holder may use a pilot, nor may any person serve, as a pilot in command of an aircraft under IFR unless, since the beginning of the 6th calendar month before that service, that pilot has passed an instrument proficiency check under this section administered by the Administrator or an authorized check pilot. … (g) If the pilot in command is authorized to use an autopilot system in place of a second in command, that pilot must show, during the required instrument proficiency check, that the pilot is able (without a second in command) both with and without using the autopilot to -
(1) Conduct instrument operations competently; and
(2) Properly conduct air/ground communications and comply with complex air traffic control instructions.
(3) Each pilot taking the autopilot check must show that, while using the autopilot, the airplane can be operated as proficiently as it would be if a second in command were present to handle air/ground communications and air traffic control instructions. The autopilot check need only be demonstrated once every 12 calendar months during the instrument proficiency check required under paragraph (a) of this section.”

On July 23, 2008, the accident pilot successfully completed an initial airman competency/proficiency check under Part 135.293, 135.297, and 135.299 using N193BS and was 1.6 hours in duration. The check was administered by the POI from the DuPage FSDO. The form shows that the “Use of Auto. Pilot” was satisfactory. The block on the airman competency/proficiency form, titled Airman Competency Information: has the following items listed and dated with an expiration date:

“Demonstrated Current Knowledge FAR 135.293(a)
Make/Model Expires 7/09 (12 months)…”

“Demonstrated Competency FAR 135.293(b)
Make/Model Expires 7/09 (12 months)…”

“Satisfactorily Demonstrated Line Checks
FAR 135.299 Expires 7/09 (12 months)…”

“Satisfactorily Demonstrated IFR Proficiency
FAR 135.297 Expires 1/09 (6 months)…”

“Use of Autopilot (is) (is not) Authorized.” is not annotated, initialed, and dated with an expiration date by the POI. During a post accident interview, the POI stated that the accident pilot did not want to be examined on the use of the autopilot and that the annotation of an autopilot check as satisfactory was a “mistake.”

From July 24, 2008 to September 8, 2008, the accident pilot’s logbook shows he accumulated a total flight time of 146.3 hours, of which 84.9 hours were in Cirrus SR22 airplanes. During this period, the pilot accumulated a total actual instrument time of 3.9 hours, a simulated instrument time 0 hours, and a night flight time 12.7 hours. He performed a total of eight instrument approaches, of which four instrument approaches were logged concurrent with the entries of actual instrument time, one instrument approach was logged concurrent with night flight and actual instrument conditions, and three instrument approaches were not concurrent with actual instrument/night conditions.

Five of the eight instrument approaches were the ILS 16 approach at PWK. The single instrument approach concurrent with actual instrument conditions and night conditions occurred on July 24, 2008, and was logged as the ILS 16 approach at PWK.

AIRCRAFT INFORMATION

The 2007 Cirrus SR22, N193BS, serial number 22-2761, was one of three Cirrus SR22 airplanes registered to Bluesky Taxi Inc. The other two Cirrus SR22 airplanes were N191BS, serial number 22-2733 and N192BS, serial number 22-2753. The Cirrus SR22 was certified under Part 23. The accident airplane was powered by a Teledyne Continental IO-550 engine, serial number 691305.

Part 135.421 Additional Maintenance Requirement states, paragraph (c), states, “For each single engine aircraft to be used in passenger-carrying IFR operations, each certificate holder must incorporate into its maintenance program either: (1) the manufacturer’s recommended engine trend monitoring program, which includes an oil analysis, if appropriate, or (2) an FAA approved engine trend monitoring program that includes an oil analysis at each 100 interval or at the manufacturer’s suggested interval, whichever is more frequent.”

There were no maintenance logbook entries showing that N191BS, N192BS, and N193BS had received an engine oil analysis or that it complied with a manufacturer’s engine trend monitoring program. During a post accident interview, the MAT president stated that prior to about August 25 or September 5 he was unaware of engine trend monitoring. Since then they have had an oil analysis done. Airplane maintenance records found at the accident site show that Illinois Aviation Academy performed engine oil and filter changes without an oil analysis on the following dates and times:

“N192BS”; May 24, 2008; Hobbs: 163.5
June 11, 2008; Hobbs: 215.9
July 22, 2008; Hobbs 251.8
September 4, 2008; Tach: 366.9

The Illinois Aviation Academy mechanic who performed the oil changes stated that he knew the BST airplanes were being used in Part 135 operations. He said that he performed oil changes on N193BS and that he had never talked to the MAT director of maintenance. He thought that he had briefly seen the aircraft logbooks on only one occasion. He used stickers citing the oil changes he performed and would give these to the pilot.

Airplane Weight and Balance Information

The airplane gross weight was 3,400 lbs, the basic empty weight was 2,281 lbs, the moment was 137.75 inches, and the moment arm was 314.212 in-lbs.

Autopsies of the pilot and passengers indicated a pilot weight of 198 pounds and passenger weights of 195 pounds and 180 pounds. Post accident weighing of baggage was reported as 63 pounds. The BST Flight Confirmation listed both passenger weights as 180 lbs and a baggage weight of 60 pounds. According to a the FAA inspector from the MKE FSDO, the Signature Flight Support service person who fueled N193BS stated that the pilot asked for 20 gallons of fuel for each wing tank. The service person stated that the airplane was full of fuel because he was only able to put 20 gallons in one fuel tank and 19 gallons in the other fuel tank.

METEOROLOGICAL INFORMATION

The North Central Area Aviation Area Forecast synopsis was valid from 1348 until September 12, 2008, at 0800. The clouds/weather forecast was valid beginning at 1348 until September 12, 2008, at 0200 with the outlook valid from 0200 to 0800.

The synopsis states that a cold front extends from northeastern Minnesota to southeastern South Dakota to northwestern Kansas. From 0800, the cold front was forecast to extend from eastern upper Michigan to southern Wisconsin to southwestern Nebraska to southwestern Kansas.

The clouds/weather forecast for the western half of Wisconsin was ceilings overcast 1,000-1,500 feet layered to flight level 250; scattered light rain showers/thunderstorms with light rain; cumulonimbus with tops to flight level 390. The outlook is marginal VFR due to ceilings and mist.

The clouds/weather forecast for the eastern half of Wisconsin was broken to overcast 5,000-7,000 feet layered to flight level 250; scattered light rain showers/thunderstorms with light rain; cumulonimbus with tops to flight level 390; becoming from 2000-2200, ceiling broken 1,500-2,500 feet, visibility 3-5 statue miles light rain and mist; outlook is IFR due to ceiling, rain, and mist.

AIRMET Sierra valid from valid from 1545 for IFR conditions that include Wisconsin due to ceilings below 1,000 feet and/or visibility below 3 statute miles due to precipitation/mist. Conditions continuing beyond 2200 thru September 12, 2008, at 0400.

The closest Terminal Aerodrome Forecast (TAF) was Oneida County Airport (RHI), Rhinelander, Wisconsin, located about 20 miles southeast of ARV. The RHI TAF valid from 1700 to September 12, 2008, at 1300, forecast:

At 1700, wind – 180 at 7 knots, visibility 6 stature miles; mist; sky condition scattered 600 feet above ground level, overcast 1,200 feet above ground level. Temporary conditions from 1700-2100, visibility – 3 statute miles, light rain showers; mist; sky condition overcast 600 feet above ground level.

The MKE Automated Surface Observing System reports indicate visual meteorological condition during each observation on the day of the accident.

The ARV AWOS System-3, located at the ARV airport with an elevation of 1,629 feet mean sea level, recorded the following observations:

At 1615, wind – 190 degrees at 10 knots, gusts at 15 knots; visibility – 10 statute miles; sky condition overcast 600 feet above ground level; temperature - 18 degrees Celsius, dew point – 16 degrees Celsius; altimeter 29.89 inches of mercury.

At 1735, wind – 180 degrees at 8 knots; visibility – 3 statute miles; rain; sky condition overcast 400 feet above ground level; temperature - 18 degrees Celsius, dew point – 16 degrees Celsius; altimeter 29.89 inches of mercury.

At 1855, wind – 200 degrees at 5 knots; visibility – 3 statute miles; mist; sky condition overcast 400 feet above ground level; temperature - 18 degrees Celsius, dew point – 16 degrees Celsius; altimeter 29.88 inches of mercury.

At 1915, wind - 200 degrees at 5 knots; visibility – 3 statute miles; mist; sky condition - overcast 200 feet above ground level; temperature – 18 degrees Celsius, dew point – 16 degrees Celsius; altimeter 29.88 inches of mercury.

Astronomical data for September 11, 2008, for Woodruff, Wisconsin, indicates sunset occurred at 1917 and the end of civil twilight occurred at 1947.

AIRPORT INFORMATION

ARV was a nontowered airport with an airport elevation of 1,629 feet above mean sea level. The airport had two runways: 18-36 (5,150 feet by 100 feet, asphalt) and 10-28 (3,602 feet by 75 feet, asphalt).

Runway 36 was equipped with high intensity runway lights, runway end identifier lights, medium-intensity approach lighting system with runway alignment indicator, and an abbreviated visual approach slope indicator.

The airport had instrument approach procedures: localizer runway 36 (LOC 36), NDB or global positioning system (GPS) runway 36, NDB or GPS runway 28, NDB or GPS runway 18.

The LOC 36 intermediate and final approach courses are 360 degrees. The intermediate segment altitude is 3,200 feet mean sea level. DOUGY is the locator outer marker/initial approach fix at 6.5 distance measure equipment (DME) and the runway 36 approach end is 1.1 DME. The straight-in approach minimum descent altitude is 1,980 feet mean sea level (354 feet above touchdown zone elevation of 1,626 feet) for aircraft categories A-D. The minimum visibility for category A and B aircraft is 1 mile visibility. The visibility minimums for category C and D aircraft have a 1 ½ and 1 ¾ miles, respectively. The approach’s straight-in minimums were higher with a Wausau altimeter setting. The missed approach procedure for LOC 36 is climb to 3,300 feet then a right turn and direct to DOUGY and hold. The depicted holding pattern is west of and along the approach course.

A facility inspection of the LOC 36 approach was performed on September 12, 2008, using FAA aircraft. The inspection reported all flight check parameters were normal.

FLIGHT RECORDERS

The airplane was equipped with a cockpit mounted Avidyne Model Exp5000 PFD, a model EX5000 Multi-Function Display (MFD) and a RDM. The National Transportation Safety Board Vehicle Recorder Division read out the PFD, MFD, and RDM memory modules.

The PFD recording contained records of 34 power cycles and approximately 17 hours of data. The accident flight was associated with the 33rd power cycle, which had a duration of approximately 1 hour and 35 minutes. Timing of the PFD data is measured in seconds from power-on.

The MFD power cycle was approximately 1 hour and 33 minutes in duration. During the MFD data retrieval process, the following subscription affectivity dates were noted.

Charts: August 22, 2008 to September 4, 2008
Navigation Data – August 28, 2008 to September 25, 2008
Obstacles – July 30, 2008 to September 24, 2008

WRECKAGE AND IMPACT INFORMATION

The main wreckage was located about 1/2 mile southwest of approach end of runway 36 (45 degrees 54.999 minutes North and 89 degrees 44.187 minutes West) at an elevation of 1,671 feet. The airplane was resting near the western edge of a grass field and was orientated in an upright position with a tail to nose heading of about 225 degrees. There was no evidence of fire.

The main wreckage consisted of the fuselage, wings, empennage, and engine. There was no ground scarring that preceded the main wreckage. The cabin doors, baggage door, and Cirrus airframe parachute system (CAPS) cover were located about 50 feet from the nose of the airplane.

Both wings were oriented about 60 degrees below the longitudinal axis and the ground scarring beneath the wing leading edges was several inches deep. Both wing flaps were extended. The flap servo motor extension was extended about 2 inches, which is consistent with a flap extension of 50 percent. The left aileron remained attached, and the right aileron was separated from its wing. The roll trim motor was noted in the full right roll position. The empennage was separated from the fuselage, and the horizontal stabilizers remained attached. The pitch trim motor was between neutral and full pitch-up positions. Examination of the flight control system confirmed continuity.

The three-blade propeller remained attached to the engine and was embedded about 3 feet into the ground. All three blades remained attached to the propeller hubs. One propeller blade was deformed rearwards and displayed chordwise scratches.

The CAPS activation handle was seated in the handle holder. The rocket motor was found with its propellant expended adjacent to the leading edge of the right wing. The rocket motor, pick-up collar, and support remained attached to the rocket motor lanyards. The parachute assembly was found within the main wreckage. The retention straps for the D-Bag remained in the enclosure compartment.

The engine was shipped to Teledyne Continental Motors where it underwent a disassembly examination. The examination did not reveal any anomalies that would have precluded normal operation.

MEDICAL AND PATHOLOGICAL INFORMATION

Toxicology tests results of the accident pilot conducted by MAT under 49 CFR Part 40 on July 15, 2008, were negative for all substances tested.

An autopsy of the accident pilot was conducted by the Fond du Lac Country Medical Examiner’s Office on September 13, 2008. The cause of death was cited as multiple traumatic injuries.

The FAA’s Final Forensic Toxicology Fatal Accident Report of the pilot was negative for tested drugs.

TEST AND RESEARCH

Destination Airport and Alternate Airport Weather Requirements

Part 135.219 IFR: Destination Airport Minimums

No person may take off an aircraft under IFR or begin an IFR or
over-the-top operation unless the latest weather reports or forecasts,
or any combination of them, indicate that weather conditions at the
estimated time of arrival at the next airport of intended landing will
be at or above authorized IFR landing minimums.

Part 135.221 IFR: Alternate Airport Weather Minimums

No person may designate an alternate airport unless the weather
reports or forecasts, or any combination of them, indicate that the
weather conditions will be at or above authorized alternate airport
landing minimums for that airport at the estimated time of arrival.

Part 135.223 IFR: Alternate airport requirements

(a) Except as provided in paragraph (b) of this section, no person
may operate an aircraft in IFR conditions unless it carries enough fuel
(considering weather reports or forecasts or any combination of them)
to—
(1) Complete the flight to the first airport of intended landing;
(2) Fly from that airport to the alternate airport; and
(3) Fly after that for 45 minutes at normal cruising speed or, for
helicopters, fly after that for 30 minutes at normal cruising speed.
(b) Paragraph (a)(2) of this section does not apply if part 97 of
this chapter prescribes a standard instrument approach procedure for the
first airport of intended landing and, for at least one hour before and
after the estimated time of arrival, the appropriate weather reports or
forecasts, or any combination of them, indicate that--
(1) The ceiling will be at least 1,500 feet above the lowest
circling approach MDA; or
(2) If a circling instrument approach is not authorized for the
airport, the ceiling will be at least 1,500 feet above the lowest
published minimum or 2,000 feet above the airport elevation, whichever
is higher; and
(3) Visibility for that airport is forecast to be at least three
miles, or two miles more than the lowest applicable visibility minimums,
whichever is the greater, for the instrument approach procedure to be
used at the destination airport.

135.225 IFR: Takeoff, approach and landing minimums, states in part:

(a) Except to the extent permitted by paragraph (b) of this section,
no pilot may begin an instrument approach procedure to an airport
unless--
(2) The latest weather report issued by that weather reporting
facility indicates that weather conditions are at or above the
authorized IFR landing minimums for that airport.
(b) A pilot conducting an eligible on-demand operation may begin an
instrument approach procedure to an airport that does not have a weather
reporting facility operated by the U.S. National Weather Service, a
source approved by the U.S. National Weather Service, or a source
approved by the Administrator if—
(1) The alternate airport has a weather reporting facility operated
by the U.S. National Weather Service, a source approved by the U.S.
National Weather Service, or a source approved by the Administrator; and
(2) The latest weather report issued by the weather reporting
facility includes a current local altimeter setting for the destination
airport. If no local altimeter setting for the destination airport is
available, the pilot may use the current altimeter setting provided by
the facility designated on the approach chart for the destination
airport.
(c) If a pilot has begun the final approach segment of an instrument
approach to an airport under paragraph (b) of this section, and the
pilot receives a later weather report indicating that conditions have
worsened to below the minimum requirements, then the pilot may continue
the approach only if the requirements of Sec. 91.175(l) of this
chapter, or both of the following conditions, are met—
(1) The later weather report is received when the aircraft is in one
of the following approach phases:
(i) The aircraft is on an ILS final approach and has passed the
final approach fix;
(ii) The aircraft is on an ASR or PAR final approach and has been
turned over to the final approach controller; or
(iii) The aircraft is on a nonprecision final approach and the
aircraft—
(A) Has passed the appropriate facility or final approach fix; or
(B) Where a final approach fix is not specified, has completed the
procedure turn and is established inbound toward the airport on the
final approach course within the distance prescribed in the procedure;
and
(2) The pilot in command finds, on reaching the authorized MDA or
DA/DH, that the actual weather conditions are at or above the minimums
prescribed for the procedure being used.

BST Information

BlueSky Taxi LLC has an office located in Lincolnshire, Illinois. BST has never held a commercial air carrier operating certificate and initially placed their airplanes on the commercial air carrier certificate held by Executive Express Aviation (EEA) located at DPA prior to placing their airplanes on the commercial air carrier operating certificate held by MAT. According to one of the two owners of BST, the business relationship with EEA was terminated April 2008, because of financial responsibility, dual standards imposed to pilots, a lack of communication, and a lack of operational control. He stated that EEA had no idea where the aircraft were at a particular moment. The second owner of BST stated that BST ended there relationship with EEA due to financial problems and not safety of flight issues.

On April 10, 2008, BlueSky Taxi LLC made an application on FAA Form 8400-6, Preapplication Statement of Intent, for an air carrier certificate to the MKE FSDO. The principal base where the operations were to be conducted was BUU. The management personnel listed on the form were the two owners of BST, listed as CEOs, the MAT president, who was listed as the director of operations on the form, a MAT pilot who was listed as chief pilot, and the MAT director of maintenance who was listed as director of maintenance on the form. The first owner of BST was asked why an application was made to the MKE FSDO when they were using MAT’s operating certificate. The owner responded by saying that it would be more convenient, cost effective, and provides for more space if the base of operations was at BUU. The owner refused to answer, under the advice of his attorney, whether MAT was going to surrender their operating certificate and begin doing business under the proposed certificate. He also refused to answer, under the advice of his attorney, why the MAT director of operations is listed on the application and would he also retain his position as MAT director of operations.

According the first owner of BST, he and the second owner of BST would provide a quotation to customers, and when they received confirmation that the flight might occur, they would relay this information to the MAT director of operations who then “takes over” and makes all the decisions relating to scheduling, whether the flight could depart, and the departure time. The information would be provided to MAT’s director of operations via telephone or email, but on most occasions, the information is placed on a calendar accessed through a secure webpage belonging to BST available to the pilots and the director of operations. He stated that he had never, not even on one occasion, called the pilots regarding scheduling or flights. The first owner stated that he couldn’t provide anything to the pilots and that he doesn’t even know the pilots. The second owner of BST stated that they have “no contact with the pilots” and that they are “transferring information just to [director of operations]”.

According to the accident pilot’s representative, the accident pilot would obtain his flight schedule from a BST website, which he was having difficulty accessing. The representative stated that in the beginning of September they had “just” come out with a flight schedule on the internet via a BST website. The accident pilot’s representative stated that the accident pilot called the first BST owner in order to obtain “specific directions” on how to access the schedule, the first owner of BST would email the accident pilot “a lot” and “believe[s]” that the first owner also called the accident pilot. The emails were sent to the accident pilot’s personal Blackberry. She stated that the first owner’s partner would also contact the accident pilot. The first owner and his partner would text the accident pilot about trips and meetings.

According to FAA Order 8900.1, Flight Standards Information Management System, Volume 3, Chapter 25, Operational Control For Air Carriers, L. Specific Policies and Procedures, 1) Advertising by Indirect Air Carriers

a) Indirect air carriers, including air charter brokers, may not purport to directly provide transportation by air.
b) Indirect air carrier advertising must indicate the name of the certificate holder providing transportation by air. This does not mean that all pages of a Web site, or a brochure or any other advertising vehicle must identify the certificate holder. If more than one certificate holder is used, language to the effect that the advertiser uses FAA-certified air carriers is acceptable. The test is that a casual reader of the advertisement would understand who is actually conducting the transportation by air.
c) The [Department of Transportation’s Office of the Secretary] considers it to be an unfair deceptive practice and unfair method of competition under its economic regulatory authority for any person or entity that is not a direct air carrier to hold out or provide air transportation as a direct carrier.

BST advertisements included a one-page “special advertising feature” in the May 2008 edition of Chicago Magazine. The advertisement did not list an operator with a commercial air carrier operating certificate. A 2008 Sheridan Road Magazine, volume 2, number 3, article, “The Fast and the Fabulous” has a photo of the “Blue Sky Taxi Founders … with director of operations…” and has a photo of the “chief pilot”. The director of operations and the chief pilot were the MAT president and a pilot employed by MAT; however, no mention is made of MAT as the operator or that these two individuals were affiliated with MAT. An August 2008 Chicago Magazine advertisement of BST does list MAT as the operator, but that listing is in the smallest font of the article and oriented vertically along the right side of the page.

BST also used brochures that were placed at fixed based operators including one located at the accident airport. BST brochures listed operators Executive Express Aviation and Midwest Transport, Inc. in the smallest relative size font. The brochure listing MAT as the operator also used the same size font for pricing based on actual miles spent in the air and fuel surcharge. The first owner of BST stated that the size of the font is probably due to a lack of space. He added that they have been told that a disclaimer showing who clearly provides transportation is present and that they are not the transportation provider.

Both brochures make claims that “our pilots are the best in the industry” and “Safest aircraft in the world, featuring a built-in parachute able to suspend the entire plane.” The first owner of BST stated that the basis that the aircraft used are the safest in the world is general aviation opinion.

FAA Advisory Circular 23.1309-1D, System Safety Analysis and Assessment for Part 23 Airplanes defines four classes of airplanes, with Class I as typically single reciprocating engine airplanes under 6,000 pounds, which have allowable quantitative probabilities of less than 1 in 100,000 and 1 in 1,000,000 for hazardous and catastrophic failure conditions. Class II, III, and IV airplane, which include single-engine turbine and multi engine reciprocating or turbine airplanes, have reduced probabilities for such failures.

Customers made payments to BST for flights using either credit card or check and those payments were not made to MAT.

Executive Express Aviation (EEA) Company Information

EEA was formed in 2003 and subsequently issued a Part 135 air carrier certificate. The EEA president stated that he learned of BST from a Cirrus Design Corporation Airplane Salesperson who recommended BST to them. In mid 2007, both owners of BST came to the offices of EEA to discuss a proposal for cost structure and that EEA were going to be the operating entity for their air taxi service. The proposal was to have four aircraft initially, followed by three more aircraft, and a total of 14 aircraft in a few years.

The EEA president stated that he forced BST to leave because there was continuous in-fighting regarding operational control. Although the owners of BST said that they didn’t want to be involved in operational control, they were continuously involved in it. The EEA president said that there were situations where either he or the EEA director of operations refused to conduct a flight due to weather or Part 135 regulations that would result in an argument between the EEA director of operations and BST owners. One instance involved the second owner of BST who was in the EEA director of operations office “continuously hammering” the director about making a flight. The second owner also had paid the pilot directly because he didn’t like the speed at which EEA pilots were being paid. The EEA president directed the second owner that he will not pay the pilots. The EEA president also stated that BST called one of the EEA pilots while he was on a long trip, which would have placed that pilot back on duty. The EEA president said that duty time was very sensitive.

The EEA president stated that EEA did not have an incentive program for pilots achieving 100 percent on-time departures rate. He said that while BST airplanes were on the EEA operating certificate 4-5 out of 11 scheduled flights were completed. He said during that time that these flights were scheduled it was a difficult winter. He estimated that EEA completed about 60 percent of the flights.

The EEA president said that a FAA DuPage FSDO inspector was aware of the loss of operational control issues with BST. A Program Tracking and Reporting System (PTRS) record indicated that operational control had been compromised.

The EEA president stated that BST never indicated to them that they wanted to make an application to the MKE FSDO nor did they indicate that they wanted to base BST airplanes in Wisconsin.

MAT Company Information

MAT’s office was located at the president’s residence in Chicago, Illinois. The MAT president stated that there were no financial interests between MAT, BST, or Illinois Aviation Academy. The MAT president also held the position of director of operations, chief pilot, and Part 135 flight instructor for MAT (he did not hold a CSIP designation). The president was authorized to hold a deviation from Part 135 chief pilot requirements under FAR 119.69(b), which states in part,

(b) The Administrator may approve positions or numbers of positions other than those listed in paragraph (a) of this section for a particular operation if the certificate holder shows that it can perform the operation with the highest degree of safety under the direction of fewer or different categories of management personnel…

The MAT president stated that there is no pressure for MAT pilots to complete flights and that the BST owners had no contact with MAT pilots regarding flights. The MAT president stated that the percentage of flights that had been completed excluding cancellations was in the “high 90’s.” MAT had a compensation program in place, known by BST, for MAT pilots for 100 percent on time departures. MAT pilots would be penalized with a verbal warning for their first offense, a one week suspension for their second offense, and termination for their third offense due to items under the pilot’s control. Pilots would be rewarded for 100 percent on time departures every quarter. Pilots were also provided with the phone numbers belonging to both owners of BST.

MAT held a commercial operating certificate for on-demand operations in common carriage under 14 CFR Part 135. The company’s primary business office was located at the president’s home. The company employed four pilots and had a total of four aircraft listed within its operating specifications. Those aircraft were four airplanes:

N1215T, serial number TE-102
N191BS, serial number 22-2733
N192BS, serial number 22-2753
N193BS, serial number 22-2761

The FAA conformity check for one of Cirrus airplanes was performed about the end of April while the other Cirrus airplanes followed “soon after.”

The company’s management personnel had the same individual for its president, director of operations, and chief pilot positions. This individual was issued a deviation for chief pilot requirements required by 14 CFR Part 135 under deviation authority 119.69 from the POI, dated August 17, 2006. The Duties and Responsibilities for these positions are listed within the company’s General Operations Manual, which states in part:

President:

Responsible for operation control, and management in its entirety and for coordination of all departments to ensure a smooth, efficient operation.

Responsible for compliance with all laws, rules, and regulations governing air operations as applicable to the company.

Responsible for coordinating with all company officers and department heads at all times, and will prescribe duties for officers and employees.

Director of Operations:

Supervises the Chief Pilot and other employees as directed by the Vice President.

Ensures that all flight operations are conducted safely and in compliance with all Federal Aviation Regulations, Operations
Specifications, and Company policies.

Schedules aircraft availability, including scheduling the aircraft
for required inspections.

Has the final approval, when necessary, on the selection, training,
and retention of all flight operations personnel.

Chief Pilot:

Supervises flight crew personnel.

Conducts or supervises all training activities of flight crew personnel.
Schedules flight crewmembers, including assigning Pilot-in-Command duties.

Prepares and maintains proficiency records, pilot files, flight schedules, duty time records, reports, and correspondence pertaining to flight operations activities.

Ensures that all flight crew personnel are certified and supervised according to the requirements specified in the Federal Aviation Regulations.

According to MAT’s Operation Specifications recovered at the accident site (Manual No. 7), Operations Specifications, A003, Aircraft Authorization, dated April 30, 2008, states that the Cirrus SR22 airplane Operation Configuration is passenger and cargo, the En Route is IFR/VFR, and the Condition of Flight is day/night. A003 was amended on August 14, 2008, showing that the Operation Configuration is passenger VFR, Cargo VFR/IFR. The MKE FSDO reported that the operations specifications were amended on September 5, 2008, to allow single-engine IFR operations with passengers. Prior to September 5, 2008, MAT had flown passengers in IFR conditions in single-engine airplanes without an engine trend monitoring and engine oil analysis program in effect.

A MAT pilot stated that when he was assigned trips, MAT did not indicate to him whether a particular flight is to be conducted under Part 91 or 135. The pilot was asked if he knew what the company operation specifications stated regarding the flying of passengers and the weather conditions that passengers can be flown in. He last flew a Part 135 flight to Kansas City about a week prior to his interview. He also said the company operation specifications allow for IFR flight with passengers. He said a later revision was issued prior to the accident allowing for IFR flight with passengers.

The pilot also stated that he provided his own instrument approach charts and that the company provided en route charts which were kept in a binder underneath the pilot seat. He said that he has made reference to the en route charts “numerous times” if he was issued a navigational fix that he didn’t know how to spell or where it was located.

Instrument approach charts for ARV, recovered at the accident site, were “licensed” to the accident pilot.

According to MAT’s Operation Specifications recovered at the accident site (Manual No. 7), Operations Specifications, A009. Airport Aeronautical Data, section a. states in part, “The system described or referenced in this paragraph is used by the certificate holder to obtain, maintain, and distribute current aeronautical data for the airports it uses. Two of the six referenced items for which the pilot-in-command will use are: 2. Enroute, VFR/IFR, and Terminal Area Charts, and 3. Instrument Approach Charts.”

The MFD’s expired charts database included instrument approach procedures and IFR en route charts. A Jeppesen Airway Manual containing United States Low Altitude IFR charts was found beneath the pilot seat of the airplane. The manual contained a total of 26 charts: 1-52, 1/2 NE Coastal and 1/2 SE Coastal. Charts 15/16 and 23/24 were not present in the Airway Manual. Of the 26 charts, 14 charts were expired.

The MAT president was asked to provide a copy of his pilot logbook from April to October 2008 to the NTSB Investigator-In-Charge. The logbook copy, based on computer logbook, shows no flights between August 5, 2008 and October 1, 2008; however, duty time records show that the president had logged flight and duty hours during this period.

The MAT president was simultaneously employed as a firefighter while holding three management positions within the company. He stated that he did not know why BST was applying for an air carrier certificate through the MKE FSDO and it was a decision that BST made. He said that he was going to keep MAT’s air carrier operating certificate and would be listed as director of operations on MAT’s and BST’s operating certificates. He was to be compensated for his position as BST’s director of operations. He added that he did not know who prepared BST’s application for their air carrier certificate and that it had to be BST who prepared the form. The BST president stated that there was no plan to merge MAT, BST, and Illinois Aviation Academy. He said that there were discussions to make the Illinois Aviation Academy president a MAT chief pilot.

Illinois Aviation Academy Company Information

Illinois Aviation Academy, located at DPA, did not hold an air carrier operating certificate nor was it a Part 141 flight school. The company provided aircraft rental and flight instruction.

The Illinois Aviation Academy president stated that he began paying for the insurance coverage on the BST airplanes because no one could be insured in the airplanes for the training and transition of the pilots under Part 91. The insurance coverage also included Part 135 operations by MST. The Illinois Aviation Academy president filed a claim of lien against N191BS and N192BS due to non-payment of aircraft insurance and maintenance fees incurred from December 1, 2008, thru January 31, 2009.

ADDITIONAL INFORMATION

The Illinois Aviation Academy instructor stated that she “probably” had to spend more time training pilots on the Cirrus airplane due to the electronic flight display (EFD) versus an airplane with “round gauges.” It depends on how current and familiar the pilot is flying the airplane. An instrument competency check could be a “little bit longer” and that Cirrus was always issuing training bulletins available to CSIPs. The instructor thought that a person with average skill and ability would require more time to get checked out in a Cirrus SR22 than a comparable airplane not equipped with EFDs. She stated that the autopilot with a vertical speed (VS) altitude option is “commonly very difficult.” She stated that the Cirrus SR22 is “not easy to stall.” During a full power stall, the PFD provides a chevron display.

A MAT pilot, who had flown as a scheduled air carrier pilot flying a Canadair Regional Jet, stated that the Cirrus SR22 is “simple” in a go-around or missed approach. During the go-around or missed approach, the autopilot is turned off, power added, and flaps reduced. He said there is a lag in power because the engine is not turbocharged. He added the “it’s pretty quick to respond.”

There were 13 (PTRS) records from October 1, 2007 to November 6, 2008, relating to DuPage FSDO’s surveillance of MAT. Every record was “favorable” and there were no comments associated with surveillances performed over the period. The last airworthiness inspection and operations inspections were August 2008 and July 2008, respectively. Also, there were no PTRS entries of the accident pilot’s failu