NTSB Identification: CHI93MA276.
The docket is stored in the Docket Management System (DMS). Please contact Records Management Division
Accident occurred Monday, July 26, 1993 in BYERS, KS
Probable Cause Approval Date: 04/29/1994
Aircraft: CANADAIR CL-600-2B19, registration: CFCRJ
Injuries: 3 Fatal.

NTSB investigators traveled in support of this investigation and used data obtained from various sources to prepare this aircraft accident report.

THE CREW WAS PERFORMING A LATERAL & DIRECTIONAL STABILITY TEST. CHANGES FROM EARLIER TESTS COMBINED NEW LEADING EDGE FAIRING, NEW FLAP SETTING, LOWER REFERENCE AIRSPEED, AND TRIAL SETTINGS FOR THE STALL PROTECTION SYSTEM (SHAKER & PUSHER). ENGINEERS HAD BRIEFED THE CREW DATA WOULD BE SUFFICIENT IF THE STEADY HEADING SIDESLIP (SHSS) MANEUVER ENDED AT A 15 DEG SIDESLIP, OR AT ONSET OF STALL WARNING; CREW AGREED TO END AT STALL WARNING. DURING THE TEST THE CAPT CONTINUED PAST STALL WARNING TO 21 DEG SIDESLIP AT FULL RUDDER. THE AIRPLANE ROLLED RAPIDLY THROUGH 360 DEG & ENTERED A DEEP STALL. THE COPILOT ATTEMPTED TO DEPLOY THE ANTI-SPIN CHUTE. HOWEVER, ALL THE CHUTE SYSTEM COCKPIT SWITCHES WERE NOT PROPERLY PRESET; INSTEAD OF ASSISTING RECOVERY, THE CHUTE PARTED FROM THE AIRPLANE. FULL CONTROL WAS NOT REGAINED BEFORE IMPACT. THE CHUTE SYSTEM DESIGN ALLOWED DEPLOYMENT OF THE CHUTE EVEN WHEN THE HYD LOCK SWITCH WAS IN THE UNLOCKED POSITION & THE HOOKS CLASPING THE CHUTE SHACKLE TO THE AIRFRAME WERE OPEN. SYSTEM TESTED OK BEFORE FLIGHT.

The National Transportation Safety Board determines the probable cause(s) of this accident to be:

THE CAPTAIN'S FAILURE TO ADHERE TO THE AGREED UPON FLIGHT TEST PLAN FOR ENDING THE TEST MANEUVER AT THE ONSET OF PRESTALL STICK SHAKER, AND THE FLIGHTCREW'S FAILURE TO ASSURE THAT ALL REQUIRED SWITCHES WERE PROPERLY POSITIONED FOR ANTI-SPIN CHUTE DEPLOYMENT. A FACTOR WHICH CONTRIBUTED TO THE ACCIDENT WAS THE INADEQUATE DESIGN OF THE ANTI-SPIN CHUTE SYSTEM WHICH ALLOWED DEPLOYMENT OF THE CHUTE WITH THE HYDRAULIC LOCK SWITCH IN THE UNLOCKED POSITION. (WHEN IN THE UNLOCKED POSITION, THE HOOKS CLASPING THE CHUTE SHACKLE TO THE AIRFRAME ARE OPEN.)

Full narrative available

Index for Jul1993 | Index of months