Crash Course In A Jet

Consider the NTSB's recently released report on an accident at South Bend, Indiana, in which the pilot of a business jet allowed an unqualified friend to fly, while trying to teach the friend about complex aircraft systems. When the accident sequence had played out, the left-seat pilot and pilot-rated friend in the right front seat were dead, the two passengers in back were seriously injured, a woman on the ground was hurt, a multimillion dollar jet was destroyed, and three houses were in ruins.

The airplane was a Hawker Beechcraft model 390 Premier 1A. Built in 2008, the jet was powered by two Williams International FJ44-2A engines. The model 390 uses a composite fuselage, which is about three times stronger than a comparable aluminum structure, while being 20 percent lighter and providing about 15 percent more interior room. The airplane was approved for single-pilot operation. It could carry six passengers in the back, with a seventh occupying the right cockpit seat when flown with only one pilot. The airplane typically cruised at up to 450 knots at flight level 410 (FL410), which is 41,000 feet calculated at the standard pressure of 29.92 inHg. It had a fully loaded range of about 800 nm with IFR reserves, which stretched to about 1,200 nm with full fuel, one pilot and two passengers.

The accident flight departed Richard Lloyd Jones Jr. Airport (KRVS) in Tulsa, Oklahoma, at 1:56 p.m., Central Daylight Time, on March 17, 2013. The airplane operated on an IFR flight plan in VFR conditions. The destination was the South Bend International Airport (KSBN). The accident occurred at 4:23 p.m., Eastern Daylight Time, about one hour and 27 minutes after departure.

The pilot, age 58, was a Tulsa businessman whose limited liability company was the airplane's registered owner. The pilot-rated passenger, age 60, was a friend the pilot first met in college, at the University of Oklahoma. At that time, the pilot was a college wrestler, and the friend was the football team's quarterback. A few weeks before the accident, they reconnected and discovered they had a mutual interest in aviation. The friend had not logged any flights in about five years, but previously had accumulated 1,877 hours. He held a private certificate for single-engine and multi-engine airplanes and instruments. He had not logged any jet airplane experience. The pilot also held a private pilot certificate with single-engine, multi-engine and instrument airplane ratings. He was type-rated for the Beech 390 Premier 1A business jet. His third class medical certificate, a special issuance, was valid for one year, expiring at the end of January 2014. Investigators didn't obtain full logbooks for the pilot, but the records they reconstructed indicated he had accumulated about 613 flight hours with 171 hours in the Beech 390.

The pilot's son submitted an affidavit to the NTSB stating that his father invited the friend on the round-trip to South Bend because they shared a common interest in flying. He stated that the friend wasn't involved in the pilot's business in any way, and that he wasn't rendering any service to the pilot such as acting as first officer on the flight.

"The NTSB determined that the probable cause of this accident was the private pilot's inadequate response to the dual-engine shutdown during cruise descent, including his failure to adhere to procedures, which ultimately resulted in his failure to maintain airplane control during a single-engine go-around. An additional cause was the pilot's decision to allow the unqualified pilot-rated passenger to manipulate the airplane controls, which directly resulted in the inadvertent dual-engine shutdown."

Even though it wasn't required, the airplane was equipped with a cockpit voice recorder (CVR). Without the 31 minutes of conversations and engine sounds captured on the CVR, investigators probably would never have been able to figure out what happened. The CVR audio begins when the airplane is cruising at FL410. The pilot tells his friend about the airplane's fuel burn and the effects of winds aloft, while explaining and demonstrating the flight management system. The pilot quizzes him on which buttons to push in order to change the display to show the airplane's route. The pilot asks, "If I want that to go away, what would I push? If I want this to go away, what would I push?" The friend doesn't know and responds, "...a lot of stuff to learn." In hindsight, one might suggest that the friend's statement offers the pilot an excellent excuse to stop the impromptu lesson and devote his full attention to piloting.

Nevertheless, the pilot explains how he views IFR and VFR charts on his iPad, and how he uses the airplane's systems to establish rates of descent, which will allow them to cross various fixes at the altitudes assigned by ATC.

At 3:52:44, Kansas City Center clears the flight to descend to FL240. The pilot and friend discuss how to begin a descent by using the autopilot's vertical speed mode. Within the next two minutes, the airplane's speed has increased, and the pilot tells his friend that "we got to get our power back....got to bring it back." The CVR picks up the airplane's overspeed warning beeping for just over 13 seconds. At 3:55:31, the friend asks, "just pull it way back?" The pilot and friend continue discussing how to hold airspeed. The friend says that he doesn't like adjusting the throttles up and down because it can be upsetting to passengers.

At 3:58:08, the controller clears the flight direct to South Bend. The pilot acknowledges, then begins explaining to his friend how to reprogram the flight management system for the new route. At 3:59:24, ATIS information Charlie is heard reporting the KSBN weather as wind from 120 degrees at 10 gusting to 15 knots, visibility 10 miles, few clouds at 3,700 feet, temperature 2 degrees C, dewpoint minus 8 degrees C, altimeter 30.15, visual approach for runway 9R in use.

At 4:00:06, the flight is handed off to Chicago Center. A minute later, it's cleared to descend to FL200. About 4:03:22, the controller asks the flight to expedite a descent to 17,000 feet. About 30 seconds after that, the pilot makes comments indicating that the passenger is doing the flying. The pilot says, in part, "watch your speed...very good, very good...great speed management." The airplane's TCAS issues a traffic alert and the controller advises there's a Challenger jet at 11 o'clock and two miles. The pilot reports the traffic in sight.

At 4:05:08, the pilot tells the friend that it's time to bring the nose back up in order to level out at 17,000 feet. Then, he adds, "Let's go to the stop...to the click (throttle detent)...MCT (maximum continuous thrust)." The pilot complains that since they were below flight levels, the controller should have given him the altimeter setting, but didn't. He tells the friend to put what the ATIS reported, 30.15, into the altimeter on his side. Then, the overspeed warning sounds again, this time lasting just over 11 seconds.

At 4:06:48, the controller clears the flight to descend and maintain 11,000 feet without delay. The controller also reports the South Bend altimeter as 30.15. At 4:10:11, the controller clears them direct to KSBN and initiates a handoff to South Bend Approach Control. The pilot tells approach they're level at 11,000 feet. They're cleared to 10,000 feet, to proceed direct to the outer marker for the ILS runway 9R approach, but to expect a visual approach. At 4:13:07, the approach controller clears them down to 3,000 feet.

The CVR picks up the pilot telling his friend, "Let's power back...let's bring it back to us...let's trend toward, uh, two twenty, two ten (knots airspeed)." The friend replies, "...and we'll have to come way out of it to do that." At 4:13:30, the recorded engine noises indicate the engines are slowing down. A few seconds later, the pilot reads the 10,000 feet checklist. "Seatbelts...recognition lights...ice protection is off...pressurization set for landing at eight hundred (feet MSL)...heat and defrost is off...altimeters are set 30.15...we've got our ref speed set. Bring up seatbelts (seatbelt chime sounds)."

At 4:14:15, the pilot tells his friend, "just pull---pull the power out." The friend replies, "Just pull it down?" The pilot says, "Yeah. Let's---let's get back to two hundred (knots)." What the friend didn't know, and the pilot didn't explain, is that when a throttle is pulled back to flight idle, it contacts a mechanical stop, which blocks it from moving even further back into the fuel cut-off position. A pull-up lever, which can be moved by the same fingers gripping the throttle, defeats the mechanical stop, allowing the throttle to be moved further aft into fuel cut-off.

The CVR picks up the engines slowing down even more, and the sound of two clicks, likely the friend activating the release and pulling the throttles so far back that fuel flow to the engines is cut. This was immediately followed by electrical power dropping off for a second, an autopilot disconnect tone and two unidentified tones. The pilot says, "Uh-oh," and his friend says, "What?" At 4:14:33, the landing gear warning horn sounds for 3½ seconds. While the horn is still sounding, the pilot says, "You went back behind the stops and we lost power."

At 4:14:43, the pilot says, "Okay let's see here...boost pumps are on...okay, we are dead stick." The landing gear warning horn again sounds for just under 11 seconds. So do two other tones and what sounds like an altitude alert. At 4:15:02, the CVR records what a sound spectrum study identified as a starter motor, which the pilot engaged in an attempt to restart one of the engines. At this point, the airplane was too low and slow for the engines to be relit just by turning on the igniters and relying on windmilling of the turbine blades for sufficient engine rotation. The pilot would have to follow a restart procedure using the starter motors.

The pilot radios, "South Bend, we have an emergency...dead engines, dead stick, no power." The controller asks the pilot to "...say intentions." The pilot replies, "We've lost all power and we have no hydraulics." The controller advises that the emergency equipment will be standing by, and asks if the aircraft is controllable. The pilot replies, "...barely controllable." The controller advises, "...all runways available at South Bend, wind one three zero at one zero." The pilot says, "...We have no navigation, if you could give us a vector please." The controller tells the pilot to turn 10 degrees left, then 20 degrees right, which would place the airport at 12 o'clock and five miles. By this time, radio transmissions from the pilot become unintelligible. The NTSB report doesn't tell why. It might have something to do with the pilot running the starting motors, thus loading the main and standby batteries and reducing available voltage. At 4:16:32, when the airplane is on approach with both engines still out, the CVR stops recording. At some point after that, the pilot manages to restart the left engine.

As the airplane gets closer to the runway, the tower controller advises the approach controller that only the nose landing gear is visible. The approach controller radios the pilot to go around. The controller asks the pilot to "ident" if he hears the go-around message. The controller sees the ident and radios, "...if you'd like to remain in the pattern that's fine. I cannot hear any of your transmissions. Anything you want to do right now is fine." The controller also radios a phone number for someone on the airplane to call on a cell phone in order to reestablish communications with ATC. In the wreckage, the gear's emergency extension handle was found partially extended. The extent to which the pilot was able to follow emergency extension procedures wasn't stated by the NTSB.

The pilot executes a climb and enters right traffic for runway 9R. A witness reported that during a second attempt to land, the airplane bounced on the runway several times with only the nose gear extended, then entered a climbing right turn, which transitioned to a nose-low rolling descent into a residential area. The airplane struck three houses, with the majority of the wreckage smashing through the roof of one house and coming to rest inside.

The NTSB determined that the probable cause of this accident was the private pilot's inadequate response to the dual-engine shutdown during cruise descent, including his failure to adhere to procedures, which ultimately resulted in his failure to maintain airplane control during a single-engine go-around. An additional cause was the pilot's decision to allow the unqualified pilot-rated passenger to manipulate the airplane controls, which directly resulted in the inadvertent dual-engine shutdown.

The NTSB skipped a discussion of using crew resource management to help deal with an emergency. Although the CVR didn't capture the last few minutes of the flight, there was nothing in what it did capture to indicate that the pilot used his friend to perform tasks such as reading emergency procedure checklists, taking over radio communications or holding the airplane straight and level while he tried to restart the engines and get the gear down.

The NTSB report didn't speculate on the possible outcome had the pilot elected to remain on the runway after touching down. By accepting the consequences of landing with the main gear retracted, and not risking another single-engine go-around, the pilot might have impressed his friend with a lesson in judgment and had a future opportunity to let him fly again.

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, visit www.ntsbreporter.us or write to: NTSB Reporter, Subscription Dept., P.O. Box 831, White Plains, NY 10602-0831.