NTSB LJ 030804 Probable Cause

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National Transportation Safety Board Printed on : 1/3/2011 6:02:50 PM

Washington, DC 20594

Brief of Accident

Adopted 07/29/2004

NYC03FA173
File No. 15963 08/04/2003 Groton, CT Aircraft Reg No. N135PT Time (Local): 06:39 EDT

Make/Model: Learjet / 35A Fatal Serious Minor/None


Engine Make/Model: Garrett / TFE-731-2-2B Crew 2 0 0
Aircraft Damage: Destroyed Pass 0 0 0
Number of Engines: 2
Operating Certificate(s): On-demand Air Taxi
Type of Flight Operation: Positioning
Reg. Flight Conducted Under: Part 91: General Aviation

Last Depart. Point: Farmingdale, NY Condition of Light: Day


Destination: Same as Accident/Incident Location Weather Info Src: Weather Observation Facility
Airport Proximity: Off Airport/Airstrip Basic Weather: Visual Conditions
Lowest Ceiling: None
Visibility: 9.00 SM
Wind Dir/Speed: 150 / 010 Kts
Temperature (°C): 23
Precip/Obscuration:

Pilot-in-Command Age: 33 Flight Time (Hours)

Certificate(s)/Rating(s) Total All Aircraft: 4300


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

About 5 miles west of the airport, the flightcrew advised the approach controller that they had visual contact with the airport, canceled
their IFR clearance, and proceeded under visual flight rules. A witness heard the airplane approach from the east, and observed the
airplane at a height consistent with the approach minimums for the VOR approach. The airplane continued over the runway, and entered a
"tight" downwind. The witness lost visual contact with the airplane due to it "skimming" into or behind clouds. The airplane reappeared
from the clouds at an altitude of about 200 feet above the ground on a base leg. As it overshot the extended centerline for the runway,
the bank angle increased to about 90-degrees. The airplane then descended out of view. The witness described the weather to the north
and northeast of the airport, as poor visibility with "scuddy" clouds. According to CVR and FDR data, about 1.5 miles from the runway
with the first officer at the controls, and south of the extended runway centerline, the airplane turned left, and then back toward the
right. During that portion of the flight, the first officer stated, "what happens if we break out, pray tell." The captain replied,
"uh, I don't see it on the left side it's gonna be a problem." When the airplane was about 1/8-mile south of the runway threshold, the
first officer relinquished the controls to the captain. The captain then made an approximate 60-degree heading change to the right back
toward the runway. The airplane crossed over the runway at an altitude of 200 feet, and began a left turn towards the center of the
airport. During the turn, the first officer set the flaps to 20 degrees. The airplane reentered a left downwind, about 1,100 feet south
of the runway, at an altitude of 400 feet. As the airplane turned onto the base leg, the captain called for "flaps twenty," and the
first officer replied, "flaps twenty coming in." The CVR recorded the sound of a click, followed by the sound of a trim-in-motion
clicker. The trim-in-motion audio clicker system would not sound if the flaps were positioned beyond 3 degrees. About 31 seconds
later, the CVR recorded a sound similar to a stick pusher stall warning tone. The airplane impacted a rooftop of a residential home
Brief of Accident (Continued)

NYC03FA173
File No. 15963 08/04/2003 Groton, CT Aircraft Reg No. N135PT Time (Local): 06:39 EDT

about 1/4-mile northeast of the approach end of the runway, struck trees, a second residential home, a second line of trees, a third
residential home, and came to rest in a river. Examination of the wreckage revealed the captain's airspeed indicator reference bug was
set to 144 knots, and the first officer's was set to 124 knots. The flap selector switch was observed in the "UP" position. A review of
the Airplane Flight Manual revealed the stall speeds for flap positions of 0 and 8 degrees, and a bank angle of 60 degrees, were 164 and
148 knots respectfully. There were no charts available to calculate stall speeds for level coordinated turns in excess of 60 degrees.
The flightcrew was trained to apply procedures set forth by the airplane's Technical Manual, which stated, "…The PF (Pilot Flying) will
call for flap and gear extension and retraction. The PNF (Pilot not flying) will normally actuate the landing gear. The PNF will
respond by checking appropriate airspeed, repeating the flap or gear setting called for, and placing the lever in the requested
position... The PNF should always verify that the requested setting is reasonable and appropriate for the phase of flighty and
speed/weight combination."
Brief of Accident (Continued)

NYC03FA173
File No. 15963 08/04/2003 Groton, CT Aircraft Reg No. N135PT Time (Local): 06:39 EDT

Occurrence #1: LOSS OF CONTROL - IN FLIGHT


Phase of Operation: MANEUVERING

Findings
1. (F) WEATHER CONDITION - CLOUDS
2. (C) LOW ALTITUDE FLIGHT/MANEUVER - PERFORMED - PILOT IN COMMAND
3. STALL - INADVERTENT - PILOT IN COMMAND
4. (F) CREW/GROUP COORDINATION - INADEQUATE - FLIGHTCREW
5. (C) RAISING OF FLAPS - INADVERTENT - COPILOT/SECOND PILOT
----------

Occurrence #2: IN FLIGHT COLLISION WITH OBJECT


Phase of Operation: DESCENT - UNCONTROLLED

Findings
6. OBJECT - RESIDENCE
----------

Occurrence #3: IN FLIGHT COLLISION WITH TERRAIN/WATER


Phase of Operation: DESCENT - UNCONTROLLED

Findings
7. TERRAIN CONDITION - RESIDENTIAL AREA
8. TERRAIN CONDITION - WATER

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


__________________________________________________________________________________________________________________________________________

The National Transportation Safety Board determines the probable cause(s) of this accident as follows.
The first officer's inadvertent retraction of the flaps during the low altitude maneuvering, which resulted in the inadvertent stall and
subsequent in-flight collision with a residential home. Factors in the accident were the captain's decision to perform a low altitude
maneuver using excessive bank angle, the flight crews inadequate coordination, and low clouds surrounding the airport.

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