CLEVELAND, Ohio -- The National Transportation Safety Board has determined that "pilot spatial disorientation" was the cause of the Lake Erie plane crash that killed six people in 2016.
The Cessna Citation 525 crashed into Lake Erie shortly after takeoff from Burke Lakefront Airport on Dec. 29, 2016.
The NTSB's final report on the crash was issued Monday.
According to their findings, the NTSB specifically determined the probable cause of the accident to be "pilot spatial disorientation." The report lists pilot fatigue, monitoring equipment/instruments and total experience with equipment as factors in the crash.
According to the report, the pilot had been awake 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."
On the night of the crash, the pilot, John Thomas Fleming, was cleared for takeoff at 10:55 p.m to the Ohio State University Airport. He was given a heading and altitude.
Less than a minute after the plane became airborne, an automated voice said "altitude," which was repeated 14 seconds later. The NTSB said a sound similar to a decrease in engine power was recorded then the enhanced ground proximity warning system gave an excessive bank angle warning. The tower controller told Fleming to contract departure control. He replied "to departure six one four sierra bravo," but the tower controller did not receive the message.
The controller tried to contact Fleming again. The pilot received a sink rate warning and he responded "six one four sierra bravo," this it was not received either.
The warning system provided seven "pull up" messages. A sound similar to the overspeed warning could be heard over the cockpit voice recorder. The recording ends about 3 minutes after Fleming was cleared to take off.
During the weeks after the crash, the U.S. Coast Guard, Cleveland police and other authorities recovered hundreds of pieces of debris. They also discovered remains belonging to three of the victims: Fleming, 45; his son John Robert Fleming, 15; and neighbor Brian Sean Casey, 50.
In June 2017, more remains washed ashore in Willowick that were identified as John Fleming. Three months later, additional remains from a crash victim were found near Lake City, Pennsylvania.
The bodies of Sue Fleming, Andrew Fleming and Megan Casey were never found.