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2023 Watertown plane crash, final report determines probable cause

NTSB Releases Final Report on Deadly 2023 Watertown Plane Crash: Pilot Error and Mechanical Issues Cited as Key Factors

WATERTOWN, Wis. – The National Transportation Safety Board (NTSB) has issued its final investigative report on the tragic plane crash that occurred in Watertown, Wisconsin, on June 5, 2023, shedding light on the sequence of events that led to the death of the sole occupant, an experienced pilot. The incident, which involved a single-engine Cessna 172, has prompted renewed discussions about aviation safety protocols, particularly for small aircraft operations at regional airports. According to the report, a combination of pilot error, potential mechanical failure, and adverse weather conditions contributed to the crash, highlighting ongoing challenges in general aviation.

The crash unfolded shortly after takeoff from Watertown Municipal Airport, a small facility located about 40 miles west of Milwaukee. The pilot, identified as 79-year-old William Buchner of nearby Ixonia, was an avid aviator with over 2,000 hours of flight experience, including significant time in Cessna models. Buchner had planned a routine local flight on that clear summer morning, with no passengers aboard. Witnesses at the airport reported seeing the plane ascend normally at first, but it quickly began to exhibit erratic behavior, banking sharply to the left before plummeting into a wooded area adjacent to the runway. Emergency responders arrived within minutes, but Buchner was pronounced dead at the scene due to massive trauma from the impact.

In its comprehensive 45-page report, the NTSB detailed the investigative process, which included analysis of wreckage, witness statements, radar data, and autopsy results. Investigators recovered the plane's engine, propeller, and flight instruments, many of which were severely damaged by the post-crash fire that engulfed the aircraft. Preliminary findings released shortly after the incident suggested possible engine trouble, but the final report provides a more nuanced picture. It concludes that the primary cause was a loss of engine power shortly after takeoff, likely due to a fuel system malfunction. Specifically, examiners found evidence of contaminated fuel lines, which may have restricted fuel flow to the engine, causing it to sputter and fail at a critical low altitude.

Compounding this mechanical issue was the pilot's response, which the NTSB described as "inadequate" for the emergency situation. Data from the plane's onboard GPS and recovered avionics indicated that Buchner attempted to return to the runway—a maneuver known as the "impossible turn" in aviation circles, often discouraged for single-engine aircraft at low altitudes due to the high risk of stalling. The report notes that Buchner, despite his experience, may have been influenced by spatial disorientation or panic, leading to a steep bank that resulted in an aerodynamic stall. "The pilot's decision to attempt a 180-degree turn back to the airport, rather than proceeding straight ahead to a suitable landing site, directly contributed to the loss of control," the report states. This finding aligns with broader NTSB data showing that attempted returns after engine failure account for a significant percentage of fatal general aviation accidents.

Weather conditions on the day of the crash were generally favorable, with light winds and good visibility, but the report mentions a slight crosswind that could have exacerbated the plane's instability during the attempted maneuver. Toxicology reports from Buchner's autopsy ruled out impairment from drugs or alcohol, though age-related factors were not explicitly dismissed. Buchner held a valid medical certificate, but the NTSB emphasized the importance of regular health evaluations for older pilots, noting that subtle declines in reaction time or decision-making can play a role in emergencies.

The Cessna 172 involved in the crash was a 1978 model, well-maintained according to maintenance logs reviewed by investigators. It had undergone its last annual inspection just three months prior, with no major issues noted. However, the fuel contamination issue raises questions about pre-flight checks and fuel storage practices at small airports. The report speculates that water or debris may have entered the fuel system during refueling or storage, a common problem in humid environments like Wisconsin's summers. This has led to recommendations for enhanced fuel testing protocols, including more frequent sumping and the use of advanced filtration systems.

In the broader context of aviation safety, the Watertown crash is part of a troubling pattern in general aviation, which accounts for the majority of U.S. aircraft accidents despite representing a small fraction of total flights. According to NTSB statistics, there were over 1,200 general aviation accidents in 2023 alone, with a fatality rate significantly higher than commercial aviation. Many of these incidents involve single-engine planes like the Cessna 172, often due to pilot error or mechanical failures. The Watertown case echoes similar crashes, such as the 2021 incident in nearby Beaver Dam where a pilot lost control during takeoff, or the 2019 crash in Dodge County that claimed two lives due to engine failure.

Local officials and aviation experts have reacted to the report with calls for action. Watertown Municipal Airport manager Jeff Baum expressed sorrow over the loss and announced plans to review safety procedures, including mandatory briefings on engine failure scenarios for all pilots using the facility. "This tragedy reminds us that even experienced pilots aren't immune to the risks of flying," Baum said in a statement. The Federal Aviation Administration (FAA), which collaborated on the investigation, is considering incorporating the findings into updated training guidelines for private pilots. Organizations like the Aircraft Owners and Pilots Association (AOPA) have praised the report's thoroughness while advocating for better access to simulator training to practice emergency maneuvers.

The impact on the Watertown community has been profound. Buchner was a well-known figure in local aviation circles, often mentoring younger pilots and participating in fly-ins. His death sent shockwaves through the tight-knit group of enthusiasts who frequent the airport. A memorial service held shortly after the crash drew hundreds, with tributes highlighting his passion for flying and contributions to the community. Family members, while declining public comment on the report, have reportedly supported efforts to improve safety in his memory.

Looking ahead, the NTSB's recommendations extend beyond this single incident. The agency urges pilots to prioritize "straight-ahead" landing options in the event of low-altitude engine failures, rather than risking turns. It also calls for improved education on fuel management and the installation of engine monitoring systems that can detect anomalies in real-time. For airports, the report suggests regular audits of fuel supplies to prevent contamination. These measures, if implemented, could reduce the incidence of similar accidents, potentially saving lives in an industry where human and mechanical factors often intersect with deadly consequences.

This crash also underscores the evolving landscape of aviation technology. Modern aircraft are increasingly equipped with advanced avionics, such as angle-of-attack indicators and automated stall warnings, which might have alerted Buchner to the impending danger. However, older models like the 1978 Cessna often lack these features unless retrofitted, prompting discussions about incentives for upgrades. Industry analysts point to programs like the FAA's Equip 2020 initiative, which encourages the adoption of next-generation technology to enhance safety.

In reflecting on the Watertown crash, it's clear that while aviation has made tremendous strides in safety—commercial flights boast an accident rate of less than one per million departures—general aviation remains a domain where vigilance is paramount. The NTSB report serves not only as a closure to this specific tragedy but as a vital lesson for the flying community. As one aviation safety expert noted, "Every accident report is a roadmap to prevention." For Watertown and beyond, the hope is that these insights will lead to fewer empty seats in the cockpit and safer skies for all.

The full NTSB report is available on the agency's website, providing detailed diagrams, data logs, and expert analyses for those interested in the technical aspects. As investigations like this continue to inform policy, the legacy of incidents like the 2023 Watertown crash may ultimately be one of progress rather than loss.

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