DECISION MAKING: An attempt to execute a go-around by a pilot of a Hawker Beechcraft jet late in the landing roll with insufficient runway contributed to a fatal accident.
While a pilot needs to evaluate the consequences of making any decision, he or she needs to know that revising a decision is likely to make a bad situation even worse. In its recently concluded investigation of an accident involving a twin-engine jet, the NTSB said that the captain made a bad situation worse by not accepting the fact that the airplane was going to run off the end of the runway, and instead attempting a last-minute go-around.
The accident occurred on July 31, 2008, at about 9:45 a.m. The Hawker Beechcraft BAE 125-800A was operated as East Coast Jets flight 81. The Part 135 flight was taking employees of an entertainment company from Atlantic City, N.J., to Owatonna, Minn. The captain, first officer and all six passengers were killed.
Their flying day began at about 6 a.m., when they repositioned the airplane from Allentown, Pa., to Atlantic City. The accident flight took off for Minnesota at about 7:13.
About 9:24, the airplane's cockpit voice recorder picked up the pilots listening to the OWA automated weather-observation system. The report was calm winds and visibility of 10 miles in thunderstorms and rain. Distant lightning was detected.
At 9:25:37, a Minneapolis Center controller asked if they saw extreme precipitation 20 miles straight ahead. The first officer radioed, "Yeah, we're paintin' it here and…what is the [cloud] bases?" The controller said he didn't know, but the tops were "quite high." The controller volunteered, "I don't recommend you go through it; I've had nobody go through it." The controller suggested a deviation north of Rochester, Minn., to get around the weather. The first officer asked for a deviation. The captain then remarked, "Let's hope we get underneath it."
At 9:27:48, the controller asked the captain to state his intentions and added, "I can't even give you a good recommendation right now." The captain replied, "I got it clear probably for another 40 miles." The controller then cleared the flight to descend to FL190, then to 14,000 feet. The captain commented to the first officer, "What do you mean what are my intentions? Get me around this…so I can go to the field…I ain't gonna turn around and go home." The CVR recorded what sounded like rain impacting the wind screen.
At 9:32:21, the captain commented that he couldn't see the weather "out there anymore," and asked, "Is it above us?" The first officer replied, "It might be above us." The flight was handed off to Minneapolis Approach. The first officer requested a turn toward OWA. The approach controller stated that he would keep the flight in his airspace for seven more miles, and then start the turn.
At 9:34:08, Minneapolis Approach gave the flight a left turn, and handed it off to Rochester Approach. Sixteen seconds later, the first officer radioed Rochester Approach and, when asked which approach he would like, responded, "...could do the ILS." The flight was cleared to 7,000 feet, and given vectors for the ILS approach.
At 9:35:44, the captain stated, "Let's do the approaches real quick," referring to the approach checklist. At 9:35:51, the first officer called, "Approach briefing," and the captain replied, "It's gonna be the ILS to three zero."
At 9:36:46, Rochester Approach instructed the flight to descend to 3,000 feet at the pilots' discretion, and turn right heading 190 degrees. Then, the controller gave weather information for OWA, which he said was about 20 minutes old and included winds 320 degrees at eight knots; visibility 10 miles or more; thunderstorms, clouds scattered at 3,700 feet and overcast at 5,000 feet; lightning in the distance in all quadrants.
The CVR recorded the captain and first officer discussing their weather radar display, with the captain saying, "I don't know what…we're looking at on this thing," and the first officer replying, "Well, neither do I." At 9:38:07, Rochester Approach radioed that a couple of heavy cells were located about five miles north and northeast of OWA.
At 9:38:50, the captain stated, "Approaches are done." The first officer responded, "Approaches are done." The captain said they were descending to 3,000 feet, and would have to start getting the airplane "slowed up."
At 9:39:58, the CVR recorded the captain calling for, "Flaps one [15 degrees]." The first officer stated, "One and indicating," to which the captain responded, "Why don't you really quickly go over and…ID that thing [the ILS]? See if the localizer's even right?" At 9:40:21, Rochester Approach cleared the flight for the ILS. The first officer then confirmed that the localizer frequency was correct and stated, "Loc's alive." At 9:42:00, the captain reported the runway in sight and canceled IFR.
At 9:42:09, the first officer contacted the FBO and stated that the flight was about eight miles out, and that they would be dropping off passengers. At 9:42:22, the CVR recorded an increase in background noise consistent with landing-gear extension. From 9:42:24 to 9:42:38, the CVR recorded the FBO talking to the first officer about refueling.
At 9:42:37, the captain stated, "Three green, no red, pressure's good, back to zero, steerings clear," indicating that the three green landing-gear annunciators were showing down-and-locked; that the hydraulic pressure was good; that the air brakes had zero pressurization and that the nosewheel-steering handwheel was clear.
The captain said, "Flaps two [25 degrees]," then told the first officer to "go through the before landings, make sure you got it all….down indicating down." At 9:44:25, the CVR recorded an electronic voice stating, "Four-hundred [feet]." At 9:44:29, the captain stated, "I'm goin' right to the tiller [ground steering] and the brakes." Three seconds later, an electronic voice said, "Three-hundred [feet]." Immediately thereafter, the captain said, "Slowin' to ref [reference landing speed]." At 9:44:47, the electronic voice alerted, "Two [hundred feet] minimums minimums," which was immediately followed by the first officer stating, "Air valves are shut [yaw] damper to go," and then, "Damper." At 9:45:04, the CVR recorded a sound consistent with tires rolling on a prepared surface, followed 2.5 seconds later by a sound similar to the air brakes moving to the OPEN position.
At 9:45:08, the first officer stated, "Dumped," followed immediately by, "We're not dumped." The first officer was referring to the deployment of the lift-dump feature of the air brake and flap systems, which is used to help decelerate the airplane on landing. About 1.5 seconds later, the captain replied, "No we're not," and, at the same time, the CVR recorded a sound similar to the air brake handle moving to the DUMP position. Ten seconds later, the CVR recorded a sound similar to the air brakes moving to the SHUT position. The captain then stated, "Flaps," and, about the same time, the CVR recorded increasing engine noise. At 9:45:27, the captain stated, "Here we go….not flyin'…not flyin'." At 9:45:36, the CVR recorded the electronic voice warning, "Bank angle, bank angle." The CVR stopped recording at 9:45:45.
The airplane ran off the runway end, then lifted off the ground six seconds later. The airplane hit the runway 30 localizer antenna support structure, which was about 1,000 feet from the runway end. It eventually came to rest in a corn field beyond a dirt access road that borders the airport, which was about 2,136 feet from the runway end.
The captain, age 40, held an ATP certificate with type ratings in HS-125 and Learjet airplanes. His first class medical had no limitations. He had about 3,600 hours. According to his girlfriend, the night before the accident, the captain went to sleep about midnight because he participated in a poker game. He awoke the morning of the accident at about 4:45.
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.