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Providing online training for business aviation professionals globally.
Author: Brent Fishlock
Today’s podcast is a new idea proposed by a business associate, and I hope you write in and tell me what you think. You can email me your thoughts and comments at podcast@trainingport.net.
I am approaching this podcast Mayday-style, and for those of you who are not familiar with the television show ‘Mayday,’ it analyzed incidents and accidents in aviation by re-enacting scenes and interviewing investigators. There are tons of them on YouTube. I won’t be interviewing investigators, but I will be telling you what happened, what the investigators found, and what was recommended as a result. By doing this, I hope to get you thinking about the job we do and what it takes to do it properly every day. I am not a trained investigator, and my opinions are my own, but I think that looking at what has happened in our industry is a great way to learn and apply it to ourselves and our operation.
Please note I will be paraphrasing and sometimes taking statements directly from the accident reports.
First, I will be reviewing the Runway Overrun During a Rejected Takeoff of a Gulfstream G-IV in Bedford, Massachusetts on May 31, 2014. The second accident happened on February 21st, 2017 in Australia involving a B200 Super King Air. In both accidents, everyone on board died.
On May 31, 2014, a Gulfstream G-IV crashed after it overran the end of Runway 11 during a rejected takeoff at Laurence G. Hanscom Field in Bedford, Massachusetts. The airplane rolled through the paved overrun area and across a grassy area, collided with approach lights and a localizer antenna, passed through the airport’s perimeter fence, and came to a stop in a ravine. The two pilots, a flight attendant, and four passengers died. The airplane was destroyed by impact forces and a post-crash fire. The corporate flight, which was destined for Atlantic City International Airport, was conducted under Part 91. An instrument flight rules flight plan was filed. Night visual meteorological conditions prevailed at the time of the accident.
During the engine start process, the flight crew neglected to disengage the airplane’s gust lock lever, which locks the elevator, ailerons, and rudder while the airplane is parked. The gust lock system protects the flight controls against wind gust loads. Also, before takeoff, the pilots neglected to perform a flight control check that would have alerted them of the locked flight controls. A review of data from the airplane’s quick access recorder or QAR revealed that the pilots had neglected to perform complete flight control checks before 98% of their previous 175 takeoffs in the airplane. This indicates that this oversight was habitual and not an anomaly.
From the time the passengers boarded the airplane to the time the airplane reached the runway, it took about 11 minutes. The Cockpit Voice Recorder recorded minimal verbal communication between the flight crew members, and there was no discussion of checklists or takeoff planning such as a briefing. The G-IV Aircraft Flight Manual includes five checklists to be completed before takeoff: Before Starting Engines checklist, Starting Engines checklist, After Starting Engines checklist, Taxi/Before Takeoff checklist, and the Lineup checklist. None of these appear to have been completed.
While taxiing onto the runway, the “rudder limit” system activated which annunciated the message “RUDDER LIMIT”. The crew commented on it and continued. This is not a no-go item; however, this message advises the flight crew when the airplane’s rudder actuator load limiter valve has been activated. The load limiter activates when the rudder contacts its stops and protects the airplane’s tail structure against overload by limiting actuator output. The load limiter ALSO activates when the rudder is restricted from reaching its commanded position, as would be the case if the rudder was commanded to move with the gust lock engaged.
According to the Flight Data Recorder, at 2139 local time, the brakes were released, and the thrust levers were advanced manually. Then the auto throttle was engaged. Maximum EPR values of about 1.6 were achieved, and the airplane reached a speed of about 60 knots. Normal EPR settings for take-off are 1.7. The EPRs then reduced, dropping to about 1.53 and stabilizing. As the EPRs were dropping, the Pilot Flying said, “couldn’t get (it manually any further).” The right seat, non-flying pilot did not respond.
The Gulfstream Lineup checklist includes a note below the checklist items that calls for the pilot to confirm at 60kts during the takeoff roll that the elevators are free, and that the control yoke has moved aft from the full forward to the neutral position. Aft movement of the control yoke is expected due to the increasing aerodynamic forces. The elevator position recorded by the Flight Data Recorder remained constant at about 13° trailing edge down as the airplane accelerated through 60kts. The control yoke would have been full forward in the cockpit. A review of QAR data from the airplane’s previous 175 takeoffs revealed that the elevators always began to move toward neutral at an airspeed of 60 – 80kts.
According to the Cockpit Voice Recorder transcript, the non-flying pilot said, “eighty,” indicating that the airplane had reached a speed of 80kts. Then he said, “V-1,” and 1.4 seconds later said, “rotate.” One second later the Pilot Flying said, “steer lock is on.” The Pilot Flying repeated this statement six times during the next 12.7 seconds. There were no other recorded statements from the Non-flying Pilot.
Runway 11 is about 7000 feet long plus an additional 1000 feet of paved overrun surface. The first time the PIC said, “steer lock is on,” there was 3900 feet remaining and the aircraft was traveling at 129 knots. Brakes were applied with 1300 feet remaining with aircraft traveling at 162 knots. Power was reduced with 326 feet remaining and a speed of 156 knots. Thrust reversers were deployed 61 feet after the aircraft left the runway surface and had entered the paved runway overrun area. The aircraft went into the grass at a speed of 105 knots.
The Pilot Flying was likely aware of the thrust lever restriction because the interlock restricted the throttle levers to about 50% of the range of movement that the flight crew was used to. The PF would not normally have encountered a restriction, and the restriction prevented him from setting the desired takeoff power at an EPR of 1.7 before engaging the autothrottle.
Despite encountering this abnormal thrust lever restriction, the Pilot Flying did not immediately call out the problem or call for a rejected takeoff before engaging the autothrottle. The absence of a prompt verbal statement about the restriction is an example of ineffective communication, which is inconsistent with Crew Resource Management training. The National Transportation Safety Board wrote, “the Non-Flying Pilot’s failure to acknowledge the Flying Pilot’s statement, ‘steer lock is on,’ and the Flying Pilot’s continuation of the takeoff without any verbal acknowledgement from the Non-Flying Pilot (or any clear resolution to the problem) are additional examples of ineffective communication.” Neither pilot called for a rejected take-off, and when the procedure was initiated, nothing was said.
The Pilot Flying clearly understood that the elevator was locked when he tried to rotate the aircraft because the gust lock was engaged. The airplane performance study determined that if the flight crew had initiated a rejected takeoff at the time of the Flying Pilot’s first “steer lock is on” comment or at any time up until about 11 seconds after this comment, the airplane could have been stopped on the paved surface. However, the flight crew delayed initiating a rejected takeoff for about 10 seconds, and then only brakes were applied. Four seconds later, the power was reduced. Therefore, the rejected takeoff was not initiated until the accident was unavoidable.
Human factors research indicates that response time is longer for unexpected events than for expected events. When a flight crew is confronted with a sudden, abnormal event, responses are more likely to be delayed or inappropriate, and a reaction time of 8 to 10 seconds may not be unusual. However, in this case, the delay in initiating a rejected takeoff was exacerbated by the flight crew’s attempt to use a strategy to resolve the problem and continue the takeoff. Flight Data Recorder information indicated that about 6 seconds after the PIC first called out “steer lock is on,” and at a speed of 150 knots, one of the pilots attempted to resolve the situation by operating the Flight Power Shutoff Valve handle. The use of the Flight Power Shutoff Valve is called for in the Aircraft Flight Manual emergency procedure for an immovable flight control. This procedure was ineffective because of the high aerodynamic loads on the elevator which were likely impeding the release of the gust lock hook. This delayed the initiation of the rejected takeoff procedure.
This was a very experienced flight crew. The Flying Pilot had 11,250 hours and the Non-Flying Pilot had 18,200 hours. They were properly trained and were rested for the trip.
The NTSB concluded that, given that the flight crew neglected to perform complete flight control checks before 98% of the previous 175 takeoffs in the airplane, the flight crew’s omission of a flight control check before the accident takeoff indicates intentional, habitual noncompliance with Standard Operating Procedures.
Errors of omission, or forgetting something, are some of the most common everyday forms of error, even among highly skilled experts. Errors of omission have occurred in about 20% of the flight crew-involved major accidents. Errors of omission are counteracted by checklists.
Checklists are key to the comprehensive framework of SOPs which is foundational to effective Crew Resource Management.
Take-aways from this accident:
The second accident I will discuss more briefly happened in Australia. A Beechcraft B200 Super King Air crashed into a shopping centre shortly after takeoff from Essendon Fields Airport on February 21st, 2017.
The aircraft was operated single-pilot and there were four passengers on board. After takeoff, the pilot had difficulty maintaining a climb and soon after lost control and crashed, killing everyone on board. The Australian Transportation Safety Board description said, “the aircraft’s take-off roll was longer than expected and a yaw to the left was observed after rotation. The aircraft’s track began diverging to the left of the runway centreline before rotation and the divergence increased as the flight progressed. The aircraft entered a shallow climb followed by a substantial left sideslip with minimal roll. The aircraft then began to descend, and the pilot transmitted a Mayday call. The aircraft collided with a building in a Retail Outlet Centre of Essendon Airport.”
The ATSB concluded that the rudder trim position was not checked prior to takeoff as per the checklist. The rudder trim was set to full deflection. The aircraft was also found to be overloaded; however, the Australian TSB determined that this did not influence the accident. The ATSB stated, “in this particular tragic accident, there were opportunities in the checklist that existed for the pilot to ensure the rudder trim was set to neutral prior to take-off.”
Pilots use checklists to verify that tasks have been completed. Many items may be completed as a part of a flow where the switch or button is selected to the correct position by memory, but this is usually verified later using a checklist. In a two-crew environment, the correct configuration is checked by the two pilots by running through the applicable checklist. For an error to go unnoticed in a two-crew environment, the switch setting would have been made incorrectly, or omitted. Then both pilots would have missed the incorrect setting when the checklist was acted and responded to.
Pilots who operate single-pilot must be extra vigilant in ensuring that what they are looking at is in fact the switch position or trim setting they want. Of course, these procedures are of no assistance to the crew that choose not to complete a checklist in the first place. It is unknown if the King Air pilot used a checklist or not. If he did, then the rudder trim position might have been the only item on the checklist that he incorrectly identified as set correctly.
As a part of the investigation, the ATSB issued a Safety Message which stated, “the improper or non-use of checklists has been cited as a factor in some aircraft accidents. Research has shown that this may occur for varying reasons and that experienced pilots are not immune to checklist errors. This accident highlights the critical importance of appropriately acting and completing checklists.”
I’ve been to a few safety conferences over the years and someone once said, “As a pilot, you don’t get to choose when you have to be great.” I personally play lots of ice hockey and it made me think about professional athletes and how they get to choose when to be great. As aviation professionals, we don’t get to choose. We must be ready all the time.
In the News
(In the news is a segment of the podcast where I discuss new developments in business aviation.)
This time, I want to bring to your attention to some new Advisory Circulars which have been released in Canada recently. Advisory Circular 604-002 has new training requirements for raft training for private operators who operate aircraft with 20 seats or more. AC 700-049 has new requirements for approaches with a greater than 425 foot per minute climb gradient requirement in the missed approach. If you already use the Restricted CAP or Canada Air Pilot approaches and you fly to mountainous terrain on a regular basis, you may want to look at this Advisory Circular.
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