NTSB faults pilot, first officer for fatal crash of organ transplant plane in Wisconsin

NTSB faults pilot, first officer for plane crash

WASHINGTON — The pilot of a 2007 medical flight that crashed into Lake Michigan, killing all six aboard, mishandled an unusual flight situation and was unable to properly coordinate with his first officer, the National Transportation Safety Board said Wednesday.

Capt. Bill Serra was flying the twin-engine Cessna from Milwaukee to Michigan. A four-member medical crew affiliated with the University of Michigan was on board, as well as human organs for transplant.

Besides faulting Serra and first officer Dennis Hoyes at a hearing, the NTSB said that a culture of lax security by flight operator Marlin Air contributed to the crash. The board also cited the failure of the Federal Aviation Administration to detect and correct deficiencies of the company.

On a cockpit voice recorder, Serra can be heard soon after take off struggling to control the plane. The NTSB was unable to determine what caused this, narrowing it to two potential causes: Hoyes inadvertently turning on the plane’s autopilot, or a problem with the aircraft’s trim control, which helps maintain the aircraft’s position. A problem with this control could have caused the plane to turn sharply, leading to the crash.

Under either scenario, NTSB experts said, the crash likely could have been avoided if the pilots had maintained a reduced airspeed.

The safety board cited the checkered history of Serra, and faulted Marlin Air for not being aware that in two separate incidents, Serra’s pilot’s license was temporarily revoked. He had been convicted of using a plane to smuggle drugs into the United States.

NTSB experts also said their investigation showed Serra had a history of cavalier behavior and rule bending.

Other pilots told NTSB investigators that Serra had instructed others to ignore treacherous weather in some cases and had once tried to fly even though a strut had collapsed on his plane.

Reports from other pilots about Serra “were disturbing,” said Malcolm Brenner, human performance group chairman for the NTSB. “At (Serra’s) initial safety meetings he said something to the effect that all of us have broken regulations at some point.”

Hoyes had logged many hours in the air, but seemed inept and unskilled as a pilot, experts said. Hoyes made a series of routine errors that distracted the pilot and may have contributed to the crash.

The NTSB also recommended that Cessna make design modifications to the aircraft involved — the Citation II — including moving the location of the button that switches the plane to autopilot. The autopilot button and another motion control button are located near each other on the center console, and some aircraft makers have redesigned consoles to avoid confusion.

(This version CORRECTS organ to organs in the second paragraph)