Scribd Logo
Upload

Welcome to Scribd!

  • 31 views

    NTSB BAC 100119 Probable Cause

    Uploaded by

    bombardierwatch
    The NTSB investigated an incident where a plane overran the runway after rejecting takeoff too late. The summary is: 1) The flight crew engaged in non-cockpit related conversation during taxi and checklists, distracting them from properly setting and verifying the flaps. 2) The captain tried to reconfigure the flaps during takeoff instead of immediately rejecting takeoff upon discovering the incorrect flap setting, resulting in the rejection starting 13 knots above the allowable speed. 3) Poor checklist discipline by the crew contributed to the missed flap setting, and the plane overran the runway but was stopped by an arrestor bed installed at the end.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd

    NTSB BAC 100119 Probable Cause

    Uploaded by

    bombardierwatch
    31 views3 pages
    The NTSB investigated an incident where a plane overran the runway after rejecting takeoff too late. The summary is: 1) The flight crew engaged in non-cockpit related conversation during taxi and checklists, distracting them from properly setting and verifying the flaps. 2) The captain tried to reconfigure the flaps during takeoff instead of immediately rejecting takeoff upon discovering the incorrect flap setting, resulting in the rejection starting 13 knots above the allowable speed. 3) Poor checklist discipline by the crew contributed to the missed flap setting, and the plane overran the runway but was stopped by an arrestor bed installed at the end.

    Copyright

    © Attribution Non-Commercial (BY-NC)

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    The NTSB investigated an incident where a plane overran the runway after rejecting takeoff too late. The summary is: 1) The flight crew engaged in non-cockpit related conversation during taxi and checklists, distracting them from properly setting and verifying the flaps. 2) The captain tried to reconfigure the flaps during takeoff instead of immediately rejecting takeoff upon discovering the incorrect flap setting, resulting in the rejection starting 13 knots above the allowable speed. 3) Poor checklist discipline by the crew contributed to the missed flap setting, and the plane overran the runway but was stopped by an arrestor bed installed at the end.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    31 views3 pages

    NTSB BAC 100119 Probable Cause

    Uploaded by

    bombardierwatch
    The NTSB investigated an incident where a plane overran the runway after rejecting takeoff too late. The summary is: 1) The flight crew engaged in non-cockpit related conversation during taxi and checklists, distracting them from properly setting and verifying the flaps. 2) The captain tried to reconfigure the flaps during takeoff instead of immediately rejecting takeoff upon discovering the incorrect flap setting, resulting in the rejection starting 13 knots above the allowable speed. 3) Poor checklist discipline by the crew contributed to the missed flap setting, and the plane overran the runway but was stopped by an arrestor bed installed at the end.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 3

    National Transportation Safety Board Printed on : 1/21/2011 7:02:47 PM

    Washington, DC 20594

    Brief of Incident

    Adopted 10/29/2010

    DCA10IA022
    File No. 0 01/19/2010 Charleston, WV Aircraft Reg No. N246PS Time (Local): 16:00 EST

    Make/Model: Bombardier / CL600 Fatal Serious Minor/None


    Engine Make/Model: Ge / CF34-3B1 Crew 0 0 3
    Aircraft Damage: Minor Pass 0 0 31
    Number of Engines: 2
    Operating Certificate(s): Flag Carrier/Domestic; Supplemental
    Name of Carrier: PSA AIRLINES INC
    Type of Flight Operation: Scheduled; Domestic; Passenger Only
    Reg. Flight Conducted Under: Part 121: Air Carrier

    Last Depart. Point: Same as Accident/Incident Location Condition of Light: Day


    Destination: Charlotte, NC Weather Info Src: Unknown
    Airport Proximity: On Airport/Airstrip Basic Weather: Visual Conditions
    Airport Name: Yeager Airport Lowest Ceiling: 2600 Ft. AGL, Overcast
    Runway Identification: 23 Visibility: 10.00 SM
    Runway Length/Width (Ft): 6300 / 150 Wind Dir/Speed: 290 / 003 Kts
    Runway Surface: Asphalt Temperature (°C): 9
    Runway Surface Condition: Dry Precip/Obscuration:

    Pilot-in-Command Age: 38 Flight Time (Hours)

    Certificate(s)/Rating(s) Total All Aircraft: 9525


    Airline Transport; Commercial; Multi-engine Land; Single-engine Land Last 90 Days: 169
    Total Make/Model: 4608
    Instrument Ratings Total Instrument Time: UnK/Nr
    Airplane

    Cockpit voice recorder (CVR) information revealed that the flight crew began a personal conversation (that is, a conversation not
    pertinent to the operation of the airplane) during departure delay. The flight crewmembers continued the nonpertinent conversation
    throughout the entire taxi, which was not in accordance with company procedures and Federal regulations regarding sterile cockpit. CVR
    information also revealed that, although the flight crew completed all of the required checklist items during the taxi, each item was
    read and responded to in a very quick and routine manner.

    About 1609, the captain called for flaps 20 and then for the Taxi checklist. Flight data recorder (FDR) data indicated that, 1 second
    later, the flaps moved from the flaps 0 to the flaps 8 position. Further, while conducting the checklist, the first officer stated,
    “flaps 8” and “eight degrees,” indicating that he had selected the flap handle to the flaps 8 position, not to the flaps 20 position as
    called for by the captain. However, the captain responded, “set” and “eight,” respectively, indicating that he did not notice the
    incorrect flap setting. The rapid and perfunctory manner in which the flight crew conducted the Taxi checklist resulted in the captain
    not visually comparing the airplane’s flap position with the aircraft communications addressing and reporting system data, which was his
    normal practice.

    After rapidly completing the Taxi checklist, the flight crew continued the nonpertinent conversation until the captain called for the
    Before Takeoff checklist. After the flight crew rapidly conducted this checklist, without including a proper takeoff briefing, the flight
    was cleared for takeoff. The takeoff was normal until the airplane reached an airspeed of about 120 knots. At this time, FDR data showed
    Brief of Incident (Continued)

    DCA10IA022
    File No. 0 01/19/2010 Charleston, WV Aircraft Reg No. N246PS Time (Local): 16:00 EST

    the flaps beginning to move from the flaps 8 to the flaps 20 position. Shortly thereafter, the first officer stated, “V one [the takeoff
    decision speed],” which was 127 knots. The CVR then recorded the sound of the airplane master caution and flaps and spoilers
    configuration aural alerts. The captain initiated a rejected takeoff (RTO) about 5 seconds after he started moving the flaps and when the
    airplane was at an airspeed of about 140 knots, which was 13 knots above V1.

    Bombardier computed the total distance required for the incident airplane to accelerate stop using data from the FAA-approved Airplane
    Flight Manual and the planned takeoff performance data (including configuration, weight, altitude, and reduced thrust takeoff). The
    calculations indicated that the airplane would have stopped about 5,730 feet from the beginning of the takeoff roll if the deceleration
    had been initiated at the planned V1 (127 knots). Given that the runway was 6,300 feet long and that FDR data indicated a normal
    deceleration during the RTO, sufficient runway distance would have existed for the airplane to stop on the runway surface if the captain
    had initiated the RTO immediately after he identified the misconfigured flap setting instead of reconfiguring the flaps. The captain
    should have called for an RTO as soon as he recognized the flaps were in the wrong position. As a result of the captain’s decision to
    attempt to reconfigure the flaps and delay the RTO, the airplane overran the runway end and entered the engineered materials arresting
    system (EMAS) at an airspeed of about 50 knots. The airplane stopped 128 feet into the EMAS arrestor bed with about 277 feet of arrestor
    bed remaining. Before the installation of the EMAS in September 2007, the runway end safety area for runway 23 was only 120 feet long. If
    this incident had occurred before the installation of the EMAS, the airplane most likely would have traveled beyond the length of the
    original safety area and off the steep slope immediately beyond its end.
    Updated at Oct 29 2010 1:57PM
    Brief of Incident (Continued)

    DCA10IA022
    File No. 0 01/19/2010 Charleston, WV Aircraft Reg No. N246PS Time (Local): 16:00 EST

    OCCURRENCES

    Takeoff-rejected takeoff - Miscellaneous/other

    FINDINGS

    Aircraft-Aircraft systems-Flight control system-TE flap control system-Incorrect use/operation - C


    Personnel issues-Task performance-Communication (personnel)-CRM/MRM techniques-Flight crew - C
    Personnel issues-Task performance-Use of equip/info-Use of checklist-Flight crew - C
    Personnel issues-Task performance-Use of equip/info-Use of equip/system-Pilot - C

    Findings Legend: (C) = Cause, (F) = Factor


    __________________________________________________________________________________________________________________________________________

    The National Transportation Safety Board determines the probable cause(s) of this incident as follows.
    (1) The flight crewmembers’ unprofessional behavior, including their nonadherence to sterile cockpit procedures by engaging in
    nonpertinent conversation, which distracted them from their primary flight-related duties and led to their failure to correctly set and
    verify the flaps; (2) the captain’s decision to reconfigure the flaps during the takeoff roll instead of rejecting the takeoff when he
    first identified the misconfiguration, which resulted in the rejected takeoff beginning when the airplane was about 13 knots above the
    takeoff decision speed and the subsequent runway overrun; and (3) the flight crewmembers’ lack of checklist discipline, which contributed
    to their failure to detect the incorrect flap setting before initiating the takeoff roll. Contributing to the survivability of this
    incident was the presence of an engineered materials arresting system beyond the runway end.

    You might also like