Tuesday, July 5, 2011
Accepting A Bad Situation
It’s better to accept a poor outcome than to create a disastrous one
The first officer, age 27, held single-engine and multi-engine commercial pilot certificates, with a type rating in the HS-125 airplane. His first-class medical required glasses. He had about 1,454 total flight hours, including 297 hours as second in command in turbine-powered aircraft.
According to his fiancée, he went to sleep about 11:00 the night before the accident, and woke up just after 5 a.m. She said he sometimes had trouble sleeping on the night before a trip. She said she gave him zolpidem pills because he didn't have a prescription.
The Safety Board said the cockpit's flight management system (FMS) displays would have shown the pilots what the winds were doing. Data taken from the captain's FMS indicated that the wind 12 seconds before landing was 195 degrees at 17 knots, which would have resulted in a 5.6-knot tailwind.
If the pilots had obtained current wind information, they might have landed on runway 12 with a headwind instead.
The NTSB said evidence indicated the pilots were impatient to land. Evidence also indicated that upon touchdown, the captain only moved the air brake handle to the OPEN position instead of fully aft to the DUMP position, and likely did not fully deploy the lift-dump system (full flaps and air brake deflection) until about seven seconds after touchdown. Investigators ruled out hydroplaning on a wet runway.
An airplane-performance study indicated that the airplane would have exited the runway end at a ground speed of between 23 and 37 knots, and stopped between 100 and 300 feet into the 1,000-foot-long runway safety area. The NTSB concluded that if the captain had stuck with his decision to land, the accident most likely would have been prevented or the severity reduced.
Both pilots showed evidence of untreated sleep difficulties that would have made them especially vulnerable to fatigue. The NTSB said the captain's error of omission when he partially deployed lift dump, and his error of commission when he delayed the go-around, provide examples of how fatigue impairment can contribute to serious errors and poor decision making.
The NTSB determined that the probable cause of this accident was the captain's decision to attempt a go-around late in the landing roll with insufficient runway remaining. Contributing to the accident were (1) the pilots' poor crew coordination and lack of cockpit discipline; (2) fatigue, which likely impaired both pilots' performance and (3) the failure of the FAA to require crew resource management training and standard operating procedures for Part 135 operators.
Peter Katz is editor and publisher of NTSB Reporter, an independent monthly update on aircraft accident investigations and other news concerning the National Transportation Safety Board. To subscribe, write to: NTSB Reporter, Subscription Dept., P.O. Box 831, White Plains, NY 10602-0831.
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