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H25B, vicinity Owatonna MN USA, 2008

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Summary
On 31 July 2008, the crew of an HS125-800 attempted to reject a landing at Owatonna MN after a prior deployment of the lift dumping system but their aircraft overran the runway then briefly became airborne before crashing. The aircraft was destroyed and all 8 occupants were killed. The Investigation attributed the accident to poor crew judgement and general cockpit indiscipline in the presence of some fatigue and also considered that it was partly consequent upon the absence of any regulatory requirement for either pilot CRM training or operator SOP specification for the type of small aircraft operation being undertaken.
Event Details
When July 2008
Actual or Potential
Event Type
Human Factors, Loss of Control, Runway Excursion
Day/Night Day
Flight Conditions VMC
Flight Details
Aircraft RAYTHEON BAe-125-700/800
Operator East Coast Jets
Domicile United States
Type of Flight Public Transport (Passenger)
Origin Atlantic City International Airport
Intended Destination Owatonna Degner Regional Airport
Take off Commenced Yes
Flight Airborne Yes
Flight Completed No
Flight Phase Landing
LDG
Location - Airport
Airport vicinity Owatonna Degner Regional Airport
HF
Tag(s) Authority Gradient,
Fatigue,
Ineffective Monitoring,
Plan Continuation Bias
LOC
Tag(s) Flight Management Error,
Collision Damage
RE
Tag(s) Significant Tailwind Component,
Landing Performance Assessment,
Reduced Thrust Take Off,
Continued Take Off
Outcome
Damage or injury Yes
Aircraft damage Hull loss
Fatalities Most or all occupants ()
Causal Factor Group(s)
Group(s) Aircraft Operation
Safety Recommendation(s)
Group(s) Aircraft Operation,
Aircraft Airworthiness
Investigation Type
Type Independent

Description

On 31 July 2008, a Hawker Beechcraft HS 125-800A (N818MV) being operated by East Coast Jets on a non-scheduled passenger flight (81) from Atlantic City NJ to Owatonna attempted a go around after touchdown on a wet runway in day Visual Meteorological Conditions (VMC) but was observed to overrun the runway and briefly become airborne before crashing beyond the airport perimeter. The aircraft was completely destroyed as a result of collision with the localiser antenna and subsequent terminal impact and the 2 crew and 6 passengers were killed. There was no post crash fire.

Investigation

An Investigation was carried out by the National Transportation Safety Board (USA) (NTSB). Recorded data relevant to the Investigation was recovered from Cockpit Voice Recorder (CVR) and from some undamaged Non Volatile Memory in one of the Flight Management System computers and the Terrain Avoidance and Warning System (TAWS) but the aircraft was not fitted with an Flight Data Recorder (FDR) and was not required to be so equipped.

No evidence was found to suggest anything other than that the aircraft had been airworthy and it was also concluded that it had been loaded within normal weight and balance limitations. The focus therefore moved to the performance of the pilots.

It was established that the 40 year old aircraft Captain had been PF and that he was experienced in command on the aircraft type and in the same role on the Learjets also operated by East Coast Jets. The 27 year old First Officer was found to have joined the company from flight school some nine months earlier and to have accumulated almost 300 hours flying since that time, nearly all of it on the HS125.

The aircraft was radar vectored around the worst of some widespread and active convective weather as it neared the destination and eventually onto the Instrument Landing System (ILS) for runway 30 at the request of the PF. The ILS approach to the unlicensed and uncontrolled airport was uneventful and visual reference was acquired in good time. The aircraft subsequently touched down within the TDZ at correct speed and it was concluded that the Captain had probably "applied sufficient pressure on the brakes during the initial part of the landing roll to take full advantage of the available runway friction" but concluded that he had not deployed the lift-dump system (a mechanically interconnected combination of a extreme trailing edge flap deflection and airbrakes lift spoilers installed as an alternative to thrust reversers) immediately after touchdown in accordance with company procedures.

About 20 seconds after touchdown, the lift dumping system appeared to have been stowed followed by thrust being applied to initiate a go around. The aircraft then overran the end of the 1676 metre long runway by approximately 300 metres before striking the ILS antenna as it became briefly airborne for about another 360 metres before finally coming to a stop in a field beyond an unsurfaced access road that borders the airport some 650 metres from the end of the runway.

Subsequent calculations indicated that at the time the go-around was initiated, the rate at which the aircraft was decelerating was such that had that action not been taken, the aircraft would have left the runway at a ground speed of between 23 and 37 knots and stopped with a maximum overrun of 90 metres, well within the 305 metre Runway End Safety Area. It was concluded that "it can be reasonably assumed that, at some point during the landing roll, the Captain likely became concerned that the airplane would run off the runway end and had to decide whether it was preferable to overrun the runway or attempt a go-around". It was noted, however, that there was no evidence to indicate that the Captain was "prepared for the possibility of a go-around".

About 8 minutes prior to landing, the final weather given to the crew by ATC was a surface wind of 320° at 8 knots - but the controller cautioned that this was already about 20 minutes old. The weather conditions subsequently found to have been recorded by the airport Automated Weather Observation System (AWOS) at the time of the accident gave a wind velocity of 170° at a mean speed of 6 knots and calculations using all the evidence available indicated that there had been an 8 knot tailwind component for the landing. However, although it was raining and the runway had been wet, there was no evidence that either reverted rubber or dynamic hydroplaning had occurred on what was found to be an un-grooved concrete runway in good condition and not prone to the accumulation of standing water.

It was noted from the CVR evidence that during the descent and approach, both pilots repeatedly failed to complete the various required checklists properly "demonstrating that neither was focused on proper checklist execution". It was considered that the Captain had "allowed an atmosphere in the cockpit that did not comply with well-designed procedures intended to minimise operational errors, including sterile cockpit adherence, and this atmosphere permitted inadequate briefing of the approach and monitoring of the current weather conditions, including the wind information on the cockpit instruments; inappropriate conversation; nonstandard terminology; and a lack of checklist discipline throughout the descent and approach phases of the flight". It was also concluded that both pilots had "exhibited poor aeronautical decision-making and managed their resources poorly, which prevented them from recognizing and fully evaluating alternatives to landing on a wet runway in changing weather conditions, eroded the safety margins provided by the checklists, and degraded the pilots’ attention, thus increasing the risk of an accident".

It was noted that whilst "both pilots had excellent performance records as individual pilots (they had) functioned less effectively as a crew". The First Officer had essentially been treated as a trainee and given minor tasks such as contacting ground operations and resetting the transponder at critical times during the approach "when both pilots should have been attentive to the landing". It was considered of particular note that "the Captain (had) never discussed the First Officer’s role in initiating or supporting a go-around decision, a role which may have provided a decisive advantage in the accident situation".

Finally, a review of the evidence led the Investigation to conclude that the performance of both pilots was probably "impaired by fatigue that resulted from their significant acute sleep loss, early start time, and possible untreated sleep disorders" and that "fatigue might have especially degraded the Captain’s performance and decision-making abilities when he had to decide while under time pressure whether to continue the landing or initiate a go-around". It was discovered that the First Officer had taken "a prescription sleep aid for which he did not have a prescription" the night before the accident, but concluded that "because of the short duration of its effects for most individuals" it was unlikely that this would have degraded his performance by the time the accident occurred.

The Investigation found that the Probable Cause of the accident was “the Captain’s decision to attempt a go-around late in the landing roll with insufficient runway remaining".

It was additionally determined that Contributory Factors 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 Federal Aviation Administration to require crew resource management training and standard operating procedures for Part 135 operators.

14 Safety Recommendations were made as a result of the Investigation as follows:

  • that the Federal Aviation Administration require manufacturers of newly certificated and in-service turbine-powered aircraft to incorporate in their Aircraft Flight Manuals a committed-to-stop point in the landing sequence (for example, in the case of the Hawker Beechcraft 125-800A airplane, once lift dump is deployed) beyond which a go-around should not be attempted. [A-11-18]
  • that the Federal Aviation Administration require 14 Code of Federal Regulations Part 121, 135, and 91 subpart K operators and Part 142 training schools to incorporate the information from the revised manufacturers’ Aircraft Flight Manuals asked for in Safety Recommendation A-11-18 into their manuals and training. [A-11-19]
  • that the Federal Aviation Administration require 14 Code of Federal Regulations Part 135 and 91 subpart K operators to establish, and ensure that their pilots adhere to, standard operating procedures. [A-11-20]
  • that the Federal Aviation Administration require principal operations inspectors of 14 Code of Federal Regulations Part 135 and 91 subpart K operators to ensure that pilots use the same checklists in operations that they used during training for normal, abnormal, and emergency conditions. [A-11-21]
  • that the Federal Aviation Administration require manufacturers and 14 Code of Federal Regulations Part 121, 135, and 91 subpart K operators to design new, or revise existing, checklists to require pilots to clearly call out and respond with the actual flap position, rather than just stating, “set” or “as required.” [A-11-22]
  • that the Federal Aviation Administration work with the National Weather Service to revise Advisory Circular 00-24B, “Thunderstorms,” by including explanations of the terms used to describe severe thunderstorms, such as “bow echo,” “derecho,” and “mesoscale convective system.” [A-11-23]
  • that the Federal Aviation Administration revise regulations and policies to permit appropriate use of prescription sleep medications by pilots under medical supervision for insomnia. [A-11-24]
  • that the Federal Aviation Administration require 14 Code of Federal Regulations Part 135 and 91 subpart K pilots to receive initial and recurrent education and training on factors that create fatigue in flight operations, fatigue signs and symptoms, and effective strategies to manage fatigue and performance during operations. [A-11-25]
  • that the Federal Aviation Administration review the policy standards for all common sleep-related conditions, including insomnia, and revise them in accordance with current scientific evidence to establish standards under which pilots can be effectively treated for common sleep disorders while retaining their medical certification. [A-11-26]
  • that the Federal Aviation Administration increase the education and training of physicians and pilots on common sleep disorders, including insomnia, emphasizing the need for aeromedically appropriate evaluation, intervention, and monitoring for sleep-related conditions. [A-11-27]
  • that the Federal Aviation Administration actively pursue with aircraft and avionics manufacturers the development of technology to reduce or prevent runway excursions and, once it becomes available, require that the technology be installed. [A-11-28]
  • that the Federal Aviation Administration inform operators of airplanes that have wet runway landing distance data based on the British Civil Air Regulations Reference Wet Hard Surface or Advisory Material Joint 25X1591 that the data contained in the Aircraft Flight Manuals (and/or performance supplemental materials) may underestimate the landing distance required to land on wet, ungrooved runways and work with industry to provide guidance to these operators on how to conduct landing distance assessments when landing on such runways. [A-11-29]
  • that the Federal Aviation Administration require that 14 Code of Federal Regulations Part 135 pilot-in-command line checks be conducted independently from other required checks and be conducted on flights that truly represent typical revenue operations, including a portion of cruise flight, to ensure that thorough and complete line checks, during which pilots demonstrate their ability to manage weather information, checklist execution, sterile cockpit adherence, and other variables that might affect revenue flights, are conducted. [A-11-30]
  • that the Federal Aviation Administration require 14 Code of Federal Regulations Part 121, 135, and 91 subpart K operators to ensure that terrain avoidance warning system-equipped aircraft in their fleet have the current terrain database installed. [A-11-31]


The Final Report was adopted by the Board on 15 March 2011 and subsequently published.

Further Reading

Further Reading